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5.hemorrhagic disorder(earl term)

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  • 1. Hemorrhagic Disorder
  • 2. Hemorrhagic Disorder • Early term: – Abortion – Ectopic Pregnancy – Hydatid Form Mole Late term Placenat previa Abruption Placenta
  • 3. Abortion Tree abortion Spontaneous A Threatened A Induced A. therapeutic inevitable missed incomplete may go to term criminal septic complete habitual
  • 4. SPONTANEOUS ABORTION • Spontaneous abortion is the unintended termination of pregnancy at any time before the fetus has attained viability (20 weeks' gestation or fetal weight of 500 g [1.1 lb]). See Table 37-1. For a discussion of therapeutic or voluntary abortion
  • 5. Spontaneous Abortion 1. Also called miscarriage 2. Unpreventable loss of pregnancy 3. Loss of pregnancy before 20 weeks 4. Maybe 20-25% of all pregnancies
  • 6. Spontaneous Abortion • Most occur before 8 weeks (about 90%) • 50% caused by chromosomal abnormalities • Late miscarriage • Miscarriage may occurs between be caused by 12 and 20 weeks several factors
  • 7. Spontaneous Abortion • Types of miscarriage 1. 2. 3. 4. 5. Incomplete Complete Missed Recurrent Septic
  • 8. Classification Clinical Manifestations Management 1. Threatened Clinical manifestation • Vaginal bleeding or spotting • Mild pain, Tenderness over uterus, low backache • Cervix closed Management • Bed rest(ABR) • Pad count 2. Inevitable Clinical manifestation • Bleeding more profuse • Cervix dilated • Painful uterine contractions • Embryo delivered complete or incomplete , followed by dilatation and curettage (D&C)
  • 9. 3. Incomplete Clinical manifestation • Fetus usually expelled • Placenta and membranes retained Management • Embryo delivered, followed by dilatation and curettage (D&C) 4. Missed Clinical manifestation • Fetus dies in utero and is retained • Maceration • No symptoms of abortion, but symptoms of pregnancy regress (uterine size, breast changes) Management • Ultrasound, • Fetal monitoring • If fetus is not passed after diagnosis, oxytocin induction may be used. • Retained dead fetus may lead to development of disseminated intravascuia coagulation or infection • Fibrinogen concentrations should be measured weekly
  • 10. 3. Habitual • Spontaneous abortion occurs in successive pregnancies (3 or more)
  • 11. Pathophysiology/Etiology 1. Cause frequently unknown, but 50% are due to chromosomal anomalies 2. Exposure or contact with teratogenic agents 3. Poor maternal nutritional status 4. Maternal illness with or specific bacterial microorganisms 5. History of diabetes, thyroid disease, 6. Smoking or drug abuse or both 7. Immunologic factor 8. Luteal phase defect 9. Postmature sperm or ova 10. Structural defect in the maternal reproductive sysytem (including an incompetent cervix)
  • 12. Induced Abortion. Therapeutic/ Voluntary Abortion • Therapeutic abortion is the termination of pregnancy before fetal viability for the purpose of safeguarding the woman's health. • Voluntary abortion is the termination of a pregnancy before fetal viability as a choice of the woman(nontherapeutic).
  • 13. Complications 1. Hemorrhage 2. Uterine infection 3. Septicemia 4. Uterine perforation 5. Disseminated intravascular coagulation (DIC) in a missed abortion
  • 14. Nursing Assessment 1. Evaluate the amount and color of blood 2. Determine gestational age, LMP and EDC 3. Monitor maternal vital signs for indications of complications such as hemorrhage, infection. 4. Evaluate any blood or clot tissue for the presence of fetal membranes, placenta, or fetus.
  • 15. Nursing Diagnoses A. Risk for Fluid Volume Deficit related to maternal bleeding B. Anticipatory Grieving related to loss of pregnancy, cause of the abortion, future childbearing C. Risk for Infection related to dilated cervix and open uterine vessels D. Pain related to uterine cramping and possible procedures
  • 16. Nursing Interventions A. Maintaining Fluid Volume 1. Report shock sign(tachycardia, hypotension, diaphoresis, or pallor) indicating hemorrhage. 2. Screen blood type, blood administration( if needed). 3. Establish and maintain an IV with large-bore catheter for possible transfusion 4. Inspect all tissue passed for completeness.
  • 17. B. Providing Support Through the Grieving Process Grieving process; Denial, Anger, Bargaining, Depression, Acceptance 1. Accesss the reaction of patient and support person and provide information regarding current status, as needed. 2. Encourage the patient to discuss feelings about the loss of the baby; include effects on relationship with the father. 3. Do not minimize the loss by focusing on future childbearing; rather acknowledge the loss and allow grieving. 4. Provide time alone for the couple to discuss their feelings. 5. Discuss the prognosis of future pregnancies with the couple. 6. If the fetus is aborted intact, provide an opportunity for viewing, if parents desire.
  • 18. C. Preventing Infection 1. Evaluate temperature every 4 hours if normal, and every 2 hours if elevated. 2. Check vaginal drainage for increased amount and odor, which may indicate infection. 3. Instruct on and encourage perineal care following each urination and defecation to prevent contamination.
  • 19. D. Promoting Comfort 1. Reduced anxiety. 2. Instruct and encourage the use of relaxation techniques to augment analgesics. 3. Administer pain medications as needed and as prescribed.
  • 20. Patient Education/Health Maintenance • 1. Provide the names of local support groups for couples who have experienced an early pregnancy loss • 2. Discuss with the couple the methods of contraception to be used. • 3. Explain the need to wait at least 3 to 6 months before attempting another pregnancy. • 4. Teach the woman to observe for signs of infection (fever, pelvic pain, change in character and amount of vaginal discharge), and advise to report them to provider immediately.
  • 21. Evaluation A. Vital signs remain normal; minimal blood loss B. Expresses feelings regarding the loss of the pregnancy C. No signs of infection, temperature normal, performs perineal care D. Verbalizes relief of pain
  • 22. ECTOPIC PREGNANCY • Ectopic pregnancy is any gestation located outside the uterine cavity.
  • 23. Pathophysiology/Etiology 1. The fertilized ovum implants outside of the uterus. a. ampler portion of fallopian tube. b. abdomen and the ovaries. 2. Structural factors; adhesions of the tube, salpingitis, congenital and developmental anomalies induced(septic) abortions. 3. Functional factors include menstrual reflux and decreased tubal motility. 4. Contributing factors may include: a. History of pelvic inflammatory disease (PID) b. Endometriosis c. Previous tubal surgery
  • 24. Clinical Manifestations 1. Abdominal or pelvic pain 2. Amenorrhea—in 75% of the cases 3. Vaginal bleeding—usually scanty and dark 4. Uterine size is usually similar to what it would be in a normally implanted pregnancy. 5. Abdominal tenderness on palpation 6. Nausea, vomiting, or faintness may be present. 7. Pelvic examination reveals a pelvic mass, posterior or lateral to the uterus, and cervical pain on movement of the cervix. 8. Pain may become severe if a tubal rupture occurs and clinical presentation will be that of shock.
  • 25. Diagnostic Evaluation 1. Serum β-human chorionic gonadotropin (βhCG)— when done serially, will not show characteristic rise as in intrauterine pregnancy 2. Ultrasound—may identify tubal mass, absence of gestational sac within the uterus 3. Culdocentesis—bloody aspirate from the cul-desac of Douglas indicates intraperitoneal bleeding from tubal rupture 4. Laparoscopy—visualization of tubal pregnancy 5. Laparotomy—indication for surgery if there is any question about the diagnosis
  • 26. Management 1. Surgeries range from removal of ectopic pregnancy with tubal resection, salpingostomy, salpingectomy, and possibly sal- pingo-oophorectomy. 2. Treat shock and hemorrhage if necessary(rupture)
  • 27. Nursing Assessment • Evaluate the following to determine pregnancy and to monitor for changes in patient's status, such as rupture or hemorrhage: 1. Maternal vital signs 2. Presence and amount of vaginal bleeding 3. Amount and type of pain 4. Presence of abdominal tenderness on palpation(bluish low lateral abdomen) 5. Date of last menstrual period 6. Presence of positive pregnancy test
  • 28. Nursing Diagnoses A. Risk for Fluid Volume Deficit related to blood loss from ruptured tube B. Pain related to ectopic pregnancy or rupture and bleeding into the peritoneal cavity C. Anticipatory Grieving related to loss of pregnancy and potential loss of childbearing capacity
  • 29. Nursing Interventions A. Maintaining Fluid Volume 1. Establish an intravenous (IV) line with a large-bore catheter and infuse fluids and blood products as prescribed. 2. Obtain blood samples for complete blood count (CBC) and type and screen for whole blood, as directed. 3. Monitor vital signs and urine output frequently, depending on condition.
  • 30. B. Promoting Comfort 1. Administer analgesics as needed and prescribed. 2. Encourage the use of relaxation techniques.
  • 31. C. Providing Support During Grief 1. Be available to patient and provide emotional support. 2. Listen to concerns of patient and significant others. 3. Be aware that family may be experiencing denial or other stage of grieving. 4. Suggest referrals such as social worker, psychiatry, and clergy, as appropriate.
  • 32. Patient Education/Health Maintenance 1. Teach signs of postoperative infection; fever, abdominal pain, and increased or malodorous vaginal discharge. 2. Reinforce that chances of another ectopic pregnancy are increased 3. Discuss contraception. 4. Teach signs of recurrent ectopic pregnancy—abnormal vaginal bleeding, abdominal pain, menstrual irregularity.
  • 33. Evaluation A. Vital signs stable B. Verbalizes pain relief C. Patient and support person express sorrow over their loss
  • 34. HYDATIDIFORM MOLE • Hydatidiform mole is an abnormal pregnancy resulting from a developmental anomaly of the placenta. • It is characterized by the conversion of the chorionic villi into a mass of clear vesicles. • There may be no fetus or a degenerating fetus may be present.
  • 35. • Abnormal fertilization results in abnormal growth of cells in uterus. The ―mole‖ grows in the uterus instead of a baby. The ―mole‖ looks like a cluster of grapes.
  • 36. • Occurrence 1. May occur in 1 out of every 1200 pregnancies (U.S data) 2. May be higher in Asian countries
  • 37. • Possible Causes 1. 2. 3. 4. Nutritional deficiencies Age: early teens, over 40 Ovulation stimulation with Clomid History of miscarriage
  • 38. Pathophysiology/Etiology 1. Large amounts of hCG are present secondary to the proliferation of chorionic tissue. Assay values of β-hCG are elevated in the condition. 2. Contributing factors may include chromosomal abnormalities, malnutrition, hormonal imbalance, age under 20 or over 40, and low economic status.
  • 39. Hydatidiform mole • Signs and Symptoms 1. 2. 3. 4. 5. 6. Pregnancy symptoms Larger than normal uterus 95% of women will eventually bleed Excessive nausea and vomiting Anemia Abdominal cramps
  • 40. Clinical Manifestations 1. First trimester bleeding 2. Absence of fetal heart tones and fetal structures (by ultrasound) 3. Rapid enlargement of the uterus; size greater than dates 4. β-hCG titers greater than expected for gestational age 5. Expulsion of the vesicles 6. Hyperemesis 7. Signs of pregnancy-induced hypertension (PIH) prior to 20 weeks' gestation
  • 41. Diagnostic Evaluation 1. β-hCG levels—elevated 2. Ultrasound—shows a characteristic picture of the mole in most cases
  • 42. Management 1. D&C(dilatation and curettage) or D&E(dilatation and evacuation) 2. Follow-up for detection of malignant changes because a complication is the development of choriocarcinoma of the endometrium.
  • 43. Complications 1. Complete mole can cause cancer. About 20% will develop into a rare cancer called choriocarcinoma. 2. 15% of women will develop early high blood pressure disease (at 9 – 12 weeks).
  • 44. Nursing Assessment 1. Monitor maternal vital signs; note presence of hypertension. 2. Assess the amount and type of vaginal bleeding; note the presence of any other vaginal discharge. 3. Assess the urine for the presence of protein and β-hCG. 4. Palpate uterine height; if above the umbilicus, measure the fundal height. 5. Determine date of last menstrual period and date of positive pregnancy test.
  • 45. Nursing Diagnoses A. Potential for Fluid Volume Deficit related to maternal hemorrhage B. Anxiety related to loss of pregnancy and medical interventions
  • 46. Nursing Interventions A. Maintaining Fluid Volume 1. Obtain blood samples for type for whole blood transfusion 2. Establish and maintain IV line. 3. Assess maternal vital signs and evaluate bleeding. 4. Monitor laboratory results to evaluate patient's status.
  • 47. B. Decreasing Anxiety 1. Prepare the patient for surgery; explain preoperative and postoperative care along with intraoperative procedures. 2. Educate patient and family on the disease process. 3. Allow the family to grieve over the loss of the pregnancy.
  • 48. Patient Education/Health Maintenance 1. Advise the woman on the need for continuous followup care(for monitor choriocarcinoma). 2. Provide reinforcement of follow-up procedures: a. Measure hCG levels every 1 to 2 weeks until normal—then begin monthly testing for 6 months, then every 2 months for a total of 1 year. b. Consider chemotherapy or hysterectomy if β-hCG levels rise or begin to plateau or there is evidence of metastasis. 3. Encourage ongoing discussion of care with health care provider. 4. Avoid pregnancy for a minimum of I year.
  • 49. Evaluation A. Vital signs stable; laboratory work within normal limits B. Verbalizes concerns about self and related procedures; describes follow-up care and its importance