Blood transfusion therapy involves transfusing whole blood or blood components (specific portion or fraction of blood lacking in patient). One unit of whole blood consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant. Whole blood stored for more than 6 hours does not provide therapeutic platelet transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII).

Blood components include:

1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygen-carrying capacity of blood with minimal expansion of blood.
2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions.
3. Platelets, either HLA (human leukocyte antigen) matched or unmatched.
4. Granulocytes ( basophils, eosinophils, and neutrophils )
5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors).
6. Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation.
7. Albumin, a plasma protein.
8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.
9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.

Advantages of blood component therapy

1. Avoids the risk of sensitizing the patients to other blood components.
2. Provides optimal therapeutic benefit while reducing risk of volume overload.
3. Increases availability of needed blood products to larger population.

Principles of blood transfusion therapy

1. Whole blood transfusion
   • Generally indicated only for patients who need both increased oxygen-carrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed.
2. Packed RBCs
   • Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%.
3. Platelets
   • Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipient’s platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension.
4. Granulocytes
   • May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production.
5. Plasma
   • Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringer’s lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing.
6. Albumin
   • Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma oncotic pressure.
7. Cryoprecipitate
   • Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated intravascular coagulation (DIC), and uremic bleeding.
8. Factor IX concentrate
   • Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors.
9. Factor VIII concentrate
   • Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission.
10. Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors.

Complications of Blood Transfusion

1. Hemolytic transfusion reaction- is a life-threatening complication occurring from transfusion of donor blood that is incompatible with the recipient’s blood.
2. In hemolytic transfusion reaction, antibodies in the recipient’s plasma combine with antigens on donor erythrocytes, causing agglutination and hemolysis in circulation or in the reticuloendothelial system. Similarly, antibodies in donor plasma combine with antigenon the recipient’s eyhrocytes; however, complications from infusion of incompatible plasma are less severe than those associated with infusion of incompatible erythrocytes. The most rapid hemolysis occurs in ABO incompatibility; Rh incompatibility is often less severe.
3. Delayed hemolytic transfusion reaction –occurs 1 to 2 weeks after transfusion; erythrocytes hemolyzed by antibody are not detectible during crossmatched but are formed rapidly after transfusion. It generally is not dangerous, but subsequent transfusions may be associated with acute hermolytic reaction.
4. In hemolytic reaction, severity of complications correlates with the amount of incompatible blood transfused; chances of fatal reactions are decreased if less than 100 ml of incompatible blood is infused.
5. Febrile, non hemolytic Transfusion reaction, the most common type of reaction, is commonly caused by sensitivity to leukocyte or platelet antigens.
6. Septic reaction is an often serious complication resulting from transfusion if a blood product contaminated with bacteria.
7. Allergic reactions may result from sensitivity to plasma protein or donor antibody, which reacts with recipient antigen.
8. Circulatory overload results from administration at a rate or volume greater than can be accommodated by the circulatory system, precipitating congestive heart failure or pulmonary edema.
9. Several infectious diseases can be transmitted through blood transfusion, including:
   • Hepatitis B
   • Non-A, non-B hepatitis
   • Malaria
   • Syphilis
   • Acquired immunodeficiency syndrome (AIDS)
10. Graft-versus-host (GVH) disease results from engraftment of immunocompetent lymphocytes in bone marrow of immunosuppressed recipients, which triggers the immune response of the graft against the host.
11. Reactions associated with massive transfusions (>10 units of packed RBCs on 1 or 6 hours) include:
    • Hypocalcemia, resulting from binding of recipient’s circulating calcium to anticoagulant (citrate) in packed RBC’s.
    • Citrate intoxication due to accumulation of citrate.
    • Hyperkalemia, in which stored red cells progressively increase extracellular potassium concentrations.
    • Exacerbation of liver disease die to increased ammonia levels in stored blood.
    • Hypothermia, in which transfusion of cold blood (below 37 C) at rates >100 mL/min may produce dysrhythmias and cardiac arrest.
    • Aggregates of leukocytes and platelets in the lungs, resulting from accumulation of these aggregates during blood storage.
    • Hemorrhage resulting from excessive dilution of the recipient’s platelets and clotting factors.

Assessment findings

1. Clinical manifestations of transfusions complications vary depending on the precipitating factor.
2. Signs and symptoms of hemolytic transfusion reaction include:
   • Fever
   • Chills
   • low back pain
   • flank pain
   • headache
   • nausea
   • flushing
   • tachycardia
   • tachypnea
   • hypotension
   • hemoglobinuria (cola-colored urine)
3. Clinical signs and laboratory findings in delayed hemolytic reaction include:
   • fever
   • mild jaundice
   • gradual fall of hemoglobin
   • positive Coombs’ test
4. Febrile non-hemolytic reaction is marked by:
   • Temperature rise during or shortly after transfusion
   • Chills
   • headache
   • flushing
   • anxiety
5. Signs and symptoms of septic reaction include;
   • Rapid onset of high fever and chills
   • vomiting
   • diarrhea
   • marked hypotension
6. Allergic reactions may produce:
   • hives
   • generalized pruritus
   • wheezing or anaphylaxis (rarely)
7. Signs and symptoms of circulatory overload include:
   • Dyspnea
   • cough
   • rales
   • jugular vein distention
8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease.
9. Characteristics of GVH disease include:
   • skin changes (e.g. erythema, ulcerations, scaling)
   • edema
   • hair loss
   • hemolytic anemia
10. Reactions associated with massive transfusion produce varying manifestations

Possible Nursing Diagnosis

1. Ineffective breathing pattern
2. Decreased Cardiac Output
3. Fluid Volume Deficit
4. Fluid Volume Excess
5. Impaired Gas Exchange
6. Hyperthermia
7. Hypothermia
8. High Risk for Infection
9. High Risk for Injury
10. Pain
11. Impaired Skin Integrity
12. Altered Tissue Perfusion

Planning and Implementation

1. Help prevent transfusion reaction by:
   • Meticulously verifying patient identification beginning with type and cross match sample collection and labeling to double check blood product and patient identification prior to transfusion.
   • Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.
   • Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion).
   • Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures.
   • Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents.
   • Preventing GVH disease by ensuring irradiation of blood products containing viable WBC’s (i.e., whole blood, platelets, packed RBC’s and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide.
   • Preventing hypothermia by warming blood unit to 37 C before transfusion.
   • Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion.
2. On detecting any signs or symptoms of reaction:
   • Stop the transfusion immediately, and notify the physician.
   • Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion.
   • Send the blood bag and tubing to the blood bank for repeat typing and culture.
   • Draw another blood sample for plasma hemoglobin, culture, and retyping.
   • Collect a urine sample as soon as possible for hemoglobin determination.
3. Intervene as appropriate to address symptoms of the specific reaction:
   • Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria.
   • Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions.
   • In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed.
   • Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.)
   • For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed.

Evaluation

1. The patient maintains normal breathing pattern.
2. The patient demonstrates adequate cardiac output.
3. The patient reports minimal or no discomfort.
4. The patient maintains good fluid balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin integrity, with no lesions or pruritus.
8. The patient maintains or returns to normal electrolyte and blood chemistry values.

Related posts:

1. Complete Blood Count (CBC) Normal Laboratory Study Values
2. Blood Chemistry Definitions
3. Fluid and Electrolyte Therapy

According to the latest reports from Merritt Hawkins & Associates, a physician recruiting and consulting firm in the United States, medical centers last year offered higher salaries and incentives to specialist nurses than to primary care doctors.

Primary care doctors were offered an average base salary of $173,000 in 2009 compared to an average base salary of $189,000 offered to certified nurse anesthetists, or CRNAs.

In 2010 their projection indicate that the average base salary for family physicians will be about $178,000 compared to $186,000 for CRNAs.

CRNA salaries have trended higher as the number of surgical procedures picked up pace over the past few years, fueling demand for anesthesiologists and anesthetists.

Looking at these compensation trends, the biggest concern for America’s health care system is how to encourage more medical students to pick primary care as their specialty at a time when the nation is already facing a shortage of about 60,000 primary care doctors.

As of now there is a growing shortage of family doctors in America and this is expected to continue when health reform happens and millions of more Americans have access to health care.

How to become a Certified Registered Nurse Anesthetists (CRNA) in the US

Related posts:

1. Admin charges recommended vs 3 doctors, nurse
2. Job Opportunities for Nurses and Other Health Professionals
3. Family Nursing Care Plan (FNCP)

Introduction:

The placenta is implanted in the lower uterine segment near or over the internal cervical os. The degree to which the internal cervical os is covered by the placenta has been used to classify four types of placenta previa; total, partial, marginal and low–lying. In total previa the internal os is entirely covered by the placenta. Partial placenta previa implies incomplete coverage of the internal os. Marginal placenta previa indicates that only an edge of the placenta extends to the margin of the internal os. And the last is the low – lying placenta has been used when the placenta is implanted in the lower uterine segment but not reach the os. The more descriptive classification that includes placenta previa is in the third trimester.

The incidence of placenta previa is approximately 0.5% of births. The most important risk factors are previous placenta previa, previous cesarean birth, and suction curettage for miscarriage or induced abortion, possible related to endometrial scarring. The risk also increases with multiple gestations because of the larger placental area, closely spaced pregnancies, advanced maternal age older than 34 years, African or Asian ethnicity, male fetal sex, smoking, cocaine use, multiparity, and tobacco use.

Classification of Placenta Previa:

1. Total Previa- the placenta completely covers the internal cervical os.
2. Partial Previa- the placenta covers a part of the internal cervical os.
3. Marginal Previa- the edge of the placenta lies at the margin of the internal cervical os and may be exposed during dilatation.
4. Low-lying placenta- the placenta is implanted in the lower uterine segment but does not reach to the internal os of the cervix.

Predisposing Factors:

1. Multiparity (80% of affected clients are multiparous)
2. Advanced maternal age (older than 35 years old in 33% of cases
3. Multiple gestation
4. Previous Cesarean birth
5. Uterine Incisions
6. Prior placenta previa ( incidence is 12 times greater in women with previous placenta previa)

Complications for the baby include:

• Problems for the baby, secondary to acute blood loss
• Intrauterine growth retardation due to poor placental perfusion
• Increased incidence of congenital anomalies

Clinical Manifestations:

• Painless vaginal bleeding > occurs after 20 weeks of gestation, bright red in color associated with the stretching and thinning of the lower uterine segment that occurs in third trimester.
• Adequately contract and stop blood flow from open vessels.
• Stop blood flow from open vessels
• Decreasing urinary output

Normal Placenta During Childbirth

Process of placental growth and uterine wall changes during pregnancy

1. The placenta grows with the placental site during pregnancy.
2. During pregnancy and early labor the area of the placental site probably changes little, even during uterine contractions.
3. The semirigid, noncontractile placenta cannot alter its surface area.

Anatomy of the uterine/placental compartment at the time of birth

1. The cotyledons of the maternal surface of the placenta extend into the decidua basalis, which forms a natural cleavage plane between the placenta and the uterine wall.
2. There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the branches of the uterine arteries that run through the wall of the uterus to the placental area.
3. The placental site is usually located on either the anterior or the posterior uterine wall.
4. The amniotic membranes are adhered to the inner wall of the uterus except where the placenta is located

Anatomy of Female Reproductive System
Physiology of Female Reproductive System
Anatomy and Physiology of Male Reproductive System

Pathophysiology

No specific cause of placenta previa has yet been found but it is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection.

In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the lower segment, it may shear off and a small section may bleed.

Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender and relaxed. Leopold’s Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position of the placenta. Praevia can be confirmed with an ultrasound.[3] In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre.

The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can be managed non-operatively until the 36th week. By this time the baby’s chance of survival is as good as at full term.

Diagnostic Evaluation:

Placenta previa is diagnosed using transabdominal ultrasound.
-    transabdominal scans with fewer false positive results

Transvaginal ultrasound

• If a woman is bleeding she is usually placed in the labor and birth unit or for cesarean birth because profound hemorrhage can occur during the examination. This type of vaginal examination knows as the double- setup procedure

Ultrasonographic scan

• If ultrasonographic scanning reveals a normally implanted placenta, an examination may be performed to rule out local causes of bleeding and a coagulation profile is obtained to rule out other causes of bleeding management of placenta previa depends of the gestational age and condition of the fetus and the amount and cesarean birth.

Complete blood count (CBC)

• To monitor mother’s blood volume

Fetoscope

• To monitor fetal heart rate and conditions

Medical Management:

• Maternal stabilization and fetal monitoring
• Control of blood loss, blood replacement
• Delivery of viable neonate
• With fetus of less than 36 weeks gestation, careful observation to determine safety of continuing pregnancy or need for preterm delivery
• Hospitalization with complete bed rest until 36 weeks gestation with complete placenta previa
• Possible vaginal delivery with minimal bleeding or rapidly progressing labor

Nursing Interventions:

1. If continuation of the pregnancy is deemed safe for patient and fetus administer magnesium sulfate as ordered for premature labor
2. Obtain blood samples for complete blood count and blood type and cross matching
3. Institute complete bed rest
4. If the patient and placenta previa is experiencing active bleeding, continuously monitor her blood pressure, pulse rate, respiration, central venous pressure, intake and output, and amount of vaginal bleeding as well as the fetal heart rate and rhythm
5. Assist with application of intermittent or continuous electronic fetal monitoring as indicated by maternal and fetal status.
6. Have oxygen readily available for use should fetal distress occur, as indicated by bradycardia, tachycardia, late or available decelerations, pathologic sinusoidal pattern, unstable baseline, or loss of variability.
7. If the patient is Rh-negative and not sensitized, administer Rh (D) immune globulin (RhoGAM) after every bleeding episode.
8. Administer prescribed IV fluids and blood products.
9. Provide information about labor progress and the condition of the fetus.
10. Prepare the patient and her family for a possible caesarian delivery and the birth of a preterm neonate, and provide thorough instructions for postpartum care.
11. If the fetus less than 36 weeks gestation expect to administer an initial dose of betamethasone: explain that additional doses may be given again in 24 hours and possibly for the next 2 weeks to help mature the neonates lungs.
12. Explain that the fetus survival depends on gestational age and amount of maternal blood loss. Request consultation with a neontologist or pediatrician to discuss a treatment plan with the patient and her family.
13. Assure the patient that frequent monitoring and prompt management greatly reduce the risk of neonatal death.
14. Encourage the patient and her family to verbalize their feelings helps them to develop effective coping strategies, and refer them for counseling, if necessary.
15. Anticipate the need for a referral for home care if the patient bleeding ceases and she’s to return home in bed rest.
16. During the postpartum period, monitor the patient for signs of early and late postpartum hemorrhage and shock.
17. Monitor VS for elevated temperature, pulse, and blood pressure, monitor laboratory results for elevated WBC count, differential shift; check for urine tenderness and malodorous vaginal discharge to detect early signs of infection resulting from exposure of placental tissue.
18. Provide or teach perineal hygiene to decrease the risk of ascending infection.
19. Observe for abnormal fetal heart rate patterns such as loss of variability, decelerations tachycardia to identify fetal distress.
20. Position the patient in side lying position and wedge for support to maximize placental perfusion.
21. Assess fetal movement to evaluate for possible fetal hypoxia.
22. Teach woman to monitor fetal movement to evaluate well being
23. Administer oxygen as ordered to increase oxygenation to mother and fetus.

Discharge Plan:

Medication

• Betamethasone (Celestone) is a corticosteroid that acts as an anti-inflammatory and immunosuppressive agent.
• Assess for contraindications of Betamethasone administration. Obtain reports of urine and cervical cultures and fibronectin.

Exercise

• Needs to adequate her time with her child to be certain he or she is all right, and nurse can states hearing fetal heart beat helps to reassure her about baby’s health.
• Attach contraction and fetal heart rate monitoring for continuous evaluation of contractions of fetal response.

Treatment

• Used of drugs
• Catheterization

Health Teaching

• Maintain a bed rest
• Maintain a 8 glasses of water

Ongoing Assessment

• Assess client’s home surrounding to determine whether they are appropriate for bed rest and continuing monitoring at home. Administer oral dose and home monitoring requires professional supervision.

Diet

• She might to begin to neglect her diet or her supplementary vitamins because “It doesn’t matter anymore”.

Spiritual

• Assess anxiety level of client over preterm labor possible feelings.
• Determine whether client wants a support person to be wit her, to the presence of a support person can offer additional comfort to a client.

Possible Nursing Diagnosis for Placenta Previa:

• Risk for Impaired Fetal Gas Exchange r/t Disruption of Placental Implantation
• Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted Placental Implantation
• Active Blood Loss (Hemorrhage) r/t Disrupted Placental Implantation
• Fear r/t Threat to Maternal and Fetal Survival Secondary to Excessive Blood Loss
• Activity Intolerance r/t Enforced Bed Rest During Pregnancy Secondary to Potential for Hemorrhage
• Altered Diversional Activity r/t Inability to Engage in Usual Activities Secondary to Enforced Bed Rest and Inactivity During Pregnancy

View Nursing Care Plan – Placenta Previa

References:

• Maternal & Child Nursing Seventh Edition Vol.1 page 413.
• Maternity nursing, Lowdermilk Perry, seventh edition, chapter 23, page 751.
• Maternal Neonatial Nursing Lippincott manual of Nursing Practice
• http://wikipedia.org
• Pregnancy care

Related posts:

1. Placenta Previa
2. Nursing Care Plan – Placenta Previa
3. Nursing Care Plan – Abruptio Placenta

Introduction:

Pregnancy Induced Hypertension (PIH) is a condition in which vasospasms occur during pregnancy in both small and large arteries. Signs of hypertension, proteinuria, and edema develop. It is unique to pregnancy and occurs in 5% to 7% of pregnancies in the united states. Despite years of research, the cause of the disorder is still unknown. Originally it was called toxemia because researchers pictured a toxin of some kind being produced by a women in response to foreign protein of the growing fetus, the toxin leading to the topical symptoms. No such toxins have ever been identified.

A condition separate from chronic hypertension, PIH tends to occur most frequently in women of color or with a multiple pregnancy; primiparas are younger than 20 years of age or older than 40 years, women from low socio economic backgrounds, those who have an underlying disease such as heart disease, diabetes with vessel or renal involvement and essential hypertension.

PIH is classified as gestational hypertension, mild preeclampsia, severe preeclampsia and eclampsia, depending on how far development advances. Gestational hypertension when develops an elevated blood pressure but has no proteinuria or edema. Perinatal mortality is not increased with simple gestational hypertension, so no drug therapy is necessary; and blood pressure returns to normal after birth. Mild preeclampsia when blood pressure rises to 140/90 mmHg or systolic pressure elevated 15 mmHg above pregnancy level; mild edema in upper extremities or face. Severe preeclampsia when blood pressure has risen to 160 mmHg systolic and 110 mmHg diastolic; proteinuria; pulmonary or cardiac involvement; extensive peripheral edema; hepatic dysfunction; theombocytopenia. Eclampsia is the most severe classification of PIH and seizure or coma Accompanied by s/s of preeclampsia. Any woman who falls into one of the high-risk categories for PIH should be observed carefully for symptoms at prenatal visits. She needs instructions about what symptoms to watch for so she can alert her clinician if additional symptoms occur between visits.

Anatomy and Physiology:

When most people hear the term cardiovascular system, they immediately think of the heart. We have all felt our own heart "pound" from time to time, and we tend to get a bit nervous when this happens. The crucial importance of the heart has been recognized for a long time. However, the cardiovascular system is much more than just the heart, and from a scientific and medical standpoint, it is important to understand why this system is so vital to life.

Most simply stated, the major function of the cardiovascular system is transportation. Using blood as the transport vehicle, the system carries oxygen, nutrients, cell wastes, hormones, and many other substances vital for body homeostasis to and from the cells. The force to move the blood around the body is provided by the beating heart. The cardiovascular system can be compared to a muscular pump equipped with one-way valves and a system of large and small plumbing tubes within which the blood travels.

HEART:

The heart is a muscular organ found in all vertebrates that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions.
The heart is enclosed in a double-walled sac called the pericardium. The superficial part of this sac is called the fibrous pericardium. This sac protects the heart, anchors its surrounding structures, and prevents overfilling of the heart with blood. It is located anterior to the vertebral column and posterior to the sternum. The size of the heart is about the size of a fist and has a mass of between 250 grams and 350 grams. The heart is composed of three layers, all of which are rich with blood vessels. The superficial layer, called the visceral layer, the middle layer, called the myocardium, and the third layer which is called the endocardium. The heart has four chambers, two superior atria and two inferior ventricles. The atria are the receiving chambers and the ventricles are the discharging chambers. The pathway of blood through the heart consists of a pulmonary circuit and a systemic circuit. Blood flows through the heart in one direction, from the atrias to the ventricles, and out of the great arteries, or the aorta for example. This is done by four valves which are the tricuspid atrioventicular valve, the mitral atrioventicular valve, the aortic semilunar valve, and the pulmonary semilunar valve.
Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation.

Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation. A separate system known as the bronchial circulation supplies blood to the tissue of the larger airways of the lung.

Arteries are blood vessels that carry blood away from the heart. All arteries, with the exception of the pulmonary and umbilical arteries, carry oxygenated blood.

Pulmonary arteries
The pulmonary arteries carry deoxygenated blood that has just returned from the body to the heart towards the lungs, where carbon dioxide is exchanged for oxygen.

Systemic arteries
Systemic arteries can be subdivided into two types – muscular and elastic – according to the relative compositions of elastic and muscle tissue in their tunica media as well as their size and the makeup of the internal and external elastic lamina. The larger arteries (>10mm diameter) are generally elastic and the smaller ones (0.1-10mm) tend to be muscular. Systemic arteries deliver blood to the arterioles, and then to the capillaries, where nutrients and gasses are exchanged.

The Aorta
The aorta is the root systemic artery. It receives blood directly from the left ventricle of the heart via the aortic valve. As the aorta branches, and these arteries branch in turn, they become successively smaller in diameter, down to the arteriole. The arterioles supply capillaries which in turn empty into venules. The very first branches off of the aorta are the coronary arteries, which supply blood to the heart muscle itself. These are followed by the branches off the aortic arch, namely the brachiocephalic artery, the left common carotid and the left subclavian arteries.

Aorta the largest artery in the body, originating from the left ventricle of the heart and extends down to the abdomen, where it branches off into two smaller arteries (the common iliacs). The aorta brings oxygenated blood to all parts of the body in the systemic circulation.

The aorta is usually divided into five segments/sections:

• Ascending aorta—the section between the heart and the arch of aorta
• Arch of aorta—the peak part that looks somewhat like an inverted "U"
• Descending aorta—the section from the arch of aorta to the point where it divides into the common iliac arteries
  o    Thoracic aorta—the half of the descending aorta above the diaphragm
  o    Abdominal aorta—the half of the descending aorta below the diaphragm

Arterioles
Arterioles, the smallest of the true arteries, help regulate blood pressure by the variable contraction of the smooth muscle of their walls, and deliver blood to the capillaries.
Veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the lungs; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood. Veins differ from arteries in structure and function; for example, arteries are more muscular than veins and they carry blood away from the heart.
Veins are classified in a number of ways, including superficial vs. deep, pulmonary vs. systemic, and large vs. small.

Superficial veins
Superficial veins are those whose course is close to the surface of the body, and have no corresponding arteries.

Deep veins
Deep veins are deeper in the body and have corresponding arteries.

Pulmonary veins
The pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the heart.

Systemic veins
Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart.
Atrium sometimes called auricle, refers to a chamber or space. It may be the atrium of the lateral ventricle in the brain or the blood collection chamber of a heart. It has a thin-walled structure that allows blood to return to the heart. There is at least one atrium in animals with a closed circulatory system.

Right atrium is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the superior and inferior vena cava and the coronary sinus, and pumps it into the right ventricle through the tricuspid valve. Attached to the right atrium is the right auricular appendix.

Left atrium is one of the four chambers in the human heart. It receives oxygenated blood from the pulmonary veins, and pumps it into the left ventricle, via the atrioventricular valve.
Ventricle is a chamber which collects blood from an atrium (another heart chamber that is smaller than a ventricle) and pumps it out of the heart.
Right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk.

Left ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aortic valve.

Pathophysiology of Pregnancy Induced Hypertension (PIH):

Clinical Manifestations:

A.  Mild Preeclampsia

• BP of 140/90
• 1+ to 2+ proteinuria on random
• weight gain of 2 lbs per week on the 2nd trimester and 1 lb per week on the 3rd trimester
• Slight edema in upper extremities and face

B. Severe Preeclampsia

• BP of 160/110
• 3-4+ protenuria on random
• Oliguria (less than 500 ml/24 hrs)
• Cerebral or visual disturbances
• Epigastric pain
• Pulmonary edema
• Peripheral edema
• Hepatic dysfunction

C. Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures.

Diagnostic Evaluation:

1. Based on the presenting symptoms. Often the disease process has been developing and affecting the renal and vascular system
2. Frequently a sudden weight gain will occur, of 2 lb. or more in 1 week, or 6 lb. or more within 1 month. This often occurs before the edema is present.

Medical Treatment and Evaluation:

1. Magnesium Sulfate (Pregnancy risk category B)
     muscle relaxant, prevent seizures
     loading dose 4-6g, maintenance dose 1-2g/h IV
     infuse IV dose slowly over 15-30 min.
      •Always administer as a piggy back infusion.
      •Assess PR, urine output, DTR, and clonus every hour.
      •Observe for CNS depression and hypotonia in infant at birth.
2. Hydrazaline (Apresoline) Pregnancy risk category C
     anti hypertensive (peripheral vasodilator) use to decrease hypertension
     5-10mg/IV
     Administer slowly to avoid sudden fall of BP
      •Maintain diastolic pressure over 90 mmHg to ensure adequate placental filling.
3. Diazepam (Valium) Pregnancy risk category D
     halt seizures
     5-10mg/IV
     administer slowly. Dose may be repeated every 10-15 min. (up to 30mg/hr)
      •Observe for respiratory depression for both mother and infant at birth.
4. Calcium Gluconate (Pregnancy risk category C)
     antidote for Magnesium Sulfate
     1g/IV (10 mL of a 10% solution)
     have prepared at bed side when administering Magnesium Sulfate
     administer at 5mL/min.

Complications of PIH:

1. Intrauterine growth restriction (IUGR) – an abnormally restricted symmetric or asymmetric growth of fetus
2. Oligohydramnios – abnormally low volume of amniotic fluid
3. Risk of placental abruption – premature separation of a normally situated placenta from the wall of uterus
4. Risk of preterm delivery (often iatrogenic) – delivery before 37 weeks of gestation
5. Coagulopathy
6. Stillbirth
7. Seizures
8. Coma
9. Renal failure
10. Maternal hepatic damage
11. Hemolysis
12. Elevated liver enzymes levels
13. Low platelet count (HELLP syndrome)

Nursing Interventions:

Discharge Plan:

Exercise

1. encourage patient’s on deep breathing exercises.
2. move extremities when lying.
3. elevate the head part when sleeping, to promote increase peripheral circulation
4. encourage overall passive and active exercises program during pregnancy to prevent need for cesarean birth.
5. exercises like tailor sitting, squatting, kegel exercise, pelvic rocking, and abdominal muscle contraction will promote easy delivery. 

Treatment:

1. use of drugs
2. catheterization
3. obtaining labs. (CBC, platelets count, liver function, BUN and creatinine, and fibrin degregation)

Health Teaching:

1. Encourage patient foe sodium restriction.
2. Encourage to avoid foods rich in oil and fats.
3. Encourage patient to limit her daily activities and exercises.

Ongoing Assessment:

1. Observe carefully for symptoms at prenatal visit.
2. Give instruction about what symptoms to watch for so she can alert her clinician if additional symptoms occur between visits.

Diet:

1. low fats and sodium diet, restriction if possible.
2. high in protein, calcium and iron.
3. Adequate fluid intake

Sex:

1. limit sexual activity
2. sexual intercourse at 2nd trimester should be avoided.

View Nursing Care Plan – Pregnancy Induced Hypertension (PIH)

References:

• Maternal and child health nursing by Adele Pillitteri 5th edition;volume 1 page 426-433;page 329-332
• All-in-one care planning resource page 748; by Pamela L. Swearlngen, RN
• Maternal neonatal nursing;page 30 by Lippincott Williams and Wilkins
• Luckman and Sorensen’s Medical-Surgical Nursing a Physiologic Approach 4th edition Volume 1 page 734
• http://wikipedia.org
• http://nursingcrib.com

Related posts:

1. Nursing Care Plan – Pregnancy Induced Hypertension (PIH; Preeclampsia and Eclampsia)
2. Fetal Circulation
3. Pathophysiology of Congestive Heart Failure

Preeclampsia is a characterized, by vsospasms, changes in the coagulation system, and disturbances in systems related to volume and BP control. Vasospasms results from an increased sensitivity to circulating pressors, such as angiotensin II, and possibly an imbalance between the prostaglandins prostacyclin and thromboxane A1.

Endothelial cell dysfunction, believed to result from decreased placental perfusion, may account for many changes in preeclampsia. Arteriolar vasospasm may cause endothelial damage and contribute to an increased capillary permeability. This increase edema and further decreases intravascular volume, predisposing the woman with preeclampsia to pulmonary edema.

Immunologic factors may play an important role in the development of preeclampsia. The presence of a foreign protein, the placenta, or the fetus maybe perceived by the mother’s immune system as an antigen. This may then trigger an abnormal immunologic response. This theory is supported by the increased incidence of preeclampsia or eclampsia in first-time mothers or to multiparous woman pregnant by a new partner. Preeclampsia maybe an immune complex disease in which the maternal antibody system is overwhelmed from excessive fetal antigens in the maternal circulation. This theory seems compatible with the high incidence of preeclampsia among women exposed to a large mass of trophoblastic tissue as seen in twin pregnancies or hydatidiform moles.

Genetic predisposition maybe another immunologic factor. Dekker reported a greater frequency of preeclampsia and eclampsia among daughters and granddaughters of women with a history of eclampsia, which suggests an autosomal recessive gene controlling the maternal immune response. Paternal factors are also examined.

Diets in inadequate nutrients, especially protein, calcium, sodium, magnesium, and vitamin E and C, maybe an etiologic factor in preeclampsia. Some practitioners prescribed high-protein diets (90 mg supplemental protein) without caloric restriction and moderate sodium intake in the prevention and treatment of this disorder. However, data are limited regarding the association between diet and preeclampsia.

Preeclampsia progress along a continuum from mild disease to severe preeclampsia, HELLP syndrome, or eclampsia. The pathophysiology of preeclampsia reflects alteration in the normal adaptations of pregnancy. Normal physiologic adaptations to pregnancy include increase blood plasma volume, vasodilation, and decreased systemic vascular resistance, elevated cardiac output, and decreased colloid osmotic pressure. Pathologic changes in the endothelial cells of the glomeruli are uniquely characteristic of preeclampsia, particularly in nulliparous women. The main pathogenic factor is not an increase in BP but poor perfusion as a result vasospasm. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and raises BP. Function in organs such as the placenta, kidneys, liver and brain is deceased by as much as 40% to 60%.

No related posts.

According to the Department of Health (DOH), 16 out of the 20 DOH-retained hospitals in Metro Manila have fully complied with the directive on phasing out the use of all apparatuses or devices in the healthcare system that contain mercury.

The phase-out is in connection with the Administrative Order No. 2008-0021 which mandates the gradual phase-out of mercury in all Philippine health care facilities and institutions.

The move to stop the use of all medical devices containing mercury was jumpstarted in 1991, when the World Health Organization (WHO) concluded that a safe level for mercury that would not have any adverse effects on a person’s health has never been established.

The following are the list of DOH-hospitals in Metro Manila which are fully-compliant:

1. San Lorenzo Ruiz Women’s Hospital
2. Dr. Jose N. Rodriguez Memorial Hospital
3. Philippine Orthopedic Center
4. Valenzuela Medical Center
5. National Center for Mental Health
6. East Avenue Medical Center
7. San Lazaro Hospital
8. Research Institute for Tropical Medicine
9. Dr. Jose R. Reyes Memorial Medical Center
10. Jose Fabella Memorial Hospital
11. Las Pinas General Hospital and Satellite Trauma Center
12. Rizal Medical Center
13. Quirino Memorial Medical Center
14. Tondo Medical Center
15. Lung Center of the Philippines a
16. Philippine Children’s Medical Center

In a report to Health Secretary Esperanza Cabral last 24 February 2010, there were only four remaining DOH-retained hospitals in Metro Manila that have not yet fully complied with the phase-out.

These four hospitals are the National Children’s Hospital, Amang Rodriguez Medical Center, Philippine Heart Center and National Kidney and Transplant Institute.

The National Children’s Hospital is still using mercurial sphygmomanometers while awaiting delivery of digital sphygmomanometers, while the Heart Center has fully phased out mercurial thermometers, but still has functioning mercurial blood pressure devices that are waiting to be replaced.

The National Kidney and Transplant Institute is still using 11 mercurial sphygmomanometers but these are only used as back up in their hemodialysis units and are awaiting replacements. The Amang Rodriguez Medical Center retrieved nine mercurial blood pressure apparatuses from the condemned equipment damaged by Typhoon Ondoy but these too are due to be replaced soon.

Meanwhile, four compliant hospitals were recognized by the group Health Care Without Harm-Southeast Asia. These are the San Lazaro Hospital, Research Institute for Tropical Medicine, Las Pinas General Hospital and Satellite Trauma Center, and the Philippine Children’s Medical Center.

According to the Health Chief, mercury must be phased out because of its potentially harmful effects to a person’s health. Mercury can damage the nervous, digestive, respiratory, endocrine and immune systems. It can also cause tremors, impaired vision and hearing, paralysis, insomnia, emotional instability, developmental effects on a fetus, and attention deficit and developmental delays during childhood.

“With all the hazards posed by mercury, it is high time that we complete the implementation of its total phase-out in all hospitals and health facilities”, Cabral concluded.

Source: DOH

Related posts:

1. DOH Wants to Ban Importation of Mercury-Containing Products
2. Basic IVT Training Schedule for November 2008, December 2008 and January 2009
3. New Hospital in Manila to Open Soon