Pre Gestational Disease
Pre Gestational Disease
DISEASES
CARDIAC DISEASE
Description and etiology
Hemodynamic changes of pregnancy increase the
workload of the heart
Treatment – depend on the degree of cardiac
compromise
Class I and II – potential for a good pregnancy
Class III and IV – at risk for serious maternal and fetal
compromise
CLASSIFICATIONS
1. Class I
Uncompromised.
Asymptomatic
Unrestricted physical activity
2. Class II
Slightly compromised.
Symptomatic with increased activity – angina,
palpitations, fatigue and dyspnea
3. Class III
Marked limitation of physical activity
Less than ordinary activity cause excessive fatigue,
palpitations, chest pain and dyspnea
poor candidate for child bearing
4. Class IV
Severely compromised.
Symptomatic at rest or with any physical activity
Poor candidate for child bearing
SIGNS AND SYMPTOMS
DOB - Dyspnea, orthopnea, nocturnal dyspnea
Palpitations lasting several minutes associated
with lightheadedness
Arrythmias
Chest pain
Hemoptysis
Syncope with exertion
Cyanosis
Clubbing of fingers
Neck vein distention
Systolic and diastolic murmurs
Cardiomegaly
Persistent split second sound
Pulmonary hypertension
ASSESSMENT
Most common complication – CHF
a. Edema of varying degree
b. Dyspnea on exertion, increasing fatigue, dyspnea at
rest, moist cough, cyanosis of nail beds, circumoral
cyanosis
c. Tachycardia, irregular pulse, murmurs, chest pain
DIAGNOSTIC TESTS
1. Electrocardiogram (ECG or EKG)
Shows abnormal rhythm – arrhythmias or
dysrhythmias
Detects heart muscle damage
2. Echocardiography/heart ultrasound
-evaluates the structure and function of the heart by
using sound waves recorded on an electronic sensor
PRIORITY NURSING DIAGNOSES
Decreased cardiac output
Fluid volume excess
Activity intolerance
Anxiety
Risk for infection
IMPLEMENTATION
NURSING CARE (antepartum)
Teach the client to report any s/s of cardiac
decompensation – moist cough, cough with rales,
increasing dyspnea, tachycardia, edema
Give diet plan – limit calorie intake; limit wt. gain;
↓Na; ↑ protein, minerals and vitamins
Weight gain of no more than 24 lb
Avoid high altitudes, smoking areas,
unpressurized planes, overcrowded areas
NURSING CARE (antepartum)
Encourage 8 – 10 hours sleep – to decrease the
workload of heart
Instruct to lie down for 30 mins after each meal.
Do not allow heavy work, stair climbing and
exhaustion
Activity limitation (class III and IV)
Cigarette smoking and alcoholic beverages are strictly
prohibited
Prevent infection
Teach client to notify health care provider at
the first sign of infection - ↑ 02 demand → ↑
workload of heart
Medication
1. iron supplementation to prevent anemia
2. Treatment of cardiac dysrhythmias:
a. Digoxin
b. Quinidine
c. Procainamide
d. Adenosine
e. verapamil
3. Cardiac glycosides/digitalis therapy – increase
the heart’s pumping action, coronary artery
perfusion, stroke volume, ventricular filling
Nursing Implications:
1. Monitor the symptoms of toxicity
- halo around lights
Anorexia
Diarrhea
N/V
Bradycardia, frequent PVCs, monitor apical heart rate
Instruct patient to report palpitations
Monitor K levels, hypokalemia (normal – 4-5.4
mEq/L)
Provide potassium supplements to prevent
digitalis toxicity and hypokalemia
Nitroglycerine to relieve chest pain
(vasodilation)
- When: 5 mins before effort
- How often: every 5 mins upto 3 tabs, if not
relieved after 15 mins, go to ER
- Storage: covered, replace after 3 mos of
opening, protect from sunlight
Side effects: hypotension, headache, flushing, stinging
sensation under the tongue
types: tablets, ointments, patch
Non-addicting but tolerance may occur.
Fetal hyperinsulinism
Fetal macrosomia
ASSESSMENT
a. Risk Factors : family history, maternal obesity,
previous LGA infants, previous unexplained still
birth
b. Classic Symptoms: 3 Ps – polyuria, polydipsia and
polyphagia
c. Client may have more frequent UTI and vaginal
candidiasis infections caused by altered pH in the
reproductive tract
ASSESSMENT
d. Urine testing for glycosuria and ketones as part of
routine prenatal care
e. Diabetes screening around 28 weeks AOG
50g OGTT – if >140mg/dl, a 3 hours 100g OGTT is
performed
Blood glucose returns to normal after delivery
of the infant
Complications
DKA- diabetic ketoacidosis
HHNK – hyperglycemic, hyperosmolar, non – ketotic
coma
PRIORITY NURSING DIAGNOSES
1. Risk for imbalance nutrition
2. Maternal and fetal: more than body requirements
3. Risk for injury: maternal and fetal
4. Anxiety
IMPLEMENTATION
Nx care
Refer to a dietician for individualized diet mngt
Calories = 1800 – 2000
Complex CHO = 40 – 45%
CHON = 12 – 20%
Fats = 30 – 40%
Take 3 meals and 3 snacks
Stress the need for exercise – metabolize excess
glucose
Stress that insulin req’t changes throughout
pregnancy
NEVER administer ORAL HYPOGLYCEMIC AGENTS to
PREGNANT MOTHERS!
Encourage regular non-strenuous exercise
Monitor fetal well-being, maternal serum alphaprotein at
16-18 weeks, ultrasound for anomalies, amniotic fluid
volume, fetal size, fetal movement counts, weekly NST
from 28-32 weeks, BPP
amniocentesis for lung maturity
a. Lecithin/sphingomyelin (LS) ratio needs to be 1:3
(normal: 1:2)
b. Phosphatidyl glycerol (PG) should be present
Monitor client for development of complications:
infection, PIH, and diabetic ketoacidosis
EVALUATION
Client maintains glucose control during pregnancy
and delivers healthy fetus without complications,
newborn remains normoglycemic
SUBSTANCE ABUSE
Description and Etiology
As many as 10% of pregnant women use tobacco,
alcohol, or other drugs, often in combination; clients
using illegal drugs may delay seeking care for fear of
prosecution
Assessment
Establish a trusting relationship with the client by
remaining open, non-judgmental
Women seeking for prenatal care are interested in
improving and safeguarding their health and that of
the fetus
Assessment
Establish a trusting relationship with the client by
remaining open, non-judgmental
Women seeking for prenatal care are interested in
improving and safeguarding their health and that of
the fetus
Encourage client to describe all substances used, the
amount, times and triggers to use
Evaluate client’s motivation, support systems and
personal strengths that may be elicited to change
behaviors.
Priority Nursing Diagnoses
Ineffective health maintenance, ineffective coping,
risk for impaired gas exchange, risk for delayed growth
and developement
Implementation
Monitor for complications:
Anemia, inadequate nutrition and weight gain, PIH,
preterm labor
Monitor fetal growth and well-being: fundal height,
UTZ, NST, BPP
Teach the client about the potential negative effects
Evaluation
Monitor for complications:
Anemia, inadequate nutrition and weight gain, PIH,
preterm labor
Monitor fetal growth and well-being: fundal height,
UTZ, NST, BPP
Teach the client about the potential negative effects
ANEMIA
ANEMIA
A condition in which
the hemoglobin
concentration is lower
than normal
Three broad categories: Anemia d/t to
1.Hypoproliferative – decrease RBC production
IDA
Megaloblastic anemia
Pernicious anemia
Aplastic anemia
2. Bleeding - Loss of RBC- occurs with bleeding
3. Hemolytic - increased RBC destruction
Sickle cell anemia
Hypoproliferative anemia
1. Iron Deficiency Anemia
Results when the dietary intake of
iron is inadequate to produce
hemoglobin
Etiologic factors
1. Bleeding- the most common cause
2. Mal-absorption
3. Malnutrition
4. Alcoholism
Hypoproliferative anemia
Pathophysiology
The body stores of iron
decrease, leading to depletion of
hemoglobin synthesis
The oxygen carrying capacity of
hemoglobin is reduced tissue
hypoxia
Hypoproliferative anemia
Assessment Findings
1. Pallor of the skin and mucous
membrane
2. Weakness and fatigue
3. General malaise
4. Pica
5. Brittle nails
7. Angular cheilosis
Hypoproliferative anemia
Laboratory findings
1. CBC- Low levels of Hct, Hgb and
RBC count
2. low serum iron, low ferritin
3. Bone marrow aspiration- MOST
definitive
Hypoproliferative anemia
Medical management
1. Hematinics
2. Blood transfusion
Hypoproliferative anemia
Nursing Management
1. Provide iron rich-foods
Organ meats (liver)
Beans
Leafy green vegetables
Raisins and molasses
Hypoproliferative anemia
2. Administer iron
Oral preparations tablets- Fe fumarate, sulfate and
gluconate
Advise to take iron ONE hour before meals
Take it with vitamin C
Continue taking it for several months
Oral preparations- liquid
It stains teeth
Drink it with a straw
Stool may turn blackish- dark in color
Advise to eat high-fiber diet to counteract constipation
IM preparation
Administer DEEP IM using the Z-track method
Avoid vigorous rubbing
Can cause local pain and staining
Hypoproliferative anemia
2. Megaloblastic anemia
Anemias characterized by abnormally large
RBC secondary to impaired DNA synthesis
due to deficiency of Folic acid or folacin.
Causative factors – folic acid deficiency
1. Alcoholism
2. Mal-absorption
3. Diet deficient in uncooked vegetables
Hypoproliferative anemia
Assessment findings
1. weakness
2. fatigue
3. listless
4. neurologic manifestations are present
only in Vit. B12 deficiency
Hypoproliferative anemia
Pathophysiology of Folic acid deficiency
Decreased folic acid impaired DNA
synthesis in the bone marrow
impaired RBC development, impaired
nuclear maturation but CYTOplasmic
maturation continues large size
Hypoproliferative anemia
3. Pernicious Anemia
Due to the absence of intrinsic factor
secreted by the parietal cells
Intrinsic factor binds with Vit. B12 to
promote absorption
Hypoproliferative anemia
Vitamin B12 deficiency
Causative factors
1. Strict vegetarian diet
2. Gastrointestinal malabsorption
3. Crohn's disease
4. Gastrectomy
Assessment findings
1. Beefy, red, swollen tongue
2. Mild diarrhea
3. Extreme pallor
4. Paresthesias in the extremities
Hypoproliferative anemia
Laboratory findings
1. Peripheral blood smear- shows giant
RBCs, WBCs with giant
hypersegmented nuclei
2. Very high MCV
3. Schilling’s test
4. Intrinsic factor antibody test
Hypoproliferative anemia
Medical Management
1. Vitamin supplementation
Folic acid 1 mg daily
2. Diet supplementation
Vegetarians should have vitamin intake
3. Lifetime monthly injection of IM Vit
B12
Hypoproliferative anemia
Nursing Management
1. Monitor patient
2. Provide assistance in ambulation
3. Oral care for tongue sore
4. Explain the need for lifetime IM
injection of vit B12
Aplastic anemia
A condition characterized by decreased
number of RBC as well as WBC and platelets
Causative factors
1. Environmental toxins- pesticides, benzene
2. Certain drugs- Chemotherapeutic agents,
chloramphenicol, phenothiazines,
Sulfonamides
3. Heavy metals
4. Radiation
Aplastic anemia
Pathophysiology
Toxins cause a direct bone marrow
depression acellualr bone marrow
decreased production of blood
elements
Aplastic anemia
Assessment findings
1. fatigue
2. pallor
3. dyspnea
4. bruising
5. splenomegaly
6. retinal hemorrhages
Aplastic anemia
Laboratory findings
1. CBC- decreased blood cell
numbers
2. Bone marrow aspiration
confirms the anemia- hypoplastic
or acellular marrow replaced by
fats
Aplastic anemia
Medical Management
1. Bone marrow transplantation
2. Immunosupressant drugs
3. Rarely, steroids
4. Blood transfusion
Nursing management
1. Assess for signs of bleeding and infection
2. Instruct to avoid exposure to
offending agents
Hemolytic Anemia: Sickle Cell
A severe chronic incurable
hemolytic anemia that results from
heritance of the sickle hemoglobin
gene.
Causative factor
Genetic inheritance of the sickle
gene- HbS gene
Hemolytic Anemia: Sickle Cell
Pathophysiology
Decreased O2, Cold,
Vasoconstriction can
precipitate sickling process
Hemolytic Anemia: Sickle Cell
Pathophysiology
Factors cause defective
hemoglobin to acquire a rigid,
crystal-like C-shaped
configuration Sickled RBCs will
adhere to endothelium pile up
and plug the vessels ischemia
results pain, swelling and fever
Hemolytic Anemia: Sickle Cell
Assessment Findings
1. jaundice
2. enlarged skull and facial bones
3. tachycardia, murmurs and
cardiomegaly
Primary sites of thrombotic
occlusion: spleen, lungs and CNS
Chest pain, dyspnea
Hemolytic Anemia: Sickle Cell
4. Sickle cell crises
Results from tissue hypoxia and
necrosis
5. Acute chest syndrome
Manifested by a rapidly falling
hemoglobin level, tachycardia, fever
and chest infiltrates in the CXR
Hemolytic Anemia: Sickle Cell
Medical Management
1. Bone marrow transplant
2. Hydroxyurea
Increases the HbF
3. Long term RBC transfusion
Nursing Management
1. Manage the pain
Support and elevate acutely inflamed joint
Relaxation techniques
Analgesics