Rocking OB/GYN Clinic!

[pagandeva2000, LPN]

I was originally supposed to orient to OB-GYN for two weeks and now, the head nurse is dying to keep me; in fact, there are rumors that this will be my permanent home. I am happy about it because it is new and different. It is, however, yet, another overburdened clinic with many new uninsured people coming due to two neighborhood hospitals closing, increasing our catchment area.

There is so much to learn! We have high risk pregnancies, urodynamics, SPC (special procedure clinic), endocrine, diabetic and it is a normal day for me to treat 10 women in a row for chlamydia. As I mentioned earlier, I haven't had as much time to post lately because I try to make sure that I get as much rest as possible because I truly need rollerskates in that joint. Those nurses are phenomenal teachers. They are all quirky, but are very giving and willing to share. We have spatial issues, however, so, it is hard to keep up with the pace because we get many walk ins a day.

Some questions for the more experienced nurses:

1. I am noticing that there are many women that are spilling proteins in their urine, but are not hypertensive. Why is that? What I notice is if they are spilling proteins, the doctor will order a 24 hour urine. I give them paperwork about PIH, but I am wondering if I am doing the right thing if there are no other indications of preeclampsia besides the spilling of proteins.

2. Another question: for GDM...the doctors really want to see glucose testing logs. Some of the readings are not particularly high in my opinion (compared to the teachings I have had for DM...), like a reading in the morning before breakfast may be for one patient 107mg/dL, and two hours after a meal, 148mg/dL, and to me, this is not really high, but the doctor will tell the patient to see a dietitican for better glucose control. The patient will ask me why, and for now, I really don't have an answer, but will promptly escort them to the dietitican. Are there different parameters for diabetic pregnant women? I do intend to ask the providers and other nurses as soon as possible, but I tend to forget because there are so many things to keep up with that it slips me. I want to have the knowledge, for myself and to explain to the patients.

They seem to love how I am functioning. I am not as lost as I was as a brand new nurse, but there is a learning curve for me. I guess I am using decent judgement, but this will take a bit longer for me to master because there is just so much! It is exciting, however. Any information you all can share would be greatly appreciated (as usual).

[Jolie, BSN]

First of all, congratulations!

As far as glucose control during pregnancy, studies show that tighter control yields fewer complications for mom and baby, so we aim for the following capillary whole blood glucose levels: ac 70-100mg/dl, 2 hour pp

Poor glucose control during pregnancy is linked to congenital malformations, especially cardiac, skeletal, gi and gu. Poor glucose control can also lead to polyhydramnios (which is linked to increased risk of preterm birth and infection), macrosomia (which is linked to birth trauma, neonatal hypoglycemia, hyperbilirubinemia, C-section), prematurity, respiratory distress syndrome and sudden fetal demise.

[netglow, ASN, RN]

Hi Pagan... so, as you know, I am not seasoned, and not an RN yet. But did part of my OB rotation in a clinic very similar, and same protein thing going on... ask about edema, and epigastric pain/nausea... We had some awful young ones (14) and they are a handful, get them to confide, and ask about eating, many will tell you they don't want to get fat, once you get them to talk, and so, they starve themselves, and if edema, they think its because they drink to much liquid so they stop, and dehydrate... on top of the preeclampsia stuff.

[Jolie, BSN]

On to your next question. There is a condition called orthostatic proteinuria in which patients excrete protein in the urine after being on their feet for a prolonged period of time. It is a benign condition that does not necessarily predict PIH, but it can be difficult to tell the difference. So when urine tests (+) for protein, it is helpful to ask about the patient's activities for several hours prior to obtaining the sample. Because proteinuria can precede hypertension, it is good to provide information regarding s/s of PIH and what to report to the clinic so that it can be detected early, especially since prenatal visits are only monthly for most patients for the 1st and 2nd trimesters.

[Elvish, BSN, DNP, RN, NP]

Hey there Pagan - glad you are finding so much stuff to learn!! :) To answer the question about proteins: it is not uncommon at all for pregnant women to spill protein, and docs don't generally worry about it unless there is a lot, or the BP is elevated, or there are other sx of pre-E. There's some debate as to exactly why proteinuria exists, but it's generally thought to be hormonal - pregnancy hormones cause dilation of the ureters, allowing more protein to spill....as well as physiological - increased renal size, increased GFR, etc.

Anecdotally, I've found that if pts don't clean themselves well before the clean catch urine, what comes up as proteinuria is actually some lady partsl discharge making its way into the urine.

Hope this helps, and good luck!!

[pagandeva2000, LPN]

Thank you all so much for the insights. This clinic has matured me as a person as well as a nurse. I can't totally explain why or how, but it has, and this was needed for my development as a health care provider.