ppt chapter 07-1
TRANSCRIPT
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Chapter 7
Life Span: Pregnant or Breast-Feeding Women
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Question
• Most drugs given during pregnancy will not pass to the fetus.
– A. True
– B. False
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Answer
• B. False
• Rationale: Unlike the blood–brain barrier, the placenta allows most drugs to travel through the maternal circulation to the fetus.
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Pharmacotherapeutics
• The important consideration in drug therapy for pregnant women is the potential adverse effects on the developing fetus.
• A clear clinical indication for drug therapy must exist before a drug is prescribed or self-administered.
• Some health problems occur secondarily to pregnancy and require drug therapy.
• If the fetus has a health problem, drugs are administered to the pregnant woman with the intent of treating the fetus as the drug passes through the placenta.
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Pharmacokinetics
• Several physiologic and anatomic changes occur during pregnancy.
• These changes can alter the pharmacokinetics of drugs.
• The primary changes occur in the endocrine, GI, cardiovascular, circulatory, and renal systems.
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Absorption
• Changes in the GI system are influenced by pregnancy hormones and mechanical pressure from the growing uterus.
• Progesterone decreases gastric tone and motility and prolongs stomach emptying time.
• Progesterone also promotes functional respiratory system changes during pregnancy.
• Tidal volume increases 30% to 40%, with a 50% increase in minute volume by term.
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Questions
• What will be the effect of inhaled medications during pregnancy?
– A. Increased absorption
– B. Decreased absorption
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Answer
• A. Increased absorption
• Rationale: Tidal volume increases 30% to 40%, with a 50% increase in minute volume by term. These increases, along with the pulmonary vasodilation that occurs during pregnancy, enhance the absorption of drugs that are inhaled.
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Distribution and Metabolism
• Hemodynamic changes in the cardiovascular system alter drug distribution and metabolism.
• Drugs are also distributed into breast milk.
• Drugs that are widely distributed throughout the mother’s body are usually minimally passed into breast milk.
• Not all drugs present in breast milk are well absorbed by the neonate.
• Drug metabolism is not altered by pregnancy or breast-feeding.
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Excretion
• By the third trimester, the renal blood flow has increased 40% to 50% from the prepregnancy level.
• The glomerular filtration rate increases by approximately 50%.
• Drug excretion rates may be increased during pregnancy.
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Pharmacodynamics
• Two dramatic physical changes occur in the mother during pregnancy:
– By 32 weeks’ gestation, cardiac output is increased by 50%.
– From the second trimester on, arterial blood pressure is decreased.
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Contraindications and Precautions
• Some drugs and vaccines are contraindicated during pregnancy, and others should be given with caution if they pose a threat to the developing fetus by passing through the placenta.
• Some drugs and vaccines can cause teratogenic effects (physical defects) in the developing fetus.
• The precise effects of drug therapy on the fetus are mostly undetermined.
• A drug is traditionally identified as a teratogen based on the findings of animal teratology studies.
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Drugs Contraindicated in Pregnancy
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Pregnancy Categories
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Lactation Categories
• In 2005, the American Academy of Pediatrics Committee on Drugs published its updated recommendations on drugs and breast-feeding.
• The report identifies several categories of drugs and their potential to cause problems with breast-feeding.
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Adverse Effects
• The common symptoms of pregnancy may mask the adverse effects of drug therapy.
• Administration of drugs during pregnancy takes careful evaluation of the effects of the drugs on the fetus.
• The critical period of organogenesis is from implantation up to approximately days 58 to 60 after conception.
• If drugs that cause teratogenic effects are administered during this period, major malformations of fetal organ systems may result.
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Drug Interactions
• Drug interactions are unchanged during pregnancy and breast-feeding.
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Question
• Which of the following are common complications of pregnancy?
– A. Heartburn
– B. Hypotension
– C. Nausea
– D. All of the above
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Answer
• D. All of the above
• Rationale: All of the above are common complications of pregnancy, making it difficult to determine whether the pregnancy or medications that are prescribed during the pregnancy are causing the adverse effect.
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Health Status• Several considerations must be taken into account when
assessing health status during pregnancy.
• First, if the patient has a preexisting condition that requires drug therapy, the health care providers must consider whether the prescribed drug therapy will have adverse effects on the fetus.
• Second, any adverse effects the pregnancy may have on the mother’s health must be identified because they may require changes in drug therapy.
• Third, if the pregnancy does induce changes in health status that require new drug therapy, any adverse effects of this drug therapy on the fetus will have to be determined.
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Conditions of Concern
• Cardiovascular
– Changes occur in the cardiovascular system
• Seizure disorders
– Antiseizure medications have been shown to be teratogenic.
• Depression
– Unclear about long-term effects on the fetus
• Diabetes mellitus
– Increased incidents of congenital abnormalities
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Life Span and Gender
• Teenage pregnancy continues to be a problem in the United States.
• Teenaged girls may be at additional risk for teratogenic drug effects because of sharing of prescription medication.
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Lifestyle, Diet, and Habits
• The lifestyle, diet, and habits of pregnant or breast-feeding women can have a serious impact on the course of the pregnancy and the development of the fetus or infant.
• Alcohol is a known human teratogen.
• Cocaine abuse is also known to cause adverse fetal effects and is suspected to be a human teratogen.
• Opiate abuse does not appear to significantly increase the risk for congenital anomalies.
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Environment
• Some changes in health status that occur in pregnancy require drug therapy to be administered in the hospital setting.
• However, most drug therapy given during pregnancy or breast-feeding is administered in the patient’s home.
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Culture and Inherited Traits
• Cultural beliefs may affect whether a woman accepts certain drug therapies while she is pregnant or breast-feeding.
• Assess for these beliefs when managing drug therapy in the pregnant or breast-feeding woman.
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Nursing Diagnoses and Outcomes• Risk for Injury to the fetus related to adverse effects of
maternal drug therapy
– Desired outcome: The patient will demonstrate therapeutic drug effects with minimal adverse effects to the fetus.
• Anxiety related to perceived danger of drug therapy to the fetus or infant
– Desired outcome: The patient’s anxiety will be minimal during drug therapy.
• Risk for Injury to the patient related to failure to receive needed drug therapy because of its potential adverse effects on the fetus or infant
– Desired outcome: The patient will not sustain an injury from choices made about receiving drug therapy.
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Maximizing Therapeutic Effects
• An important element of patient teaching is adverse reactions to medications.
• Discuss the risks versus the benefits of the medication to the patient and unborn fetus.
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Minimizing Adverse Effects
• Limiting drug use in pregnancy decreases maternal and fetal adverse effects.
• No drug can be considered absolutely safe when administered during pregnancy.
• Women of childbearing age should always be assessed for pregnancy before any drug therapy is initiated.
• During pregnancy, nonpharmacologic alternatives to drug therapy should be used if possible.
• Monitor the pregnant woman and the fetus for both therapeutic and adverse effects of drug therapy.
• When evaluating a patient, be careful to distinguish discomforts of pregnancy from possible adverse drug effects.
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Providing Patient and Family Education
• The nurse’s role in counseling about pregnancy and fetal drug effects ideally begins before pregnancy.
• Informing women of childbearing age about fetal drug effects can help them make decisions about planning pregnancy and about what to do when they become pregnant.
• Patient and family education during pregnancy and breast-feeding is primarily focused on adverse effects to the fetus and infant.
• The pregnant patient should also be taught how to anticipate adverse effects of drug therapy and distinguish them from normal pregnancy-related problems.
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Assessment and Evaluation
• Nursing management of drug therapy during pregnancy and lactation is considered effective when maternal therapeutic needs have been met without harm to the fetus or the breast-feeding infant.
• Other measures of effective drug therapy include successful patient- and family-oriented drug education.
• Assessment findings indicate that the mother and child are not experiencing adverse drug effects.