Absence is medically required when: Recovery or quarantine requires confinement to bed or home. Being in the workplace or traveling to work is medically contra-indicated poses a specific hazard to the public, coworkers, or to the worker personally, i.
Although maternal mortality due to other causes such as infection, hemorrhage, hypertension, and thromboembolism, has declined over the years, the number of maternal deaths due to penetrating trauma, suicide, homicide and motor vehicle accidents has risen steadily.
In the case of gunshot wounds to the pregnant abdomen, overall maternal mortality is low 3. Although the initial assessment and management priorities for resuscitation of the injured pregnant patient are the same as those for other traumatized patients, the specific anatomic and physiologic changes that occur during pregnancy may alter the response to injury and hence necessitate a modified approach to the resuscitation process.
The main principle guiding therapy must be that resuscitating the mother will resuscitate the fetus. Fetal Physiology The effect of trauma on pregnancy depends on the gestational age of the fetus, the type and severity of the trauma, and the extent of disruption of normal uterine and fetal physiology.
The survival of the fetus depends on adequate uterine perfusion and delivery of oxygen. The uterine circulation has no autoregulation which implies that uterine blood flow is related directly to maternal systemic blood pressure, at least until the mother approaches hypovolemic shock.
At that point, peripheral vasoconstriction will further compromise uterine perfusion. If fetal oxygenation or perfusion are compromised by trauma, the response of the fetus may include bradycardia or tachycardia, a decrease in the baseline variability of the heart rate, the absence of normal accelerations in the heart rate, or recurrent decelerations.
It should be noted that an abnormal fetal heart rate may be the first indication of an important disruption in fetal homeostasis. During trauma resuscitation, evaluation of the fetus should begin with auscultation of heart tones and continuous recording of the heart rate.
Trauma to the uterus direct or indirect can also injure the myometrium and destabilize decidual lysosomes, releasing arachidonic acid that can cause uterine contractions, and perhaps inducing premature labor.
This relative hypervolemic state and hemodilution is protective for the mother because fewer red blood cells are lost during hemorrhage. The hypervolemia prepares the mother for the blood loss that accompanies vaginal delivery ml or cesarean section ml.
Despite the increase in blood volume and cardiac output, the parturient is susceptible to hypotension from aortocaval compression in the supine position. Uterine displacement must be maintained at all times during resuscitation, transport and perioperatively for nonobstetrical surgery.
Care should be taken to consider these anatomic changes when thoracic procedures such as thoracostomies are being performed. The most important respiratory change during pregnancy is the decrease in functional residual capacity FRC.
All these changes predispose to rapid falls in PaO2 during periods of apnea or airway obstruction. Hence, supplemental oxygen is always indicated for these patients in the resuscitation room. Increased levels of progesterone and estrogen inhibit gastrointestinal motility. In addition, there is a decrease competency of the gastroesophageal sphincter, which increases the potential for aspiration.
As the uterus enlarges, it displaces the intestines upward and laterally, stretching the peritoneum and making the abdominal physical examination unreliable. Blood urea nitrogen BUN and serum creatinine are reduced. Also, the kidneys enlarge by hypertrophy and hyperemia as early as the 10th week of gestation secondary to hormonal and mechanical factors.
This means that loss of consciousness can occur even at "sedative" doses. General Approach to the Trauma Patient The primary initial goal in treating a pregnant trauma victim is to stabilize the mother's condition.
The priorities for treatment of an injured pregnant patient remain the same as those for the nonpregnant patient. Supplemental oxygen is essential to prevent maternal and fetal hypoxia. Severe trauma stimulates maternal catecholamine release, which causes uteroplacental vasoconstriction and compromised fetal circulation.
Prevention of aortocaval compression is also essential to optimize maternal and fetal hemodynamics. Pregnant patients beyond 20 weeks' gestation should not be left supine during the initial assessment. Left uterine displacement should be used by tilting the backboard to the left or as a final measure, the uterus can be manually displaced.
Hypovolemia should be suspected before it becomes apparent because of the relative pregnancy induced hypervolemia and hemodilution that may mask significant blood losses.
Aggressive volume resuscitation is encouraged even for normotensive patients. The pneumatic antishock garment PASG may be used to stabilize lower extremity fractures and perhaps control hemorrhage.
In the pregnant patient, inflation of the abdominal compartment of the PASG should be avoided because if compromises uteroplacental blood flow.
Secondary Survey The secondary survey consists of obtaining a complete history, including an obstetrical history, performing a physical examination, and evaluating and monitoring the fetus. The obstetrical history is important because the identification of comorbid factors may alter management decisions.
A history of preterm labor or placental abruption puts the patient at increased risk for the recurrence of the condition. The obstetrical history should include the date of the last menstruation, expected date of delivery and any problems or complications of the current and previous pregnancies.DEPRESSION.
Patient Health Questionnaire (PHQ-9) is the most common screening tool to identify depression. It is available in Spanish, as well as in a modified version for adolescents.; The MacArthur Foundation Initiative on Depression and Primary Care has created a Depression Tool kit is intended to help primary care clinicians recognize and manage depression.
Pedophilia (alternatively spelled paedophilia) is a psychiatric disorder in which an adult or older adolescent experiences a primary or exclusive sexual attraction to prepubescent children.
Although girls typically begin the process of puberty at age 10 or 11, and boys at age 11 or 12, criteria for pedophilia extend the cut-off point for prepubescence to age Patient assessment commences with assessing the general appearance of the patient.
Use observation to identify the general appearance of the patient which includes level of interaction, looks well or unwell, pale or flushed, lethargic or active, agitated or calm, compliant or combative, posture and movement.
Distress Screening for Oncology Patients Practical steps for developingand implementing to improve levels of distress, anxiety, and depression, but a referral • Assessing the distress screening program’s effectiveness.
The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment . assessment tools that can be incorporated into normal practice.
Nurses in a busy oncology radiation clinic were able to as-sess distress, provide educational and referral resources, and increase patient satisfaction through planned imple-mentation of an assessment and intervention process.