LESSON: 2

DURATION: 6 hours

NURSING CARE OF A FAMILY EXPERIENCING A PREGNANCY COMPLICATION

FROM A PRE-EXISTING OR NEWLY ACQUIRED ILLNESS

SPECIFIC OBJECTIVES:

At the end of the lesson, the students should be able to:

1. Define high risk pregnancy, including pre-existing factors that contribute to its
development such as diabetes mellitus or cardiovascular disease.
2. Assess a woman with an illness during pregnancy for changes occurring in the illness
because of the pregnancy or in the pregnancy because of the illness.
3. Formulate nursing diagnosis related to the effect of a preexisting or newly acquired illness
on pregnancy.
4. Identify expected outcomes that will contribute to a safe pregnancy outcome when illness
occurs with pregnancy as well as help families manage seamless transitions across
differing healthcare settings.
5. Implement nursing care for a woman when illness complicates pregnancy, such as
teaching her how to measure blood sugar.
6. Evaluate expected outcomes for achievement and effectiveness of care.

LESSON PROPER:

A. THE NURSING ROLE AND NURSING CARE DURING PREGNANCY

COMPLICATIONS

Nursing Process Overview:

1. Assessment - focus on the signs and symptoms of the illness: subjective and objective
data.
Examples:
a. Subjective Data: woman’s level of exhaustion
b. Objective Data: vital signs, extent of edema

2. Nursing Diagnosis
Examples:
 Ineffective tissue perfusion (cardiopulmonary) related to poor heart function
secondary to mitral valve prolapse during pregnancy.
 Pain related to pyelonephritis secondary to uterine pressure on ureters.
 Social isolation related to prescribed bed rest during pregnancy secondary to
concurrent illness.
 Ineffective role performance related to increasing level of daily restrictions secondary
to chronic illness and pregnancy.
  Knowledge deficit related to normal changes of pregnancy versus illness
complications.
 Fear regarding pregnancy outcome related to chronic illness.
 Health – seeking behaviors related to the effects of illness on pregnancy.
 Situational low self-esteem related to illness during pregnancy.

3. Outcome Identification and Planning

Example:
 Outcome should be related to the entire family’s health.
 For chronic illness: To maintain woman’s health during pregnancy so she can
remain at home as long as possible, thereby minimizing hospitalization and family
disruptions.
 For new illness: Allowing a woman to choose among alternatives to help her to
participate in her own care and also to maintain self-esteem as well as helps her move
a step toward parenthood and assuming care for her family.

4. Implementation:
Example: Teaching woman on her new or additional measures to maintain health during the
pregnancy.

5. Outcome Evaluation
Example:
 Patient states she rests for 2Hours morning and afternoon; dependent edema remains
at 1+ or less at next prenatal visit.
 Family members state they are all participating in an exercise program since mother
developed gestational diabetes.
 Patient reports no burning on urination or flank pain at next prenatal visit.
 Patient states she understands the importance of talking daily thyroid medicine for
total length of pregnancy.

A. CARDIOVASCULAR DISORDER AND PREGNANCY

The danger of pregnancy in a woman with cardiac disease occurs primarily due to the
increase in circulatory volume. The most dangerous time for a woman is in 28 to 32 weeks,
after the blood volume peaks.
1. A Woman with Left Sided Heart Failure:
 Occurs in conditions such as mitral stenosis, mitral insufficiency and aortic
coarctation.
 The left ventricle cannot move the volume of blood forward that is received by the
left atrium from the pulmonary circulation.
 The level for the failure is often at the level of the mitral valve.
 The normal physiologic tachycardia of pregnancy shortens diastole (atrial
contraction) and decreases the time available for blood to flow across this valve.
 The inability of the mitral valve to push blood forward causes back-pressure on the
pulmonary circulation, causing it to become distended, systemic blood pressure
decreases in the face of lowered cardiac output and pulmonary hypertension occurs.
  When pressure in the pulmonary vein reaches a point of 25 mm Hg, fluid begins to
pass from the pulmonary capillary membranes into the interstitial spaces surrounding
the alveoli and into the alveoli leads to Pulmonary Edema.
Pulmonary Edema - interferes with oxygen-carbon dioxide exchange because fluid
coats the alveolar exchange space. If pulmonary capillaries rupture under the pressure,
small amounts of blood leak into the alveoli.
Signs and Symptoms:
 Productive cough of blood-speckled sputum
 Increased fatigue
 Weaknesses
 Dizziness – lack of oxygen in the brain
 HR increases.
 Peripheral constriction occurs in an attempt to increase the systemic BP.
 Pulmonary edema
 Orthopneic
 Paroxysmal nocturnal dyspnea (suddenly waking at night with shortness of breath) –
occurs because heart action is more effective when she is at rest.
Risks:
 Spontaneous miscarriage – because oxygen is limited.
 Preterm labor
 Maternal death
As oxygen saturation of the blood decreases from dysfunction of the alveoli, chemoreceptors
stimulate the respiratory center to increase RR.
Medication:
 Antihypertensives – to control increased BP.
 Diuretics – to reduce blood volume.
 Beta blockers – to improve ventricular filling.
Diet: low sodium diet
Laboratory Management: serial UTZ and non-stress test after 30 – 32 weeks of pregnancy
and monitor FHR.
Surgical Management:
 Balloon valve angioplasty to loosen mitral valve adhesions.
 If an anticoagulant is required, heparin is the drug of choice – it does not cross the
placenta.

2. A Woman with Right Sided Heart Failure

Causes:
 Congenital heart defects – pulmonary valve stenosis and atrial and ventricular septal
defects can result in right-sided heart failure.
 Occurs when the output of the right ventricle is less than the blood volume received
by the right atrium from the vena cava.
 Back pressure from this results in congestion of the systemic venous circulation and
decreased cardiac output to the lungs.
 Blood pressure decreases in the aorta because less blood is reaching it
 Pressure is high in the vena cava, both jugular distention and increased portal
circulation occur.
Signs and Symptoms:
 Liver and spleen distended – leading to dyspnea and pain in pregnant woman because
the enlarged liver, as it pressed upward by the enlarged uterus, puts extreme pressure
on the diaphragm.
 Ascites – distention of abdominal vessels can lead to exudates of fluid from the
vessels into the peritoneal cavity.
 Peripheral edema – fluid also moves from the systemic circulation into lower
extremity interstitial spaces.
 Eisenmenger Syndrome – the congenital anomaly most apt to cause the right sided
heart failure in women of reproductive age.
Management:
 Oxygen administration
 Frequent arterial blood assessment to ensure fetal growth.
 During labor – pulmonary artery catheter to monitor pulmonary pressure.
 Close monitoring to minimize the risk of hypotension after epidural anesthesia.