Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)-Lecture

INSTRUCTOR’S GUIDE BS NURSING / SECOND YEAR
Session # 1

LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT Materials:

CLIENT (PRE-GESTATIONAL CONDITIONS-
Book, pen and notebook, index card/class list,
CARDIOVASCULAR DISORDERS AND PREGNANCY)
speaker and LCD projector
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:

1. Define types and effects of cardiovascular disorders to

pregnancy, including preexisting factors that contribute to its
development such as cardiovascular disease.
2. Integrate knowledge of cardiovascular disorders to nursing
process to achieve quality maternal and child health nursing
care.
Reference:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
Maternal and Child Health Nursing, 8th Edition. USA:
Lippincott Williams and Wilkins

SUBJECT ORIENTATION (10 minutes)

The instructor will be starting to introduce himself/herself to the class and the assigned subject, Care of Mother and
Child At-Risk or with Problems (Acute and Chronic)-Lecture. The course outline will be distributed and discussed
accordingly. Listed below are the additional information vital in orientation:

1. The calendar of activities for major examinations must be relayed.

2. Classroom rules and regulations will be informed per the instructor’s discretions.
3. Computation of grades specific for this subject must be thoroughly explained to students.
4. The essence and significance in grade computation of these modules must be introduced.
5. If this is the first subject of the class, the instructor must initiate an election for block officers.
6. Any other information that will be deemed necessary by the instructor must be properly coordinated to the class.

MAIN LESSON (50 minutes)

(Please refer to Chapter 20 Nursing Care of a Family Experiencing a Pregnancy Complication from a Preexisting or Newly
Acquired Illness page 489.)

HIGH-RISK PREGNANCY- is one in which a concurrent RISK FACTORS

disorder, pregnancy-related complication, or external A. DEMOGRAPHIC FACTORS
factor jeopardizes the health of the woman, the fetus, or  Age: <16 or over 35 (optimal age: 20-30yo)
both  Weight: overweight or underweight
 Height: <5 feet
 Mother or fetus has a significant increased chance
of harm, damage, injury, or disability(morbidity), B. SOCIOECONOMIC STATUS
and loss of life or death(mortality)  Inadequate finances
 Overcrowding, poor standards of housing
 Nutritional deprivation
 Severe social problems
 Unplanned & unprepared pregnancy, especially
adolescents
C. OBSTETRIC HISTORY D. CURRENT OBSTETRICAL STATUS

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 1 of 7
  History of infertility or multiple gestation  Late or no prenatal care
 Grand multiparity  Maternal anemia
 Previous abortion or ectopic pregnancy  Rh sensitization
 Previous losses: fetal death, stillbirth, neonatal  Antepartal bleeding; placenta previa, Abruptio
deaths Placenta
 Previous operative OB: Cesarean Section,  Pregnancy Induced Hypertension
forceps delivery  Multiple gestation
 Previous uterine/cervical abnormality  Premature or postmature labor
 Previous high-risk infant: Low Birth Weight, Large  Polyhydramnios
for Gestational Age, birth injury or malformation  Premature Rupture of Membranes
 Previous hydatidiform mole  Small for Gestational Age, Large for Gestational
Age, abnormality in tests and presentation
E. MATERNAL MEDICAL HISTORY/STATUS  Hemoglobinopathies
 Cardiac/pulmonary disease  Seizure disorder
 Metabolic disease: Diabetes Mellitus, thyroid  Malignancy
disease  Major emotional disorders, mental retardation
 Endocrine disorders: pituitary, adrenal
 Chronic renal disease: repeated Urinary Tract F. HABITS/LIFESTYLE
Infection, bacteriuria • Smoking during pregnancy
 Chronic hypertension • Regular alcohol intake
 Sexually Transmitted Infections and other • Drug use/abuse
infections
 Major congenital anomalies of the reproductive
tract
IDENTIFYING CLIENT AT RISK
 It begins with the 1st prenatal visit & continues throughout the pregnancy

 It involves subjective as well as objective assessment techniques such as screening procedures, laboratory
and diagnostic examinations
Standard Examinations Done in a Prenatal Visit  Leopold’s Maneuver
 Complete Blood Count- screens for anemia  Pelvic adequacy examination
 Edema Check-normally in Lower extremities (if  Urinalysis and Culture-screening for
found on leg; in arms & feet, may indicate pre- asymptomatic bacteruria as early as 1st prenatal
eclampsia) visit; if (+), culture is done
 Fetal heart Rate (N= 120-160 bpm)  Vital Signs
 Fundic Height- measured from 22-34 weeks &  Weight- pattern of weight gain/loss is recorded
correlates with gestational age with normal  Non-Stress Test
pregnancy  Oxytocin Contraction Test/Contraction Stress
 Height- during initial visit Test
 Biophysical Profile
Cardiovascular Disorders and Pregnancy

Effects of Pregnancy on Heart Disease

Blood Volume & Cardiac output

-Blood Volume peaks at 24-28 weeks
-Cardiac output increases 50%
-Heart must contract harder& faster
-Postpartum-blood circulating in the uterus & placenta returns to maternal circulation
*Team approach to care during pregnancy (internist, OB and nurse)
*Most dangerous period is in weeks 28 to 32, just after the BV peaks, earlier in more severe cases

Most Commonly Cause Difficulty During Pregnancy Risk Factors

1. Valve Damage due to Kawasaki Disease or Rheumatic 1. Rheumatic fever- 90% 5. Pulmonary
Fever of all cases disease
2. Congenital Anomalies such as ASD or Uncorrected 2. Congenital heart defects 6. Renal
Coarctation of Aorta 3. Arteriosclerosis diseases

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 2 of 7
3. Aortic Dilatation 4. Myocardial Infarction: 7. Heart surgery
4. Marfan Syndrome pregnancy is generally
contraindicated with
previous MI and who have
severe left ventricular
damage & heart failure

Classification of Heart Disease (table 20.1 on page 487)

Class Description
I Uncompromised. Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency and no
anginal pain.
II Slightly compromised. Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or anginal
pain.
III Markedly compromised. During less than ordinary activity, woman experiences excessive fatigue, palpitations,
dyspnea, or anginal pain.
IV Severely compromised. Woman is unable to carry out any physical activity without experiencing discomfort.
Even at rest, symptoms of cardiac insufficiency or anginal pain are present.
From Criteria Committee of the New York Heart Association. (1994). Nomenclature and criteria for diagnosis of diseases
of the heart and great vessels (9th ed.). Boston, MA: Little, Brown & Co.

Prognosis & Management

1. Woman with Artificial valve Prosthesis

a. Pregnant women in the past was not advised to get pregnant to the increase blood volume and increase
work load of the heart.
b. To watch out for SUBCLINICAL BLEEDING/HEMOLYSIS
Observe the ff:
a. PETECHIAE
b. PREMATURE SEPARATION OF PLACENTA

2. Women with Chronic Hypertensive Vascular Disorder

Women with chronic hypertensive vascular disease before pregnancy is usually associated with atherosclerosis or
renal disease and usually puts the mother and the fetus at risk.

3. Women with Venous Thromboembolic Disease (DVT)

Increases with a combination of the ff:
1. Stasis of blood in the lower extremities from uterine pressure
2. Hypercoagulability (effect of elevated estrogen levels)
3. Vessel damage

AT RISK of DEVELOPING Deep Vein Thrombosis (DVT)

a. Spontaneous Miscarriage
b. Fetal death
c. Hypertension of Pregnancy
d. Antiphospholipid antibodies(aPLA)/Antiphospholipid Syndrome
Complications
PULMONARY EMBOLI Congestive heart failure (LSCHF)
S/sx Maternal dysrhythmias
Chest pain Spontaneous abortion
Sudden onset of dyspnea Premature labor
Hemoptysis Intrauterine growth retardation

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 3 of 7
 Tachycardia/Missed Beats
Dizziness
Fainting

Assessment
Diagnostic Test Criteria for establishing Signs of Cardiac Other Signs
diagnosis of Heart Disease Decompensation
ECG Persistent murmurs moist cough Syncope w/ exertion
Echocardiography Permanent cardiomegaly Pedal edema: signs of pulmonary Cyanosis
Echocardiogram Severe dysrhythmias edema Clubbing of fingers
(ultrasound of the Severe dyspnea Dyspnea, increasing with activity Neck vein distention
heart) Tachycardia Cardiomegaly
Tachypnea Pulmonary hypertension
Chest pains on exertion
Cyanosis
Persistent heart murmurs
*Safety alert: presence of severe dyspnea, syncope with exertion, hemoptysis, nocturnal tachycardia and angina
require prompt evaluation

*A pregnant woman w/ heart disease should avoid infection, excessive weight gain, edema and anemia because these
conditions increase the workload of the heart

Treatment/Management: Individualized
1. Frequent prenatal visits 7. Iron supplement- prevent/treat anemia
2. Rest, physical and mental: 8. Oxygen as necessary
a. Sleep at least 8-10 hours at night & 2 rest 9. Anticoagulant-Heparin/Enoxaparin to prevent clot
periods during the day formation with DVT and Pulmonary Emboli as
b. Instruct client to lie down for 30 mins after complication
meals 10. Nitroglycerin- relieves angina by vasodilation
c. Allow only light work, no stair climbing, no a. take: 5 min before effort
exhaustion b. how often: q 5 mins up to 3 tabs, if the
d. Activity limitation especially for Class 3 & chest pain is not relieved after 15 mins, go to ER
4 c. take tablet while sitting down
3. Severely affected clients may need to be admitted d. storage: covered, replace every 3 months
as early as mid-2nd trimester Side Effects: hypotension, Headache, flushing, burning &
4. Digitalis. Withhold if PR <60bpm or >100bpm stinging sensation under the tongue
5. Diuretics. If Potassium-excreting (e.g. Furosemide types: tablet, patch, cream, sublingual
(Lasix)) 11. Corticosteroid- help to reduce the formation of
SIDE EFFECTS: hypokalemia increases the risk for additional antibodies in aPLA
digitalis toxicity; report signs like bradycardia, N/V,
diarrhea, colored vision deficiency (xanthopsia)
6. Antibiotics-before any invasive procedure;
prophylaxis vs. Rheumatic Fever; treatment of
bacterial infection
CHECK FOR UNDERSTANDING (25 minutes)
The instructor will prepare 10-15 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

Multiple Choice

(For 1-10 items, please refer to the questions in the Rationalization Activity)

RATIONALIZATION ACTIVITY (DURING THE FACE-TO-FACE INTERACTION WITH THE STUDENTS)

The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss
among their classmates.

1. A 26-year-old pregnant client has a history of Heart Disease and she told the doctor that ordinary physical
activity causes no discomfort and has no symptoms of cardiac insufficiency and no anginal pain. Which of the
following class of heart disease does the client has?

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 4 of 7
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised
ANSWER: E
RATIONALE: Class 1 or Uncompromised has the following criteria: ordinary physical activity causes no discomfort. No
symptoms of cardiac insufficiency and no anginal pain.

2. A 28-year-old pregnant client has Uncorrected Coarctation of Aorta and she told the doctor that when she do
ordinary physical activity it causes excessive fatigue, palpitation, and dyspnea or anginal pain. Which of the
following class of heart disease does the client has?
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised
ANSWER: B
RATIONALE: Class 2 or Slightly compromised has the following criteria: Ordinary physical activity causes excessive
fatigue, palpitation, and dyspnea or anginal pain.

3. A pregnant patient was diagnosed when she was a child with Atrial Septal Defect and now pregnant, she went
to the hospital due to extreme fatigue, dyspneic and palpitations every time she takes the stairs or walk a couple
of meters. According to the Classification of Heart Disease which class does the patient belongs to?
A. Class 1
B. Class 2
C. Class 3
D. Class 4
ANSWER: B
RATIONALE: Class 2 is Slightly compromised that ordinary physical activity causes excessive fatigue, palpitation, and
dyspnea or anginal pain.

4. A pregnant client is experiencing chest pain and was diagnosed with Chronic Hypertensive Vascular Disorder;
her doctor ordered a medication called Nitroglycerin. The following are correct statement regarding Nitroglycerin,
EXCEPT:
A. Nitroglycerin works by relaxing the smooth muscle and blood vessels in the body.
B. A vasodilator drug used for the treatment of chest pain and high blood pressure.
C. Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed.
D. It is taken within 5 mins up to 3 tablets and if the chest pain is not relieved after 15 minutes the patient will take a rest.
ANSWER: D
RATIONALE: It is taken within 5 mins up to 3 tablets and if the chest pain is not relieved after 15 minutes the patient will
go to Emergency Room Department for further evaluation of her chest pain.

5. A 28 weeks pregnant woman came to the Outpatient Department for her prenatal check-up and was requested
to do Ultrasound of her heart. Which of the following diagnostic test is called Ultrasound of the Heart?
A. Electrocardiogram
B. Electrocardiography
C. Echocardiogram
D. Electroencephalogram
ANSWER: C
RATIONALE: An echocardiogram (echo) is a test that uses high frequency sound waves (ultrasound) to make pictures of
your heart. The test is also called echocardiography or diagnostic cardiac ultrasound.

6. A pregnant client ask you what are the common causes of heart disorder in pregnancy. The following are most
common cause of cardiovascular disorder during pregnancy, EXCEPT:
A. Atrial Septal Defect
B. Uncorrected Coarctation of Aorta
C. Marfan Syndrome
D. Pulmonary Embolism
ANSWER: D

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 5 of 7
RATIONALE: Pulmonary Embolism is a complication associated with women who has thromboembolic disease that can
be associated with Increases with a combination of Stasis of blood in the lower extremities from uterine pressure,
Hypercoagulability (effect of elevated estrogen levels) and Vessel damage.

7. A 29 weeks pregnant came to the emergency room department due to severe dyspnea, hemoptysis, nocturnal
tachycardia and angina. What makes the client prompt actions means?
A. requires no intervention.
B. requires referral to her doctor.
C. requires immediate intervention.
D. requires rest and oxygen therapy
ANSWER: C
RATIONALE: Presence of severe dyspnea, syncope with exertion, hemoptysis, nocturnal tachycardia and angina require
prompt evaluation.

8. Althea, an 18 weeks pregnant client with an Aortic Dilatation was advised to decrease the workload of the
heart. The following conditions increases the workload of the heart.
A. Infection
B. Eupnea
C. Weight Loss
D. Vasodilation
ANSWERS: A
RATIONALE: A pregnant woman with heart disease should avoid infection, excessive weight gain, edema and anemia
because these conditions increase the workload of the heart.

9. A pregnant client is taking Furosemide for the treatment of her edema and she asked you what are the side
effects of Potassium-wasting diuretics. The following are side effects of potassium-wasting diuretics, EXCEPT:
A. Hyperkalemia
B. Hypokalemia
C. Bradycardia
D. Xanthopsia
ANSWER: A
RATIONALE: Hyperkalemia is not part of the side effects of potassium-wasting diuretics but of potassium-sparing
diuretics that are mainly used in combination with thiazide or loop diuretics to prevent hypokalemia.

10. A 28-year-old pregnant client has Marfan Syndrome and she told the doctor that during less than ordinary
activity, woman experiences excessive fatigue, palpitations, dyspnea, or anginal pain. Which of the following
class of heart disease does the client has?
A. Compromised
B. Slightly compromised
C. Markedly compromised
D. Severely compromised
E. Uncompromised
ANSWER: C
RATIONALE: Markedly compromised. During less than ordinary activity, woman experiences excessive fatigue,
palpitations, dyspnea, or anginal pain.

LESSON WRAP-UP (5 minutes)

Teacher directs the student to mark (encircle) their place in the work tracker which is simply a visual to help students track
how much work they have accomplished and how much work there is left to do. This tracker will be part of the student
activity sheet.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PERIOD 2
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
PERIOD 3
32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 6 of 7
AL STRATEGY: CAT: Student Response Cards
1. The instructor will create a set of student response card for each student. Cards can be created with index cards
or colored pieces of paper or cardstocks.
2. The instructor will label each card with answer choices, such as A, B, C, D or color-coded such as green for Yes
and red for No and put it on an envelope or punch holes and attach red strings.
3. Pose a question to the class regarding information just covered in your lesson.
4. Have the students hold up their card with the corresponding answer to your question.
5. Perform a quick scan across the classroom to see each student’s answer. This will give the instructor an idea of
who has a grasp on the questions and information that was presented and who does not.

This document and the information thereon is the property of PHINMA

Education (Department of Nursing) 7 of 7