OB Module Outcomes Remediation

Acknowledge community resources available to victims of violence.

- Crisis Intervention Center - S.A.R.A.- Sexual Assault Response Advocate volunteers to provide emotional support. Free and confidential - S.A.N.E.- Sexual Assault Nurse Examiner (AdolescentAdult) - Fort Smith PD - Sparks Health System Emergency Room - Mercy Hospital Emergency Room - Hannah House- you women age 13-29 who are experiencing crisis situations in their lives - Next Step Homeless Services- Separate location for females and women with children - Hamilton House Child and Family Safety Center- Center for abused children. SANE pediatric examiner on call - Two Resources for Pregnancy Help

Summarize the nutritional needs of the pregnant woman.

- Replace saturated fats with unsaturated - Make half the plate fruits and veggies - Whole grains in place of refined - Choose foods high in fiber to prevent constipation - Avoid hydrogenated or partially-hydrogenated - Don't consume alcohol, use reduced-fat spreads and dairy products instead of full-fat - At least 2 servings of fish/wk, one being oily - 2 quarts of water daily - Variety of foods from all groups, portion control - Increase vit, mineral, and dietary fiber intake - Lower intake of saturated/trans fat and cholesterol - Adequate synthetic folic acid - Balance caloric intake with exercise to maintain healthy weight

Identify therapeutic nursing communication and non-therapeutic communication statements about violence against women.

- you must be doing something to provoke him. Not therapeutic b/c you are blaming them - I'm really sorry about what has happened to you and your children how can we help you? Yes - Why do you stay with loser? Not therapeutic b/c this is judgmental - You are not responsible for your partners violence. Yes - If you're really being abused you would leave him. This suggest disbelief - What does your partner understand about you being alone we know this can be dangerous

Identify the nursing interventions to provide postpartum and postoperative (C-section) care.

-fundal exam every 15 min. for first hour -allow for privacy if partner/family members are present if mother is stable -place an ice-filled glove wrapped in a wash cloth on her episiotomy site to reduce swelling & trauma to the area -offer fluids to the mother to hydrate her -don't become a 'wedge' between newborn & mother -provide optimal cultural care -promote comfort -assist w/elimination -promote activity, rest, & exercise -prevent stress incontinence -assist w/self-care measures -ensure safety -counsel about sexuality & contraception -promote maternal nutrition -Support the woman's choice of infant feeding method -teach about breast care -promote family adjustment & well-being -prepare for discharge

Analyze key historical changes of maternal and newborn health care.

1700's - men didn't watch - indecent - women NO joy - fear - untrained midwives at home 1800's- 19th Century - doctors for middle class - OB = to stand before - puerperal (childbed fever) = epidemic - 1st C-section - 1st x ray 1900's- 20th Century - twilight Sleep - meds not women were in control - US 17th/20 nations for infant mortality - 50-75% 90% used hospitals - nurseries started due to chloroform gas - Dr. Lamaze wrote book - amniocentesis 1966 - C-section rate 5% in 1970's (NOW 33%) - Non-Medicated/Non-Intervening childbirth in late 1980's - birth classes - 1990's epidural becomes more popular (NOW 50% of women get it) - freestanding Birthing centers 2000's- 21st Century - 1 in 3 C-section - CNM = certified nursing midwife - lots of birthing classes - US 48th in world for maternal deaths; 55th for infant mortality

Describe fetal circulation.

3 Unique Fetal Structure - Ductus venosus: connects the umbilical vein to the inferior vena cava - Ductus arteriosus: connects the main pulmonary artery to the aorta - Foramen ovale: anatomic opening between the right and left atrium Principles - 1 vein (O2 blood via placenta) 2 arteries (de-O2 blood back to placenta) - Fetal lungs and liver fxns are done by placenta

Discuss ethical and legal issues that may arise when caring for women

Abortion Substance Abuse Intrauterine therapy Maternal-fetal conflict Stem cell research Umbilical cord blood banking Informed consent/Assent (agree to) Refusal of Medical treatment Advanced directives Client rights Confidentiality

Compare and contrast various types of contraceptive methods available and their overall effectiveness.

Abstinence: refrain from sexual activity. The only sure way to prevent pregnancy or STIs. Barrier Methods: include male and female condoms. Watch out for latex and spermicidal allergies with barrier method. Patch: Transdermal patch that releases estrogen and progesterone. Looks like a bandaid and gets dirty over time. Apply every week for 3 weeks then leave off for a week. (Period week) Never apply patch to breast tissue. Oral Contraceptives: Most popular method of birth control. Low estrogen pills how fewer SE. Overweight women may need higher doses. Use backup method if on antibiotics. Modest risk for blood clots and PE. Increased risk for MI and stroke. Slight increase risk for breast cancer. Use a back up method if not starting the pack on the first day of the menstrual cycle. Nuva Ring: Vaginal contraceptive ring about 2 inches in diameter that is inserted into the vagina; released estrogen and progesterone. Used when oral contraceptive makes pt. nauseated. Stays in for 3 weeks, removed the 4th week. It can be taken out or up to 3 hours without a back up method. (most often for sex) Intrauterine Contraceptives: T-shaped device inserted into the uterus that releases copper or progesterone or levonorgestrel. The pt may bleed and cramp with each of the IUCs, the hormonal methods do better at stopping the menstrual period. (Mirena, Skyla, copper) Mirena- good for 5 years. For women who already have children. Skyla- good for 3 years. For women who have not yet had children. Copper- good for 10 years. Non hormonal. Depo Provera: An injectable progestin that inhibits ovulation. Be careful in teenagers because it can cause bone loss. Most prevalent of causing weight gain. Shouldn't be prescribed to women who are struggling with their weight. Return visit every 12 weeks.

Examine common reproductive concerns in terms of symptoms, diagnostic tests, and appropriate interventions.

Amenorrhea - The absence of menses (normal in prepubertal, pregnant, postpartum and postmenopausal women) - Primary: (1) Absences of menses by age 14 with absence of growth and development of secondary sex characteristics (a) Intervention: Correction of underlying disorder, estrogen replacement therapy to stimulate development of secondary sex characteristics (2) Absence of menses by age 16 with normal development of secondary sexual characteristics (a) Intervention: Oral contraceptives, nutrition counseling, gonadotropin-releasing hormone (GnRH), thyroid hormone replacement - Secondary (1) pregnancy/breastfeeding, emotional stress/depression/antidepressants, pituitary/ovarian/adrenal tumors, hyper/hypothyroidism, malnutrition, rapid weight gain/loss, chemo/radiation, early menopause, colitis, kidney failure, Sheehan syndrome - Diagnostic tests: ultrasound, hCG, thyroid fnx test, prolactin level, FSH & LH, 17-ketosteroids (elevated could mean adrenal tumor), Karyotype (for Turner syndrome) Dysmenorrhea - Painful menstruation (cyclic perimenstrual pain) - Secondary: caused by painful pelvic or uterine patho - Tests: Blood count, urinalysis, preg test, cervical culture (for STI), Erythrocyte sedimentation rate, stool guaiac test, pelvic/vaginal ultrasound, laparoscopy/laparotomy Interventions: NSAIDS, hormonal contraceptives, Selective estrogen receptor modulators (SERMs), Complementary therapies (Vit B & E, Magnesium, Omega-3), Lifestyle changes (exercise, limit salt, weight loss, no smoking, relaxation techniques) Endometriosis - Most common cause of secondary dysmenorrhea (1) Associated with pain beyond menstruation, dysmenorrhea, dyspareunia, low back pain, heavy/irregular bleeding, bloating, n/v, infertility - Treatment: remove underlying cause - Intervention: surgical intervention, NSAIDS, oral contraceptives, progesterone, Antiestrogens, GnRH-a Infertility - The inability to conceive a child after 1 yr of regular sexual-intercourse unprotected by contraception - Treatment: fertility drugs, surrogacy, donor oocytes or sperm, in vitro fertilization - Lab tests: home ovulation predictor kits, clomiphene citrate challenge test, hysterosalpingography, laparoscopy Premenstrual Syndrome - A constellation of recurrent symptoms that occur during the luteal phase or half last of the menstrual cycle and resolve with the onset of menstruation - Symptoms: anxiety, craving, depression, hydration, hot flashes or cold sweats, nausea, change in bowel habits, aches/pains, dysmenorrhea, acne breakouts - Interventions: CAM Menopause - Natural process that occurs as part of normal aging (1) When menses and fertility cease - Symptoms: (1) Brain: hot flashes, disturbed sleep, mood and memory problems (2) Cardio: lower levels of HDL and increased risk of CVD (3) Skeletal: rapid loss of bone density that increase risk of osteoporosis (4) Breast: replacement of duct and glandular tissue by fat (5) GU: vaginal dryness, stress incontinence, cystitis (6) GI: less absorption of calcium from food, increasing fracture risk (7) Integumentary: dry, thick skin and decreased collagen (8) Body shape: more ab fat; waist swells relative to hips

Discuss the structure and function of the placenta, the umbilical cord and the amniotic fluid.

Amniotic Fluid: - Provides a protective environment and stable temp for fetus - Allows room and buoyancy for fetal movement - Comes from 2 sources: fetal urine and fluid transported from material blood - 98% water, 2% organic solids- clear in color Umbilical Cord: - 1 large vein, 2 small arteries - Wharton's jelly (special connective tissue) surrounds the 3 vessels to prevent compression to not cut off blood and nutrient supply - Reaches max length at 30 wks- determined by genetics, intrauterine space and fetal activity Placenta: - Major fxns: 1) Metabolic 2) transfer of substances between mom and fetus 3) endocrine - ⅙ weight of fetus at term - Maternal side is red, flesh-like - Fetal side is shiny gray-white with vessels showing

Identify the components of the immediate newborn assessment (Apgar Score).

Appearance (color) 0 = cyanotic (bluish or grayish color of the skin) or pale 1 = appropriate body color; blue extremities (acrocyanosis) 2 = completely appropriate color (pink on both trunk and extremities) Pulse 0 = absent or <60 1 = slow between 60-100 2 = >100 Grimace (reflex irritability) 0 = no response 1 = grimace or frown when irritated, weak cries, not very angry when poked 2 = sneeze, cough, or vigorous cry, jerks away when stimulated Activity (muscle tone) 0 = limp, flaccid, no movement 1 = some flexion, limited resistance to extension 2 = tight flexion, good resistance to extension w/ quick return to flexed position after extension. Respiratory (respiratory effort) 0 = apneic (suspension of breathing) "absence of breathing 1 = slow, irregular, shallow 2 = regular respiration's (30-60), strong good cry

Examine the incidence of violence against women.

Assault (homicide) is within the top five causes of death of women aged Birth-44. (Violence Policy Center, 2015) - 94% of women are killed by someone they know. - 62% of those who are killed, are killed by husbands or intimate partners. (Violence Policy Center, 2015) - 25-44% of women will be victims of some kind of violence in their lifetime. - The risk for IPV goes up with pregnancy! - Most professional organizations agree that screening for intimate partner violence is warranted in health care

Assess and discuss the physiological (BUBBLE EE) and psychosocial status of the postpartum woman and nursing interventions for common discomforts.

Breasts Uterus Bladder Bowels Lochia Episiotomy/Laceration Extremities Emotional Status Postpartum: Breasts -have pt lie flat on the bed -palpate both breasts for engorgement -inspect nipples for cracks, fissures -educate pt about wearing a supportive bra 24hr daily (new research supports not bra-more milk) -expose nipples to air after breastfeeding -apply lanolin to nipples to keep soft [does not hurt the baby] Postpartum: Uterus -have pt lie flat on the bed -locate uterus using both hands (one symphysis pubis & one on umbilicus) -uterus should be in the midline & firm (should feel like a grapefruit) -should be located near the umbilicus -usually involutes approximately 1cm/day -massage fundus, if found boggy -assess for full bladder if displaced to right/left Postpartum: Bladder -tremendous diuresis after delivery & should void >200mL each voiding -ask pt of she feels she is emptying her bladder each time she voids [a full bladder can displace the uterus to the right/left causing a postpartum hemorrhage] -palpate bladder to determine residual -2500mL of fluids daily is recommended--need fluid to make milk Postpartum: Bowels -during labor: peristalses ceases -usually is 24hr post delivery before the client's first BM -progressive exercise, fluids, fiber & comfort measures are needed to promote good bowel elimination -hemorrhoids/perineal laceration (check for hemorrhoids while assessing episiotomy) Postpartum: Lochia -assess color, amount & odor of lochia -usually has a 'fleshy' smell; if odor is different mom could have an infection -Lochia rubra -Lochia serosa Postpartum: Episiotomy/laceration -turn pt to either side to examine area -have adequate lightening to visualize area -separate buttocks to expose perineum -inspect for REEDA -severe intractable episiotomy pain = hematoma

Discuss sexually transmitted infections and their treatment

Chlamydia: Azithromycin (Zithromax), Doxycycline (Vibramycin), Erythromycin (EES), Levofloxacin Ofloxacin (Floxin),. Sexual partners need evaluation, testing, and treatment also. Abstinence form sexual activity until therapy is complete and symptoms no longer present. Retesting in 3 months to rule recurrence. Gonorrhea: Dual therapy with Ceftriaxone and azithromycin. Sexual partners need evaluation, testing, and treatment also. Abstinence form sexual activity until therapy is complete and symptoms no longer present. Retesting in 3 months to rule recurrence Herpes type 2: Antivirals used to treat first episode, recurrence and suppression. Acyclovir, valacyclovir, and famiciclovir mainstay in treatment. Does not cure; just controls symptoms. Counseling is important to help adolescent cope and prevent transmission. Sexual partners benefit from counseling. If symptomatic, need treatment. Syphilis: Benzathine penicillin G injection (if PNC allergy, doxycycline, tetracycline, or erythromycin) Sexual partners need evaluation and testing. Trichomoniasis: Metronidazole (Flagyl) or tinidazole. Sexual partners need eval, testing, and treatment also. Abstinence commended until therapy completed. Vereneal warts: Treatment is aimed at removing lesions rather than HPV itself. No optimal treatment has been identified, but there are several ways depending on size and location. Most methods rely on chemical/physical destruction. Freezing, burning, laser treatment, surgical excision. Imiquimod cream.

Discuss sexually transmitted infections, recognizing sexually transmitted infections by assessment findings.

Chlamydia: curable STI. Transmitted by vaginal, anal, and oral sex, and by childbirth. Gonorrhea: curable STI. Adolescents often coinfected with chlamydia. Herpes type 2: lifelong recurrent viral disease. Most people have not been diagnosed. There is no cure. Syphilis: Chronic, multistage, curable bacterial infection. Trichomoniasis: common vaginal infection that causes a discharge, but it is not always sexually transmitted. Venereal warts: one of the most common STIs in the US. Could lead to cancers of the cervix, vagina, anus, or penis. No cure. Warts can be removed, but virus remains. See table 5.2 page 178-181 for S&S.

Develop a safety plan for patients who are victim of intimate partner violence.

Emergency plan: preparing to leave. having somewhere to go, get away bag and hide it, let neighbors know, collecting money and hiding it, if they have children pack them a bag, don't go to a room with no exit not good idea because men can break thru door The women has no resources for help Hide the handouts because she can be more at risk Teaching guideline - Drivers license or photo ID - SS number or green card - Birth certificates for you & kids - Phone numbers for social services or women's shelter - The deed or lease to your home or apartment - Any court papers or orders - A change of clothing for you & your children - Pay stubs, checkbooks, credit cards, & cash - Health insurance cards - Turn to authorities for assistance in gathering this material - Develop a game plan for leaving & rehearse it - Don't use pay phone cards- they leave a trail to follow

Contrast the structure and function of the major external and internal female genital organs.

External Organs a) Mons Pubis - Elevated, rounded, fleshy prominence of fatty tissue that overlay the symphysis pubis; covered with coarse pubuc hair afte puberty - Fxn: Protects the symphysis pubis during sexual intercourse b) Labia majora - Large and fleshy, has sweat and sebaceous glands; covered with hair after puberty - Fxn: to protect the vaginal opening and provide cushioning during sexual activity c) Labia minor - Delicate, hairless folds of skin; lay inside the labia majora and surround opening to urethra and vagina; extend upward to protect clitoris and urethra; highly vascular and high nerve supply - Fxn: lubricate the vulva, swell when stimulated, highly sensitive d) Clitoris and prepuce - Clitoris: small mass of erectile tissue and nerves; highly sensitive and parallel to head of penis - Fxn: purely erogenous - Prepuce: hood-like covering above clitoris of connective tissue of vulva in anterior junction of labia minora e) Vestibule - Oval area closed by labia minora; opening into vestibule are urethra, vagina, and 2 sets of glands f) Perineum - Most posterior part of external female reproductive organs; between vulva and anus Internal Organs a) Vagina - In front of rectum and behind bladder; tubular, fibromuscular organ lined with mucous membrane that lies in a series of transverse folds (rugae)- allows for extreme dilation of canal during birth and labor; connects external to cervix; receives penis and sperm and passageway for menstrual blood and fetus b) Uterus - Inverted, pear-shaped, muscular organ at top of vagina; behind bladder and in front of retcum; site of mensturation, receiving fertilized ovum, development of fetus and contraction to help fetus and placenta out - Cervix: lower part of uterus; opening to vagina; has channel that allows sperm to enter and menstrual discharge to exit; stretches during labor - Corpus: main body of uterus c) Fallopian Tubes - Hollow, cylindrical structure that goes from uterus to ovaries; allows passage of egg to uterus d) Ovaries - Set of paired glands that are the organs of gamete production in females

Assess factors that affect maternity health care.

Family Genetics Society Culture Health status/Access to it Lifestyle Improvements in diagnosis/treatment Empowerment of healthcare consumers

Evaluate the tests used to assess maternal and fetal well being, including nursing management for each.

Fetal/Maternal Assessment a) Alpha Fetoprotein (AFP): predominant protein in fetal plasma - Used to determine the possibility of neural tube defects, DS, molar preg - Can be measured in both maternal serum and amniotic fluid b) Glycosylated Hemoglobin (Ghb Alc): minor hemoglobin w/ glucose attached - Ghb-A1c concentration represents the average blood glucose level over the previous weeks & is a measurement for glycemic control in diabetic therapy

Identify the risk factors, screening methods, characteristics of, and treatment modalities of benign breast conditions (fibrocystic breast changes, fibroadenomas, and mastitis).

Fibrocystic breast changes: may or may not have nipple discharge, found in bilateral upper outer quadrant. Round, smooth several lesions. Cyclic, palpable 30-50 yo. Tenderness present. Aspiration and biopsy. Limit caffeine, ibuprofen, wear support bra. Fibroadenomas: no nipple discharge, found in unilateral nipple area or upper outer quadrant. Round, firm, movable, palpable, rubbery, well delineated single lesion. 15-30 years old. Tender breast. Mammogram "watchful waiting" aspiration biopsy or surgical excision. Mastitis: no nipple discharge, found unilateral outer quadrant. Wedge shaped, warm, redness, swelling, nipple cracking, breast engorgement. Breast tenderness. Antibiotics, warm shower, supportive bra, breast-feed, increase fluids.

Discuss social, political, economic and cultural trends that affect the health status of women and children.

Finances: childbirth is the leading reason for hospitalization - Vaginal delivery: 10-17,000 - C-section: 16-25,000 - Many do not have insurance or enough to cover costs (Medicare, Medicaid, Private insurance: overwhelming so many women do not apply) Sociocultural: lack of transport - Do not schedule or follow-up with appointments - knowledge/language/spiritual/cultural barriers - More children/small children that have to brought along Healthcare Delivery System: - Uninsured - Discharge asap

Calculate a woman's gravidity and parity data while taking history (GTPAL).

G (gravidity): total # of pregnancies T: total # of term delivers (37+ wks) P: total # of preterm delivers (>20 wks, <37 wks) A: total # of abortions L: total # of living children - Parity (P): total # of term + preterm delivers

Identify intimate partner violence screening tools

HITS screening tool (ask verbally) - rate following questions in a way that best describe the frequency your partner acts the way depicted: 1=never, 2=less than monthly, 3= monthly, 4= weekly, 5= daily (score greater than 10 considered positive)

Identify risk factors for intimate partner violence in men.

Individual factors - Young age - Heavy drinking - Personality disorders - Depression - Low academic achievement - Witnessing violence as a child - Experiences violence as child - Low income/unemployment - Desire for power and control - Anger and hostility Relationship factors - Marital conflict - Economic stress - Dysfunctional family - Marital instability - Male dominance in family - Cohabitation - Having outside sexual partners - Taking aggression out on others while growing up Community factors - Weak, sanctions against IPV - Poverty - Low social capital Societal factors - Traditional gender norms - Social norms supportive of violence

Differentiate the advantages and disadvantages of external and internal fetal monitoring, including the appropriate use of each.

Internal fetal monitoring: - IUPC measures amount of pressure inside the uterus in mm of mercury (can be placed by a physician only) - FSE screws on babies head to measure FHR (can be placed by nurses & physicians) advantages: - good option for labor patients at high risk - more accurate - allows for more maternal movement w/o interfering w/ the quality of the tracing disadvantages: - requires ruptured membranes - must have dilation (2cm or more) of the cervix - must have high level of skill to be placed correctly - higher risk for trauma/infection to mother/fetus External fetal monitoring: - TOCO and external ultrasound advantages: - supplies continuous information about fetus - prints/achieves a permanent record - standard of care in US - source of comfort by mother by listening disadvantages: - reduced mobility by the mother - uncomfortable belts around abdomen - limited ability to detect variability (can't measure strength of contractions)

Determine the estimated date of delivery.

LMP: 12-9-17 -3 +7 +1 Due= 9-16-18

Analyze the actions and interactions of hormones that affect the reproductive system and menstrual cycle.

Menstruation: the normal physiologic where inner lining of uterus if shed by body; monthly; at average starts at 12.8 yrs with range 8-18 - thelarche (development of breast buds), adrenarche (appearance of pubic and then axillary hair, followed by growth spurt) to menarche which occurs 2 years after the start of breast development. Menstrual Cycle Hormones - Gonadotropin-releasing hormone (GnRD): secreted from hypothalamus throughout reproductive cycle; pulsates slowly during the follicular phase and increases during the luteal phase; includes release of FSH/LH to help with ovulation - Follicle-Stimulating Hormone (FSH): secreted by anterior pituitary and is responsible for maturation of ovarian follicle; highest and most important during the first week of follicular phase of reproductive cycle - Luteinizing hormone (LH): secreted by anterior pituitary; required for both final maturation of preovulatory follicles and luteinization of ruptured follicle, results in decline in estrogen and continued progesterone - Estrogen: secreted by ovaries and crucial for development and maturation of follicle; end of proliferation phase; drops after ovulation; causes uterus to increase in size and weight - Progesterone: secreted by corpus luteum; increase just before ovulation and peak 5-7 days after; increases swelling and increased secretion of endometrium during luteal phase; reduces uterine contractions - Prostaglandins: primary in body's inflammatory process and for normal fxn of female reproductive system; increase during follicular maturation & key role in ovulation by freeing ovum; large amounts found in menstrual blood and endometrial fluid

Discuss normal neonatal patterns of behavior during the first several hours after birth (newborn reflexes).

Moro Reflex - startle posture w/"C" fingers Palmar Grasp Reflex - firm tight fist when held Babinski Reflex - flaring toes when sole stroked Rooting Reflex - stroke cheek to illicit sucking Tonic Neck Reflex - fencing position while supine Stepping Reflex - legs move up & down on surface

Evaluate the myths and facts about violence.

Myths - Battering of women occurs only in lower socioeconomic classes - Substance abuse causes the violence - Men have the right to discipline their partners. Battering is not a crime - Violence occurs to only a small percentage of women - IPV is a typically a one time, isolated occurrence - Women can easily choose to leave an abusive relationship - Only men with mental health problems commit violence against women - Pregnant women are protected from abuse by their partners - Women provoke their partners to abuse them - Violent tendencies have gone on for generations & are accepted - IPV is only a heterosexual issue Facts - Violence occurs in all socioeconomic classes - Violence is a learned behavior and can be changed. The presence of drugs & alcohol can make a bad problem worse. - In the past, our patriarchal legal system afforded men the right to physically chastise their wives & children; we no longer live under that system. Women & kids are no longer considered the property of men, violence is against them is a crime in every state. - One in 4 women will be victims of violence - Battering is a pattern of coercion & control that one person exerts over another. It is repeated using a number of tactics, including, intimidation, threats, physical injury, economic deprivation, isolation, & sexual abuse - Women stay in the abusive relationship because they feel they have no other option - Abusers often seem normal & do not appear to suffer from personality disorders or other forms of mental illness - 1 in 5 women is physically abused during pregnancy. The effects of violence on infant outcomes can include preterm delivery, fetal distress, low birth weight, & child abuse - Women may be willing to blame themselves for someone else's bad behavior, but nobody deserves to be beaten - The police, justice system, & society are being to make IPV socially unacceptable - There is much IPV in the lesbian/gay/bi/transgender, population as in heterosexual relations with the added psychological abuse of "outing" (when one partner threatens to disclose the others sexual preference in an effort to maintain power and control)

Analyze the physiologic aspects of menopause.

Natural process that occurs as part of normal aging- when menses and fertility cease Symptoms: - Brain: hot flashes, disturbed sleep, mood and memory problems - Cardio: lower levels of HDL and increased risk of CVD - Skeletal: rapid loss of bone density that increase risk of osteoporosis - Breast: replacement of duct and glandular tissue by fat - GU: vaginal dryness, stress incontinence, cystitis - GI: less absorption of calcium from food, increasing fracture risk - Integumentary: dry, thick skin and decreased collagen

Identify the components of the complete newborn assessment (head-to-toe, know variations of "normal").

Newborn: Head sutures palpable w/ small separation, fontanelles Newborn: Ears low set ears = renal/chromosomal disorder Newborn: Eyes symmetrical, clear, reactive to light, edema Newborn: Abdomen rounded, soft, + bowel sounds -meconium & urine passed within 24hr after birth Newborn: Genitals -small reddish mucous vaginal discharge -testes in scrotal sac, rugae on scrotum Newborn: Temp -97.7-99.5 axillary Newborn: HR 110-160, reg rhythm Newborn: BP 50-75 /30-45 Newborn: Respirations 30-60 (irregular, shallow, unlabored; symmetrical chest movements) Newborn: weight 5lb 8oz, 8lb 14oz Newborn: length 17-22 in. Newborn: head circumference 13-15 in. Newborn: chest circumference 12-14 in.

Identify specific interventions for caring for a newborn (bath, medications, thermoregulation, feeding/nutrition, cord care, safety)

Newborn: bathing -undress newborn down to shirt & diaper -always support the head & neck when moving/positioning him/her -wipe eyes with plain water, using either cotton balls or a washcloth. Wipe inner corner of eyes to outer. -wash the rest of the face, then using baby shampoo, wash the hair and rinse with water. -wash extremities, trunk, and back. Wash rinse, dry, cover. -wash diaper area LAST. -put on clean diaper and clean clothes after bath. Newborn: meds vitamin K + erythromycin Newborn: thermoregulation -pre-warm blankets & infant caps -keep isolette charged & warmed -dry newborn completely at birth -encourage skin-to-skin contact w/mother -defer bathing until temperature is stable -promote early breastfeeding to provide fuel Newborn: Feeding/Nutrition -Breast feeding -Formula feeding Newborn: Cord Care -let it fall off on its own -do not try to pull off -do not give submerged bath until it falls off General Newborn Safety -have emergency telephone numbers readily available (emergency medical assistance & poison control center) -keep small/sharp objects out of reach to prevent them from being aspirated -put safety plugs in wall sockets within the child's reach to prevent electrocution -do not leave the infant alone in any room without a portable intercom on -always supervise the newborn in the tub: a newborn can drown in 2 inches of water -make sure the crib/changing table is sturdy, without any loose hardware, & is painted w/lead-free paint -avoid placing the crib/changing table near blinds or curtain cords -provide a smoke-free environment for all infants -place all infants on their backs to sleep to prevent SIDS -to prevent falls, do not leave the newborn alone on any elevated surface -use sun shields on strollers & hats to avoid overexposing the newborn to the sun -to prevent infection, thoroughly wash your hands before preparing formula -thoroughly investigate any infant care facility before using it

Characterize the major pelvic relaxation disorders in terms of etiology, management, and nursing interventions.

Pelvic Organ prolapse (from the Latin prolapses, "a slipping forth")- abnormal descent of herniation of the pelvic organs from their original attachment sites or their normal position in the pelvis. - Structures of the pelvis shift and protrude into or outside of the vaginal canal. Types of POP: 1. Cystocele-occurs when the posterior bladder wall protrudes downward through the anterior vaginal wall 2. Rectocele- occurs when the rectum sags and pushes against or into the posterior vaginal wall. 3. Enterocele- occurs when the small intestine bulges thought the posterior vaginal wall (especially common when straining). 4. Uterine prolapse- occurs when the uterus descends through the pelvic floor and into the vaginal canal. (multiparous women are at particular risk for uterine prolapse) Etiology of pelvic organ prolapse- dysfunction of levator ani muscle complex and the connective tissue attachments of the pelvic organ fascia (which provide anatomic support) - Constant downward gravity because of erect human posture - Atrophy of supporting tissues with aging and decline of estrogen levels - Weakening of pelvic floor support related to childbirth trauma - Reproductive surgery - Family history of POP - Young age at first birth - Connective tissue disorders - Infant birth of more than 4,500 g - Pelvic radiation - Increased abdominal pressure secondary to: - Lifting of children or heavy objects - Straining due to chronic constipation - Respiratory problems or chronic coughing - Obesity Management of Pelvic Organ Prolapse: - Kegel exercises - Hormone replacement therapy - Dietary and lifestyle modifications - Pessaries - Colpexin Sphere - Surgical Interventions Nursing Interventions of Pelvic Organ Prolapse: - Encourage pelvic floor muscle training - Encourage dietary and lifestyle modifications - Provide teaching for pessary use *must be taken out and cleaned at least every 1-2 weeks!!!* - Promote prevention strategies Urinary (and fecal) Incontinence- involuntary loss of urine that represents a hygienic or social problem to the individual - Embarrassment and depression are common - May decrease social interactions, excursions out of the home, and sexual activity - More common than diabetes and Alzheimer's disease Etiology of Urinary Incontinence - Fluid intake, especially alcohol, carbonated drinks, and caffeinated beverages - Constipations: alters the position of the pelvic organs and puts pressure on the bladder - Habitual "preventative" emptying: may result in training the bladder to hold only small amounts of urine - Menopause and depletion of estrogen - Chronic disease such as stroke, multiple sclerosis, or diabetes - Smoking: Nicotine increases detrusor muscle contractions - Advancing age: age-related anatomic changes provide less pelvic support - Pregnancy and childbirth: damage to pelvic structures during childbirth - Obesity: increases abdominal pressure Management of Urinary Incontinence - Avoid drinking too much fluid (i.e. 1.5 L total daily limit), but do not decrease your intake of fluids - Reduce intake of fluids and foods that are bladder irritants and precipitate urgency, such as chocolate, caffeine, sodas, alcohol, artificial sweetener, hot spicy foods, orange juice, tomatoes, and watermelon. - Increase fiber and fluids in diet to reduce constipation - Control blood glucose levels to prevent polyuria - Treat chronic cough - Remove any barriers that delay you from reaching the toilet - Practice good perineal hygiene by using mild soap and water. Wipe from front to back to prevent urinary tract infections - Become aware of adverse drug effects - Take your meds as prescribed - Continue to do pelvic floor (kegel) exercises Nursing Interventions of Urinary Incontinence: - Encourage women to seek help with troublesome symptoms - Discuss treatment options with patient - Provide education about good bladder habits and strategies to reduce the incidence or severity of incontinence - Provide support and encouragement to ensure compliance - Review the anatomy and physiology of urinary system and offer simple explanations to help woman cope with urinary alterations - Therapeutic listening is important - Be aware of the courage it takes for a woman to disclose an embarrassing condition

Summarize the pharmacological and non-pharmacological methods to relieving pain in childbirth and pain in postpartum with the possible complications of each.

Pharmacological: - systemic analgesia - inhaled analgesics - regional analgesia/anesthesia - general anesthesia Non-Pharmacological: - continuous labor support - hydrotherapy- showering or soaking in a regular tub or whirlpool bath. - ambulation & changing position - acupuncture & acupressure - application of heat & cold - attention focusing & imaging - effleurage and massage - breathing techniques

Identify the time intervals and major events of the pre-embryonic, embryonic and fetal stages of development.

Pre-: fertilization through the second week Embryonic: end of 2nd wk through 8th week Fetal: end of 8th week till birth

Outline normal fetal development milestones from conception to birth.

Pre-stage: - fertilization takes place in ampulla of the fallopian tube - union of sperm and ovum forms a zygote - cleavage cell division continues to form a morula - inner cell mass is called blastocyst, which forms the embryo and amnion - outer cell mass is called trophoblast, which forms the placenta and chorion - implantation occurs 7 to 10 days after conception in the endometrium Embryonic Period: begins at 15 days to 8th week - Differentiation of cells and rapid growth - Rudimentary body part formed - Heart has 4 chambers and begins beating - Beginning of all major body parts - External genitalia present but not on ultrasound - Some jerky limb movements Fetal period: 9th week to birth - 9-12 wks​:eyelids fused; teeth and bones begin to appear; kidneys begin to fxn; digestive system shows some activity; gender there but not able to view - 13-16 wks: ​much spontaneous fetal movement; rapid skeletal development; sucking motion made by mouth; lanugo (fine hair) appears over body; Quickening - 17-20 wks: ​fetal heart tones can be heard with stethoscope; skeleton begins to harden; rapid brain growth; vernix caseosa appears - 21-24 wks​: mini baby in appearance; extra uterine life possible (surfactant); skin is red, translucent; responds to external sounds (moro); very active - 25-28 wks: ​eyelids are no longer fused; testes begin to decent for males; head-down position; SC fat deposits under skin more rapidly - 29-32 wks: ​fat and minerals storage increases; skin loses reddish color; exhibits good reflex development; rhythmic breathing movements - 33-40 wks: ​fetal body begins to round out; fetus completely fills uterus; ear cartilage firm on both ears; lanugo and vernix caesora disappears; high absorption of maternal hormones; ready for birth 38-41 wks

Differentiate presumptive, probable and positive signs of pregnancy.

Presumptive (sub) - fatigue, breast tenderness, n/v, amenorrhea, urinary freq, hyperpigmentation of skin, fetal movements, uterine/breast enlargement Probable (time of occurrence) - Braxton Hicks contractions, + preg test, abd enlargement, ballottement, Goodell's sign, Chadwick's sign, Hegar's sign Positive (time of occurrence) - Ultrasound verification of embryo/fetus, fetal movement felt by experienced clinician, auscultation of fetal heart tones via doppler

Explain the different levels of prevention in women's health nursing, provide an example of each.

Preventative care ​ - Key part of maternal and ped nursing - Emphasis on health care delivery has moved beyond primary preventative health care (1) Well child check-ups (2) Routine physical exams (3) Prenatal care and treatment of common acute illness &now includes secondary and tertiary care Primary prevention (1) Preventing disease/condition before it occurs by reducing a person's vulnerability to any illness by strengthening the person's capacity to withstand physical, emotional, and environmental stressors (2) Ex: immunizations, good hygiene/nutrition, drug education, seat belts Secondary prevention (1) Early detection and treatment aimed at halting the disease (2) Ex: health screenings, preg tests, BP/cholesterol monitoring, breast exams, hearing/vision exams Tertiary prevention (1) Designed to reduce/limit the progression of permanent, irreversible disease or disability; restore individuals to max potential (2) Ex: minimizing and managing the effects of a chronic illnesses/diseases Nursing role in preventative care (1) Involves prevention, early identification, prompt treatment of health problems and monitoring for emerging threats that could lead to health problems; often involves advocacy for services to meet pt's needs

Discuss the nurse's role in providing sexual and reproductive health care.

Screening for sexual and reproductive cancer (breast, cervical, ovarian); routine breast exams and pap smears

Formulate a teaching plan for managing urinary incontinence.

Simple diet and lifestyle modification alterations, combined with a proper pelvic floor muscle strengthening program, can often produce significant improvements for women of all ages.

Differentiate among the four stages of labor according to the duration, work accomplished, contraction patterns and maternal behavior + Identify nursing interventions for each stage of labor

Stage 1 = true labor through complete cervical dilation (10 cm) Latent phase = mild contractions, dilation 0-3cm, 0-40% effaced - very beginning of labor - the mother is usually at home trying to decide "is this the real deal or not??" - upright position Active phase = progressive fetal descent, dilation 4-7cm, 40-80% effaced - this stage is intense and the woman knowns she's in labor; usually arrives at the hospital during the active phase Transition phase = increase in fetal descent; dilation 8-10cm, 80-100% effaced - significant anxiety, restless, irritable, 'can't take anymore' - contractions 1-2 min. apart - strong intensity & lasting 60-90 sec - usually breaks down & asks for an epidural even if the plan was a natural childbirth Maternal behaviors during transition phase: Anxiety Restlessness Irritability "Can't take it anymore" N/V Backache Overwhelmed Diaphoresis Comfort measures: -straddling w/ forward leaning over a chair -walking w/ partner support -rocking back & forth w/ foot on chair Stage 2 (pushing stage) = cervix is 10cm dilated and ends w/ birth of infant - usually < 1hr - urge to push during this stage - crowning occurs when fatal head bulges at the vaginal opening & birth is imminent Stage 3 = birth of infant to placental separation - 5 min - shortest stage of labor Stage 4 = 1-4 hrs after delivery when physiological readjustment of the mother's body takes place - usually in the LDR room - uterus remains contracted & in the midline - bladder may be hypotonic - vital taken every 15 minutes: bradycardic pulse - lochia rubra: moderate amount - emotional state: excited, fatigued, or quiet

Describe the signs and symptoms of impending labor (True versus false labor).

True labor - contractions occur at regular intervals - increase in intensity & duration - discomfort begins in back & radiates around to abdomen - walking increases their intensity - progressive effacement & dilation - cervix changes False labor - usually no change in intensity & duration - discomfort is centered to abdomen - walking has no effect or may stop or slow contractions - no cervical change takes place

Differentiate between urge and stress incontinence.

Urge incontinence - overactive bladder causes by detrusor muscle contractions Stress incontinence - inadequate urinary sphincter function (mixed incontinence involves both stress and urge incontinence)

Differentiate between the benign disorders of the female reproductive tract and understand nursing management of each (uterine polyps, uterine fibroids, genital fistulas, Bartholin cysts, ovarian cysts).

Uterine polyps - small, usually benign growths - cause of polyp is not well understood, but they are frequently the result of infection - most commonly occur in multiparous women - can appear anywhere but mostly occur on the cervix and uterus Nursing management of Uterine Polyps: explain condition and rationale for removal and give follow up care instructions (nurse also assists HCP with removal procedure) Uterine fibroids (aka Leiomyomas) - benign tumors composed of smooth muscle and fibrous connective tissue in the uterus - asymptomatic so most women do not know they have them - usually grow slowly and cells do not typically break away and invade other parts of the body - peak incidence occurs around age 45; 3 times more prevalent in African American women than Caucasian women - MOST COMMON INDICATION FOR HYSTERECTOMY IN U.S. Nursing management of Uterine fibroids: explain any current treatment options and the implications of a diagnosis of fibroids. Explain meds, SE, and why meds should only be taken for a limited duration of time. If surgery is selected, verbal and written info about it and aftercare should be addressed Genital fistulas: - abnormal openings between a genital tract organ and another organ such as the urinary tract or the gastrointestinal tract - can result from a congenital anomaly, surgical complications, Bartholin's gland abscesses, radiation, malignancy, but most are related to obstetric trauma and female genital cutting Nursing Management of Genital fistulas: provide guidance and support. Offer info to help learn about condition and how appropriate intervention could improve her quality of life. Ensure the woman understands female anatomy and why she is having the symptoms she is having. Provide a thorough explanation of each treatment option so she can make an informed decision. Be sensitive about the woman's shame and fear which could be the reason she delayed seeking care. Address all needs (physical and emotional) Bartholin cysts - Swollen, fluid-filled, sac-like structure that results when one of the ducts of the Bartholin's gland becomes blocks - Most common cystic growths in the vulva Nursing management - Be knowledgeable about vulvar cysts and treatment options. The woman may be aware of a vulvar cyst secondary to pain or may be unaware of it if is asymptomatic. A Bartholin's cyst may be an incidental finding during a routine pelvic examination. Explain cause of cyst and assist with cultures if needed. Provide reassurance and support for patient. Ovarian cysts: - fluid-filled sac that forms on the ovary - very common growths which are benign 90% of the time - asymptomatic in many women - when cysts grow large and exert pressure on surrounding structures, women often seek medical health Nursing management: include education about condition, treatment options, and diagnostic test arrangements, and referral surgery if needed. Provide support and reassurance during diagnostic period. Listen to concerns about her appearance, infertility, and facial hair growth (hiritism). Encourage patient to make positive lifestyle changes and also educated her on associated risk factors to prevent long-term health problems. Make community referrals to local support groups to help the woman build her coping skills.

Describe the physiological changes that occur during pregnancy and their etiologies.

Uterus- 2 oz to 2lbs at term - Increase in size due to hypertrophy of myometrium cells under estrogen influence - ⅙ total maternal BV is contained w/in vascular system of uterus by term Cervix - Estrogen causes the cervix to become congested with blood (hyperemic) resulting in bluish color that extends into vagina (Chadwick's Sign) - Increase vascularity causes cervix to soften (Goodell's sign) - Increase mucus forms mucus plug to seal off from outside bacteria Ovaries - Cease ovum production during preg - Corpus luteum persists till 12 wks to secrete progesterone until placenta takes over Vagina - Increased vascularity and hyperplasia - Increased vaginal secretions and decrease in pH to prevent infections Breasts - Increase in size & nodularity to prep for lactation - Nipples increase in size, become more erect and more pigmented - Colostrum- an antibody-rich, yellow fluid can be expressed after the 12th wk; converts to mature milk after delivery Resp - O2 consumption increases by 20-40% - Tidal volume increased by 40% - By 3rd trimester, diaphragm is lifted by 4 cm which prevents lungs from expanding fully - Breathing becomes thoracic rather then abdominal Cardio - 50% increase in BV which peaks at 7th month of preg - 30% increases in total RBC (mostly plasma) which causes the hemodilution of preg in 2nd trimester - WBCs increase throughout gestation GI - Reflux of gastric contents common due to relaxation of smooth muscle by progesterone - Ptyalism: excessive salivation - Constipation - n/v (morning sickness) is high due to hCG levels from 6-12 wks Renal - 50% increase in GFR - Kidneys and ureter dilate due to high progesterone levels - Glycosuria is common due to kidneys inability to absorb all the glucose filter by the glomeruli; increase UTI risk Integumentary - Increase in sweat and sebaceous glands = perspiration and acne - hyperpigmentation - melasma or mask of preg darkens forehead, cheek, nose - Linea nigra- dark line of pigmentation from umbilicus to the symphysis pubis - Striae (stretch marks) Metabolism - BMR increase to support the additional demands of the growing fetus - 25-35 lbs is the average weight gain - Increase in water retention of 7L by term

Identify nursing measures to relieve the discomforts caused by the physiological changes of pregnancy.

Vaginal discharge: first rule out vaginal infection (suggest panty liners) Urinary frequency or incontinence - pelvic floor exercises - empty bladder when feels full - avoid caffeine - reduce fluid intake after dinner Fatigue - get full nights sleep - eat healthy, balanced diet - naps - rest N&V - avoid empty stomach - eat crackers/dry toast - eat small meals - avoid brushing teeth after eating - acupressure wristbands - drink fluid between meals rather with meals - avoid fried foods Backache - avoid sitting/standing in one position for long time - support lower back with pillows - heating pad to small of back - proper body mechanisms for lifting - wear supportive shoes - stand with shoulders back Leg cramps - elevate legs above heart - if get cramp, straighten both legs & flex feet toward body Varicosities - walk dialy - elevate legs above heart - don't cross legs when sitting for long time

Summarize the components of the first prenatal visit in relation to history taking, physical assessment and risk assessment.

a) history - Comprehensive: age, menstrual Hx, prio OB Hx, past medical/surgical Hx, psychological screening, family Hx, genetic screening, dietary habits, lifestyle/health practices, meds/drug use, STI Hx b) Physical Assessment pgs 406-408 - Prep: pt should undress and put gown on; empty bladder and collect clean catch urine sample; obtain VS - Head-to-toe: head, neck, chest, abdomen, extremities - Pelvic exam: external and internal genitalia, pelvic size, shape and measurements c) Risk Assessment: ID any areas such as health problems. Lifestyle or social concerns - Danger signs: (1) 1st trimester: - Spotting or bleeding (miscarriage) - Painful urination/Fever 100+ (infection) - severe/persistent vomiting (hyperemesis gravidarum) - Lower abd pain w/ dizziness and shoulder pain (ectopic preg) (2) 2nd trimester - Regular uterine contractions (preterm labor) - Pain in calf increased w/ foot flexion (DVT) - Sudden gush of fluid from vagina (premature rupture of membranes) - Absence of fetal movement for more than 12h (possible fetal distress/demise) (3) 3rd trimester - Sudden weight gain - periorbital/facial edema - Severe upper abd pain or HA w/ visual changes - Decrease in fetal movement for 24h+

Identify common complementary and alternative therapies (CAM) used in women's health.

aromatherapy, homeopathy, acupressure, feng shui, guided imagery, reflexology, therapeutic touch, herbs, spiritual healing, chiropractic, massages

Discuss the unique risks of sexually transmitted infections related to pregnancy and their potential effects on the fetus/newborn.

candidiasis = thrush trichomoniasis = risk for prematurity bacterial vaginosis = neonatal sepsis chlamydia = conjunctivitis - blind gonorrhea = gonococcal ophthalmia genital herpes = sores syphilis = congenital syphilis HPV = no known Hep B = chronic carrier - liver cancer/cirrhosis HIV = transplacentally - can get through breast milk

Evaluate the effects of Oxytocin IV.

induce/augment labor by stimulating uterine contractions

Implement nursing interventions to promote positive breast and formula feeding outcomes for the mother and her infant

nurses can emphasize the positive aspects of breast-feeding and encouraging bonding experiences parents need to be informed on types of formulas, equipment, and feeding positions

Describe appropriate etiologies and interventions for each fetal heart rate pattern.

variable decelerations: - change maternal position to various positions - amnioinfusion may be ordered [warm NS through IUCP, inflates uterus & unkink cord] - C/S if can't change pattern early declarations: - continue monitoring FHR - identify labor progression by performing a vaginal exam (dilation) late decelerations: - turn pt to left side or on hands/knees, give O2 mask 8-10L, >primary IV LR at 999 or open up to gravity - turn Pitocin off if infusing - document & report observations - call physician & report everything that happened & all your interventions prolonged decelerations: identify underlying cause & correct it

Differentiate between the fetal heart rate patterns: variable decelerations, early decelerations, late decelerations, prolonged decelerations, fetal bradycardia, and fetal tachycardia.

variable decelerations: cord compression early decelerations: fetal head compression (baby is dropping lower into pelvis, closer to delivery) late decelerations: utero-placental insufficiency, which occurs when blood flow within the intervillous space is decreased to the extent that fetal hypoxia or myocardial depression prolonged decerlerations: -prolonged cord compression -abruptio placenta -cord prolapse -supine maternal position -vaginal examination -fetal blood sampling -maternal seizures -regional anesthesia -uterine rupture fetal bradycardia: low fetal heart rate fetal tachycardia: high fetal heart rate