Chapter 24
Conditions in the Newborn
Related to Gestational Age, Size,
Injury, and Pain
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Preterm Infants
❖ Approximately 11.6% of babies are born before 37 weeks every year in
the United States.
❖ Of those babies, 3.4% are born before 34 weeks.
❖ Preterm babies face many challenges including:
o Respiratory distress syndrome (RDS)
o Intraventricular hemorrhage (IVH)
❖ Risks for prematurity are many and include:
o
Infection
o
Fetal anomalies
o
Preeclampsia/eclampsia
“Connor”-26 wks.-<11oz
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Preterm Infants: Terminology #1
AGA
SGA
LGA
Growth
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Late Preterm Infants
❖ Infants born from 34-0/7 to 36-6/7 weeks are considered late preterm.
❖ Although their size may appear to be term, late preterm infants have
higher morbidity and mortality due to immaturity.
❖ Late preterm infants are at high risk for:
o
Hypothermia
o
Hypoglycemia
o
Respiratory distress
o
Jaundice
o
Feeding difficulties
❖ Late preterm infants may appear to be feeding appropriately but have
difficulties related to the inability to coordinate sucking, swallowing, and
breathing.
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Postterm Infants
❖ Postterm infants are born beyond 42 weeks of gestation.
❖ Postterm infants may be macrosomic or small for
gestational age (SGA) because of the aging placenta.
❖ Complications for postterm infants include:
o Birth injuries
o Oligohydramnios
o Low Apgar scores
o Cerebral palsy
❖ Meconium aspiration
❖ Almost leather-like, dry, cracked skin, insignificant vernix
caseosa.
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Small or Large for Gestational Age (SGA
or LGA) Infants
❖ SGA infants may be normal based on ethnicity or the height
and weight of the parents or it could be due to environmental
or pathologic genetic reasons.
o
At risk for hypoglycemia, polycythemia (resulting from
hypoxia in utero), or hypocalcemia (potentially caused by
perinatal asphyxia, hypoparathyroidism, or maternal
diabetes).
❖ LGA infants are at high risk for birth injury, perinatal
asphyxia, and hypoglycemia.
o
Common in infants of mothers with obesity, diabetes,
and excessive weight gain in pregnancy.
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Birth Injuries #1
❖ Newborns should be assessed for birth injuries
such as:
o Bruising – generally self-limiting but
may contribute to hyperbilirubinemia.
o Lacerations—may be obtained during a
cesarean or operative vaginal delivery. May
be serious enough to require plastic surgery.
o Fractures—most common is a clavicle
fracture and generally heals spontaneously.
o Subconjunctival hemorrhage—looks alarming
(ocular bleed) but are very common in
neonates and resolve spontaneously within 2
weeks.
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Birth Injuries #2
❖ Brachial plexus injury – typically unilateral
nerve damage from stretching and traction on
the brachial plexus. May heal without
treatment.
❖ Facial nerve trauma – due to prolonged
pressure against maternal pelvis or forceps
delivery. There are reduced movement on the
side of the injury, may heal in a few hours or
may take months. Facial nerve trauma may
cause feeding difficulties.
❖ Spinal cord injury – rare but may be caused by
forceps or vaginal breech delivery. Prognosis
depends on the location and severity of the
injury.
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Neonatal Pain
❖ Infants admitted to the NICU experience an average of 5 to 15
painful procedures every day.
❖ Pain should be treated anticipately when possible.
❖ Pain management for neonates include:
o Breastfeeding
o Nonnutritive sucking (pacifier)
o Skin-to-skin contact
o Oral sucrose
o Topical anesthesia
o Acetaminophen or opioid analgesics
o Nerve block with lidocaine
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Neonatal Pain Assessment
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Question #3
A preterm infant is scheduled to have a new peripheral
IV line inserted. How might the nurse best address pain
related to this procedure?
A. Observe the infant for signs of pain during the
procedure.
B. Understand that neonates do not experience
pain.
C. Swaddle the infant and provide a pacifier before
the procedure.
D. Administer opioid analgesics prior to the
procedure.
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Neonatal Intensive Care Equipment #1
❖ The neonatal intensive care unit (NICU) can be stressful.
❖ Nasogastric tubes are used for feeding and for gastric suction.
❖ An umbilical artery catheter: placed in the umbilical stump to one of
the two umbilical arteries and into the aorta. Used to monitor arterial
blood glasses.
❖ An umbilical vein catheter : placed into the umbilical stump to the
ductus venosus and into the inferior vena cava. Used for fluid and
medication administration and can be used for blood pressure
monitoring. https://youtu.be/G0oPnF3IqK4
❖ Both are rarely left in place more than 1 week.
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Neonatal Intensive Care Equipment #2
❖ Peripherally inserted central line (PICC) is used when intermediateterm intravenous (IV) access is required.
❖ Nasal canula (NC) are available in different sizes and allows for
visualization of the baby’s face.
❖ Continuous positive airway pressure (CPAP) is useful for infants
unable to obtain adequate oxygenation by nasal canula alone.
❖ An endotracheal tube (ET) is placed by intubation through the
infant's mouth. The ET tube is then attached to a ventilator.
❖ An oxygen hood is for infants who do not need supplemental oxygen
pressure. If the infant is removed from the hood (for example, during
a feeding) oxygen should be supplied by NC.
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Chapter 25
Acquired Conditions and
Congenital Abnormalities in the
Newborn
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hyperbilirubinemia in the Newborn
❖ Hyperbilirubinemia is a bilirubin serum >5 ml/dL.
❖ Bilirubin comes from the breakdown of red blood cells
(unconjugated). Is bound to albumin and transferred to
liver for conjugation.
o conjugated will be excreted normally ( becomes
water soluble), excreted poop and pee.
o unconjugated bilirubin remains in the blood
stream to cause the jaundice. Can deposit in the
brain tissue causing damage (kernicterus)
intellectual deficit, death.
❖ Jaundice is from head to toe (progressive)
❖ Hyperbilirubinemia is common in newborns and is known
as physiologic jaundice but can also be pathologic .
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Physiologic Jaundice #1
❖ physiologic (after 24 hrs. of live) results from:
o Newborn's shortened red blood cell lifespan and
breakdown of fetal RBC’s
o Live immaturity
❖ pathologic jaundice (within 24 hrs. of live) results form an
underlying disease.
o
Caused by a blood group incompatibility (ABO),
infections, or RBC disorders.
❖ To prevent complications, the nurse should carefully assess
infant feeding and ensure frequent feedings.
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Pathologic Jaundice #2
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Jaundice: Assessments
❖ A assess all infants after birth for jaundice by visual inspection
every 8 to 12 hours.
❖ Expects yellowish tint to skin, sclera and mucous membranes
❖ Check mom and baby blood type.
❖ Direct Coombs test is a blood test to check for hemolytic
disease of newborn (determine the cause).
o Done on the baby’s cord blood to detect antibody coated
RH positive red blood cells.
❖ Screen infants by transcutaneous bilirubin (TcB)
measurements. Results are often confirmed by total serum
bilirubin (TSB) measurements.
❖ Preterm infants are at higher risk
for pathologic jaundice.
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Jaundice: Treatments
❖ The goal of treating hyperbilirubinemia is to avoid kernicterus
o
Fatty portion of bilirubin attaches the brain basal ganglia.
o
Causes neurological damage.
o
Can cause Cerebral Palsy baby
o Occurs if Bili is > 20ml/dl
❖ Phototherapy used in hospital or home, exposes the infant's
skin to a particular wavelength of light. This exposure converts
the bilirubin to a water-soluble form that can be excreted in
bile or urine.
o
Phototherapy blankets
o
Single or double banks.
❖
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Jaundice: Treatments
❖ Nurses monitor the infant’s temperature, serum
bilirubin, hydration status, and exposure time during
phototherapy.
❖ Cover the eyes, avoid lotions, minimal clothing (diapers
only)
❖ Phototherapy Side Effects: diarrhea, increased
insensible water loss, skin rash, and transient bronzing
of the skin .
❖ Exchange transfusion effectively removes bilirubin from
the circulation but is expensive, requires clinical
expertise, and is rarely used.
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Question #1
A 39-week infant had a tachycardic fetal heart rate (FHR)
baseline and persistent variable decelerations during labor. The
infant has a cephalohematoma from a vacuum-assisted delivery
and is exclusively formula feeding. Which of the following
predisposes the infant to hyperbilirubinemia?
A. Tachycardic FHR baseline
B. Variable decelerations in labor
C. A cephalohematoma
D. Exclusive formula feeding
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Cold Stress
❖ Occurs with uncontrolled hypothermia when blood
vessels constrict to conserve heat. The metabolic
rate increases as does oxygen consumption.
❖ Prolonged cold stress can lead to
o respiratory distress, acidosis, hypoglycemia,
and reopening or failure to close of the ductus
arteriosus.
❖ Treatment
o Monitor for skin pallor with mottling and
cyanotic trunk, tachypnea
o Warm slowly over a period of 2-4 hrs.
o Give o2
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Hypoglycemia
❖ Hypoglycemia in the newborn is defined as a blood
sugar less than 40 mg/dl.
❖ Symptoms:
o Hypotonic, lethargy, Tremors,
o Irritability, Seizures
o Temperature instability
o Poor feeding, Vomiting
❖ Monitor as per facility protocol.
❖ Infants with mild hypoglycemia should have early
feedings
❖ Give Iv dextrose for a symptomatic newborn or TPN
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Question #2
A nurse is caring for a newborn who is 4 hr. old
and has a bedside glucometer reading of 68 mg/
dL. The newborn’s mother has type 2 diabetes
mellitus. Which of the following actions should
the nurse take?
A. Obtain a blood sample for a serum glucose
level
B. Feed the newborn immediately
C. Administer 30 mL of dextrose solution IV
D. Reassess the blood glucose level prior to
the next feeding
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Respiratory Distress Syndrome (RDS) and
Apnea
❖ (RDS) is the respiratory condition most associated with
prematurity.
o
Is caused by surfactant insufficiency, immature lungs,
regardless of newborn birth weight.
o
Symptoms include tachypnea, nasal flaring, expiratory
grunting, retractions, cyanosis, and pallor.
o
Treated with assisted ventilation, surfactant, and
supportive therapy.
❖ Apnea is common and significant if : breathing stops for
more than 20 seconds or with either a Heart Rate less than
70 to 80 bpm or oxygen saturation below 80% to 85%.
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Respiratory Distress Syndrome (RDS) # 2
❖ Conditions causing RDS include:
o
Bronchopulmonary dysplasia (BPD) causes the lungs are stiff and
noncompliant requiring treatment complication of artificial
respiratory support.
o
Persistent Pulmonary Hypertension of the Neonate (PPHN)is a
left to right shunting and hypoxia, underdeveloped or abnormal
pulmonary vascular, or lung disease.
o
Transient tachypnea of the newborn (TTN) form of pulmonary
edema resulting from failure to clear fluid from the lungs
o
Meconium Aspiration Syndrome (MAS); aspiration
of meconium in the fetal lungs resulting in airway
obstruction, inflammation and chemical irritation,
infection, and inactivation of surfactant.
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Question #3
❖ A neonatal intensive care nurse monitors patients for
what signs of respiratory distress syndrome?
A. Nasal flaring
B. Expiratory grunting
C. Use of accessory muscles to breathe
D. All of the above
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Retinopathy of Prematurity (ROP)
❖ (ROP) is a leading cause of blindness in children in the United
States.
o
caused by abnormal vascular growth of the blood vessels
of the retina in infants born prematurely.
o
Linked to resuscitation method
❖ Complications associated with oxygen administration to the
newborn can cause mild to severe eye and vision problems
❖ Keep target oxygenation to no more than 90%.
❖ Eval Ophthalmology Pediatrician before 30 wks
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Patent ductus arteriosus (PDA).
❖ A common cardiovascular issue.
❖ Occurs when the ductus arteriosus reopens after birth due to
neonatal hypoxia or when the it does not close after birth.
•
Extra blood gets pumped from the body artery (aorta) into
the lung (pulmonary) arteries.
❖ Signs and symptoms:
o
Systolic murmur
o Ventricular dilation
o
Cyanosis
❖ Treatment include diuretics, ibuprofen or indomethacin. ECHO,
cardiac counseling .
❖ Infants who do not respond to medications may need surgery.
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Intraventricular hemorrhage (IVH)
❖ Bleeding in or around ventricles of the brain and s one
of the most common and dangerous causes of brain
injury.
❖ Treatment incudes supportive care such as
o avoiding hyper- or hypotension,
o providing adequate oxygen and nutrition,
o and treat seizures to avoid alterations in cerebral
blood flow.
o Minimal TOUCH
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Necrotizing Enterocolitis (NEC)
❖ (NEC) is ischemic necrosis of the intestines and a gastrointestinal emergency.
❖ Most infants with NEC appear healthy. Predominantly in preterm infants.
❖ The first sign of a problem is typically a feeding intolerance.
❖ Other signs of NEC include:
Abdominal distension, discoloration, loops
•
•
Hypotension
•
Temperature instability
•
Respiratory failure
•
Vomiting, bloody stools
❖ Treatment includes antibiotics, laboratory monitoring (CBC, electrolytes, BUN,
creatinine, and acid base studies), radiographic monitoring every 6 to 12 hours
(monitors progression), and bowel resection surgery.
❖ Put newborn NPO , give TPN and connect to a low suction gastric decompression.
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Question #4
❖ Necrotizing enterocolitis (NEC) is an inflammatory
disease of the gastrointestinal mucosa. The signs of NEC
are nonspecific. Some generalized signs include :
A. hypertonia, tachycardia, and metabolic alkalosis
B. abdominal distension, temperature in stability, and
grossly bloody stools.
C. hypertension, absence of apnea, and ruddy skin color
D. scaphoid abdomen , no residual with feedings Coleman
and increase urinary output.
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Maternal Substance Abuse: Neonatal
Abstinence Syndrome
❖ Urine toxicology serum will confirm the drug the newborn was exposed
to.
❖ Provide a quiet environment, swaddle ,small feedings, avoid
eye contact (cocaine),cluster care, initiate seizure precautions.
❖ The goal of treatment is to reduce symptoms. Infants are given
opioids and then weaned from them after they are stable for 24 hours.
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Maternal Substance Abuse: Signs of NAS*
(projectile)
Interventions: Swaddle, put baby in a flexed position, minimum stimuli
Discharge planning includes an evaluation of the home environment
and maternal substance abuse treatment.
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Question # 5
❖ A newborn has been diagnosed with NAS. The nurse is
planning to contact the provider regarding the
newborn's status. Which of the following prescriptions
should the nurse anticipate? Select the 3 interventions
the nurse should anticipate.
A. Encourage the birthing parent to breastfeed.
B. Swaddle the newborn.
C. Initiate seizure precautions
D. Administer naloxone for NAS scores greater than 24.
E. Administer oral morphine.
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Maternal Substance Abuse: Fetal Alcohol
Spectrum Disorder
❖ Exposure to alcohol in utero is the number one cause of preventable
birth defects and developmental disabilities.
o
Prenatal exposure can result in fetal alcohol spectrum disorder
(FASD), which expresses as a wide range of physical, mental,
and cognitive issues.
o
CNS Teratogen.
❖ Care considerations:
Include:
social work,
occupational,
physical and
speech therapy.
,
❖ In both NAS and FAS Allow extra time for feeding.
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Neonatal Infections
❖ May be acquired in utero or during or after birth.
❖ Newborns have an immature immune system, making them
susceptible to infections having severe consequences from infection.
❖ Maternal immunoglobulin (antibodies) G (IgG) is transferred to the
fetus via the placenta after 32 weeks.
❖ Neonatal sepsis is the presence of a bacterium (E. coli), fungus, or
virus in the blood as confirmed by blood culture and manifested by
systemic signs of infection.
o
Risk factors for neonatal sepsis include chorioamnionitis,
maternal temperature greater than 100.4˚F, delivery prior to 37
weeks, or an Apgar score of 6 or less.
o
Sepsis is treated with antibiotics.
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Neonatal Infections :Guidelines and
Evaluation
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Neonatal Infections: Group B
Streptococcus (GBS) #1
❖ GBS bacterial infection .
o
Can cause sepsis, pneumonia, RDS, or meningitis, with most
displaying symptoms within 24 hours after birth.
o
Fist sign unstable temp.
❖ Risk factors for early-onset GBS disease include:
o
Delivery less than 37 weeks
o
Premature rupture of membranes >18 hours prior to delivery
o
Chorioamnionitis
o
GBS in urine in current pregnancy
❖ Treatment: ALL status- X2 antibiotics at least 4 hours prior to
delivery ( IV-PCN- G, Ampicillin or Cefazolin, and Clindamycin or
Vancomycin in allergies to PCN)
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Neonatal Infections: Group B
Streptococcus #2
❖ Late-onset GBS is less likely to exhibit signs of shock than early-onset
GBS.
❖ Late-onset GBS symptoms may include:
o
Fever
o
Cellulitis
o
Irritability
o
Lethargic with poor feeding
o
Grunting
o
Tachypnea
o
Apnea
o
Nuchal rigidity
o
Seizure
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Other Sources of Neonatal Infections #1
❖ Congenital syphilis is transmitted vertically from mother to fetus and can
result in stillbirth, prematurity, or hydrops fetalis.
o
Symptoms of congenital syphilis vary widely
and is identified with a blood test or
an evaluation of cerebrospinal fluid for (VDRL).
Treatment is with Penicillin G.
❖ Gonorrhea neonatorum (newborn conjunctivitis) was once a leading cause of
blindness and is now routinely treated with an antibiotic eye ointment
(Erythromycin) at the time of birth.
❖ Chlamydia can cause conjunctivitis or pneumonia. Often transmitted through
a vaginal birth but may pass the membranes or the placenta. Treated with
oral antibiotic and antibiotic eye ointment( Erythromycin) at the time of
birth.
❖ Herpes is most common when vaginally delivered by a mother experiencing a
herpes outbreak. May cause sepsis. Treatment is antiviral medication
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(Acyclovir) therapy forCopyright
14 to
21Wolters
days.
Other Sources of Neonatal Infections #2
❖ Toxoplasmosis is caused by a common protozoan parasite found in cat
feces, contaminated soil, and undercooked meat.
o
may cause anemia, seizure activity, calcifications in the brain,
thrombocytopenia, or jaundice. Diagnosed with blood test or
CSF evaluation.
❖ Infants born to hepatitis B positive mothers are treated with HBsAG
after birth and receive the first dose of Hep B vaccine within 12 hours
❖ HIV occurs during the intrapartum period.
o
o
o
Prophylactic treatment of infants with ART is begun 6 to 12 hours
after delivery until 18 month of age.
Breastfeeding is contraindicated for HIV-positive mothers*.
During vaginal delivery do not use instruments.
As early in life as possible, HIV-exposed infants and children should
receive all vaccines under the Expanded Programme for
Immunization (EPI), including Haemophilus influenzae type B and
pneumococcal vaccine.
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Other Sources of Neonatal Infections #3*
❖ Congenital Cytomegalovirus is a leading cause of nonhereditary
hearing loss and other long-term neurodevelopmental disabilities.
Trasmission Treatment includes IV antiviral medications.
❖ Congenital rubella syndrome is rare in countries with high
immunization rates. Symptoms include hearing loss, cataracts, and
jaundice.
❖ Neonatal varicella is dangerous if the infection occurs within the
first 5 days of life. Treated with acyclovir as soon as possible.
❖ Candidiasis is a common cause of late onset neonatal sepsis due to
invasive colonization. Diagnosed by blood culture and treated with
antifungal medication and by removing any medical hardware such
as IV lines or urinary catheters immediately.
❖ Zika is transmitted sexually or by mosquito bite and transmitted
prenatally to a fetus. Associated with microcephaly, craniofacial
disproportion, and hearing loss. There is no specific treatment.
❖ USE GLOVES until first bath, and bathe before skin-to-skin
contact.
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Congenital Anomalies: Heart Disease #1
Structure anomalies of the heart
include:
Risk factors include:
❑ Family history
❖ Transposition of great arteries
❖ Double outlet right ventricle
❖ Ventricular septal defect
❖ Tetralogy of Fallot
❖ Atrioventricular septum defect
❖ Coarctation of the aorta
❖ Atrial septum defect
❑ Certain genetic
syndromes
❑ Prematurity
❑ Certain in utero
infections
❑ Use of assisted
reproductive
technology
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Congenital Anomalies: Symptoms of Heart
Disease
❖ Defects may be identified prior to birth.
❖ Symptoms of heart defects can be subtle
and possibly missed during assessment.
❖ Symptoms of defects after birth include:
o Cyanosis
o Tachypnea
o Pulmonary edema
o Cardiogenic shock
❖ Some infants will appear normal at birth and begin to
decompensate as the ductus arteriosus closes.
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Congenital Anomalies: Heart Disease
Screening
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Congenital Anomalies: Neurologic
Abnormalities #1
❖ Anencephaly: cranial anterior neural tube failing to close
post conception.
at day 25
❖ Encephalocele: Brain or meninges protrude
through a skull defect called a cranium bifidum.
❖ Spina bifida: Incomplete closure of the vertebra
surrounding the spinal cord. Results from the spinal neural tube failing to close
by 28 days after fertilization. https://youtu.be/bLnYzCcTEEA
❖ Adequate levels of folic acid (400 mcg daily) prior to conception may help
prevent neural tube defects.
❖ Risk factors include:
o
Family history
o
Obesity
o
Elevated temperature in the first trimester
of pregnancy (e.g., a sauna, fever, or hot tub)
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Congenital Anomalies: Neurologic
Abnormalities #2
Figure 25.10. Spina bifida. (A) Normal spine. (B) Spina bifida occulta. (C) Spina
bifida with meningocele. (D) Spina bifida with myelomeningocele (most common)
Occulta: neural tissue is not exposed, and the skin remains intact
Meningocele. Skin intact, the meninges (the membrane surrounding the spinal cord) protrudes
through the opening in the spine. The nervous system remains undamaged,
Myelomeningocele. Both the meninges and the nerve tissue come through the opening in the
spine, resulting in damage to both. complete paralysis and absence of sensation. fecal and
urinary function compromise.
Cover the area with sterile gauze (non-adherent dressing( and normal saline.
Place the baby in prone position until tranfer to surgically repair.
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Question # 6
❖ A baby was born 2 hours ago by Cesarean section. The
newborn has a myelomeningocele with the sac intact and
has been placed in an incubator. Select all that apply
regarding this condition:
A. Potential risk for infection
B. The sac should be kept moist with normal saline
C. Keep the baby in prone position
D. Complications of hydrocephalus
E. Prenatal test screen is alpha-Fetoprotein(AFP)
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Congenital Anomalies: Orofacial Cleft
❖ An orofacial cleft is a cleft lip with or without
a cleft palate or a cleft palate without a cleft
lip.
o may be caused by a genetic syndrome,
maternal exposure to certain teratogens,
smoking, diabetes, or obesity.
o surgery are usually performed at 3
months, cleft palates at 6 months of
age.
❖ With this defect the sucking ability most
likely be compromised because they cannot
create suction to extract milk. A special
bottle and nipple may be used.
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Congenital Anomalies: Gastrointestinal
Anomalies
Often immediately apparent on routine prenatal
screening or at the time of birth; but may
become apparent over time.
❖ A tracheoesophageal fistula (TEF) is an abnormal
passage joining the trachea and the esophagus.
•
Excess secretions, choking, drooling,
and respiratory distress. Require surgery.
• Hirschsprung disease is a disorder of the nerves
of the colon (absence) causing a functional
obstruction.
•
abdominal distention, vomiting of bile, and
failure to pass meconium within the first 48
hours of life. Confirmed by biopsy, barium
enema, and imaging. Require surgery.
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Congenital Anomalies: Gastrointestinal
Anomalies #3
❖An omphalocele is an opening of the
abdominal wall at the level of the
umbilical cord that contains abdominal
contents contained in a membrane.
❖Gastroschisis is an abdominal wall
defect associated with bowel herniation
with no containing membrane.
❖In the delivery room, is wrapped in a
sterile dressing with Normal Saline to
prevent heat and fluid loss.
❖Multiple surgeries may be required.
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Congenital Anomalies: Respiratory
Anomalies
❖ A congenital diaphragmatic hernia is a condition in which the
abdominal contents herniate through the diaphragm into the chest.
❖ Signs and symptoms include:
o
Respiratory distress consistent with the degree of herniation.
o
Development of persistent pulmonary
hypertension in the neonate.
o
Breath sounds may be diminished or absent.
o
Heart sounds may be displaced.
❖ Diagnosis in the neonate is done by chest x-ray.
❖ Perinatal intrauterine repair may be attempted.
❖ Postnatal management includes stabilization followed by immediate
surgical repair.
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Congenital Anomalies: Genitourinary
Anomalies #1
❖ Hypospadias is the malplacement of the
urethra on the ventral aspect of the penis.
❖ Epispadias is abnormal placement of the
urethra on the dorsal aspect of the penis.
❖ Risk factors include maternal diabetes,
advanced maternal age, and placental insufficiency.
o It is important not to circumcise these infants because the
foreskin may be needed for surgical repair.
❖ Ambiguous genitalia, Undescended testicles, hydrocele.
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Congenital Anomalies: Musculoskeletal
Anomalies
❖ Hip dysplasia may be evident at birth or
become evident during infancy or childhood.
o May occur as part of a syndrome but
often an isolated occurrence.
o
The goal of treatment is to facilitate the
alignment of the acetabulum and the
femoral head. Is generally not initiated
until after 4 weeks of age to allow time
for spontaneous resolution.
o
The most common intervention when
treatment is deemed necessary is a
Pavlik harness, which limits adduction
and extension while stabilizing the hip.
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Question #4
A nurse uses pulse oximetry to screen for critical congenital heart
defects (CCHD). What is the best rationale for this screening test?
A. Screening for congenital heart defects should only be done if a
heart defect is suspected.
B. Congenital heart defect screenings should only be used for
infants with tachycardia or bradycardia.
C. Infants with a congenital heart defects are always diagnosed via
prenatal ultrasounds.
D. An infant with a congenital heart defect may appear well but
then decompensate after discharge.
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Chapter 26
Wellness and Health
Promotion
https://youtu.be/-UsuqWkfbQY
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cervical Cancer Screening #1
https://youtu.be/UwyzCg57dlA
❖ Detects precancerous screening as well as early
disease when it can still be managed.
❖ Done primarily with the collection of a small number
of cervical cells called the Pap test (Pap smear).
❖ Two types of HPV are responsible for most cervical
cancers ( types 16 and 18) and genital warts.
❖ When teaching about pelvic exams and Pap smear,
advise clients:
▪
Do not douche 24 hours before exam/test (can
interfere with accuracy of Pap smear)
▪
Avoid intercourse
▪
Avoid using feminine hygiene products or
spermicidal agents immediately before
▪
Specimens should not be obtained during
menstruation
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Cervical Cancer Screening #2
➢ Recommendations for screening include:
▪ First screening at the age of 21 regardless of sexual activity.
▪ Subsequent screening every 3 years until age 30.
▪ After age 30, women should receive a Pap test and HPV
testing every 5 years until age 65. Or a Pap test alone every
3 years.
➢ Screening may end at age 65,
▪
provided the woman is not at increased risk for cervical
cancer, has had two negative co-tests or three negative Pap
tests, and no history of high-grade abnormalities.
➢ Pelvic examination should be done yearly.
➢ If test is abnormal colposcopy is performed to further examine
the cervix
o Risk : Multiple sexual partners
o Administer HPV vaccine.
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Breast Cancer Routine Screening
❖ The American College of Obstetricians and
Gynecologists (ACOG) recommends the
following breast cancer screening guidelines for
women of average risk:
✓ Mammograms every 1 to 2 years between the
ages of 40 and 49 years based on shared
decision making (SDM) between the patient and
provider
✓ Every 1 to 2 years between the ages of 50 to
75.
✓ After age 75, women should have
mammograms based on SDM.
✓ Should receive a clinical breast exam (CBE)
every 1 to 3 years between the age of 29 and
39 and annually after .
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Breast Cancer Breast Examination
❖ Many organizations do not recommend Clinical Breast
Examinations or Breast Self-examination because of
lack of efficacy.
❖ Of the breast cancers discovered by women (rather
than mammograms), most women identified changes
during her routine (e.g., dressing, showering, etc.)
and not by self-examination.
❖ Therefore, current recommendations are for women to
develop breast awareness or familiarity will her own
breasts to be able to indicate changes that might be
breast cancer.
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Question #1
❖ A client has come to the clinic for an annual check up
and expresses concern about developing breast
cancer. Which factors in the client's history would the
nurse discuss as possibly placing this client at risk
for breast cancer? Select all that apply.
A. Family history of breast, ovarian, or peritoneal
cancer
B. Use of aluminum chlorohydrate antiperspirant
C. Dense breasts
D. Never given birth
E. Positive BRCA1 and BRCA2 gene mutations
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Question #2
Which statement made by a patient requires further
education by the nurse?
A. “Because I have no risk factors for breast cancer,
I do not need a mammogram until I am at least
40.”
B. “It is important for me to have awareness of
what is normal for my breasts.”
C. “Since I am 52, I should schedule a
mammogram every 1 to 2 years.”
D. “I should do monthly self breast examinations.”
E. I must be aware of what is normal for my
breasts”
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Heart disease
❖ The term heart disease refers to several types of heart
conditions, including coronary artery disease and heart
attack.
o *According to CDC databased on February 21,
2022, Heart disease is the leading cause of death
for women in the United States, killing 314,186
women in 2020—or about 1 in every 5 female
deaths.
o Women are much more likely to have atypical heart
attack symptoms.
▪ Classic chest or absent, women are much more
likely to get symptoms such as indigestion,
abdominal pain, shortness of breath, neck and
back pain, sweating, light-headness.
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Intimate Partner Violence (IPV)
Screening
❖ IPV is any actual or threatened psychological, sexual, or physical harm of
one current or past partner by the other. Increases during pregnancy.
❖ Victims of IPV may be of any gender identity, age, socioeconomic class,
ethnicity, or sexual preference. They are often reluctant to disclose IPV for
shame, guilt, or fear. Have a few friends ,low self steam, low academic
achievement, lots of problem with partner, can be using alcohol and drugs.
❖ May present with:
o
bruises in different phases, frequency of injuries (face, head, neck),
reported history of the injury inconsistent with the presenting
problem, depression, anxiety, or substance abuse
❖ Abuser extremely controller, jealous, possessive,
don’t leave her side, blame partner for everything.
❖ All women are screened by a paper or computer
questionnaire and by engaging in an open-ended questions.
o
Regardless of method, the partner of the patient must not be present
during the screening.
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Question #3
❖ A nurse is working in a local community health care
facility where she frequently encounters victims of abuse.
For which signs should the nurse assess to find out if a
client is a victim of abuse? Select all that apply.
A. injuries on the face, head, and neck
B. reported history of the injury inconsistent with the
presenting problem
C. frequent STIs
D. mental health problems such as depression,
anxiety, or substance abuse
E. partner of suspected victim relaxed and not overly
worried
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Sexual Assault and Human Trafficking
❖ Sexual violence is unwanted sexual experiences, sexual
contact, and sexual coercion.
❖ Nurses are mandated reporters, and it is the
responsibility of the nurse to know the reporting
requirements in his or her state.
❖ After an assault, individuals are tested for sexually
transmitted infections, pregnancy, Hep B, HIV.
❖ Offer:
o prophylactic treatment for STIs
o postcoital contraceptive therapy.
o sexual assault counseling.
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Question #4
The nurse is caring for a client who adheres to a vegan
diet. Which micronutrient does the nurse recommend
for this client?
A. The client needs to take supplemental folic acid and
iron.
B. The client needs more protein and fat.
C. Additional calcium is needed in the vegan diet.
D. client needs to include a B vitamin supplement.
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Physical Activity #1
❖ Current physical activity guidelines
recommend
❖ 2.5 hours moderate-intensity aerobic
activity per week
o
E.g., walking briskly (3 miles
per hour or faster), water
aerobics, slow bicycling, doubles
tennis, ballroom dancing, and
general gardening)
❖ 0R 1 hour and 15 minutes of
vigorous-intensity aerobic activity
per week.
o
E.g., swimming laps, jogging,
aerobic dancing.
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Screening for Sexually Transmitted
Infections (STIs) #1
❖ Screening for STIs is based on risk in accordance with sexual
activity and sex.
❖ Screening guidelines include:
o
Chlamydia and gonorrhea:
▪ Annually for all sexually active women under 25 years.
▪ Women 25 or older with new sex partners, more than
one sex partner, or a sex partner with known STI.
▪ Pregnant women
o
Syphilis:
▪ Pregnant women at the first visit
▪ At least annually for men who have sex with men
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Screening for Sexually Transmitted
Infections #2
❖ Human immunodeficiency virus (HIV):
o
All adolescents
o
Pregnant women at their first visit
o
Annually for men who have sex with men
❖ Hepatitis B virus:
o
All pregnant women at their first visit
o
Past and current drug users
❖ Hepatitis C virus:
o
All pregnant women with current or past injection drug use, an
unregulated tattoo, or long-term hemodialysis.
o
Past and current drug users
o
Individuals who test positive for HIV
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Question #3
Which of the following patients is a priority for sexually
transmitted infection screening?
A. A woman 6 weeks pregnant during her initial
prenatal visit
B. A 17-year-old sexually active male
C. A 24-year-old woman being seen for an annual
gynecologic exam
D. All of the above
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Osteoporosis
❖ Loss of bone mass. After the age of 35 decreased.
❖ Diagnosed; DXA scan- T-scores > or equal to -2.5
❖ Sign and symptoms:
o Back pain, loss of height, stooping posture
❖ Risk: thin, Caucasian, chronic or current smoker, 3 or
more drinks/day, lack of exercise, corticosteroids, BMI >20
❖ Medication Bisphosphonates. E.g., Fosamax (Alendronate)
inhibits the process through which the body breaks down
bone tissue.
o Side effects: Musculoskeletal pain, GI irritation and
ulcers.
▪ Take in the morning, sitting or standing, upright for
30 min, before breakfast with 8 ounces of water. No
coffee or juice.
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Chapter 27
Common Gynecologic
Conditions
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Endometriosis
❖ Is the presence of endometrial tissue outside the uterus.
Lesion usually in peritoneal area or reproductive organs
that cause pain.
❖ Symptoms include dysmenorrhea, dyspareunia, infertility,
pelvic mass, pelvic pain/cramping.
❖ The cause hormonal changes (Estrogen and Progesterone).
inflammation of the endometrium, hereditary, immunologic
defects.
❖ Treatment: NSAIDs, combined oral contraceptive, or
Medroxyprogesterone (MPA), Danazol , GnRH agonist
(Lupron).Category X
• laparoscopy for definitive diagnosis and removal of
endometrial lesions (electrocautery) or Hysterectomy.
❖ Nurses should provide information on likely outcomes
Fi of
treatment options.
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Endometriosis #2
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Pelvic Prolapse
❖ Pelvic organs are held in place by a combination of
connective tissue and the muscles of the pelvic floor.
Hormonal changes makes those muscle weak and pelvic
organs descend into the vagina
o May involve prolapse of the bladder (cystocele),
rectum (rectocele), bowel (enterocele), or uterus.
❖ Risk for pelvic floor prolapse include:
o Multiple births
o The use of forceps to assist delivery
o Perineal tears during delivery
o Episiotomy during birth
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Pelvic Prolapse: Classifications by Stage
Figure 27.12. Types of pelvic organ prolapse. (A) No prolapse. (B)
Cystocele. (C) Rectocele. (D) Enterocele. (E) Uterine prolapse.
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Pelvic Prolapse: Symptoms and Treatment
❖ Signs and symptoms may include:
o Vaginal pressure
o Pelvic pain
o Bulge at the opening of the vagina
o Problems with defecation
urination. Stress incontinence.
or
o Painful intercourse.
❖ Treatment may include vaginal pessaries (silicone ring) to assist
with pelvic organ support, physical therapy, or surgery, when
the women experiences distressing symptoms.
• https://youtu.be/_pXG815daDs
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Question #1
Which of the following statements is false?
A. Risks for pelvic prolapse include obesity and
having a baby.
B. Symptoms include vaginal pressure and pelvic
pain.
C. Treatment is indicated when the woman
experiences distressing symptoms.
D. Treatment always involves surgery.
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Menopause
PMS-https://youtu.be/ZtrynEEffMw
❖ Natural menopause is when a woman has not menstruated for a
full 12 months in the absence of any other reason. Typically occurs around
age 51 or 52.
❖ The time prior to menopause is referred to as perimenopause and
typically lasts around 4 years.
❖ Perimenopause and Menopause symptoms : hot flashes, night sweats,
increased anxiety, depression, insomnia, sporadic ovulation, mood swings,
increased abdominal fat, dry, thinning skin, and increased waist size.
❖ Best indicator : High FSH ,and Estrogen levels drop, vaginal mucosa
becomes progressively dry and less elastic (vaginal Atrophy) Use OTC
moisturizing ,lubricants.
❖ Estrogen replacement therapy is no longer recommended for symptoms
due to the risk for cardiovascular disease and osteoporosis.
❖ Postmenopausal bleeding is highly suspicious of endometrial cancer.
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Polycystic Ovarian Syndrome (PCOS)
❖ The most common endocrine disorder that causes infertility in women.
❖ Usually appears in Childbearing age. Cyst in ovaries .
❖ Is associated with obesity, hyperinsulinemia, Increase estrogen,
testosterone, LH, decrease FSH, Dyslipidemia, Sleep apnea, anovulation,
amenorrhea, hirsutism, acne, virilization, oily skin.
❖ Long terms RISK : Hypertension and cardiovascular disease and
metabolic syndrome.
❖ Patients may ovulate intermittently. Should use contraception if they do
not want to get pregnant.
o
If pregnancy is an immediate goal: Clomiphene citrate (Clomid), ART
❖ Treatment:
•
Metformin (Glucophage) to improve insulin sensitivity and utilization.
•
Spironolactone (Aldactone) or Eflornithine to decrease symptoms
such as excessive hair growth and acne.
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PCOS Diagnostic Criteria for Adolescents
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Question #2
The nurse counsels a patient recently diagnosed with
polycystic ovarian syndrome. Which of the following should
be included in the patient education:
A. The need to use reliable birth control
B. The importance of annual testing for STIs
C. Lifestyle behaviors to manage urinary incontinence
D. Self-care measures for secondary dysmenorrhea
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Gynecologic Cancers
❖ Uterine, cervical, ovarian (“silent killer’), vaginal, and vulvar.
❖ Diagnoses: Biopsy
❖ Risk : Multiple sexual partners
❖ Symptoms: Vaginal discharge, watery, pink brown and foul smelling,
leaking urine and feces from the vagina, abnormal vaginal bleeding
between periods, intercourse or menopause, painful sex, loss of
appetite, fatigue, pelvic pain.
❖ The prognosis depends on the type and stage.
❖ Treatment includes total hysterectomy(TA-remove uterus and
cervix), with bilateral salpingo-oophorectomy(both
ovaries)(TAH,BSO), surgical removal of the cancerous tissue
,chemotherapy and radiation as needed.
❖ Advise woman (TAH,BSO) will cause premature menopause.
❖ All cancers are staged based on the TNM staging system.
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Breast Cancer #1
❖ Approximately 1 in 8 women will be diagnosed with breast
cancer during their lifetime. Major risk nulliparas.
❖ A majority of breast cancers are discovered by mammogram
and diagnosed by needle biopsy of the core lesion.
❖ Prognostic factors depend on factors such as tumor stage,
gene expression, circulating tumor cells, age, race, and
smoking status.
❖ Treatment may include:
o Surgery (lumpectomy, radical mastectomy, modified
radical mastectomy, simple mastectomy)
o Chemotherapy, Radiation therapy, Hormone therapy
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Breast Cancer #2
❖ Symptoms to report:
o
New lump in the breast or underarm (armpit).
o
Redness, irritation, dimpling ,thickening, swelling or
enlarge pores of the breast. (Peau d’orange)
o
Pulling in of the nipple or discharge other than breast
milk, including blood.
o
Any change in the size or the shape of the breast.
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Breast Cancer #3
❖ After surgery asses wound for healing.
❖ Side Effects from chemo and radiation:
o Diarrhea, mouth ulcers, weight loss, nausea,
vomiting.
o Ask to drink more fluids, Gatorade, eat small
frequent meals, cook meals very well, plenty of
rest. Antidiarrheal medications, baby wipes,
o Check for skin changes on the area of radiation.
❖ Teach: Post mastectomy arm exercises to prevent
lymphedema.
❖ Women with fibrocystic breast are not
at increase for breast cancer.
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Chapter 28
Infections
https://youtu.be/BOksgV3g9Bo
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Urinary Tract Infections (UTIs)
❖ https://www.cdc.gov/std/default.htm
❖ The result of bacteria (often Escherichia coli) ascending
into the urethra, bladder, and kidneys (pyelonephritis).
❖ Cystitis most common form limited to the bladder
❖ Symptoms urinary frequency, urgency, a sensation of
incomplete emptying, pain with urination, and
sometimes hematuria.
❖ Point-of-care urinalysis may be used .Values specific to
UTI are leukocytes, nitrites, and blood.
❖ A urine culture must be done in a laboratory
❖ Elderly presentation unusual of UTI: confusion,
disorientation, agitation (mental status changes),
falling.
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Urinary Tract Infections: Treatments
❖ Often resolve without treatment or may need antibiotics.
o
Trimethoprim/sulfamethoxazole (Bactrim), Nitrofurantoin
❖ If antibiotics, patients should be taught to finish their course
of antibiotics even if they feel better.
❖ Phenazopyridine (Pyridium) urinary analgesic that can manage
symptoms related to cystitis, but it does not cure the UTI.
o
Teach do not take more than 2 days
it can mask UTI symptoms
o
changes urine color to bright orange,
which can be alarming.
❖ Complications: Pyelonephritis: UTI that has ascended into
the kidneys.
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Question #1
A patient calls the clinic with complaints of fever, back
pain, urinary frequency, and urinary urgency. The nurse
suspects the provider will do which of the following?
A. Recommend the patient stay home and drink a
lot of water.
B. Recommend the patient come to the clinic to be
evaluated for pyelonephritis.
C. Diagnose the patient with a urinary tract
infection and call in a prescription.
D. Recommend the patient take phenazopyridine
for 2 days and call back if symptoms persist.
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Vaginosis
❖ Any abnormality of vaginal discharge.
❖ Bacterial vaginosis (BV) is associated with higher-than-normal
pH in the vagina that allows certain bacteria to become
dominant. Not an STI. Only females are affected.
❖ Conditions that raise the pH include pregnancy, intercourse,
and tampons. having multiple sex partners, vaginal douching.
❖ Signs and symptoms of BV include fishy vaginal odor and thin
white/gray vaginal discharge. Clue" cells are seen on wetmount preparation.
❖ Often resolves spontaneously but may be treated with
Clindamycin, oral Metronidazole or vaginal cream.
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Vaginitis
❖ Means inflammation of the mucosa of the vagina.
❖ Candida vulvovaginitis, also known as yeast infection. Causative
organism is Candida albicans. No STI
o
Associated with use of antibiotics, restrictive clothing, underwear
made with artificial fibers, and glucose intolerance. It may
occasionally be shared sexually.
❖ Women may report a thick, cottage cheese-like vaginal discharge
and/or acute vaginal dryness, itchiness. Examination findings include
inflamed tissue of the vulva.
o
Men rash or excoriation of the skin of the penis, possible pruritus.
❖ Treatment: Monistat (OTC) or topical -azoles fluconazole, miconazole
Intravaginal . Male generally no treatment is necessary.
❖ Women with recurrent yeast infections should be assessed for diabetes.
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Vaginitis 2
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Vaginitis: Trichomoniasis
❖ A sexually transmitted form of vaginitis caused by Trichomonas
vaginalis.
❖ Trichomoniasis is the most common asymptomatic nonviral STI.
❖ Signs and symptoms include a thin, yellow-green, frothy vaginal
or urethral Malodorous discharge , vaginal or vulvar erythema,
dyspareunia, pelvic pain, dysuria, urinary frequency, and offschedule bleeding. Some women, however, are asymptomatic.
❖ Findings include cervical bleeding on contact, cervical petechiae,
and vaginal or vulvar erythema
❖ If untreated, may lead to pelvic inflammatory disease (PID).
❖ Trichomoniasis may be treated with a single dose of
Metronidazole.
❖ Sexual partners must be treated as well to avoid reinfection.
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Trichomoniasis
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Chlamydia
❖ Most commonly diagnosed bacterial STI in the States.
❖ Often asymptomatic. Most common symptoms are dysuria
and frequency of urination. Men may experience urethritis,
females may experience cervicitis, PID
❖ Can scar fallopian tubes, cause infertility, ectopic pregnancy,
postpartum endometritis, PROM. Pneumonia in babies and
conjunctivitis.
❖ Diagnosed by urinalysis or swab sampling to culture.
❖ Treatment includes Azithromycin or Doxycycline.
❖ Sexual partners should also be treated.
❖ Retesting should be done 3 months after treatment.
❖ The law mandates reporting
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Gonorrhea
❖ Bacterial STI may cause infertility, ectopic pregnancy,
and pelvic pain.
❖ Symptoms are similar to chlamydia.
o Locally enlarged lymph nodes
❖ Because most people are asymptomatic, routine
screening is recommended.
❖ First-line treatment often single dose of ceftriaxone and
azithromycin, or doxycycline. Although some strains are
antibiotic resistant.
❖ Sexual partners should also be treated.
❖ The law mandates reporting .
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Gonorrhea
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Syphilis
❖ STI occurs in 4 stages:
o
Primary: May present as single, painless chancre, multiple or
uncomfortable lesions where the point of entry was.
o
Secondary : Individual may have a rash, fever. Weight loss.
o
Latent: Asymptomatic period that may last for years.
o
Tertiary: May affect multiple organ systems including brain,
nerves, and joints.
❖ Blood tests: Venereal disease research laboratory (VDRL)(RPR)
serum
❖ Penicillin G is the treatment of choice single dose. Treat both
partners. Doxycycline or tetracycline if allergy to PCN.
❖ The law mandates reporting
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Syphilis
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HPV
❖ Most common STI
❖ Presents with wart-like lesions that are soft, moist, or flesh
colored and appear on the vulva and cervix, and inside and
surrounding the vagina and anus.
❖ Two types of HPV are responsible for the majority of cervical
cancers ( types 16 and 18)
❖ HPV vaccination: Gardasil or Gardasil 9 for 9 to 26 years old,
(before having sex0, ideally at age 11, both sexes, 3 doses.
❖ Dx; warts: based on appearance, based on Pap: colposcopy or
biopsy.
❖ Treatment : For genital warts ,apply creams Imiquimod,
podofilox (Condylox).
❖ Lesion are contagious.
❖ Even after warts are removed the HPV infection remains.
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HPV
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Pelvic Inflammatory Disease (PID)
❖ Inflammation of upper female genital tract.
❖ Causative agents:
o
Chlamydia, trichomoniasis and Neisseria gonorrhoeae.
❖ Infertility may occur due to post- infection.
❖ More common-sexually active women younger than 25 years.
❖ Risk factors – multiple partners, IUD, regular douching.
❖ Symptoms:
❖ Women may be asymptomatic or
o
Severe abdominal, uterine, and ovarian pain and tenderness
fever ,elevated WBC
❖ Treatment
o
o
Antibiotics, analgesic
Sexual partner.
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Toxic Shock Syndrome (TSS)
❖ Primarily a disease of women at or near menses, or during
the postpartum period, but it can happen to anyone exposed
to the bacteria.
❖ Causative organism is a toxin released by a strain of
Staphylococcus aureus.
❖ Related to the use of superabsorbent tampons, contraceptive
devices - cervical cap or diaphragm during menses.
❖ Signs and Symptoms: abnormally hypotension, flu-like
symptom, rashes especially on the palms and bottoms of the
feet, peeling skin, and seizures.
❖ Treatment- antibiotics, low blood pressure
medication, other supportive care.
❖ Instruct the patient to change tampons
frequently.
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Herpes Simplex Virus
❖ Transmitted by skin-to-skin contact, usually of the mucosa. No
cure.
❖ HSV 1 and HSV 2
❖ Presents with small red bumps with blisters or open sores in
the area where the virus enters the body. Cervix, vagina or
outer peritoneal area. Results in inflammation and pain.
❖ Flu-like symptoms may develop or asymptomatic. Itching or
burning genital ,anus area.
❖ Treated with Acyclovir. Oral analgesics, cool compresses that
has peppermint.
❖ Outbreaks are triggered by emotional stress, use of
corticosteroids, sexual intercourse.
➢ Abstain from sex while the lesions resolve.
➢ Good handwashing
technique.
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Herpes Simplex Virus
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Hepatitis B
❖ Primary modes of Hepatitis B transmission are perinatally,
unprotected sex, and IV drug use.
❖ may be asymptomatic or include symptoms
❖ People with hepatitis B are at risk for cirrhosis, liver failure, liver
cancer, and death.
❖ Vaccination is the most effective means of avoiding hepatitis B
infection.
o
hepatitis B recombinant vaccine
o
Provided in 3 doses, first dose at birth, with the second dose 1
month after the first and the third dose 6 months after the first.
❖ Risk factors include having multiple sex partners, engaging in
unprotected anal intercourse, and having a history of other STIs.
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Human Immunodeficiency Virus (HIV) and
Acquired Immunodeficiency Syndrome (AIDS)
❖ HIV retrovirus attacks and destroys T Lymphocytes.
❖ Symtoms: fever, fatigue, anemia, diarrhea and weight loss.
❖ Risk: contaminated blood products, IV drug use, and having
unprotected intercourse.
❖ Dx: Antibody screening (EIA), Confirm Western Blot.
o
Rapid antibody (blood and urine) for client in labor
o
Screen for STI if seeking treatment
o
Obtain viral load levels ad CD4 cell counts through pregnancy
❖ Treatment :ART( antiretroviral therapy) PO
❖ Has profound implications for the fetus if infected woman is
pregnant. Know treatment in pregnancy/Labor/ postpartum!!
❖ The law mandates reporting.
❖ If vaginal deliver do not use instruments can mixed with baby's
blood.
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Question #2
The nurse plays a vital role in screening patients for a
possible HIV infection. What questions below could the
nurse ask to help identify a patient who is at risk for HIV?
Select all that apply:
A. “How often do you use alcohol or drugs?”
B.
“Have you recently experienced an abusive
relationship?”
C.
“If you are sexually active, do you or your partner
use protection?”
D.
“In the past month, have you felt sad or unable to
get out of bed?”
E.
“Have you ever been treated for a sexually
transmitted infection?”
F.
“Do you ever experience intrusive or unwanted
thoughts?”
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Chapter 29
Family Planning
Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Family Planning
❖ Family Planning -https://youtu.be/IEffOROmkbQ
❖ Family planning includes any educational, social, or
health care interventions that allow people to plan
reproduction.
❖ Family planning includes contraception, abortion, and
subfertility or infertility care.
❖ Nurses participating in family planning
o must be respectful of patient choice and careful
not to interject his or her own biases.
o must establish realistic outcomes for the patient
o must be sensitive to the couple's religious,
cultural, and moral beliefs.
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Contraception
❖ The goal of contraception is to prevent unwanted or mistimed pregnancy. (specially with
teenagers).
❖ Major types of contraception include:
o
Long-acting reversible contraception (LARC)
o
Combined oral contraceptives (COCs)
o
Progestin only pills (POPs)
o
Hormonal patches
o
Hormonal vaginal rings
o
Barrier methods
o
Spermicide
o
Natural family planning (NFP)
o
Withdrawal
o
Contraceptive injections
o
Sterilization
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Contraception Considerations
❖ The most effective methods of birth control are
bilateral tubal ligation (BTL), vasectomy, and
methods of LARC (contraceptive implants and
intrauterine contraception).
❖ Contraception decisions involve evaluating family
planning goals.
❖ A contraceptive method is only as good as the
patient’s adherence to and continued, consistent use
of the method once adopted.
❖ When counseling nurses must consider the efficacy of
the method and the future childbearing plans.
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Hormone-Containing Birth Control:
COCs
❖ Relief of menstrual symptoms, lessened cramps, decreased
flow, improved cycle regularity.
❖ Contain 21 hormone-containing pills followed by 7 placebo
pills or packaging is 84 hormone pills followed by 7 placebo
pills (known as extended cycling)
❖ Works by increasing viscosity of cervical mucus, suppressing
ovulation, and thinning the uterine lining.
❖ Contraindications for birth control containing estrogen include
migraine with aura, history of DVT, hypertension, >35 y/old,
diabetic retinopathy.
❖ Side effects: weight gain, depression ,breakthrough bleeding
(specially with teenagers), and thromboembolism.
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Hormone-Containing Birth Control: POPs
❖ Progestin-only pills (POPs) contain only progestin
(artificial form of progestin).
❖ Safe for breastfeeding mothers.
❖ All 28 pills in a pack contain progestin (no placebo
pills).
❖ Must be taken within a 3-hour window every day to
be effective.
❖ Primary side effect is a less regular period and more
breakthrough bleeding, clots
❖ Patients on OCP reporting chest pain and SOB
should go to the Emergency room.
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Hormone-Containing Birth Control:
Vaginal Ring
❖ Contraceptive rings are flexible silicone
rings impregnated with estrogen and
progestin.
❖ The woman places the ring inside her
vagina for 3 weeks, removes it for a week
to create a withdrawal bleed, and then
replaces it with a new ring. E.g, NuvaRing.
❖ Ring can be removed for intercourse and
left out for up to 3 hours per day.
❖ The ring can be dislodged during a bowel
movement. The nurse should teach the
patient to check placement of the ring.
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Hormone-Containing Birth Control:
Contraceptive Patch
❖ A contraceptive patch contains
estrogen and progestin and is
applied weekly for 3 weeks.
Followed by a patch-free week,
which will cause a withdrawal
bleed.
❖ The patch should be applied on
the upper back, upper arm,
upper buttock, or lower
abdomen, but not on the breast.
❖ The woman should rotate the
cite weekly to avoid skin
irritation.
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Hormone-Containing Birth Control:
Emergency Contraception
❖ Emergency contraception (EC) “morning-after pill”.
o
Levonorgestrel (PlanB):
▪ Available over the counter or by prescription and is most
effective when taken within 72 hours of unprotective
intercourse.
▪ Works by preventing ovulation and does not affect an
established pregnancy.
o
Ulipristal (Ella):
▪ Available by prescription only. May be used within 120
hours of unprotected intercourse.
▪ Works as a progestin blocker and may affect an existing
pregnancy.
❖ Side effects: nausea, vomiting, headache, and irregular bleeding.
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Hormone-Containing Birth Control:
Contraceptive Injection *
❖ Medroxyprogesterone acetate (brand name: Provera)
is a progestin-only injection given every 13 weeks until
pregnancy is desired.
❖ Start DMPA within 7 days of the start of her last
menstrual cycle. Breastfeeding clients start 6 weeks
postpartum.
❖ Concerns include weight gain. Decreased bone mineral
density. Maintain adequate intake of calcium or increase it
and weight bearing exercises.
❖ Not a good choice for patients that wants to get pregnant
within 3 months.
❖ Benefits include less frequent or scant menses.
❖ Do not massage the site, decreased absorption.
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Hormone-Containing Birth Control:
Contraceptive Implant
❖ A 4-cm rod of nonestrogen etonogestrel is inserted
under the skin of the inner upper arm. E.g., Implanon
and Nexplanon.
❖ Approved for use for 3 years, contraceptive implant
works by creating changes to cervical mucus and to
fallopian tube motility that impede fertilization. Also
suppresses follicle maturation and ovulation.
❖ A BMI greater than 30 may make contraceptive
implants less effective.
❖ Unscheduled bleeding is a common side effect.
❖ A majority of women ovulate within a month of
removal.
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Hormone-Containing Birth Control:
Intrauterine Contraception #1
❖ (IUCs or IUDs) are T-shaped plastic devices
inserted into the uterus. Releases chemical
substance that damage the sperm.
❖ The copper IUD may last 10 years. E.g.,
ParaGard. Does not contain hormones.
❖ The progestin IUD may last 5 years. E.g., Skyla,
Liletta, Mirena.
❖ Sign a consent
❖ Perform a pregnancy test.
❖ Perform a U/S if pregnancy is suspected after
insertion.
❖ Contraception can be reverse immediately.
❖ Can cause irregular menstrual bleeding.
❖ Require the collection of cultures for sexually
transmitted infections prior to placement.
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Intrauterine Contraception #2
❖ Women should report new acute cramping, bleeding, late
period, fever, unusual bleeding, pain with intercourse.
❖ Not longer recommended to check for string placement
monthly to verify placement.
❖ With IUC placement, women are screened for STIs.
❖ Contraindicated in women with menorrhagia
❖ Risk for bacterila vaginosis , PID, uterine perforation or
uterine expulsion.
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Barrier Methods of Birth Control: Condoms
❖ Male condoms are generally less effective as
contraceptives but the best protection against STIs
(other than abstinence).
❖ A new condom should be used with each episode of
oral, rectal, or vaginal sex with a partner whose STI
status is unknown.
❖ The condom should be applied prior to genital
contact, on an erect penis ,leaving a space at the
tip for sperm reservoir.
❖ Condoms should be removed and discarded
immediately after ejaculation.
❖ Latex and polyurethane protect against STI , but
made of natural skin no.
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Barrier Methods of Birth Control:
Diaphragm
❖ The diaphragm is a flexible saucer that
is placed into the vagina to cover the
cervix and area around it. It does not
protect against STIs.
❖ Fit should be checked if the woman
gives birth, has a miscarriage or
abortion, or gains or loses more than
10 pounds.
❖ Should be replaced every 2 years.
❖ Avoid if latex allergy.
❖ Used with spermicidal cream or gel.
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Barrier Methods of Birth Control:
Contraceptive Sponge
❖ A contraceptive sponge is a 2-inch round, spermicideinfused, foam disk that fits over the cervix, and is
available over the counter. Protect the sperm form
entering the vagina.
❖ One size fits all.
❖ Prior to insertion, the woman wets the sponge and
inserts it with her fingers into the top of her vagina.
❖ May be placed up to 24 hours before sexual
intercourse but should stay in no more than 30 hours.
❖ Risk for TSS if left in the vagina.
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Natural Family Planning (NFP)
❖ Abstinence: The most effective contraception
method.
❖ Calendar: track menstrual cycle to determine
time of ovulation. Avoid intercourse on days
8-19 of the cycle and record menstrual cycles
6-8 months to determine fertile days.
❖ Basal Body Temperature (BBT):Symptom base
method. a slight dip temperature just before
ovulation, then rises sharply and thinning
cervical mucus).
o Teach to take temperature before
getting out of bed in the morning .
o avoid intercourse when temperature
rise and for at least three days after.
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Natural Family Planning (NFP) 2
❖ Billings or cervical mucous method.
o At time of ovulation mucous is
clear and stretchy (spinnbarkeit)
amiable to sperm.
❖ Withdrawal or coitus interruptus:
o
Be aware ejaculatory fluid can
leak form the penis prior to
ejaculation. It contain sperm.
o
Free, safe and acceptable where
religious beliefs prohibit other
methods.
o Highest risk for unintended
pregnancy.
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Question #1
A couple plans to try for a baby after they get married in 3
months. Based on their situation, what method of birth
control might be best for them?
A. A progestin intrauterine device
B. A Depo Provera injection
C. Condoms
D. None of the above
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Question #2
A patient is interested in emergency contraception due to
unprotected intercourse that occurred 1 week ago. What is the
best response by the nurse?
A. “Levonorgestrel (Plan B) can be use now as emergency
contraception.”
B. “Emergency contraception is only available after a sexual
assault.”
C. “Emergency contraception should be taken within 72 to
120 hours to be effective.”
D. “A progestin intrauterine device may be inserted at this
time for emergency contraception.”
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Sterilization
❖ Bilateral Tubal Ligation (BTL) may involve the cauterization, suturing,
clamping, or removal of a portion the fallopian tubes. (Normal ovulation
continues).
❖ Surgical, permanent procedure with general or spinal anesthesia.
❖ Vasectomy is the safest means of permanent sterilization and the most
cost-effective. Involve clamping, cutting and sealing the vas deferens to
prevent the release of sperm. Local anesthesia.
o
Does not produce immediate sterility. Takes about 6–8 weeks.
o
Resume sexual intercourse in about 1 week.
o
Use a birth control method until a negative sperm reports occur.
o
Does not protect against STIs
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Abortion #1
❖ Abortion is the spontaneous or elective termination of
pregnancy before 20 weeks’ gestation
❖ Abortions are referred to as
o
Induced medical or surgical termination of pregnancy
before fetal viability
▪ Medical abortions : 200 mg of Mifepristone (RU-486)
followed by 800 μg of Misoprostol 6 hours later.
✓ Complications :prolonged bleeding and incomplete
abortion.
✓ Monitor vital signs, pain, and bleeding, for at least
30 minutes after the procedure.
▪ Surgical :is typically done by uterine aspiration and is
also called dilation and curettage (D&C).
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Abortion #2
❖ Elective: termination of pregnancy before fetal viability at
the request of the woman
❖ Therapeutic: termination of pregnancy for serious maternal
medical indications or serious fetal anomalies.
❖ Spontaneous: (SAB) abortion occurring without medical or
mechanical means, also called miscarriage.
o The majority (80%) occur in the first 12 weeks of
gestation and are termed early abortion, and more than
half of those are a result of chromosomal abnormalities.
❖ Women who are Rh negative should be given Rh o (D)
immune globulin
❖ Nurses who participate in abortion care should know state
laws
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Fertility
❖ Infertility is defined as lack of conception despite unprotected
sex for at least 1 year (6 months if the woman is over 35 years
old).
❖ Some couples may need information about ovulation and
timing intercourse.
❖ Infertility may be related to male factors or female factors. The
cause is determined after tests are done.
❖ Overweight or underweight women may be counseled to lose
or gain weight to induce ovulation.
❖ Test: Hysterosalpingogram. Do not perform in patients allergic
to selfish.
❖ Patients may experience anger at others who have babies,
feelings of failure because they cannot make a baby and guilt
of one partner because unable to give the other a baby.
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Fertility: Evaluation
Prolonged heat exposure is a gonadotoxin.
Several medications such as calcium channel blockers can influence
sperm production.
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Fertility: Clomid
❖ Clomiphene citrate (Clomid) is a selective estrogen receptor
modulator and common first-line medication to induce
ovulation.
❖ Usually is started 5 days after the start of menses.
❖ Ovarian hyperstimulation syndrome (OHSS) may occur:
o ovarian enlargement, severe GI symptoms, abdominal
swelling/ pain, shortness of breath, pleural effusions,
decreased urination.
o Seek medical care if these symptoms develop.
❖ The risk of multiple gestation increase.
❖ Side effect: breast pain or tenderness, nausea, vomiting,
flushing.
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Artificial Reproductive Technology (ART)
❖ ART is used to treat infertility.
❖ Intrauterine insemination: sperm is prepared and then
introduced in the uterus at the time of ovulation.
❖ In Vitro Fertilization (IVF) fertilized eggs with sperm in the
laboratory will be transferred into the woman uterus
❖ Gamete intrafallopian tube: gametes injected into fallopian
tubes via laparoscopy after being placed together in a catheter.
❖ Donor oocyte or Donor embryo,
❖ Gestational carrier,
❖ Surrogate mother,
❖ Therapeutic donor insemination.
❖ Risk for eptopic and multiple pregnancies
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Question #3
Which of the following would a provider diagnose with
infertility?
A. A 37-year-old woman trying to get pregnant for
7 months
B. A 24-year-old woman trying to get pregnant for
11 months
C. A 30-year-old woman trying to get pregnant for
6 months
D. A 34-year-old woman trying to get pregnant for
10 months
E. None of the above
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