NCLEX: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Lifestyle Choices and Influences That Impact Health in Pregnancy, Intrapartum, Postpartum, and Newborn

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

I. OTHER HIGH-RISK WOMEN

A. An adolescent who is pregnant

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. General aspects:

a. Pregnancy in women between 12 and 17 years old.

b. Incidence has started to ↓; approximately one third of all births are to adolescents.

c. Predisposing factors: early menarche, early experimentation with sex, poor family relationships, poverty, late or no prenatal care, cultural influence.

d. Associated health problems: preeclampsia, preterm labor, SGA infants, anemia, bleeding disorders, infections, CPD.

e. Social problems: mothers who are poorly educated, child abuse, single-parent families, mothers who are unemployed or working at minimum wage or who lack support system.

2. Assessment:

a. Present physical/health status.

b. Feelings toward pregnancy.

c. Plans for the future.

d. Factors influencing decisions related to self, pregnancy, baby.

e. Signs and symptoms of complications of pregnancy.

f. Need/desire for health maintenance information (family planning).

3. Analysis/nursing diagnosis:

a. Ineffective coping, individual/family, related to need to alter lifestyle, plans, expectations.

b. Altered family processes related to unexpected/unwanted pregnancy.

c. Altered parenting related to intrafamily stress secondary to unexpected pregnancy, developmental tasks.

d. Self-esteem disturbance related to altered self-concept, body image, role performance, personal identity.

e. Knowledge deficit related to family planning, health maintenance, risk factors, pregnancy options.

f. Altered nutrition related to lifestyle.

4. Nursing care plan/implementation:

a. Goal: emotional support.

  • Ensure confidentiality.
  • Establish acceptant, supportive environment.
  • Encourage verbalization of feelings, concerns, fears, desires, etc.
  • Maintain continuity of care—consistency of nursing approach, to establish trust, confidentiality.

b. Goal: facilitate informed decision making. Discuss available options; aid in exploring implications of possible decisions.

c. Goal: nutritional counseling (anemia).

  • Needs for own growth and that of fetus.
  • High-quality diet—value for character of skin, return to prepregnant figure.
  • Include pizza, hamburgers, milkshakes as acceptable—to minimize anger at being “different.”

d. Goal: health teaching.

  • Rest, exercise, hygiene—as for other women.
  • Prevention of infection—STI, UTI, etc.
  • Breast self-examination; Pap smear.
  • Future family planning options.

e. Goal: assist in achievement of normal developmental tasks. Encourage exploration of new role and responsibilities.

f. Goal: referral to appropriate resources.

  • Abortion; adoption resources.
  • Preparation for childbirth and parenting classes.
  • Family counseling.
  • Social services.

g. Goal: assist in facilitating/continuing/completing basic education.

  • Communicate with school nurse.
  • Explore other options available in community.

5. Evaluation/outcome criteria:

a. Makes informed decisions appropriate to individual and family needs, desires.

b. Actively participates in own health maintenance.

  • Complies with medical/nursing recommendations.
  • Minimizes potential for complications of pregnancy.

c. Copes effectively with normal physiological and psychosocial alterations of pregnancy.

d. Both woman and baby’s father express satisfaction with decision and management of this pregnancy. If parenthood is chosen and pregnancy is successful, accepts parenting role.

B. Older mother: primigravida over age 35

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. General aspects—higher incidence of congenital anomalies (e.g., Down syndrome), increased possibility of complications of pregnancy. However, generally it is a conscious decision to have postponed childbearing. Individuals are usually used to making own decisions regarding career and health care.

2. Assessment:

a. Same as for other women who are pregnant.

b. Reaction to reality of pregnancy.

c. Family response to pregnancy.

3. Analysis/nursing diagnosis:

a. Fear related to threat to pregnancy.

b. Knowledge deficit related to aspects of pregnancy care.

4. Nursing care plan/implementation:

a. Goal: anticipatory guidance. Preparation for parenthood, altered lifestyle, potential change of career. Assist with realistic expectations. Refer to “over 30” parents’ support group.

b. Goal: health teaching. Explain, discuss special diagnostic procedures (Amniocentesis).

c. Other—same as for other women who are pregnant.

5. Evaluation/outcome criteria:

a. Experiences normal, uncomplicated pregnancy, labor, and birth of a newborn who is normal and healthy.

b. Expresses satisfaction with decision and outcome of this pregnancy.

C. Older mother: multipara over age 40

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. General aspects

a. Increased incidence of preexisting and coexisting medical disorders (hypertension, diabetes, arthritis).

b. Increased incidence of complications of pregnancy (preeclampsia/eclampsia, hemorrhage).

c. Smoking is major risk factor.

2. Assessment:

a. Same as for other women who are pregnant.

b. Reaction to pregnancy (varies from pleasure at still being “young enough,” to despair, if facing decision to abort).

c. History, signs and symptoms of coexisting disorders.

d. Indications of reduced physical ability to cope with normal physiological alterations of pregnancy.

e. Family constellation: stage of family developmental cycle, responses to this pregnancy (especially adolescents’ reaction to parents’ pregnancy).

3. Analysis/nursing diagnosis: same as for over-35 age group.

4. Nursing care plan/implementation:

a. Goal: emotional support. Encourage verbalization of feelings, fears, concerns.

b. Goal: referral to appropriate resource.

  • Genetic counseling.
  • Abortion/support groups.
  • Preparation for childbirth and parenthood classes.

c. Goal: facilitate/support effective family process. Involve family in preparation for birth and integration of newborn into family unit.

d. Other—same as for other women who are pregnant.

5. Evaluation/outcome criteria:

a. Makes informed decisions related to pregnancy.

b. Expresses satisfaction with decision and outcome of this pregnancy.

c. Experiences uncomplicated pregnancy, labor, and birth of a newborn who is normal and healthy.

D. AIDS

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. General aspects—AIDS is a serious condition affecting the immune system. Heterosexual women are considered at risk if they or their sexual partners:

a. Are HIV positive.

b. Use IV drugs (50%).

c. Received blood between 1977 and 1985 (9%).

d. Are homosexual or bisexual men (39%).

e. Have hemophilia.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

2. Assessment—general symptoms:

a. Malaise.

b. Chronic cough; possible tuberculosis.

c. Chronic diarrhea.

d. HIV positive.

e. Weight loss: 10 lb in 2 months.

f. Night sweats; lymphadenopathy.

g. Skin lesions; thrush.

h. Pelvic inflammatory disease (PID); STIs; vulvovaginitis (usually, yeast [Candidiasis]), often refractory and severe.

i. Cervical cytologic abnormalities; often infected with human papillomavirus (HPV).

3. Analysis/nursing diagnosis:

a. Altered nutrition, less than body requirements, related to general malaise.

b. Fatigue, related to altered health status, weight loss.

c. Fear related to progressively debilitating disease.

d. Knowledge deficit related to disease progression, treatment, life expectancy.

e. Ineffective individual coping related to disease progression.

4. Nursing care plan/implementation:

a. Identify women at risk.

b. Protect confidentiality.

c. Implement standard precautions.

d. Use proper gloves, gown, hand washing.

e. Use protective eye-wear and mask during labor, birth.

5. Evaluation/outcome criteria:

a. No further transmission of virus.

b. Woman’s confidentiality maintained.

c. Standard precautions implemented.

d. Emotional support implemented.

e. Supportive groups contacted.

6. Women who are HIV positivepregnancy management:

a. Antepartum

  • Increased incidence of other STIs (gonorrhea, syphilis, herpes, HPV).
  • Increased incidence of cytomegalovirus (CMV).
  • Differential diagnosis for all pregnancy-induced complaints.
  • Counsel regarding nutrition.
  • Advise about risk to infant.
  • Counsel regarding safer sex.

b. Intrapartum

  • Focus on prevention of transmission.
  • Mode of birth not based on disease.
  • External electronic fetal monitoring (EFM) preferred.
  • Avoid use of fetal scalp electrodes or fetal scalp sampling.

c. Postpartum

  • No remarkable alteration in disease progression.
  • Breastfeeding contraindicated.
  • Implement standard precautions for mother and infant.
  • Refer to specialists in AIDS care and treatment.

7. Newborn or neonate:

a. General aspects: Neonatal AIDS—transmission may be transplacental, contact with maternal blood at birth, or postnatal exposure to parent who is infected (i.e., breastfeeding). Classic signs evident in adult often not present. Common signs: lymphadenopathy, hepatosplenomegaly, oral candidiasis, bacterial infections, failure to thrive.

b. Implement standard precautions for all invasive procedures. Bathe infant immediately after birth to decrease contact with mother’s blood. Wear gloves for all contact before first bath.

c. Provide supportive nursing care (thermoregulation, respiratory).

d. Encourage parent-infant contact.

e. Provide opportunities for sensory stimuli and touch.

f. Monitor intake and weight gain.

g. Observe for signs of infection.

h. Initiate social service consultation.

i. Counsel family about vaccinations (should receive all except oral polio).

j. Administer medications as ordered (zidovudine [AZT]).

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Common Complications of Pregnancy

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

First-Trimester Complications

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

I. COMPLICATIONS AFFECTING FLUID-GAS TRANSPORT: HEMORRHAGIC DISORDERS

A. General aspects (review Emergency Conditions)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Assessment:

a. Vital signs, output, general status.

b. Evidence of internal/external bleeding.

c. Pain.

d. Emotional response.

e. Perineal pads saturated and number (pad count).

f. Speculum examination.

2. Analysis/nursing diagnosis:

a. Knowledge deficit related to diagnosis, prognosis, treatment, sequelae.

b. Anxiety/fear related to loss of pregnancy, surgery.

c. Fluid volume deficit, potential/actual, related to excessive blood loss.

d. Pain.

e. Ineffective coping, individual/family, related to knowledge deficit and fear.

f. Anticipatory/dysfunctional grieving, related to loss of pregnancy.

g. Disturbance in self-esteem, body image, role performance, related to threat to self-image as woman and childbearer.

Health Promotion and Maintenance; Nursing Care of the Childbearing FamilyHealth Promotion and Maintenance; Nursing Care of the Childbearing FamilyHealth Promotion and Maintenance; Nursing Care of the Childbearing Family

 

3. Nursing care plan/implementation:

a. Goal: minimize blood loss, stabilize physiological status.

  • Facilitate prompt medical management.
  • Administer IV fluids, blood, as ordered.
  • Administer analgesics, as needed.

b. Goal: prevent infection. Strict aseptic technique.

c. Goal: emotional support.

  • Encourage verbalization of anxiety, fears, concerns.
  • Supportive care for grief reaction.

4. Evaluation/outcome criteria:

a. Blood loss minimized; physiological status stable.

b. Copes effectively with loss of pregnancy.

B. Spontaneous abortion: before viable age of 20 to 22 weeks

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Etiology:

a. Defective products of conception.

b. Insufficient production of progesterone.

c. Acute infections.

d. Reproductive system abnormalities (e.g., incompetent cervical os).

e. Trauma (physical or emotional).

f. Rh incompatibility.

2. Assessment: types

a. Threatened—mild bleeding, spotting, cramping; cervix closed.

b. Inevitable—moderate bleeding, painful cramping; cervix dilated, positive nitrazine test (membranes ruptured).

c. Imminent—profuse bleeding, severe cramping, urge to bear down.

d. Incomplete—fetal parts or fetus expelled; placenta and membranes retained.

e. Complete—all products of conception expelled; minimal vaginal bleeding.

f. Habitual/recurrent—history of spontaneous loss of three or more successive pregnancies.

g. Missed—fetal death with no spontaneous expulsion within 4 weeks.

  • Anorexia, malaise, headache.
  • Fundal height—inconsistent with gestational estimate.
  • Laboratory—prolonged clotting time, due to resultant concurrent hypofibrinogenemia (disseminated intravascular coagulation [DIC], a major threat to mother).

h. Elective abortions (intentionally induced loss of pregnancy).

3. Analysis/nursing diagnosis:

a. Altered family processes related to pregnancy, circumstances surrounding abortion.

b. Sexual dysfunction related to compromised self-image, altered interpersonal relationship, guilt feelings.

4. Nursing care plan/implementation:

a. Threatened—Goal: health teaching. Suggest: avoid coitus and orgasm, especially around normal time for menstrual period.

b. Incomplete, inevitable, imminent.

  • Goal: safeguard status.
    (a) Save all pads, clots, tissue for expert diagnosis.
    (b) Report immediately any change in status, excessive bleeding, signs of infection, shock.
    (c) Prepare for surgery.
  • Goal: comfort measures.
    (a) Administer analgesics, as necessary.
    (b) Bed rest, quiet diversional activities.
  • Goal: emotional support.
    (a) Encourage verbalization of fear, concerns.
    (b) Reduce anxiety, as possible.
    (c) If pregnancy terminates, facilitate grieving process; assist in working through guilt feelings (see pp. 183–184).
    (d) Supportive care for grief reaction.
  • Goal: prevent isoimmunization.
  • Medical management:
    (a) Laboratory—blood type and Rh factor, indirect Coombs’ test, platelets, serum fibrinogen, clotting time.
    (b)Replace blood loss; maintain fluid levels with IV.
    (c) Dilation and curettage or dilation and evacuation.
    (d) Habitual—determine etiology.

5. Evaluation/outcome criteria:

a. Threatened—responds to medical/nursing regimen; abortion avoided, successfully carries pregnancy to term.

b. Spontaneous abortion—after uterus emptied.

  • Bleeding is controlled.
  • Vital signs are stable.
  • Copes effectively with loss of pregnancy.
  • Expresses satisfaction with care.

c. Habitual abortion—cause identified and corrected; carries subsequent pregnancy to successful termination.

C. Hydatidiform mole (complete)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—chorionic villi degenerate into grape-like cluster of vesicles; may be antecedent to choriocarcinoma.

2. Etiology—genetic base of complete mole (sperm enters empty egg and its chromosomes replicate; 23 pairs of chromosomes are all paternal); rare complication; more common in women over 45 years of age and women who are Asian.

3. Assessment:

a. Uterus—rapid enlargement; fundal height inconsistent with gestational estimate.

b. Brownish discharge—beginning about week 12; may contain vesicles.

c. Signs and symptoms of preeclampsia/eclampsia (before third trimester), increased incidence of hyperemesis gravidarum.

d. Medical evaluation—procedures:

  • Sonography, x-ray, amniography—no fetal parts present; “snowstorm.”
  • Laboratory test—for elevated human chorionic gonadotropin (HCG) levels.
  • Follow-up surveillance of HCG levels for at least 1 year; persistent HCG level is consistent with choriocarcinoma; x-ray.

4. Analysis/nursing diagnosis:

a. Anxiety/fear related to treatment, possible sequelae of hydatidiform mole (choriocarcinoma).

b. Potential for injury related to hemorrhage, perforation of uterine wall, preeclampsia/ eclampsia.

c. Fluid volume deficit related to hemorrhage.

5. Nursing care plan/implementation:

a. Medical management

  • Monitor for preeclampsia.
  • Evacuate the uterus—hysterectomy may be necessary.
  • Strict contraception for at least 1 year to enable accurate assessment of status.
  • Choriocarcinoma—chemotherapy (methotrexate plus dactinomycin) or radiation therapy, or both.

b. Nursing management

  • Goal: safeguard status. Observe for hemorrhage, passage of retained vesicles and abdominal pain, or signs of infection (because woman is at risk for perforation of uterine wall).
  • Goal: health teaching.
    (a) Explain, discuss diagnostic tests; prepare for tests.
    (b) Discuss contraceptive options.
    (c) Importance of follow-up.
  • Goal: preoperative and postoperative care.
  • Goal: emotional support. Facilitate grieving.

6. Evaluation/outcome criteria:

a. Verbalizes understanding of diagnosis, tests, and treatment.

b. Complies with medical/nursing recommendations.

c. Tolerates surgical procedure well.

  • Bleeding controlled.
  • Vital signs stable.
  • Urinary output adequate.

d. Copes effectively with loss of pregnancy.

e. Returns for follow-up care/surveillance.

f. Selects and effectively implements method of contraception; avoids pregnancy for 1 year or more.

g. Tests for HCG remain negative for 1 year; no evidence of malignancy.

h. Achieves a pregnancy when desired.

i. Successfully carries pregnancy to term; normal, uncomplicated birth of viable infant.

D. Ectopic pregnancy (Ectopic pregnancy)

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

1. Pathophysiology—implantation outside of uterine cavity.

2. Types:

a. Tubal (most common).

b. Cervical.

c. Abdominal.

d. Ovarian.

3. Etiology:

a. PID—pelvic salpingitis and endometritis.

b. 43% caused by STI-related factors: 25%, chlamydial; 20%, previous STI.

c. Tubal or uterine anomalies, tubal spasm.

d. Adhesions from PID or past surgeries.

e. Presence of IUD.

4. Assessment: dependent on implantation site.

a. Early signs—abnormal menstrual period (usually following a missed menstrual period), spotting, some symptoms of pregnancy; possible dull pain on affected side.

 

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

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II. COMPLICATIONS AFFECTING NUTRITION/ELIMINATION: HYPEREMESIS GRAVIDARUM

Focus topic: Health Promotion and Maintenance; Nursing Care of the Childbearing Family

A. Pathophysiology—pernicious vomiting during first 14 to 16 weeks (peak incidence around 10 weeks of gestation); excessive vomiting at any time during pregnancy. Potential hazards include the following:

1. Dehydration with fluid and electrolyte imbalance.

2. Starvation, with loss of 5% or more of body weight; protein and vitamin deficiencies.

3. Metabolic acidosis—due to breakdown of fat stores to meet metabolic needs.

4. Hypovolemia and hemoconcentration; increased blood urea nitrogen (BUN); decreased urinary output.

5. Embryonic or fetal death may result, and the woman may suffer irreversible metabolic changes or death.

B. Etiology:

1. Physiological—secretion of HCG, decrease in free gastric HCl, decreased gastrointestinal motility. Increased incidence in hydatidiform mole and multifetal pregnancy (due to high levels of HCG).

2. Psychological—thought to be related to rejection of pregnancy or sexual relations.

C. Assessment:

1. Intractable vomiting.

2. Abdominal pain.

3. Hiccups.

4. Marked weight loss.

5. Dehydration—thirst, tachycardia, skin turgor.

6. Increased respiratory rate (metabolic acidosis).

7. Laboratory—elevated BUN.

8. Medical evaluation: rule out other causes (infection, tumors).

D. Analysis/nursing diagnosis:

1. Altered nutrition, less than body requirements, related to inability to retain oral feedings.

2. Fluid volume deficit related to dehydration.

3. Ineffective individual coping related to symptoms, insecurity in role, psychological stress of unwanted pregnancy.

4. Personal identity disturbance related to symptoms or perception of self as inadequate in role, sick, socially unpresentable.

E. Nursing care plan/implementation:

1. Goal: physiological stability.

a. Rest GI tract (keep NPO) (e.g., maintain IV fluids, parenteral nutrition).

b. Progress diet, as ordered; present small feedings attractively; ↑ carbohydrates, ↓ fat, ↓ acidic foods.

c. Weigh daily, assess hydration; note weight gain.

d. Antiemetics (IV, suppository).

2. Goal: minimize environmental stimuli.

a. Limit visitors and phone calls.

b. Bedrest with bathroom privileges.

3. Goal: emotional support.

a. Establish accepting, supportive environment.

b. Encourage verbalization of anxiety, fears, concerns.

c. Support positive self-image.

F. Evaluation/outcome criteria:

1. Woman’s signs and symptoms subside; she takes oral nourishment and gains weight.

2. Woman’s pregnancy continues to term without recurrence of hyperemesis.

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FURTHER READING/STUDY:

Resources:

 

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