Nursing Assessment for Polyhydramnios

Polyhydramnios

Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn infant.

Causes

Polyhydramnios can occur if the fetus does not swallow and absorb amniotic fluid in normal amounts. This can happen due to:

• Gastrointestinal disorders, such as duodenal atresia, esophageal atresia, gastroschisis, and diaphragmatic hernia
• Brain and nervous system (neurological) problems, such as anencephaly and myotonic dystrophy
• A variety of other causes, such as poorly controlled diabetes, achondroplasia,Beckwith-Wiedemann syndrome

Polyhydramnios may also be related to increased fluid production, which occurs with:

• Certain fetal lung disorders
• Multiple gestation (for example, twins or triplets)
• Hydrops fetalis
• Sometimes, no specific cause for polyhydramnios is found.

Nursing Assessment for Polyhydramnios

Inspection

• Looks very distended and tense abdomen, abdominal skin shiny, cracked skin is clear and sometimes flat umbilicus.
• If acute, the mother will look shortness of breath and cyanosis, and visible effort to bring the pregnancy.

Palpation

• Abdominal tension and tenderness, and edema occur in the abdominal wall, vulva and legs.
• Fundus is higher than actual age.
• Parts of the fetus is difficult to identify.
• If the location of the head, fetal head can be palpated then balotement obvious.
• Because the fetus moves freely and is not fixed to, they can lead to inaccuracies where the fetus.

Auscultation

• Difficult to hear the fetal heart rate and if there was only once.

Abdominal x-ray photos

• It appears a shadow shrouded in mist, because the number of fluid sometimes shadows obscure the fetus.
• X-rays on the hydramnios is useful for diagnostics and to determine the etiology.

Nursing Assessment for Polyhydramnios

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