Republic of the PhilippinesUNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City

GRADUATE SCHOOL

MCN 202 NURSING CARE OF CHILDREN

Ma. Erika Athenae Emeci P. Bajet Larguita Reotutar, Ed.DMAN STUDENT PROFESSOR

1.a An adolescent, age 17, with acute lymphoblastic leukemia is receiving chemotherapy for the treatment. During discharge preparation, what are the important topics for the nurse to discuss with the child and parents? Discuss fully these topics.

The following are the topics to be emphasized or discussed to the child and to his parents:

Diet: It is important that he gets good nutrition because he has cancer. He should eat a variety of healthy foods from all the food groups. The food groups include breads, vegetables, fruits, milk and milk products, and protein (beans, eggs, poultry, meat and fish). Eating healthy foods may help him feel better and have more

energy. He may need to make diet changes depending on his tolerance, the location of his cancer, or treatment side effects. For example, if he has trouble swallowing, try eating foods that are soft or in liquid form. They should ask their caregiver if you should add special drinks or vitamins to your diet. Tell your caregiver if you are nauseated, vomiting, or have other problems eating or digesting your food.

Drinking liquids: He should drink about two to three Liters of liquid each day. It is especially important to drink enough liquids if he is vomiting (throwing up) from chemotherapy. I would suggest him of trying to drink enough liquid each day, and not just when he feels thirsty. It may be helpful to drink liquids between his meals instead of with meals.

Rest:  He should match his activity to the amount of energy he has. Nap a couple of times during the day. Going to bed early and getting up late may also help.

Exercise: Exercising helps keep him healthy. Caregivers may tell him to decrease his activities while his blood cell count is low. It is best to start slowly and do more as he get stronger.

Avoid things that can cause cuts or bruises: Advise not to play contact sports since he may bleed or bruise easily.

Avoid exposure to crowds and people with contagious illnesses, especially children with viral infections.

In addition, a neutropenic diet is recommended for him, as follows:

No fresh fruits or vegetables may be eaten. All foods must be cooked. Meats are to be cooked until well done.

1.b The same child was discharged with written information about chemotherapy administration and the outpatient appointment schedule. The child now is in the maintenance phase of chemotherapy but has missed clinic appointments for blood work and admits to omitting some chemotherapy doses. To improve the

client’s compliance, what should the nurse include in her intervention plan of care? Make a plan of care for this child.The child is already in the maintenance phase of chemotherapy which is the treatment stage that further reduces the number of leukemia cells through the use of repeated courses of less intense chemotherapy every 28 days for an additional 30 months in boys. Advise him to have regular outpatient visits which are required to determine his response to treatment, detect any recurrent disease and manage any side effects of the treatment. I will explain to him and to his parents that relapse may occur if he would continue omitting chemotherapy doses.

Nursing Care Plan

Assessment Bleeding from the gums Fever Frequent infections Frequent or severe nosebleeds Lumps caused by swollen lymph nodes in and around

the neck, underarm, stomach or groin Pale skin Shortness of breath Weakness, fatigue or a general decrease in energy

Nursing Diagnoses Risk for Infection and Bleeding Risk for Impaired Skin Integrity related to toxic effects of chemotherapy,

alteration in nutrition, and impaired mobility Impaired Gas Exchange Impaired mucous membranes due to changes in epithelial lining of the GI tract

from chemotherapy or prolonged use of antimicrobial medications Imbalanced nutrition, less than body requirements, related to hypermetabolic

state, anorexia, mucositis, pain. And nausea Acute pain and discomfort related to mucositis, leukocyte infiltration of

systemic tissues, fever, and infection Fatigue and activity intolerance related to anemia or infection Impaired physical mobility due to anemia and protective isolation Risk for excess fluid volume related to renal dysfunction, hypoproteinemia,

need for multiple IV medications and blood products Diarrhea due to altered GI flora, mucosal denudation Risk for deficient fluid volume related to potential for diarrhea, bleeding,

infection, and increased metabolic rate Self-care deficit due to fatigue, malaise, and protective isolation Anxiety due to knowledge deficit and uncertainty about future Disturbed body image related to change in appearance, function, and roles Grieving related to anticipatory loss and altered role functioning Potential for spiritual distress Deficient knowledge about disease process, treatment, complication

management, and self-care measures

Planning and Goals The major goals for the patient may include absence of complications and

pain, attainment and maintenance of adequate nutrition, activity tolerance, ability to provide self-care and to cope with the diagnosis and prognosis, positive body image, and an understanding of the disease process and its treatment.

Nursing Interventions Thorough hand hygiene must be performed by everyone before entering

patient’s room each and every time. Allow no fresh flowers. Avoid suppositories, enemas, and rectal temperatures. Provide low microbial diet. Soft bristled toothbrush should be used.

Small, frequent feedings of foods that are soft in texture and moderate in temperature may be better tolerated.

Acetaminophen is typically given to decrease fever, but it does so by increasing diaphoresis.

Sponging with cool water or ice packs should be avoided because the heat cannot dissipate from constricted blood vessels.

Assist patient to establish a balance between activity and rest. Encourage patient to maintain some physical activity and exercise to prevent

the deconditioning that results from inactivity. Encourage to sit up in a chair while awake rather than staying in bed to

improve the patient’s tidal volume and enhance circulation. Measure intake and output accurately and daily body weights are useful in

monitoring fluid status.

Evaluation Shows no evidence of infection Experiences no bleeding Has intact oral mucous membranes

a. Participates in oral hygiene regimenb. Reports no discomfort in mouth

Attains optimal level of nutritiona. Maintains weight with increased food and fluid intakeb. Maintains adequate protein stores (albumin)

Reports satisfaction with pain and comfort levels Has less fatigue and increased activity Maintains fluid and electrolyte balance Participates in self care Copes with anxiety and grief

a. Discussed concerns and fearsb. Uses stress management strategies appropriatelyc. Participates in decisions regarding end-of-life care

Absence of complications

2. The nurse is caring for a young child with tetralogy of fallot. The child is upset and crying. The nurse observes that he’s dyspneic and cyanotic. What are the 4 characteristics of this disease? Explain why this condition is cyanotic. Explain the manifestations, therapeutic management as to medical and surgical management. Prepare a nursing plan of care pre and post operatively.

The classic form of tetralogy of fallot includes four related defects of the heart and its major blood vessels:

Ventricular septal defect (hole between the right and left ventricles) Pulmonary Stenosis (the valve and artery that connect the heart with the lungs) Overriding aorta (the artery that carries oxygen-rich blood to the body) that is

shifted over the right ventricle and ventricular septal defect, instead of coming out only from the left ventricle

Right Ventricular Hypertrophy (A thickened muscular wall of the right ventricle)

The right ventricular outflow tract obstruction may be minimal in the beginning leading to significant left-to-right shunting at the VSD with symptoms and signs of congestive heart failure. As the right ventricular outflow tract becomes more and more obstructive the pulmonary vascular resistance will exceed the systemic vascular resistance and right-to-left shunting will occur causing cyanosis. Cyanosis is influenced by hemoglobin level and therefore if it is low it may not be evident. Cyanosis induces an increase in the hemoglobin concentration and increase in erythropoietin production. When there are large or multiple collaterals from the systemic arterial circulation to the pulmonary arterial circulation there will be minimal cyanosis as pulmonary blood flow will be increased. The long systolic murmur of tetralogy of Fallot is secondary to the turbulent flow across the RVOT obstruction and pulmonary stenosis and not due to the VSD. Twenty-five per cent (25%) of tetralogy of Fallot patients are cyanotic at birth and 75% of patients become cyanotic at 1 year of age. Spells of hypercyanosis are uncommon in the first six months of life. They are most common in infants and toddlers. They again become rare in children more than 4 years of age.

Squatting helps to relieve cyanotic spells possibly due to increase in systemic vascular resistance because of kinking of femoral arteries as well as in a decrease in the venous return. Due to deformity of the pulmonary valve there may be a single second heart sound. When continuous murmurs are auscultated this might indicate the presence of a PDA or collateral vessels.

Manifestations

Clubbing of fingers (skin or bone enlargement around the fingernails)

Difficult feeding (poor feeding habits) Failure to gain weight The skin, lips, and mucous membranes inside the mouth

and nose take on a noticeably dusky blue color. Only some infants with very severe obstruction of the

right ventricle outflow turn blue at birth. A small number of children with tetralogy of Fallot never

turn blue at all, especially if the pulmonary stenosis is mild, the ventricular septal defect is small, or both.

In some children, the cyanosis is quite subtle and may go undetected for some time.

Growth and development are slower, especially if the pulmonary stenosis is severe. Puberty may be delayed if the tetralogy is untreated.

The child usually tires easily and begins panting with any form of exertion. He or she may play for only a short time before sitting or lying down.

Once able to walk, the child often assumes a squatting position to catch his or her breath and then resumes physical activity. Squatting increases the pressure transiently in the aorta and left ventricle, causing less blood to move into the left ventricle, more out the pulmonary artery to the lungs.

Medical ManagementAsymptomatic infants need no special medical treatment.

Surgery is the definitive treatment for the cyanotic patient with tetralogy of Fallot (TOF).

The child will be placed on his or her back in the knee-to-chest position to increase aortic resistance. The increased aortic and left ventricular pressure reduces the rush of blood through the septal hole from the right ventricle and improves blood circulation to the lungs, so more red blood reaches the tissues.

The child may be given oxygen through a face mask to increase the amount of oxygen in the blood.

The child may be given morphine,propranolol (or metoprolol), or, in extreme cases, phenylephrine (Alconefrin, Vicks Sinex). These medications decrease the frequency and severity of tet spells.

Surgery

The Blalock-Taussig operation is a palliative procedure performed in smaller infants to increase blood flow to the lungs. This allows the child to grow big enough to have complete surgical repair.A connection is made between one of the majorarteries of the body, usually the rightsubclavian artery,and the right pulmonary artery, which increases the amount of red oxygenated blood reaching the lungs, relieving cyanosis with dramatic relief of the patient's symptoms.

Total correction: The hole in the ventricular septum (between the ventricles) is closed with a patch and the obstruction to right ventricular outflow, pulmonic stenosis, isopened. These corrections allow blood flow to the lungs foroxygenation before being pumped out into the body.

The timing of the operation depends on symptoms. Surgery usually is performed within the first 2 years of life. Operative mortality rates have dramatically dropped over the last 20 years. Still, about 1-5% of children who undergo complete correction die during or immediately after the procedure, secondary to other additional defects in the body and/or heart, and the heart lung bypass procedure it.

This image shows completed blocking This image shows a closed ventricular with a Taussig shunt septal defect and closure of right

ventriculotomy with Gore-Tex.

Gore-Tex is used for complete closure of right ventriculotomy

Preoperative:

The preoperative evaluation includes an assessment of functional status and pulmonary evaluation. Chest radiographic findings may depict the classic boot-shaped heart. Echocardiography is diagnostic, and associated anomalies can be excluded. Cardiac catheterization is indicated before repair of tetralogy of Fallot in patients with previous palliation and when aortopulmonary collaterals and pulmonary artery branching abnormalities are suspected.

Postoperative:

Children will spend time in the intensive care unit (ICU) after tetralogy of Fallot repair. During the first several hours after surgery, your child will be very drowsy from the anesthesia that was used during the operation, and from medications given to relax him/her and to help with pain. As time goes by, your child will become more alert.

 While your child is in the ICU, special equipment will be used to help him/her recover, and may include the following:

ventilator - a machine that helps your child breathe while he/she is under anesthesia during the operation. A small, plastic tube is guided into the windpipe and attached to the ventilator, which breathes for your child while he/she is too sleepy to breathe effectively on his/her own. After a truncus repair, children will benefit from remaining on the ventilator overnight or even longer so they can rest.

intravenous (IV) catheters - small, plastic tubes inserted through the skin into blood vessels to provide IV fluids and important medicines that help your child recover from the operation.

arterial line - a specialized IV placed in the wrist or other area of the body where a pulse can be felt, that measures blood pressure continuously during surgery and while your child is in the ICU.

nasogastric (NG) tube - a small, flexible tube that keeps the stomach drained of acid and gas bubbles that may build up during surgery.

urinary catheter - a small, flexible tube that allows urine to drain out of the bladder and accurately measures how much urine the body makes, which helps determine how well the heart is functioning. After surgery, the heart will be a little weaker than it was before, and, therefore, the body may start to hold onto fluid, causing swelling and puffiness. Diuretics may be given to help the kidneys to remove excess fluid from the body.

chest tube - a drainage tube may be inserted to keep the chest free of blood that would otherwise accumulate after the incision is closed. Bleeding may occur for several hours, or even a few days after surgery.

heart monitor - a machine that constantly displays a picture of your child's heart rhythm, and monitors heart rate, arterial blood pressure, and other values.

3.a In a remote area where parents are not very familiar with newborn screening, if you were the nurse, what can you do to disseminate this very important topic? Make a plan of action to follow in increasing awareness of the community people about this vital test.

Parents and providers had limited knowledge and awareness about newborn screening practices. Parents wanted brief to-the-point information on newborn screening and its benefits, including the possible need for retesting and the importance of returning promptly for retesting if initial results are abnormal.

Parents wanted the information orally from the primary care provider. Parents, providers, and newborn screening professionals all thought that an accompanying concise, easy-to-read brochure with contact information would be helpful. Parents should receive this information before the birth of the infant, preferably in the third trimester of pregnancy. Providers should have a brief checklist of information and resources to prepare them to educate parents effectively.

CONCLUSION. I recommend prenatal and primary care providers be more involved in educating parents about newborn screening. Professional societies and state health officials should work together to encourage parent and provider education. User-friendly patient and provider education materials, such as those we developed, could form the basis for this educational approach.

3.b In case the child was found to be positive of one or two of the diseases screened by this newborn screening test, and the parents and relatives ask you to explain the disorders that may be screened, how would you explain these in a level that may be very well understood by them?

I’ll explain to them as clear as this:

Newborn Screening: A Guide for Parents

Newborn screening is a blood test to check for metabolic and other disorders.  To do the screening, a nurse takes a few drops of blood from your baby’s heel soon after birth. This blood sample is required from ALL newborn babies in order to screen for metabolic and other disorders. A follow-up test for newborn screening occurs whenever there is the slightest reason for concern.

Expanded Newborn Screening

Some states offer additional, optional tests. These tests do not require any extra blood from your baby. In Massachusetts, all newborn babies are required to be screened for 10 disorders. There are 19 additional metabolic disorders that can also be screened for with the same blood specimen.

Metabolic Disorders

Metabolism is the process by which the body breaks down, stores and transforms food into energy for use within the body. A metabolic disorder can lead to abnormal levels of chemicals in the body because this metabolic process is not working properly.

Why Newborn Screening is Important

If a metabolic disorder is not detected and treated early on, it can lead to significant health problems. Often early testing is the only way to detect a disorder before it harms the infant. This is why follow-up testing should occur whenever there is any concern. These disorders are treatable and therefore proper diagnosis and treatment early on allows infants to develop into healthy children.

Follow-up Testing: Just in Case

If your doctor calls and says that your baby needs follow-up testing, it does not necessarily mean your baby is at risk. The blood sample may have been too small, or it may have been taken too early. Abnormal results are often due to premature birth and/or low birth weight. It is estimated that only 1 in 12 babies who have follow-up testing actually have a disorder. However, abnormal screening results can indicate a disorder so it is important to follow your doctor’s advice and get your baby tested quickly so that final results can be confirmed.

Positive Diagnosis

If additional tests show that your baby has a metabolic disorder, your doctor will refer you to a metabolic center. At the center you will be told more about your baby’s disorder and your baby will be provided with medical treatment that can prevent serious consequences.

4. Explain the pathophysiology of diabetes in children. How can you assess a child with this disease? How can the condition be confirmed or diagnosed? Discuss the therapeutic management and the nursing care.

Diabetes Mellitus in children is caused by genetic factors and autoimmune factors, and may also develop as a result of a viral infection. Children born to fathers who have type 1 are about three times more likely to develop diabetes mellitus than children born to mothers with type 1. About 70% to 85% of newly diagnosed type 1 diabetes mellitus patients are found to have pancreatic islet cell antibodies. These antibodies disappear in most people

after diagnosis. It’s thought that the presence of these antibodies makes the immune system vulnerable to a trigger event, such as a virus, bacteria, or chemical irritant. Several viruses, including coxsackie B, mumps, and congenital rubella, have been associated with the development of type 1 diabetes mellitus. The pancreatic islet cells are susceptible to injury by these viruses and can suffer damage or be changed. This alteration triggers an autoimmune response. The virus becomes a trigger to the development of type 1 diabetes mellitus.

You can assess the child if he/she has diabetes mellitus if the three cardinal signs such as polyuria, polidipsia, polyphagia are present. Other general signs and symptoms would include weakness and fatigue, nocturia in a child who has already attained night time control, dehydration,, weight loss and hunger, vision changes, frequent skin and urinary tract infections and skin changes.

If your child's doctor suspects diabetes, he or she will recommend a screening test. The primary test used to diagnose type 1 diabetes in children is the:

Random blood sugar test. A blood sample will be taken at a random time. Blood sugar values are expressed in milligrams per deciliter (mg/dL) or millimoles per liter (mmol/L). Regardless of when the child last ate, a random blood sugar level of 200 mg/dL (11.1 mmol/L) or higher suggests diabetes.If the child's random blood sugar test results don't suggest diabetes, but the doctor still suspects it because of the child's symptoms, the doctor may do a:

Glycated hemoglobin (A1C) test. This blood test indicates an average blood sugar level for the past two to three months. It works by measuring the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. The higher the blood sugar levels, the more hemoglobin that has sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates diabetes.

Another test the doctor might use is a fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, thev child will be diagnosed with diabetes.

If the child is diagnosed with diabetes, the doctor will also run blood tests to check for autoantibodies that are common in type 1 diabetes and help doctors distinguish between type 1 and type 2 diabetes. The presence of ketones — byproducts from the breakdown of fat — in the child's urine also suggests type 1 diabetes, rather than type 2.

Therapeutic management and nursing care would include the following:

Stress the importance of lifelong diabetes care Review the prescribed meal plan and teach the child and his family how to adjust his

diet when engaged in extra activity. Advise the child and his parents about aerobic exercise programs; explain how

exercise affects blood glucose levels, and provide safety guidelines. Instruct the child and his family on insulin administration, if prescribed, including

type, peak times, dosage, drawing up the insulin, mixing (if applicable), administration technique, site rotation, sharps disposal, and storage.

Teach the child and his parents how to perform blood glucose monitoring. Instruct the child and his parents on oral antidiabetic therapy, if prescribed, including

dosage, frequency and time of administration, and potential adverse reactions. Concentrated sweets are discouraged; teach the child and his parents about

alternate snack ideas to help him feel more like his peers. Everyone needs regular aerobic exercise, and children who have type 1 diabetes are

no exception. Encourage the child to get regular physical activity.

Republic of the PhilippinesUNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City

GRADUATE SCHOOL

MCN 203 – ADVANCED MATERNAL CHILD NURSING

Ma. Erika Athenae Emeci P. Bajet Larguita Reotutar, Ed.DMAN STUDENT PROFESSOR

1. Why do you think pre-conceptual care is important for a woman? Discuss fully what should be the assessment to be done to a woman during pregnancy, delivery and puerprium. How can the nurse identify whether her pregnancy is healthy or at risk? What assessment tools or laboratory procedures be done to identify a complicated pregnancy, answer fully.

I think pre conceptual care is really important for a woman for the following reasons:

Prevention of risk behaviours such as smoking, alcoholism and the use of drugs (cannabis...)

Prevention of infectious risks: tracking of patients with HIV, HBV, HCV virus, tracking of toxoplasmosis.

Correction of diabetes and the prediabetic states, while monitoring the rate of hemoglobin A1C which will have to be lower than 7%.

Correct obesity Supervise the folic acid amount to avoid Spina bifida Controlled diet excluding phenylalanine in the event of congenital

phenylketonuria

Research also suggested that attending a pre conception check up with your GP can help increase your chance of conceiving a health pregnancy with fewer complications. This is thought to be because any potential problems that may affect you or your partners’ fertility can be identified early on so that treatment or lifestyle alterations can be made. This helps to ensure that you and your partner are in the best of health when you start trying to conceive and so gives your baby the best possible start in life.

ASSESSMENT

Test What it is How it is done

Amniocentesis

This test can diagnosis certain birth defects, including:

Down syndrome Cystic fibrosis Spina bifida

It is performed at 14 to 20 weeks.

A thin needle is used to draw out a small amount of amniotic fluid and cells from the sac surrounding the fetus. The sample is sent to a lab for testing.

It may be suggested for couples at higher risk for genetic disorders. It also provides DNA for paternity testing.

Biophysical profile

This test is used in the third trimester to monitor the overall health of the baby and to help decide if the baby should be delivered early.

BPP involves an ultrasound exam along with a nonstress test. The BPP looks at the baby's breathing, movement, muscle tone, heart rate, and the amount of amniotic fluid.

Chorionic villus sampling

A test done at 10 to 13 weeks to diagnose certain birth defects, including:

Chromosomal disorders, including Down

Genetic disorders, such as cystic fibrosis

CVS may be suggested for couples at higher risk for genetic disorders. It also provides DNA for paternity testing.

A needle removes a small sample of cells from the placenta to be tested.

First trimester screen

A screening test done at 11 to 14 weeks to detect higher risk of:

Chromosomal disorders, including Down syndrome and trisomy 18

Other problems, such as heart defects

It also can reveal multiple births. Based on test results, your doctor may suggest other tests to diagnose a disorder.

This test involves both a blood test and an ultrasound exam called nuchal translucency screening. The blood test measures the levels of certain substances in the mother's blood. The ultrasound exam measures the thickness at the back of the baby's neck. This information, combined with the mother's age, help doctors determine risk to the fetus.

Glucose challenge screening

A screening test done at 26 to 28 weeks to determine the mother's risk of gestational.

Based on test results, your doctor may suggest a glucose tolerance test.

First, you consume a special sugary drink from your doctor. A blood sample is taken one hour later to look for high blood sugar levels.

Glucose tolerance test

This test is done at 26 to 28 weeks to diagnose gestational diabetes.

Your doctor will tell you what to eat a few days before the test. Then, you cannot eat or drink anything but sips of water for 14 hours before the test. Your blood is drawn to test your "fasting blood glucose level." Then, you will consume a sugary drink. Your

blood will be tested every hour for three hours to see how well your body processes sugar.

GroupB streptococcus infection

This test is done at 36 to 37 weeks to look for bacteria that can cause pneumonia or serious infection in newborn.

A swab is used to take cells from your vagina and rectum to be tested.

Maternal serum screen (also called quad screen, triple test, triple screen, multiple marker screen, or AFP)

A screening test done at 15 to 20 weeks to detect higher risk of:

Chromosomal disorders, including Down and trisomy 18

Neural tube defects, such as spina bifida

Based on test results, your doctor may suggest other tests to diagnose a disorder.

Blood is drawn to measure the levels of certain substances in the mother's blood.

Nonstress test

This test is performed after 28 weeks to monitor your baby's health. It can show signs of fetal distress, such as your baby not getting enough oxygen.

A belt is placed around the mother's belly to measure the baby's heart rate in response to its own movements.

Ultrasound exam

An ultrasound exam can be performed at any point during the pregnancy. Ultrasound exams are not routine. But it is not uncommon for women to have a standard ultrasound exam between 18 and 20 weeks to look for signs of problems with the baby's organs and body systems and confirm the age of the fetus and proper growth. It also might be able to tell the sex of your baby.

Ultrasound exam is also used as part of the first trimester screen and biophysical profile (BPP).

Based on exam results, your doctor may suggest other tests or other types of ultrasound to help detect a problem.

Ultrasound uses sound waves to create a "picture" of your baby on a monitor. With a standard ultrasound, a gel is spread on your abdomen. A special tool is moved over your abdomen, which allows your doctor and you to view the baby on a monitor.

Urine testA urine sample can look for signs of health problems, such as:

Urinary tract infection Diabetes Preeclampsia

You will collect a small sample of clean, midstream urine in a sterile plastic cup. Testing strips that look for certain substances in your urine are dipped in the sample. The sample also can be looked at under a microscope.

If your doctor suspects a problem, the sample might be sent to a lab for more in-depth testing.

High-risk Pregnancy

Pregnancies with a greater chance of complications are called "high-risk." But this doesn't mean there will be problems. The following factors may increase the risk of problems during pregnancy:

Very young age or older than 35 Overweight or underweight Problems in previous pregnancy Health conditions you have before you become pregnant, such as high blood

pressure, diabetes, autoimmune disorders, cancer, and HIV Pregnancy with twins or other multiples

Health problems also may develop during a pregnancy that make it high-risk, such as gestational diabetes or preeclampsia. Women with high-risk pregnancies need prenatal care more often and sometimes from a specially trained doctor. A maternal-fetal medicine specialist is a medical doctor that cares for high-risk pregnancies.

If your pregnancy is considered high risk, you might worry about your unborn baby's health and have trouble enjoying your pregnancy. Share your concerns with your doctor. Your doctor can explain your risks and the chances of a real problem. Also, be sure to follow your doctor's advice. For example, if your doctor tells you to take it easy, then ask your partner, family members, and friends to help you out in the months ahead. You will feel better knowing that you are doing all you can to care for your unborn baby.

ASSESSMENT TOOLS FOR COMPLICATED PREGNANCY

Vaginal UltrasoundIn this test, an ultrasound device is placed in your vagina. In early pregnancy, this test can help determine whether a pregnancy is happening in the fallopian tube instead of the uterus. It also can check the length of your cervix in women prone to preterm labor and can be used to look for other pregnancy problems.

Level II UltrasoundObstetricians routinely use a basic type of ultrasound (called Level I ultrasound) to determine the due date, diagnose multiple births and assess the baby's general well-being. All pregnant moms who receive care at Lehigh Valley Health Network also receive a Level II ultrasound, which provides a more detailed scan of the baby for structural abnormalities, such as those involving the skeleton and internal organs. This more detailed scan, interpreted by our specialists, uses state-of-the-art technology and is usually performed at approximately 18-20 weeks of pregnancy.

Fetal Echocardiogram

This test uses ultrasound to scan the baby's heart to detect problems in structure and function. You may need this test if your medical background or family history increases your risk for having a child with a heart defect.

Doppler Flow StudiesColor Flow Doppler is a type of ultrasound that uses sound waves to detect abnormalities in blood flow through the umbilical cord from you to your baby. Dopplers are indicated in pregnancies that are affected by high risk fetal conditions such as intrauterine growth restriction or in high risk maternal conditions such as hypertension.

3D and 4D UltrasoundUnder certain circumstances, our specialists may choose to use 3D or 4D ultrasound technology to perform special examinations to assist with pregnancy management.

Non-stress Test (NST)Usually performed during the last trimester of pregnancy, this test records how your baby's heart rate responds to your baby's movement. During the test, you will wear a fetal heart rate monitor. As the monitor records the baby's heart beat, you will press a button whenever you feel your baby move. Normally the baby's heart rate increases in response to movement. If it does not, you may need additional testing.

Biophysical Profile (BPP)Often used in conjunction with a non-stress test (NST), the BPP uses ultrasound to measure your baby's heart rate, muscle tone, movement, breathing and the amount of amniotic fluid surrounding the baby.

Diagnostic Tests

First Trimester

CVSThis diagnostic test stands for chronic villus sampling. It is a procedure that is done in early pregnancy between 11-13 weeks of pregnancy. A professional inserts a needle through the mother's abdomen or cervix into part of the placenta, called the chorionic villi. A sample of placental tissue is removed through the abdomen or vagina. The retrieved tissue is then grown up in the laboratory and specific genetic and chromosomal abnormalities are looked for. The results of this test take about 12-14 days.

Second Trimester

AmniocentesisIn this procedure, a professional inserts a needle through the mother's abdomen into the sac of fluid surrounding the baby and then withdraws some of the amniotic fluid from around the baby within the maternal abdomen. It can be performed at approximately 16-20 weeks to detect chromosomal abnormalities. In the late third trimester, amniocentesis also can help your physician assess whether your baby's lungs are developed enough for birth if earlier delivery is contemplated due to maternal or fetal condition.

Screening Options

First and Second Trimester

Sequential ScreenThis is the newest option in genetic screening tests, offering a two part screen, it combines a special ultrasound (measures the nuchal translucency or fluid at the back of the baby's neck) and blood tests done in both the first trimester and the 2nd trimester. It gives an early preliminary result after the 1st trimester screening (ultrasound and bloodwork), and a final, more complete result after the 2nd trimester bloodwork is drawn. It was designed to give you the most information available about your risk for Down syndrome, trisomy 18 and open neural tube defects. If you choose Sequential Screen, it will be done at Maternal Fetal Medicine--starting at 11-12 weeks.

Second Trimester

Quad ScreenThe "Quad Screen" is the more traditional blood test done at 15-20 weeks which measures four components: alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), Estiol and Inhibin A in the maternal blood. It also takes into account maternal age in its risk assessment. The detection rate for both Down's syndrome and Trisomy 18 is about 80%. A screen positive test could lead to an amniocentesis for diagnosis. This test is usually performed in your health care provider's office.

2.Why do you think genetic assessment is important before conception? Discuss fully how diseases could be transferred from the mother to the child. Discuss the role of the nurse in the care of a patient with genetic disorder.

Giving birth to a child can be one of the most exciting times in a woman's life. However, it can also be a time filled with concern and reservation if the health of the baby is in question.

Couples who are thinking about having a child may consider genetic counseling before conception to determine if they have an increased risk for having a child with a birth defect, Down syndrome or an inherited condition. Others may use genetic counseling and prenatal diagnosis after they conceive to evaluate the condition of the fetus.

Deborah Driscoll, MD, a specialist in reproductive genetics and Chair of the Department of Obstetrics and Gynecology at the University of Pennsylvania Health System states, "Genetic counseling and prenatal diagnosis are used to help answer some key questions for potential parents and to provide parents with information that they need to make important decisions about pregnancy."

Genetic counselors are health care professionals certified by the American Board of Genetic Counseling. A counselor will ask you detailed questions about your family history to determine if your child is at risk for inheriting a genetic condition or birth defect. They coordinate screening and provide answers to your questions.

"Preconception testing can only provide the odds of having a child with a certain birth defect; a genetic counselor will help you interpret the results of the testing and will offer options for your next steps should you have positive results," says Rose Giardine, a genetic counselor at the Hospital of the University of Pennsylvania.

To help reduce some of the anxiety related to the health of the baby, pregnant women now have the option of first trimester screening for genetic defects. This new screening method was developed to inform physicians and their patients earlier in the pregnancy of the risk for the fetus to have Down syndrome.

In pregnant women, most infections are no more serious than in non-pregnant women. However, some infections can be transmitted to the fetus in utero through the amniotic fluid or hematogeneous pathway, or to the infant during or immediately after delivery (close contact, breast feeding). These infections caused by bacteria, viruses or parasites can lead to potentially serious sequelae for the fetus or infant. 

Antenatal screening (through IgG, IgM, and Avidity for dating onset of infection), and more importantly preconception screening (through IgG), therefore play an essential role in the prevention of vertically transmissible infections. Diagnostic tests are key at all phases of pregnancy as well as for the diagnosis and monitoring of newborns and infants.

Role of the Nurse

Provide appropriate genetics information before, during, and in follow up to genetic counselling.

Help gather relevant family and medical history information.

Offer support to patients and families through the genetic counselling process.

Coordinate genetics-related health care with relevant community and national support resources.

Provide emotional and social support.

Decision-making support.

3. Discuss fully the pathophysiology of the following in an algorithm. Make a nursing care for the patient with these conditions.

a. Osteoporosis

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Osteoporosis is osteopenia due to reduction in both bone matrix and mineralization. Osteopenia is a reduction of bone mass greater than that expected for a given age, race and sex. It results in brittle bones that fracture quite easily. Because bone remodelling with reabsorption balanced by formation, normally occurs throughout life, anything that either increases reabsorption or decreases formation causes loss of bone mass. The rate of reabsorption follows the surface-volume mass of bones. Therefore, because the trabeculae are composed of sheets of bone and have more surface volume than cortical bone, they are lost more rapidly. This loss leads to increased frequency of fractures in the weight-bearing bones, where trabecular bone predominates. The vertebral bodies, radial head, and femoral neck are examples of this type of bone. Likewise, reabsorption is accelerated on the endosteal surfaces of trabecular bone while formation is occurring at the periosteal surfaces, thus leading to wider bones with a thinner, more porous cortex. The ratio of bone mineral to matrix formation is constant, but there is simply a reduction in both. This contrasts with osteomalacia, in which the matrix is normal but the mineralization is deficient.

NURSING CARE

1. Focus on careful positioning, ambulation, and prescribed exercises.

2. Administer analgesics and heat to relieve pain as ordered. 3. Include the patient and his family in all phases of care.4. Encourage the patient to perform as much self-care as her

immobility and pain allow.5. Provide the patient activities that involve mild exercise.6. Check the patient’s skin daily for redness, warmth, and new

pain sites.7. Monitor the patient’s pain level, and assess her response to

analgesic’s, heat therapy, and diversional activities.8. Explain all treatments, tests, and procedure to the patient.9. Make sure the patient and her family clearly understand the

prescribed drug regimen.10.Tell the patient to report any new pain sites immediately,

especially after trauma.11.Provide emotional support and reassurance to help the

patient cope with limited mobility.

What to do to prevent bone loss?

There are several things you can do to help improve your bone strength:

* Calcium-eat calcium rich foods (dairy, calcium fortified grains) and use supplements to get at least 1,200 mg/day

* Vitamin D-use supplements to get 800 to 1,000 international units per day

* Exercise-include weight bearing and resistance exercises; walking helps the lower spine, hips, and legs; hand weights help the arms; overhead weights help the shoulders and upper spine)

* Do not smoke

* Limit intake of salt, caffeine, soda, and alcohol; instead drink calcium-rich milk or calcium-fortified juice

* Prevent falls-use nightlights in case you need to get up at night, clear hallways and stairs, remove cords and wires from walking paths, use nonskid mats in showers/tubs, remove scatter and throw rugs, and clear ice and snow from walking paths

* Take medicine to avoid more bone loss exactly as your clinician recommends.

b. Cancer of the Uterus

Predisposing Factors:-Age: over 50 yrs old-Race: black Americans-Genetic-Disease: Endometrial hyperplasia,colorectal menstruation-Physiologic changes: Early menstruation,Late menopausal stage, amenorrhea

Precipitating Factors:-Hormone Replacement Therapy (HRT):ESTROGEN-Obesity: increase ESTROGEN-Lifestyle: exposure to carcinogens-Sexual Activity: nulliparity

Excessive increase e strogen

Suppress LH &

Slows ovarian cycle

Increase reformation of endometrial lining and slow regeneration

Extra cell form together

Normal cells continuously growing and old cells do not die

TUMOR

ENDOMETRIAL

Nursing Care

1. RelievingPain Administer pain medications as prescribed and monitor patient’s response.  Encourage use of relaxation techniques to help promote comfort.

2. Relieving Fear Support patient through the disease process and reinforce information given by

health care provider about treatment options. Prepare for radiation therapy and surgery.

3. Nutrition Encourage intake of calories and protein to promote healing, maintain strength,

and keep a healthy weight.4. Support client on side effects of chemo therapeutic drugs.5. Follow up care

Prevention

To reduce your risk of endometrial cancer, you may wish to:

Talk to your doctor about the risks of hormone therapy after menopause. If you're considering hormone replacement therapy to help control menopause symptoms, talk to your doctor about the risks and benefits. Unless you've undergone a hysterectomy, replacing estrogen alone after menopause may increase your risk of endometrial cancer. Taking a combination of estrogen and progestin can reduce this risk. Hormone therapy carries other risks, such as a possible increase in the risk of breast cancer, so weigh the benefits and risks with your doctor.

Consider taking birth control pills. Using oral contraceptives for at least one year may reduce endometrial cancer risk. The risk reduction is thought to last for several years after you stop taking oral contraceptives. Oral contraceptives have side effects, though, so discuss the benefits and risks with your doctor.

Maintain a healthy weight. Obesity increases the risk of endometrial cancer, so work to achieve and maintain a healthy weight. If you need to lose weight, increase your physical activity and reduce the number of calories you eat each day.

Exercise most days of the week. Work physical activity into your daily routine. Try to exercise 30 minutes most days of the week. If you can exercise more, that's even better.

Watery, malodorous vaginal discharge

Bladder PainUNUSUAL vaginal bleeding