Case Study: Polyhydramnios

Polyhydramnios

• Abnormally large amount of amniotic fluid in the uterus.
• Normal range from 500 to 1,000 ml at term; typically greater than 2,000 ml in polyhydramnios at 40 weeks’ gestation.

Also called hydramnios

• Possible complications: 

1. prolapsed umbilical cord when membranes rupture
2. increased incidence of malpresentations
3. increased perinatal mortality from fetal malformations and premature deliveries
4. increased incidence of postpartum maternal hemorrhage

Kinds/Degrees of Polyhydramnios

1.       Mild Polyhydramnios – when amniotic fluid pockets is between 8 to 11 cm in vertical dimensions. (85%)

2.       Moderate Polyhydramnios – when amniotic fluid pockets is between 12 to 15 cm in vertical dimensions. (17%)

Predisposing Factors

• Multiple pregnancy
• Fetal abnormalities – esophageal atresia, anencephaly, spina bifida
• Diabetes Mellitus

Pathophysiology

• Normally, amniotic volume is maintained by a balance of fetal fluid production (lung liquid and urine) and fluid resorption (fetal swallowing and flow across the membrane to the fetus or the maternal uterus).
• Fetal urine is the primary source of amniotic fluid with output at term ranging from 400 to 1,200 ml/day.
• Fetal swallowing is believed to be the major route of amniotic fluidresorption.
• With polyhydramnios, fluid accumulates because of a problem with the fetus’s ability to swallow or absorb the fluid or as a result of over production of urine.
• Fluid may have increased gradually (chronic type) by the third trimester or rapidly (acute type) between 20 and 24 week’s gestation.

Causes

• Exact cause is unknown in about 35% of all cases.
• May be associated with:

1. diabetes mellitus (about 25%)
2. erythroblastosis ( about 10%)
3. multiple gestations (about 10%)
4. anomalies of the central nervous system (such as neural tube defects)
5. GI anomalies such as tracheoesophageal fistula that prevent ingestion of the amniotic fluid (about 20%).

Assessment Findings

• Depend on the length of gestation, the amount of amniotic fluid, and whether the disorder is chronic or acute.
• Mild signs and symptoms; maternal abdominal discomfort, slight dyspnea, and edema of feet and ankles.
• Severe signs and symptoms; severe dyspnea, orthopnea, and significant edema of the vulva, legs, and abdomen.
• Symptoms common to mild and severe cases: uterine enlargement greater than expected for the length of gestation, and difficulty in outlining the fetal parts and in detecting fetal heart sounds.

Test Results

• Ultrasonography shows evidence of excess amniotic fluid as well as underlying conditions.
• Amniotic fluid index is 20 cm or greater.

Treatment

• High protein, low sodium diet
• Mild sedation
• Indomethacin therapy – a drug that decreases the fetal urine formation. The side effect of indomethacin, as with other prostaglandin synthase inhibitors, is the potential premature closure of the ductus arteriosus.
• Amniotomy – The fluid is removed by a needle inserted through the cervix. The danger of this procedure is cord proplapse and abruptio placenta. to prevent these complications, amniotic fluid must be removed gradually.Watch closely for hemorrhage after delivery, prevent uterine relaxation by massaging the uterus and administering oxytoxin as ordered.
• Induction of labor if the fetus is mature and symptoms are severe.

Nursing Interventions

• Mild to moderate degrees usually does not require treatment.
• Hospitalization if symptoms are severe dyspnea, abdominal pain and difficult ambulation.
• Maintain bed rest with sedation to make the situation endurable.
• Monitor the patient for signs and symptoms of premature labor.
• Monitor maternal vital signs and fetal heart rate frequently; report changes immediately.
• Prepare the patient for amniocentesis and possible labor induction, as appropriate; keep in mind that amniocentesis for fluid removals is only temporary and may need to be done repeatedly.

Case Study: Oligohydramnios

Oligohydramnios

§ Severe reduction of amniotic fluid volume (typically less than 500 ml at term); highly concentrated urine.

§ Possibility of prolonged, dysfunctional labor (usually beginning before term).

§ Fetal risk: renal anomalies, pulmonary hyperplasia, hypoxia, increased skeletal deformities, and wrinkled, leathery skin.

Causes

§ Exact cause is unknown.

§ Any condition that prevents the fetus from making urine or that blocks urine from going into the amniotic sac.

§ Contributing factors: uteroplacental insufficiency, premature rupture of membranes prior to labor onset, maternal hypertension, maternal diabetes, intrauterine growth restriction, postterm pregnancy, fetal renal genesis, polycystic kidneys, and urinary tract obstructions.

Assessment

§ Asymptomatic

§ Lagging fundal height growth.

Test result

§ Ultrasonography reveals no pockets of amniotic fluid larger than 1 cm.

Treatment

§ Close medical supervision of the mother and fetus.

§ Fetal monitoring

§ Amnioinfusion (infusion of warmed sterile normal saline or lactated Ringer’s solution) to treat or prevent variable decelerations during labor.

Nursing Interventions

1.     Monitor maternal and fetal status closely, including vital signs and fetal heart rate patterns.

2.     Monitor maternal weight gain pattern, notifying the health care provider if weight loss occurs.

3.     Provide emotional support before, during, and after ultrasonography.

4.     Inform the patient about coping measures if fetal anomalies are suspected.

5.     Instruct her about signs and symptoms of labor, including those she’ll need to report immediately.

6.     Reinforce the need for close supervision and follow up.

7.     Assist with amnioinfusion as indicated.

8.     Encourage the patient to lie on her left side.

9.     Ensure that amnioinfusion solution is warmed to body temperature.

10.  Continuously monitor maternal vital signs and fetal heart rate during the amnioinfusion procedure.

11.  Note the development of any uterine contractions, notify the health care provider, and continue to monitor closely.

12.   Maintain strict sterile technique during amnioinfusion.

Article: History of Nursing in the Philippines

Early Beliefs, Practices and Care of the sick

• Early Filipinos subscribed to superstitious belief and practices in relation to health and sickness
• Diseases, their causes and treatment were associated with mysticism and superstitions
• Cause of disease was caused by another person (an enemy of witch) or evil spirits
•  Persons suffering from diseases without any identified cause were believed bewitched by “mangkukulam”
•  Difficult childbirth were attributed to “nonos”
• Evil spirits could be driven away by persons with powers to expel demons
• Belief in special Gods of healing: priest-physician, word doctors, herbolarios/herb doctors

Early Hospitals during the Spanish Regime – religious orders exerted efforts to care for the sick by building hospitals in different parts of the Philippines:

• ·         Hospital Real de Manila San Juan de Dios Hospital
• ·         San Lazaro Hospital Hospital de Aguas Santas
• ·         Hospital de Indios

Prominent personages involved during the Philippine Revolution

1.        Josephine Bracken – wife of Jose Rizal installed a field hospital in an estate in Tejeros that provided nursing care to the wounded night and day.

2.        Rose Sevilla de Alvaro – converted their house into quanters for Filipino soldiers during the Phil-American War in 1899.

3.        Hilaria de Aguinaldo –wife of Emlio Aginaldo organized the Filipino Red Cross.

4.        Melchora Aquino – (Tandang Sora) nursed the wounded Filipino soldiers, gave them shelter and food.

5.        Captain Salomen – a revolutionary leader in Nueva Ecija provided nursing care to the wounded when not in combat.

6.        Agueda Kahabagan – revolutionary leader in Laguna also provided nursing services to her troops.

7.        Trinidad Tecson (Ina ng Biak na Bato) – stayed in the hospital at Biac na Bato to care for the wounded soldiers.

School Of Nursing

1.        St. Paul’s Hospital School of Nursing, Intramuros Manila – 1900

2.        Iloilo Mission Hospital Training School of Nursing – 1906

1909 – distinction of graduating the 1^st trained nurses in the Phils.With no standard requirements for admission of applicants except their “willingness to work”

April 1946 – a board exam was held outside of Manila. It was held in the Iloilo Mission Hospital thru the request of Ms. Loreto Tupas, principal of the school.

3.        St. Luke’s Hospital School of Nursing – 1907;opened after four years as a dispensary clinic.

4.        Mary Johnston Hospital School of Nursing – 1907

5.        Philippines General Hospital school of Nursing – 1910

College of Nursing

1.        UST College of Nursing – 1^st College of Nursing in the Phils: 1877

2.        MCU College of Nursing – June 1947 (1^st College who offered BSN – 4 year program)

3.        UP College of Nursing – June 1948

4.        FEU Institute of Nursing – June 1955

5.        UE College of Nursing – Oct 1958

1909

• ·         3 female graduated as “qualified medical-surgical nurses”

1919

• ·         The 1^st Nurses Law (Act#2808) was enacted regulating the practice of the nursing profession in the Philippines Islands. It also provided the holding of exam for the practice of nursing on the 2^nd Monday of June and December of each year.

1920

• ·         1^st board examination for nurses was conducted by the Board of Examiners, 93 candidates took the exam, 68 passed with the highest rating of 93.5%-Anna Dahlgren theoretical exam was held at the UP Amphitheater of the College of Medicine and Surgery. Practical exam at the PGH Library.

1921

• ·         Filipino Nurses Association was established (now PNA) as the National Organization Of Filipino Nurses

PNA: 1^st President – Rosario Delgado
Founder – Anastacia Giron-Tupas

1953

• ·         Republic Act 877, known as the “Nursing Practice Law” was approved.

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Article: Historical Evolution of Nursing

I. Period of Intuitive Nursing/Medieval Period

• Nursing was “untaught” and instinctive. It was performed of compassion for others, out of the wish to help others.
• Nursing was a function that belonged to women. It was viewed as a natural nurturing job for women. She is expected to take good care of the children, the sick and the aged.
• No caregiving training is evident. It was based on experience and observation.
• Primitive men believed that illness was caused by the invasion of the victim’s body of evil spirits. They believed that the medicine man, Shaman or witch doctor had the power to heal by using white magic, hypnosis, charms, dances, incantation, purgatives, massage, fire, water and herbs as a mean of driving illness from the victim.
• Trephining – drilling a hole in the skull with a rock or stone without anesthesia was a last resort to drive evil spirits from the body of the afflicted.

II. Period of Apprentice Nursing/Middle Ages

• Care was done by crusaders, prisoners, religious orders
• Nursing care was performed without any formal education and by people who were directed by more experienced nurses (on the job training).This kind of nursing was developed by religious orders of the Christian Church.
• Nursing went down to the lowest level

1. wrath/anger of Protestantism confiscated properties of hospitals and schools connected with Roman Catholicism
2. Nurses fled their lives; soon there was shortage of people to care for the sick
3. Hundreds of Hospitals closed, there was no provision for the sick, no one to care for the sick
4. Nursing became the work of the least desirable of women – prostitutes, alcoholics, prisoners

• Pastor Theodore Fliedner and his wife, frederika established the Kaiserswerth Institute for the training of Deaconesses (the 1^st formal training school for nurses) in Germany.
• This was where Florence Nightingale received her 3-month course of stude in nursing.

III. Period of Educated Nursing/Nightingale Era 19^th-20^th century

• The development of nursing during this period was strongly influenced by:

1. trends resulting from wars – Crimean, civil war
2. arousal of social consciousness
3. increased educational opportunities offered to women.

• Florence Nightingale was asked by Sir Sidney Herbert of the British War Department to recruit female nurses to provide care for the sick and injured in the Crimean War.
• In 1860, The Nightingale Training School of Nurses opened at St. Thomas Hospital in London.

1. The school served as a model for other training schools. Its graduates traveled to other countries to manage hospitals and institute nurse-training programs.
2. Nightingale focus vision of nursing Nightingale system was more on developing the profession within hospitals. Nurses should be taught in hospitals associated with medical schools and that the curriculum should include both theory and practice.
3. It was the 1^st school of nursing that provided both theory-based knowledge and clinical skill building.

• Nursing evolved as an art and science
• Formal nursing education and nursing service begun

FACTS ABOUT FLORENCE NIGHTINGALE

• Mother of modern nursing. Lady with the Lamp because of her achievements in improving the standards for the care of war casualties in the Crimean war.
• Born may 12, 1800 in Florence, Italy
• Raised in England in an atmosphere of culture and affluence
• Not contended with the social custom imposed upon her as a Victorian Lady, she developed her self-appointed goal: To change the profile of Nursing
• She compiled notes of her visits to hospitals and her observations of the sanitary facilities, social problems of the places she visited.
• Noted the need for preventive medicine and god nursing
• Advocated for care of those afflicted with diseases caused by lack of hygienic practices
• At age 31, she entered the Deaconesses School at Kaiserswerth inspite of her family’s resistance to her ambitions. She became a nurse over the objections of society and her family.
• Worked as a superintendent for Gentlewomen Hospital, a charity hospital for ill governesses.
• Disapproved the restrictions on admission of patients and considered this unchristian and incompatible with health care
• Upgraded the practice of nursing and made nursing an honorable profession for women.
• Led nurses that took care of the wounded during the Crimean war
• Put down her ideas in 2 published books: Notes on Nursing, What It Is ans What It Is Not and Notes on Hospitals.
• She revolutionized the public’s perception of nursing (not the image of a doctor’s handmaiden) and the method for educating nurses.

IV. Period of Contemporary Nursing/20^th Century

• Licensure of nurses started
• Specialization of Hospital and diagnosis
• Training of Nurses in diploma program
• Development of baccalaureate and advance degree programs
• Scientific and technological development as well as social changes mark this period.

1. Health is perceived as a fundamental human right
2. Nursing involvement in community health
3. Techological advances – disposable supplies and equipments
4. Expanded roles of nurses was developed
5. WHO was established by the United Nations
6. Aerospace Nursing was developed
7. Use of atomic energies for medical diagnosis, treatment
8. Computers were utilized-data collection, teaching, diagnosis, inventory, payrolls, record keeping, billing.
9. Use of sophisticated equipment for diagnosis and therapy.

Article: Periods in the History of Nursing

Intuitive Nursing

• From Prehistoric times up to the early Christian Era
• Untaught and Instinctive
• Nursing performed out of compassion
• Nursing belonged to women

Apprentice Nursing

• From the founding of the Religious orders in the 11th century up to 1836 with the establishment of the Kaiserwerth Institute for training of Deaconesses
• Period of “on-the-job training”
• Nursing performed without any formal education and by people who were directed by more experienced nurses
• Important personalities in this period:

1. St. Clare-gave nursing care to the sick and the afflicted
2. St. Elizabeth of Hungary- Patrones of nurses
3. St. Catherine of Siena- First lady with a lamp

Dark period of Nursing

• From the 17th century up to 19th century
• Nursing became the work of the least desirable of women

Educated Nursing

• Began on June 15, 1860 when Florence Nightingale School of nursing opened St. Thomas Hospital in London
• Development of nursing was strongly influenced by trends resulting from wars, from an arousal of social consciousness, from the increased educational opportunities offered to women

Contemporary Nursing

• Covers the period after the world war II to the present
• Marked by scientific and technological developments as well as social changes

Article: Florence Nightingale Biography

Florence Nightingale was born in Italy on 12th May 1820. Despite opposition from her family she decided to devote her life to nursing and campaigning for better health care and sanitation for all. It was her work during theCrimean War that created the legend of the Lady with the Lamp and it was her experience here that drove her to continue, researching, writing and tirelessly campaigning.

After the Crimean War she demanded a Royal Commission into the Military Hospitals and the health of the Army, she began investigating the health and sanitation in the British Army in India, and the local population. Money which had been sent by the general public to thank her for her work in the Crimea was used to establish the first organised, training school for nurses, the Nightingale Training School at St Thomas’ Hospital.

Her greatest achievement was to make nursing a respectable profession for women. Florence’s writings on hospital planning and organization had a profound effect in England and across the world, publishing over 200 books, reports and pamphlets.

Florence died at the age of 90, on 13th August 1910, she had become one of the most famous and influential women of the 19th century. Her writings continue to be a resource for nurses, health managers and planners to this day.

Florence Nightingale is famous for being the ‘Lady with the Lamp’ who nursed soldiers during the Crimean War, but this was just one of her many great achievements.

Case Study with NCP: Pregnancy Induced Hypertension

Pregnancy Induced Hypertension (PIH) is a condition in which vasospasms occur during pregnancy in both small and large arteries. Signs of hypertension, proteinuria, and edema develop. It is unique to pregnancy and occurs in 5% to 7% of pregnancies in the united states. Despite years of research, the cause of the disorder is still unknown. Originally it was called toxemia because researchers pictured a toxin of some kind being produced by a women in response to foreign protein of the growing fetus, the toxin leading to the topical symptoms. No such toxins have ever been identified.

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