NURSING CONSIDERATION (HNBB)

LEGENDS
ELEVATED BLOOD  Drug compatibility should be monitored closely in patients requiring adjunctive therapy
S/SX  Avoid driving & operating machinery after parenteral administration.
LABOR PRESSURE (130/80mmHG)
 Avoid strict heat
DIAGNOSTIC EXAM  Raise side rails as a precaution because some patients become temporarily excited or
NURSING disoriented and some develop amnesia or become drowsy.
DIAGNOSIS V NURSING DIAGNOSIS  Reorient patient, as needed, Tolerance may develop when therapy is prolonged
PHARMACOLOGICAL  Atropine-like toxicity may cause dose related adverse reactions. Individual tolerance varies
Risk for injury related Cephalo pelvic greatly
MANAGEMENT disproportion  Oerdose may cause curare-like effects, such as respiratory paralysis. Keep emergency
to prolonged labor
SURGICAL equipment available.
MANAGEMENT
NURSING OXYTOCIN
NURSING MANAGEMENT TRAIL LABOR
 Start flow charts to record maternal BP and other vital signs, I&O ratio, weight, strength,
MANAGEMENT
duration, and frequency of contractions, as well as fetal heart tone and rate, before
 MONITOR PROGRESSION OF
instituting treatment.
LABOR  Monitor fetal heart rate and maternal BP
 MONITOR FOR FETAL PROLONG LABOR PHARMACOLOGICAL  If local or regional (caudal, spinal) anesthesia is being given to the patient receiving
DISTRESS oxytocin, be alert to the possibility of hypertensive crisis (sudden intense occipital
MANAGEMENT headache, palpitation, marked hypertension, stiff neck, nausea, vomiting, sweating, fever,
 ASSES FHR CAREFULFY photophobia, dilated pupils, bradycardia or tachycardia, constricting chest pain).
 ESTABLISH A THERAPEUTIC  HNBB  Monitor I&O during labor. If patient is receiving drug by prolonged IV infusion, watch for
RELATIONSHIP, CONVEYING DELAYED SECOND  OXYTOCIN symptoms of water intoxication (drowsiness, listlessness, headache, confusion, anuria,
STAGE weight gain).
EMPATHY AND  Check fundus frequently during the first few postpartum hours and several times daily
UNCONDITIONAL POSITIVE thereafter.
REGARD
FETAL DISTRESS C-SECTION
 CONVEY CONFUDENCE IN
PTS, ABILITY TO COPE WITH
CURRENT SITUATION
POST OPERATIVE

ELEVATED BLOOD
POSTPARTUM NURSING DIAGNOSIS
PRESSURE
PREECLAMPSIA
(170/100mmHG) Risk for injury related
to hypertension
PLACENTAL
PHARMACOLOGICAL DELIVERY
MANAGEMENET

 MAGNESIUM ENDOTHELIAL
SULFATE DYSFUNCTION
 NICADEPINE

VASOCONSTRICTION
 NURSING MANAGEMENT
INCREASE BLOOD
NURSING CONSIDERATION (MAG SULFATE)  Assess blood pressure
PRESSURE
and pulse every one
 Observe constantly when given IV. Check BP and pulse
q10–15 min or more often if indicated.
(1) hour or as
 Lab tests: Monitor plasma magnesium levels in patients
NURSING MANAGEMENT PHARMACOLOGICAL indicated.
receiving drug parenterally (normal: 1.8–3.0 mEq/L). MANAGEMENET  Administer
Plasma levels in excess of 4 mEq/L are reflected in  Monitor vital sign
depressed deep tendon reflexes and other symptoms of  Assess for signs and symptoms  AMLODIPINE antihypertensive
magnesium intoxication (see ADVERSE EFFECTS).
of hypertension, such as medications as
Cardiac arrest occurs at levels in excess of 25 mEq/L. ordered to lower
Monitor calcium and phosphorus levels also. headache, dizziness, blurred
 Early indicators of magnesium toxicity vision, and shortness of blood pressure and
(hypermagnesemia) include cathartic effect, profound
breath. prevent complications
thirst, feeling of warmth, sedation, confusion, depressed such as seizures and
deep tendon reflexes, and muscle weakness.  Encourage the patient to rest
 Monitor respiratory rate closely. Report immediately if and avoid physical exertion, as stroke
rate falls below 12.
this can exacerbate  Restrict sodium and
 Test patellar reflex before each repeated parenteral dose. fluid intake to prevent
Depression or absence of reflexes is a useful index of hypertension.
early magnesium intoxication.  Educate the patient about the fluid overload and
 Check urinary output, especially in patients with impaired
importance of adhering to hypertension.
kidney function. Therapy is generally not continued if  Monitor for signs of
urinary output is less than 100 mL during the 4 h medication regimens and
preceding each dose. attending follow-up worsening
 Observe newborns of mothers who received parenteral
appointments with the preeclampsia, such as
magnesium sulfate within a few hours of delivery for headache, visual
signs of toxicity, including respiratory and neuromuscular healthcare provider.
depression. changes, epigastric
 Observe patients receiving drug for hypomagnesemia for pain, and
improvement in these signs of deficiency: Irritability, hyperreflexia.
choreiform movements, tremors, tetany, twitching, NURSING CONSIDERATION (AMLODIPINE)
muscle cramps, tachycardia, hypertension, psychotic
behavior.  Monitor BP for therapeutic effectiveness. BP reduction is
 Have calcium gluconate readily available in case of greatest after peak levels of amlodipine are achieved 6–9 h
magnesium sulfate toxicity
following oral doses.
 Monitor for S&S of dose-related peripheral or facial edema
that may not be accompanied by weight gain; rarely, severe
edema may cause discontinuation of drug.
 Monitor BP with postural changes. Report postural
hypotension. Monitor more frequently when additional
antihypertensives or diuretics are added.
 Monitor heart rate; dose-related palpitations (more
common in women) may occur.
NURSING CONSIDERATION (NICARDIPINE)
NURSING RESPONSIBILITIES
 Establish baseline data before treatment
is started including BP, pulse, and lab
values of liver and kidney function.
 Monitor BP during initiation and
titration of dosage carefully.
Hypotension with or without an increase
in heart rate may occur, especially in
patients who are hypertensive or who
are already taking antihypertensive
medication.
 Avoid too rapid reduction in either
systolic or diastolic pressure during
parenteral administration.
 Discontinue IV infusion if hypotension
or tachycardia develop.
 Observe for large peak and trough
differences in BP. Initially, measure BP
at peak effect (1–2 h after dosing) and at
trough effect (8 h after dosing).
 Assess the woman about past surgeries, secondary illnesses, allergies to foods or drugs,
reaction to anesthesia, and medications that could increase any surgical risk.
 The woman should be in the best possible physical and psychological state before
undergoing any surgery.
 An obese woman with poor nutritional status is at risk for a slow wound healing.
 Tissue that contains extra fatty cells would be difficult to suture and the incision will
heal much slower and predispose the woman to infection and dehiscence.
 An obese woman would also have difficulty in initiating ambulation and turning after
surgery as it will increase the risk for pneumonia or thrombophlebitis.
 A woman with protein or vitamin deficiency is also at risk for poorer healing because
these are needed for new cell formation at the incision site.
 Age can also affect surgical risk because it can cause decreased circulatory and renal
function.
 A woman who has secondary illness is also at greater surgical risk depending on the
extent of the disease because the secondary illness may affect the woman’s ability to
adapt to the demands of the surgery.
 The general medication history of the woman must also be assessed because there are
drugs that could increase the surgical risk by interfering with the effects of anesthesia.
 A woman with lower than normal blood volume might feel the effects of surgery more
than a woman with normal blood volume.
 An example of this is a woman who began labor and was told later on that she should
undergo cesarean birth instead because she may not have had anything to eat or drink
for almost 24 hours.
 To prevent fluid and electrolyte imbalance, intravenous fluid replacement is initiated
preoperatively and postoperatively.
 There are women who are very worried about the procedure, so they need a very
detailed explanation of the procedure before they can enter surgery without intense
fear.
 A woman who is frightened is at greater risk for cardiac arrest during anesthesia
administration.
 Acknowledge that the woman’s fear of surgery is normal so that she can view her
feelings as expected which could increase her self-esteem.
 The newborn is also at greater risk than those newborn born through vaginal delivery.
 Infants born through cesarean delivery develop a degree of respiratory difficulty
because when a fetus is pushed through the birth canal, pressure on the chest helps to
rid the newborn lungs of fluid.