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 Primary Survey / Resuscitation  Secondary Survey.

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Presentation on theme: " Primary Survey / Resuscitation  Secondary Survey."— Presentation transcript:

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2  Primary Survey / Resuscitation  Secondary Survey

3  Age: consider in ages 12 years to 55 years  Nationality / ethnicity  Occupation  Economic capabilities and resources  Social support system  Reproductive history  Nutritional  Genetic

4  Subjective Data  History of present illness LNMP EDC or + pregnancy test Bleeding, discharge, pain, N&V, fever / chills Visual disturbances Fetal movement ROM ? Contractions Urinary symptoms Trauma

5  Subjective Data  Medical History Reproductive Prenatal care Recent delivery ?? Abd / pelvic surgery Sexual activity Contraceptive use STD’s Substance abuse Meds, Allergies etc.

6  Objective Data  Physical Exam  Diagnostic Procedures  Radiology  Other 12 lead ECG pH for amniotic fluid

7  Any pregnant patient should be assessed for…  EDC / LNMP  Reproductive history including complications with current and previous pregnancies  Uterine size, tone, presence of contractions  Vaginal discharge or bleeding, fluid leaking?  FHT’s

8  ABC’s first  IV’s and O2 as indicated  Monitor and treat…  Hemodynamic status  Vaginal bleeding, passage of clots, products of conception  Pain  Anticipate educational and emotional needs fo patient and family.  Anticipate equipment needs

9  Pediatrics  Sexual abuse  STD’s / PID  Teen preganancy  Geriatrics

10 Vaginal Bleeding in Early Pregnancy / Abortion Vaginal Bleeding in Late Pregnancy Ectopic Pregnancy PIH: preeclampsia / eclampsia Hyperemesis gravidarum Postpartum hemorrhage Emergency Delivery Neonatal Resuscitation Trauma in Pregnancy

11  Termination of pregnancy before viability (20-24 weeks).  10% to 15% of all recognized pregnancies  Etiology  Endocrine dysfunction  Chromosomal abnormalities  Maldevelopment  Trauma

12  Additional factors  Maternal infections  Malnutrition  Substance abuse  Immunological incompatibility  Surgery  Structural abnormalities of the uterus

13  Threatened  Incomplete  Complete  Missed  Septic

14  Subjective and Objective information same for any pregnant patient  Diagnostic procedures  Pregnancy test - ? Quantitative  CBC  Blood type and Rh  STD  Pelvic US

15  IV access  Assist with US, exam  Prep for surgery as appropriate  Drug Therapy  Rh immune globulin to all Rh negative mothers  Oxytocin  Methergine  Analgesics  Antibiotics  Conscious sedation  Supportive / Psychosocial care

16  Bedrest x hours or until bleeding stops  Pelvic rest until bleeding / cramping cease  Pads only  Temp. four times a day, return for >  Save clots / tissue  Follow up care with OB

17  Placenta Previa  Abnormally implanted placenta partially or completely obstructs cervical os  45% in second trimester  1% at term  Painless bright red bleeding occurs as cervix effaces / dilates  Multiparity, multigestation, advanced maternal age, uterine surgery, smoking.

18  Abruptio placenta  3% of all pregnancies, 15% of all perinatal deaths  Partial or complete separation of a normally implanted placenta  Significant blood loss  Risk for DIC  Etiology: HTN, trauma, substance abuse, PROM, …

19  Implantation of fertilized ovum outside of the normal uterine cavity  95% in the fallopian tube, frequently right  Rupture leads to severe pain, intraperitoneal hemorrhage and shock

20  Pain: diffuse, unilateral or bilateral, tube rupture is sharp, sudden, severe  Referred shoulder pain  Vaginal bleeding irregular / mild  Fatigue, dizziness, syncope  History: LNMP, reproductive hx, PID / STD’s, IUD use, tubal surgery, infertility, meds, allergies

21  Physical Exam:  orthostatic VS  abdominal exam  pelvic  Quantitative BHcG, CBC, T&C, PT/PTT, electrolytes, U/S

22  ABC’s  2 large bore IV’s  Reassess hemodynamic status / pain  Prepare for OR  Methotrexate  Supportive care / pregnancy loss

23  PIH: hypertension unique to pregnancy  Preeclampsia: HTN, proteinuria and non-dependent edema after 20 weeks  Eclampsia: includes convulsions, coma or both  HELLP: hemolysis, elevated liver enzymes, low platelets. The most severe form of preeclampsia.

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25  Exact cause unknown  Underlying pathology is vasospasm  Complicates 5-8% of preganancies  Leading obstetric cause of maternal death

26  Risk factors:  extremes of maternal age,chronic hypertension  hx of eclampsia  mother or sister with hx  multiple gestation  diabetes, SLE, vascular disease  molar pregnancy  More common in primigravida

27  Headache, weight gain, epigastric or RUQ tenderness, generalized edema, visual disturbances, anxiety  BP > 140/90 or 30 mmHg systolic or 15 mmHg diastolic over baseline. 2 BP readings 6 hours apart with Mom on L. side.

28  Urinalysis: proteinuria greater than 1+  CBC  Electrolytes, creatinine, liver enzymes  PT / PTT

29  ABC’s  Supplemental O2  Foley - monitor hourly UO  Magnesium sulfate for seizure prophylaxis  Seizure precautions  Benzodiazepines for seizures  Antihypertensive therapy  Reassess ABC’s, FHT’s, signs of Mg++toxicity (Ca gluconate is antidote)

30  Severe vomiting occurring before 20 th week.  Lasts 4-8 weeks  Significant weight loss, dehydration, malnutrition  Metabolic acidosis, ketonuria, hypokalemic alkalosis, oliguria, hemoconcentration, constipation  Complications: G.I. Bleeding, Mallory – Weiss tears, and Boerhaave’s esophogeal disruption

31  ABC’s  IV access, 1-2 liters NS rapidly  Antiemetics as ordered  Gradual oral rehydration as tolerated

32  Blood loss exceeding 500 ml  Early – within 24 hours of delivery  Uterine atony  Retained placental fragments  Lower genital tract lacerations  Uterine inversion or rupture  Maternal coagulopathy  Late - usually 6-10 days  Retained products of conception  Infection  Episiotomy breakdown  Coital trauma

33  Overdistention of uterus  High parity  Prolonged difficult labor, especially after oxytocin induction  History of PPH  Preeclampsia  Placenta previa  Precipitous labor

34  Assessment to include: orthostatic VS, Uterine size / tone, amount / color of bleeding  Diagnostics: CBC, T&C, Coagulation profile, fibrinogen, fibrin split products, US  2 large bore IV’s – fluids / blood as appropriate  Firm bimanual massage of uterus  Oxytocin, Methergine as ordered  Prepare for surgery

35  Rapid obstetric assessment / history  Contractions: frequency, intensity, duration  Rupture of membranes: time, color, odor  Bloody show?  Rectal pressure or passage of feces  FHT’s  Pelvic Exam for effacement, dilation, station

36  Position side lying or fowlers  Encourage mother to “pant” to prevent uncontrolled delivery  Allow head to emerge slowly  Once head delivered, assess for nuchal cord  Loose – slip over head  Tight – clamp in 2 places and cut between clamps  Wipe infants face, suction mouth then nose.  Support head, deliver anterior then posterior shoulder.  Body will follow rapidly….slippery, don’t drop

37  Hold infant head down at level of perineum, suction mouth then nose again  Clamp cord 4-5 cm from infants abdomen when cord stops pulsating. Cut between clamps  Dry wrap, warm, stimulate infant  Apgar at birth and 5 minutes  Do not massage uterus until placenta is delivered

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39  Trauma is primary cause of mortality in pregnancy causing up to 22% of maternal deaths  Maternal death is leading cause of fetal death  Management priorities for pregnant trauma patient are identical to those for any trauma patient.

40  ABDOMINAL  CARDIOVASCULAR  PULMONARY

41 Vaginal bleeding / Dysfunctional uterine bleeding Pelvic pain Vaginal discharge Sexually Transmitted diseases Pelvic Inflammatory Disease Sexual Assault

42  Vaginal bleeding: uterine fibroids, menstrual cycle irregularities, trauma, infection, malignancy or coagulopathy  DUB: hormonal imbalance  Assessment: include sexual and contraceptive history, quantity, duration, quality of bleeding  Diagnostics: BHCG, CBC, coags, T&S, UA, STD screening, Thyroid, liver function, FSH, LH as appropriate.

43  Variety of causes…assess pain carefully (PQRST).

44  Variety of causes.  Bacterial 40-50%  Candida albicans 20-25%  Trichomonas 15-20%  Non-infectious processes  Retained FB  Chemicals  Hormonal changes  Alteration in vaginal flora due to pregnancy, antibiotics, diabetes, HIV infection, poor hygiene  See table 13-5

45  Vaginitis, cervicitis, PID, urethritis, epididymitis, pharyngitis, proctitis, skin and mucous membrane lesions, AIDS  See table 13-6

46 One RN will triage, assess, provide care, perform the sexual assault kit, provide referrals as needed, and discharge this patient. There is to be no more than one RN giving care


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