Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 14 Women’s Health
TREATMENTS
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Dilation and Curettage (D&C) to remove all trophoblastic cells.
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Frequent testing of hCG levels to ensure no further cells remain.
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Chest x-ray to assess for lung metastasis.
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Liver function tests to assess for liver metastasis.
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Contraception for a full year.
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Chemotherapy till hCG levels return to normal:
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methotrexate
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actinomycin-d
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Total abdominal hysterectomy and chemotherapy.
NURSING DIAGNOSES
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Risk of altered parenting
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Anticipatory grieving
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Powerlessness
NURSING INTERVENTIONS
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Educate the patient:
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Trophoblastic disease.
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Discuss further testing.
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Allow for grieving.
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Provide referrals to counselors, clergy.
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Discuss need for year-long birth control.
Pregnancy
Gestational age is measured from the first day of the last menstrual period (LMP).
At each prenatal visit, the fundus (the top of the uterus) will be measured as to its
location in the abdomen. This information is used to assess the growth of the
fetus. Pregnancy is usually divided into trimesters. The first trimester is from 0 to
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14 weeks, and starts at implantation. During this time, it is not uncommon to feel
more fatigue, nausea, and morning sickness. At two months, the uterus is the size
of a grapefruit. At nine weeks, the embryo is called a fetus and is about one inch
in length. During the first trimester, most major organs have developed. The sec-
ond trimester is from 14 to 28 weeks, and is characterized by less breast tender-
ness, less fatigue, and a diminishing of morning sickness. However, some back pain
may begin, as well as stretch marks, heartburn, and hemorrhoids. At 16 weeks, the
fundus is halfway between the pubic bone and the umbilicus. At 16 to 18 weeks,
fetal movement may be felt. At 27 weeks, the fundus is two inches above the
umbilicus. The third trimester is from 28 weeks to birth. Less movement will be
felt due to the limited space for the fetus to move about. The mother may feel
some respiratory difficulty as the uterus is directly underneath the diaphragm,
pushing up the lungs. She may experience some edema, have difficulty sleeping,
and an increased urge to urinate due to pressure on the bladder. She may feel
Braxton-Hicks contractions, which are mild abdominal cramping.
WHAT WENT WRONG?
Nothing.
PROGNOSIS
Healthy baby after nine months gestation.
HALLMARK SIGNS AND SYMPTOMS
Symptoms and signs are usually due to pregnancy, but none are diagnostic.
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Symptoms:
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Nausea, vomiting
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Breast enlargement and tenderness
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Quickening (feeling fetal movements)
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Weight gain
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Absence of menses
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Signs:
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Abdominal enlargement
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Breast enlargement
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Softening of cervix
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Increased pigmentation and enlargement of areolae
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Chadwick’s sign—vagina and cervix show a blue hue from increased vas-
culature
INTERPRETING TEST RESULTS
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Human chorionic gonadotropin (hCG):
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plasma hCG—positive 3 to 4 weeks after LMP.
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urine hCG—positive one week after first missed menses.
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serum hCG—will also be elevated in ectopic pregnancy, trophoblastic
tumors.
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Fetal heart tones—a positive test of pregnancy.
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Ultrasound—confirms pregnancy.
TREATMENTS
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Regular visits with health care provider.
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Prenatal vitamins.
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Routine labwork.
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Ultrasound.
NURSING DIAGNOSES
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Altered nutrition
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Body image disturbance
NURSING INTERVENTIONS
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Discuss bodily changes.
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Stress importance of prenatal vitamins.
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Reinforce diet, exercise.
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Remind of obstetrician appointments.
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Advise patient when to call the obstetrician:
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Vaginal bleeding, discharge.
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Several-hour duration of cramping, pain.
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Fever.
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Diminished fetal movements.
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Sustained vomiting.
Labor and Delivery
Labor is usually shorter in women who have previously had children than in first-
time mothers. The average labor is anywhere from 12 to 24 hours. Labor is typi-
cally divided into three stages, with the first stage having two phases. The first
stage starts with the beginning of labor, which is uterine contractions which result
in thinning (effacement) and dilation of the cervix. The first stage of labor ends
with full dilation, at 10 cm, and complete effacement. This is the longest part of
labor. Contractions are milder, last 60 to 90 seconds, and are 15 to 20 minutes apart
in this first phase of labor, termed the latent phase. The active phase occurs when
the cervix dilates from 4 to 8 cm, contractions become stronger, last about 30 to
45 seconds, and are closer together. This is often when the membranes rupture,
releasing amniotic fluid. A backache is common, as is some vaginal bleeding.
When the cervix is fully dilated at 10 cm, the second stage of labor has started.
This phase is fetal expulsion. Contractions continue, but feel different. There is
pressure on the rectum, and a strong urge to push. The second stage of labor ends
with the birth of the baby. Delivery of the placenta, or afterbirth, is the third stage
of labor. Contractions will continue, but will be milder, as the uterus contracts,
which helps to expel the placenta and slow the bleeding.
WHAT WENT WRONG?
Nothing.
PROGNOSIS
A healthy baby.
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HALLMARK SIGNS AND SYMPTOMS
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Bloody show which is the mucous plug, expelled from the vagina
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Rupture of membranes, which releases amniotic fluid (commonly referred to
as water breaking)
INTERPRETING TEST RESULTS
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CBC to assess any anemia.
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Blood typing.
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Rh factor.
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Urinalysis to look for protein and glucose.
TREATMENTS
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Some medications may be administered to stimulate uterine contractions:
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oxytocin
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prostaglandins
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Pain medications may be administered, but always with the safety of the fetus
in mind. The risk versus the benefit must be weighed.
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Analgesia and sedation:
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stadol
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butorphanol
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meperidine
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fentanyl
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nalbuphine
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General anesthesia:
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nitrous Oxide inhalation
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Regional anesthesia:
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pudendal block
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paracervical block
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spinal block
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Epidural analgesia.
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Local infiltration.
NURSING DIAGNOSES
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Anxiety
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Pain, discomfort
NURSING INTERVENTIONS
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Teach the patient:
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Benefit of continued exercise.
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Increase fluids, especially in nausea.
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Observe for signs of dehydration.
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Eliminate spicy foods to decrease heartburn.
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Eat small, frequent meals.
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Increase high-fiber foods to avoid constipation.
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Prenatal vitamins daily.
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Support hose for varicose veins.
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Stool softeners to aid in hemorrhoid pain.
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Avoid high heels if backache persists.
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Avoid prolonged sitting.
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Avoid MMR vaccine in pregnancy.
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Suggest Lamaze or other labor support groups.
Postpartum
The time from birth to 6 weeks when involutionary changes occur.
WHAT WENT WRONG?
Nothing.
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PROGNOSIS
Return to prepregnant state.
HALLMARK SIGNS AND SYMPTOMS
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Vaginal drainage (lochia) lessens, becomes lighter in color
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Uterus shrinks in size
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Abdomen shrinks
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Breasts enlarge and fill with milk
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Body weight decreases
INTERPRETING TEST RESULTS
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CBC to assess blood loss.
TREATMENTS
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Iron supplementation if indicated.
NURSING DIAGNOSES
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Fatigue
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Disturbance in body image
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Effective breastfeeding
NURSING INTERVENTIONS
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Explain lochia (postpartum vaginal discharge)—color, amount.
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Answer breast-feeding questions.
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Remind patient to call obstetrician if fever develops, or if there is excessive
vaginal bleeding, chest pain, or dyspnea.
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Discuss contraception—ovulation may occur before menses resume.
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Rh Incompatibility
WHAT WENT WRONG?
Rh incompatibility is assessed on each mother during pregnancy. An antigen, Rh,
may or may not be on the surface of the red blood cell. If a mother is Rh positive,
she carried the Rhesus antigen on the RBC. A fetus has antigens from its mother
and father. The Rh is problematic when the mother is Rh− and the father is Rh+.
When the mother is Rh− and the fetus is Rh+, she may develop antibodies that will
cross the placenta and attack the fetal RBCs, which are recognized as foreign.
PROGNOSIS
Prognosis is good as all mothers are tested during prenatal care.
HALLMARK SIGNS AND SYMPTOMS
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Incompatibility with Rh of mother and baby
INTERPRETING TEST RESULTS
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Rh type.
TREATMENT
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RhoGAM is Rh IgG (immunoglobulin) to prevent an immune response by the
mother.
NURSING DIAGNOSES
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Safety
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Risk for injury
NURSING INTERVENTIONS
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Retest if unsure of antibody titer.
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Administer RhoGAM.
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Explain Rh status to the mother.
Preeclampsia and Eclampsia
Preeclampsia is a condition that women may get in the latter half of pregnancy. It
is pregnancy-induced hypertension and more often occurs in a first pregnancy.
If preeclampsia is left untreated, eclampsia (which is severe) will result.
WHAT WENT WRONG?
The etiology of preeclampsia and eclampsia is unknown. Pre-pregnant hyper-
tension, obesity, and poor nutrition may be contributing factors. First-time mothers
have a greater risk of preeclampsia, as do women with a family history of the
condition.
PROGNOSIS
Preeclampsia can cause a small baby, premature birth, and learning disabilities.
Untreated eclampsia can lead to seizures, coma, and even death of the mother
and baby.
HALLMARK SIGNS AND SYMPTOMS
•
Preeclampsia (may be asymptomatic):
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BP > 140/90
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Proteinuria (presence of excess serum protein in the urine) >300 mg / 24
hours
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Elevated creatinine
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Headache
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Edema
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Pulmonary edema
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Hemolysis
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Rapid weight gain
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Abdominal pain
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Diminished urine output
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Excessive vomiting and nausea
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Eclampsia:
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As above
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Seizures
INTERPRETING TEST RESULTS
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Chemistry panel to assess hydration status as well as kidney and liver function.
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CBC to asses anemia and platelet count.
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Urinalysis to look for protein and creatinine in the urine.
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Fetal ultrasound.
TREATMENT
Birth of the baby is the only cure for eclampsia and preeclampsia. Mild preeclamp-
sia with mild hypertension and a small amount of protein in the urine can be man-
aged at home with rest and frequent health care provider checks, depending on the
status and gestational age of the baby. All other preeclampsia and eclampsia patients
are hospitalized.
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Bedrest.
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Low-salt diet.
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Medications:
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To control blood pressure:
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hydralazine
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labetolol
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methyldopa
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nifedipine
•
To control seizures:
•
magnesium sulfate
NURSING DIAGNOSES
•
Safety