NUR1213


Nursing Care of High-risk If vomiting returns, administer antiemetic
and enteral/parenteral nutrition as
Pregnant Client (Medical prescribed.
 Monitor fetal and maternal distress
Complications)
OUTLINE Evaluation!
I. Hyperemesis Gravidarum
II. Hypertension Disorders  The client eats at least 2500 calories or
III. Diabetes Mellitus receive supplemental IV or enteral
IV. Heart Disease nutrition
V. Urinary Tract Infection  Client remains free of signs and symptoms
VI. Anemia of dehydration.
VII. Substance Abuse in Pregnancy
VIII. Human Immunodeficiency Virus II. Hypertension Disorders

I. Hyperemesis Gravidarum A condition which vasospasm occurs during

Nausea and vomiting of pregnancy that is
prolonged past week 12 of pregnancy or is so
severe that dehydration, ketonuria, and significant
weight loss occur within the first 12 weeks of
pregnancy.
Assessment!
 May show an elevated hematocrit
concentration at monthly prenatal visit.
 Hypokalemic alkalosis
 Polyneuritis, because of a deficiency of B
vitamins
 Weight loss can be severe
 Urine may be positive for ketones
Outcome Identification/Planning!
 Hospitalize client for 24 hours and monitor
intake, output, and blood chemistries and
restore hydration.
 May withheld all oral food and fluids. IV
fluid may be administered for hydration
 May start enteral and parenteral nutrition
 Administer Antiemetic drugs
(Metoclopramide – (Reglan))
Implementation!
 Monitor and document intake, output,
amount of vomitus, and electrolytes
 Small amounts of clear fluid if no
vomiting after the first 24 hours of oral
restriction. Then gradually advanced to
soft diet.
pregnancy in both small and large arteries. It is the
leading case of infant and maternal morbidity and
mortality worldwide.
Major risks includes: Multiple pregnancy,
primiparas younger than 20 years or older than 40
years, women from low socioeconomic
backgrounds, those who have hydramnios
(overproduction of amniotic fluid), or those who
have heart disease, diabetes with vessel or renal
involvement, and essential hypertension.
Watch out for:
- Vasoconstriction
- Vasospasm in the kidney
- Degenerative changes and Interstitial
effects
- Lowered urine output and clearance of
creatinine
- Edema
Assessment!
 Vision changes
 Hypertensive
 Proteinuria
 Edema
Symptoms occur before 20 weeks of pregnancy.
Any women with a high risk for PIH should be
observed carefully for symptoms at prenatal visits.
1. Gestational Hypertension
 140/90 mm Hg but has no proteinuria or
edema.
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2. Mild Pre-eclampsia
 Presence of proteinuria (1+ or 2+ on a
reagent test strip)
 Blood pressure rises to 140/90 mm Hg
taken twice at least 6 hours apart
 Systolic blood pressure greater than 30
mm Hg and a diastolic pressure greater
than 15 mm Hg
3. Severe Pre-eclampsia
 Blood pressure rises to 160 mm Hg
systolic and 110 diastolic or above on at
least two occasions 6 hours apart
 Diastolic pressure is 30 mm Hg above her
pregnancy level at bed rest position
 Presence of proteinuria 3+ or 4+ or more
than 5g in a 24 hour sample.
 Extensive Edema
4. Eclampsia
 Most severe classification
 Acute Cerebral edema
 Grand-mal seizure (Tonic-clonic)
 Coma
3 phases of Tonic-clonic
a. First phase – Tonic phase
- Body contract, back arches, arms and legs
stiffen, and jaw closes abruptly.
- Biting of the tongue
- Respirations approximately 20 seconds
b. Second phase – Clonic
- Bladder and bowel muscles contract and
relax
- Incontinence of urine and feces
- Breathing is not entirely effective
- Last for 1 minute
c. Third phase – Postictal
- The client is semi-comatose and cannot be
roused except by painful stimuli for 1 to 4
hours
Roll-over test: Assess the probability of
developing toxemia when done between the 28th
and 32nd week of pregnancy.
Procedure of Roll-over test:
1. Patient in lateral recumbent position for
15 minutes until BP Stable
2. Rolls over to supine position
3. BP taken at 1 minute and 5 minutes after
roll over
If diastolic pressure increases 20 mmHg or more,
the patient is prone to toxemia (preeclampsia).
Nursing Interventions!
Mild PIH
 Promote bed rest
 Promote Good Nutrition
 Provide Emotional Support
Severe PIH
 Support bedrest
 Away from loud noises
 Raise side rails to help prevent injury if
seizure occurs.
 Darken the room if possible to prevent
triggering seizures
 Monitor Maternal well-being – take vital
signs regularly
 Monitor Fetal well-being – single doppler
auscultation 4 hour interval
 Support a nutritious diet
 Administer Medications: Hypotensive
drugs such as hydralazine (Apresoline),
labetalol (Normodyne), nifedipine
1. Digitalis (with heart failure) – increases
the force of contraction of the heart. Check
cardiac rate prior to administration DO
NOT GIVE if CR <60/min
2. Potassium supplements – prevent
arrythmias
3. Barbiturates – sedation by CNS depression
4. Analgesics, Antihypertensive, Antibiotics,
Anticonvulsants, Sedatives
5. Magnesium Sulfate – prevents seizures
Eclampsia
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Priority care for tonic-clonic seizures includes:
First – Second phase
 Maintain a patent airway
 Administer oxygen by face mask to protect
the fetus
 To prevent aspiration, turn a woman on her
side to allow secretions to drain from her
mouth.
 IV administration of Magnesium sulfate or
diazepam
 Assess oxygen saturation
 Apply an external fetal heart monitor if
one is not already in place to assess the
condition of the fetus.
 Check vaginal bleeding to detect placental
separation
Postictal
 Extremely monitor seizure, labor,
secretions, and vaginal bleeding
 Caesarean Section is the preferred method
of delivery
III. Diabetes Mellitus
An endocrine disorder in which the pancreas
cannot produce adequate insulin to regulate body
glucose levels. Most frequently seen medical
condition and accounts 3% to 5% in pregnancy.
Hyperglycemia – glucose serum levels continue to
rise
Glycosuria – presence of glucose in the urine
Polyuria – large quantities of fluid are lost in urine
Normal serum glucose level: 80 to 120 mg/dL
Pathway
1. If insulin level is insufficient, glucose
cannot be used by body cells.
2. So the serum glucose levels continue to
rise, until the kidneys begin to secrete
quantities of glucose in the urine.
3. The increased amount of glucose in the
urine reduces fluid absorption in the
kidney resulting to polyuria.
4. Dehydration occurs and blood serum
becomes concentrated and blood flow are
reduced.
5. Oxygen distribution falls and anaerobic
metabolic reactions occurs.
6. Fat are metabolized fir energy, pouring
large amounts of ketone bodies (acidic)
intro the blood stream resulting to low pH
of blood and metabolic acidosis.
7. Proteins are tapped by the body to find a
source of energy. They breakdown and
release potassium and sodium and excreted
through polyuria
Diabetes in Pregnancy
 Increase amount of amniotic fluid occurs
in at least 25% of diabetic women.
 A macrosomic infant may create birth
problem at the end of the pregnancy
because of cephalopelvic disproportion.
Risk factors
 Obesity
 Age over 25 years
 History of large babies (l0 lb or more)
 History of unexplained fetal or perinatal
loss
 History of congenital anomalies in
previous pregnancies
 History of polycystic ovary syndrome
 Family history of diabetes (one close
relative or two distant ones)
 Member of a population with a high risk
for diabetes
Assessment!
 A fasting plasma glucose of 126 mg/dl or
above or a nonfasting plasma glucose of
200 mg/dl or above meets the threshold for
diagnosis of diabetes and needs to be
confirmed as soon as possible.
 Usually done using a 50g oral glucose
challenge test
 Glycosylated hemoglobin levels to detect
the degree of hyperglycemia presence
 Ophthalmic examination at each trimester
 Urine culture at each trimester to detect
UTI
Classification of Diabetes Mellitus
Type 1 - Known as insulin dependent diabetes
mellitus. A state characterized by the destruction
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of the beta cells in the pancreas that usually leads
to absolute insulin deficiency
Type 2 - Formerly known as non-insulin
dependent .A state that usually arises because of
insulin resistance combined with a relative
deficiency in the production of insulin.
Gestational diabetes – a condition of abnormal
glucose metabolism that arises during pregnancy.
Can be a signal of an increased risk for Type 2.
Impaired glucose homeostasis – a state between
“normal” and “diabetes” in which the body is no
longer using or secreting insulin properly.
Nursing Interventions!
 Promote home monitoring of glucose
levels during pregnancy
 Educate Regarding Nutrition
 Educate Regarding Exercising
 Therapeutic Management includes: Insulin
management, Blood glucose monitoring,
Insulin Pump Therapy
 Tests for Placental Function and Fetal
well-Being: a woman will have a serum
alpha-fetoprotein level obtained at 15 to 17
weeks to assess for a neural tube defect
and an ultrasound examination performed
at approximately 18 to 20 weeks to detect
gross abnormalities.
IV. Heart Disease
Cardiac disease affects either the left or right side
of the heart
1. 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 has received by the left atrium
from the pulmonary circulation. Consequently, the
heart becomes overwhelmed it fails to function.
Oxygen saturation of the blood decreases from
dysfunction of the alveoli, chemoreceptors then
stimulate respiratory center to increase RR.
As blood pressure falls, renal-angiotensin system
allows retention of sodium and water. Placenta do
not receive adequate blood and pulmonary edema
becomes severe.
 Increased fatigue
 Weakness
 Dizziness (lacking of O2 in brain)
 Paroxysmal nocturnal dyspnea (sudden
waking at night short of breath)
If complications occur, the woman needs serial
ultrasound and nonstress tests done after weeks
30 to 32 to monitor fetal health.
If an anticoagulant is required, heparin is the
drug of choice. Heparin does not cross the
placenta and enter the fetus. SAFE!
2. Right-Sided Heart Failure
Occurs in conditions such as pulmonary valve
stenosis, atrial and ventricular septal defects.
Right-sided failure occurs when the output of the
right ventricle is less than the blood received by
the right atrium from vena cava. Results in
congestion of the systemic venous circulation and
decreased cardiac output to the lungs.
Because of the high pressure in vena cava from
back pressure of blood; both jugular venous
distention , and increased portal circulation
occurs.
Liver and spleen become distended. Liver
enlargement occurs and extreme dyspnea and pain
occurs.
Women who have uncorrected anomaly may not
be advised to get pregnant. They need oxygen
administration and frequent arterial blood gas
assessment to ensure fetal growth.
3. Peripartum Heart Disease
An extremely rare condition, peripartal
cardiomyopathy can originate in pregnancy in
women with no previous history of heart disease.
 Shortness of breath
 Chest pain
 Edema
 Increase heart size (cardiomegaly)

Assessment!
 Health history
 Physical Activity
 Cough or Edema
 Fatigue
 Tachycardia
 Poor fetal heart tone
 Decreased amniotic fluid
Electrocardiogram (ECG), Chest radiograph,
Echocardiogram done at periodic points in
pregnancy.
Nursing Interventions!
 Promote Rest
 Promote Healthy Nutrition
 Educate regarding medication
 Educate regarding avoidance of infection
4. Blood/RH Incompatibility
Antigen-antibody reaction causes
destruction of fetal red blood cells.
It occurs when a Rh negative mother carries a
fetus with and Rh positive blood type.
NUR1213
positive child to prevent from forming
natural antibodies.
V. Urinary Tract Infection
In pregnant woman, because the ureters dilate
from the effect of progesterone, stasis of urine
occurs.
The minimal glucosuria that occurs with
pregnancy allows more than the usual number of
organisms to grow. This causes asymptomatic
UTIs.
Asymptomatic infections can progress to
pyelonephritis (infection of the pelvis of the
kidney) and are associated with preterm labor and
premature rupture of membranes.
Escherichia coli – organism responsible for UTI.
Assessment!
 Urine culture will reveal over 100,000
organisms per ml of urine = level
excessive
diagnostic of infection.
 Frequency and Pain on urination\
Management!

For such situation to occur: The father must be
either homozygous (DD) 100% or heterozygous
(Dd) 50% Rh positive.
Erythroblastosis fetalis/Hemolytic disease of the
newborn – Rh factor are attacked by maternal
antibodies and causes red blood cell destruction.
A fetus can become oxygen deficient and body
cannot be maintained.
 Obtain a clean-catch of urine sample
 Administer Amoxicillin, ampicillin,
cephalosporins as prescribed because
these are effective against most organisms
causing UTIs and are safe antibiotics
during pregnancy.
 Monitor Body Temperature
 Educate women on the common measure
for prevention

Assessment! VI. Anemia

 All women with Rh-negative blood should

have an anti-D antibody titer done at a first
pregnancy visit.
 To reduce the number of Rh (D) antibodies
being formed, Rh (D) immune globulin
(RhIG), is administered to women who are
Rh-negative at 28th week of pregnancy.
 These cannot cross the placenta and
destroy fetal RBCs.
 It is given again by injection to the mother
in the first 72 hours after birth of an Rh
Pseudo-anemia – a condition were blood volume
expands during pregnancy slightly ahead of the
red blood cell count. It is normal and should not
be confused with true types of anemia.
True anemia – when the hemoglobin
concentration is less than 11g/dL (hematocrit
<33%) in the first or third trimester. Hemoglobin
concentration is less than 10.5 g/dL (hematocrit
<32%) in the second trimester.
 NUR1213
Iron deficiency anemia – when hemoglobin level
is below 12 mg/dL (hematocrit <33%). Confirmed
by a corresponding low serum iron level and an
increased iron-binding capacity.
 Diet low in iron
 Heavy menstrua; periods
 Unwise weight reducing programs
Nursing Interventions!
 Advise to take prenatal iron supplement of
60 mg
 Diet high in iron and vitamins (green leafy
veg., meat, legumes, fruits)
Folic Acid Deficiency Anemia
 Occurs most often in multiple pregnancies
because of the increased fetal demand
 Women with secondary hemolytic illness
 Women taking hydantoin (anticonvulsant
that interfere folate absorption)
 Taking oral contraceptives
 Woman who had a gastric bypass for
morbid obesity
VII. Substance Abuse in Pregnancy
The use of cocaine, amphetamines, and multiple
drugs. It is defined as the inability to meet major
role obligations, an increase in legal problems or
risk-taking behavior, exposure to hazardous
situations because of an addicting substance.
Illicit drugs have small molecular weight, so they
cross the placenta. The fetus then has a drug
concentration of 50%. This can lead to fetal
effects such as abnormalities or preterm birth.
If woman is still abusing drug at the time of labor,
the infant may experience drug withdrawal and
breastfeeding from the mother is not encouraged.
Management!
 Referral to the substance abuse treatment
program
 Monitor and Assist in good program and
nutrition activity
 Advise not to breastfeed to prevent transfer
to the baby
VIII. Human Immunodeficiency Virus
 HIV invades and destroys certain white
blood cells called CD4+ cells.
 May show signs and symptoms during
pregnancy
 Suppression of the maternal immune
system
Diagnostic Test
 Enzyme-linked Immunosorbent Assay
(ELISA), Western blot,
Immunofluorescence Assay (IFA).
 Positive Western blot or IFA is a
confirmatory for HIV
Assessment!
 Assess progression of disease
 Minor mucocutaneous manifestations
 Recurrent upper respiratory tract infections
 Unexplained chronic diarrhea
 Several bacterial infections
 Pulmonary tuberculosis
 Toxoplasmosis in the brain
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 Candidiasis of esophagus, trachea,
bronchi, lungs and Kaposi’s sarcoma
(Indicators of AIDS)

Interventions!

 Normal CD4+ T cell count = between 500

and 1600 cells/L
 Administer the three drug combination
(HAART) Highly Active Antiretroviral
Therapy treatment to reduce
transmission.

1. Zidovudine – recommended for the prevention

of MTCT:

a. Antepartum: Orally beginning after 12

weeks of gestation

b. Intrapartum: IV during labor,

zidovudine is given 1 hour before vaginal
birth or 3 hours before CS.

c. Postpartum: form of syrup to the

newborn 2 hours after birth and every 12
hours for 6 weeks. Newborn is monitored
in NICU.

 Avoid amniocentesis and fetal scalp

sampling
 Avoid episiotomy to decrease amount of
maternal blood in and around the birth
canal.
 Avoid administration of oxytocin
 Promptly remove the neonate from the
mother’s blood after delivery
 Monitor sigs of infection
 Placed mother in protective isolation room
 Breastfeeding is restricted