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

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

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


A. General aspects of prenatal management

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

1. Scheduled visits:

  • Once monthly—until week 28.
  • Every 2 weeks—weeks 28 to 36.
  • Weekly—week 36 until labor.

2. Assessment:

a. General well-being, signs of deviations, concerns, questions.

b. Weight gain pattern.

c. Blood pressure (sitting).

d. Abdominal palpation:

  • Fundal height; tenderness, masses, hernia.
  • Fetal heart rate (FHR).
  • Leopold’s maneuver for presentation (after week 32).

e. Laboratory tests:

  • Urinalysis—for protein, sugar, signs of asymptomatic infection; drug screen for high-risk groups.
  • Venous blood—Hgb, Hct; blood type and Rh factor; rapid plasma reagin (RPR); rubella titer, antibody titer, sickle cell. HIV and hepatitis antigen recommended for all pregnant clients.
  • Cultures (vaginal discharge; cervical scrapings, for Chlamydia trachomatis, Neisseria gonorrhoeae).
  • Tuberculosis (TB) screening in high-risk areas.
  • Multiple marker screen, 16 to 18 weeks optimum time.
  • Serum glucose screen, 24 to 28 weeks; 1-hour glucose tolerance test.

f. Follow up on medications (vitamins, iron) and nutrition.

g. If TB positive during pregnancy, isoniazid (INH) and rifampin given daily. INH is associated with increase in fetal malformations, particularly neurotoxicity. Pyridoxine administered simultaneously to prevent their development.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

B. Common minor discomforts during pregnancy (for Assessment, see Common Discomforts During Pregnancy).

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

1. Etiology: normal maternal physiological/psychological alterations in pregnancy.

2. Nursing care plan/implementation:

a. Goal: anticipatory guidance. Discuss the importance of adequate rest, exercise, diet, and hydration in minimizing symptoms.

b. Goal: health teaching (see Common Discomforts During Pregnancy).

3. Evaluation/outcome criteria: woman avoids, minimizes, or copes effectively with minor usual discomforts of pregnancy.

C. Danger signs:

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

1. Etiology: Specific disease processes are discussed under Complications.

2. Nursing care plan/implementation: Goal: health teaching—to safeguard status. Signs to report immediately:

a. Persistent vomiting beyond first trimester or severe vomiting at any time. Possible cause: Hyperemesis gravidarum.

b. Fluid discharge from vagina—bleeding or amniotic fluid (anything other than leukorrhea). Possible causes: Placental problem, rupture of membranes (ROM).

c. Severe or unusual pain: abdominal. Possible cause: Abruptio placentae.

d. Chills or fever (if lasts over 24 hours, or over 102°F). Possible cause: Infection.

e. Urinary frequency or burning on urination. Possible cause: UTI.

f. Absence of fetal movements after quickening, lasting more than 24 hours. Possible cause: Intrauterine fetal death.

g. Visual disturbances—blurring, double vision, “spots before eyes.” Possible cause: Preeclampsia.

h. Swelling of fingers, ankles, hands, feet, or face. Possible cause: Preeclampsia.

i. Severe, frequent, or continual headache. Possible cause: Preeclampsia.

j. Muscle irritability or convulsions. Possible cause: Preeclampsia.

k. Rapid weight gain not associated with eating. Possible cause: Preeclampsia.

l. More than four uterine contractions per hour (before 38 weeks). Possible cause: Preterm labor.

3. Evaluation/outcome criteria:

a. Actively participates in own health maintenance/pregnancy management.

b. Identifies early signs of potentially serious complications during the antepartal period.

c. Promptly reports and seeks medical attention.


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

A. General aspects:

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

1. Etiology:

a. Normal alterations and increasing physiological stress of pregnancy affect status of coexisting medical disorders.

b. Conditions affecting mother’s general health also affect ability to adapt successfully to normal physiological stress of pregnancy.

c. Aberrations of normal pregnancy.

2. Goal: reduce incidence of health problems affecting maternal/fetal health and pregnancy outcome.

a. Identify presence of risk factors and signs and symptoms of complications early.

b. Treat emerging complications promptly and effectively.

c. Minimize effects of complications on pregnancy outcome.

3. Assessment: risk factors:

a. Age:

  • Adolescent.
  • Primigravida, age 35 or older.
  • Multigravida, age 40 or older.

b. Socioeconomic level: lower.

c. Ethnic group.

d. Previous pregnancy history:

  • Habitual abortion.
  • Multiparity greater than 5.
  • Previous stillbirths.
  • Previous cesarean birth.
  • Previous preterm labor or delivery.

e. Multifetal pregnancy.

f. Prenatal care:

  • Enters health-care system late in pregnancy.
  • Irregular/episodic prenatal care visits.
  • Noncompliance with medical/nursing recommendations.

g. Preexisting or coexisting medical disorders:

  • Cardiovascular: hypertension, heart disease.
  • Diabetes.
  • Other: renal, respiratory, infections, acquired immunodeficiency syndrome (AIDS).

h. Substance abuse.

4. Nursing care plan/implementation:

a. Goal: health teaching (discussed under specific health problem).

b. Goal: early identification/treatment of emerging health problems (if any).

  • Monitor status and progress of pregnancy.
  • Refer for medical management, as necessary.

c. Goal: emotional support.

5. Evaluation/outcome criteria:

a. Understands present health status, interactions of coexisting disorder and pregnancy.

b. Accepts responsibility for own health maintenance.

c. Makes informed decisions regarding pregnancy.

d. Minimizes potential for complications of coexisting disorder/pregnancy.

  • Avoids factors predisposing to health problems.
  • Understands and implements therapeutic management of coexisting disorder/pregnancy.
  • Increases compliance with medical/nursing recommendations.

e. Carries uneventful pregnancy to term.

B. Disorders affecting fluid-gas transport: cardiac disease

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

1. Pathophysiology: cardiac overload → cardiac decompensation → right-sided heart failure → systemic edema.

2. Etiology:

a. Congenital heart defects.

b. Valvular damage—due to rheumatic fever (most common lesion is mitral stenosis, which can lead to pulmonary edema and emboli).

c. Increased circulating blood volume and cardiac output—exceeds cardiac reserve. Greatest risk: after 28 weeks of gestation—reaches maximum (30%–50%) volume increase; postpartum—due to diuresis.

d. Secondary to treatment (e.g., tocolysis and steroids).

e. Pregnancy after valve replacement.

3. Normal physiological alterations during pregnancy that mimic cardiac disorders:

a. Systolic murmurs, palpitations, tachycardia, and hyperventilation with some dyspnea on normal moderate exertion.

b. Edema of lower extremities.

c. Cardiac enlargement.

d. Elevated sedimentation rate near term.

4. Assessment:

a. Medical evaluation of cardiac status. Classification of severity of cardiac involvement:

  • Class I—least affected; asymptomatic with ordinary activity.
  • Class II—activities somewhat limited; ordinary activities cause fatigue, dyspnea, angina.
  • Class III—moderate/marked limitation of activity; common activities result in severe symptoms of fatigue, etc.
  • Class IV—most affected; symptomatic (dyspnea, angina) at rest; should avoid pregnancy.

b. Cardiac decompensation:

  • Subjective symptoms
    (a) Palpitations; feeling that the heart is “racing.”
    (b) Increasing fatigue or difficulty breathing, or both, with the usual activities.
    (c) Feeling of smothering and/or frequent cough.
    (d)Periorbital edema; edema of face, fingers (e.g., rings do not fit anymore), feet, legs.
  • Objective signs
    (a) Irregular weak, rapid pulse (≥100 beats/min).
    (b) Rapid respirations (≥25 breaths/min).
    (c) Progressive, generalized edema.
    (d)Crackles (rales) at base of lungs, after two inspirations and exhalations.
    (e) Orthopnea; increasing dyspnea on minimal physical activity.
    (f)Moist, frequent cough.
    (g)Cyanosis of lips and nailbeds.

5. Analysis/nursing diagnosis:

a. Fluid volume excess related to inability of compromised heart to handle increased workload (decreased cardiac reserve → congestive heart failure).

b. Impaired gas exchange related to pulmonary edema secondary to congestive heart failure.

6. Nursing care plan/implementation:

a. Medical management:

  • Diuretics, electrolyte supplements.
  • Digitalis (dose may need to be higher because of dilution in the increased blood volume of pregnancy).
  • Antibiotics—prophylaxis against rheumatic fever; treatment of bacterial infections during pregnancy.
  • Anticoagulants. Heparin is preferred because its large molecule cannot easily cross placenta. Occasionally, sequelae may include maternal hemorrhage, preterm birth, stillbirth.
  • Oxygen, as needed.
  • Mitral valvotomy for mitral stenosis often brings dramatic relief.

b. Goal: health teaching.

  • Need for compliance with therapeutic regimen, medical/nursing recommendations.
  • Drug actions, dosage, necessary actions (how to take own pulse, reportable signs/symptoms).
  • Methods for decreasing work of heart:
    (a) Adequate rest—minimum 10 hours sleep each night; 30-minute nap after each meal.
    (b) Avoid heavy physical activity (including housework), fatigue, excessive weight gain, emotional stress, infection.
    (c) Avoid situations of reduced ambient [latex]O_2[/latex], such as smoking, exposure to pollutants, flight in unpressurized small planes.

c. Goal: nutritional counseling.

  • Well-balanced diet; adequate protein, fresh fruits and vegetables, water.
  • Avoid “junk food,” stimulants (caffeine), excessive salt intake.

d. Goal: anticipatory planning: management of labor.

  • Goal: minimize physiological and psychological stress.
  • Medical management:
    (a) Reevaluation of cardiac status before EDD and labor.
    (b) Regional anesthesia for labor/birth.
    (c) Low-outlet forceps or vacuum extraction birth; episiotomy.
    (d) Continuous hemodynamic monitoring.
  • Assessment: continuous.
    (a) Physiological response to labor stimuli—frequent vital signs (pulse rate most sensitive and reliable indicator of impending congestive heart failure).
    (b) Color, respiratory effort, diaphoresis.
    (c) Contractions, etc.—same as for any mother in labor.
  • Nursing care plan/implementation: labor.
    (a) Goal: safeguard status.
    (i) Report promptly: pulse rate over 100; respirations more than 24 between contractions.
    (ii) Oxygen at 6 liters, as needed.
    (b) Goal: emotional support—to reduce anxiety, facilitate cooperation.
    (i) Encourage verbalization of feelings, fears, concerns.
    (ii) Explain all procedures.
    (c) Goal: promote cardiac function. Position—semirecumbent; support arms and legs.
    (d) Goal: promote relaxation/control over labor discomfort. Encourage Lamaze (or other) breathing/relaxation techniques.
    (e) Goal: reduce stress on cardiopulmonary system. Discourage bearing-down efforts.
    (f) Goal: relieve stress of pain, eliminate bearing-down. Prepare for regional anesthesia.
    (g) Goal: maintain effective cardiac function. Administer medications, as ordered (e.g., digitalis, diuretics, antibiotics).

e. Goal: anticipatory planning: postpartum management.

  • Factors increasing risk of cardiac decompensation:
    (a) Delivery → rapid, decreased intra-abdominal pressure → vasocongestion and rapid rise in cardiac output.
    (b) Loss of placental circulation.
    (c) Normal diuresis increases circulating blood volume.
  • Assessment:
    (a) Observe for tachycardia or respiratory distress.
    (b) Monitor blood loss, I&O—potential hypovolemic shock, cardiac overload due to diuresis.
    (c) Pain level—potential neurogenic shock.
    (d) Same as for any woman who is postpartum (fundus, signs of infection, etc.).
  • Nursing care plan/implementation: postpartum.
    (a) Goal: minimize stress on cardiopulmonary system.
    (i) Rest, dangle, ambulate with assistance.
    (ii) Gradual increase in activity—as tolerated without symptoms.
    (iii) Position: semi-Fowler’s if needed.
    (iv) Extra help with newborn care.

7. Evaluation/outcome criteria:

a. Successfully carries uneventful pregnancy to term.

b. Experiences no cardiopulmonary decompensation during labor, birth, or postpartum.

C. Disorders affecting fluid-gas transport in fetus: Rh incompatibility

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

1. Pathophysiology—in a mother who is Rh negative: Rh-positive fetal red blood cells enter the maternal circulation → maternal antibody formation → antibodies cross placenta and enter fetal bloodstream → attack fetal red blood cells → hemolysis → anemia, hypoxia.

a. The mother who is pregnant and Rh positive carries her infant (Rh negative or positive) without incident.

b. The mother who is pregnant and Rh positive carries an Rh-negative infant without incident.

c. The mother who is pregnant and Rh negative usually carries her first Rh-positive child without problems unless she has been sensitized by inadvertent transfusion with Rh-positive blood. Note: Fetal cells do not usually enter the maternal bloodstream until placental separation (at abortion, abruptio placentae, amniocentesis, or birth).

2. Etiology:

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

a. The Rh factor is an antigen on the red blood cells of some people (these people are Rh positive); the Rh factor is dominant; a person may be homozygous or heterozygous for Rh factor.

b. A person who is Rh negative is homozygous for this recessive trait—does not carry the antigen; develops antibodies when exposed to Rh-positive red blood cells (isoimmunization) through transplacental (or other) transfusion.

c. Following birth of an infant who is Rh positive, if fetal cells enter the mother’s bloodstream, maternal antibody formation begins; antibodies remain in the maternal circulation.

d. At time of next pregnancy with fetus who is Rh positive, antibodies cross placenta → hemolysis. Note: Degree of hemolysis depends on amount (titer) of maternal antibodies present.

3. Possible serious complication (fetal)—rare today. Hydrops fetalis—most severe hemolytic reaction: severe anemia, cardiac decompensation, hypoxia, edema, ascites, hydrothorax; may be stillborn.

4. Assessment:

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

a. Prenatal—diagnostic procedures:

  • Maternal blood type and Rh factor.
  • Indirect Coombs’ test—to determine presence of Rh sensitization (titer indicates amount of maternal antibodies).
  • Amniocentesis—as early as 26 weeks of gestation—amount of bilirubin byproducts indicates severity of hemolytic activity.

b. Intrapartum observation of amniotic fluid (after membrane rupture).

  • Straw-colored fluid—mild disease.
  • Golden fluid—severe fetal disease.

c. Postnatal (see III. A. Rh incompatibility).

5. Nursing care plan/implementation:

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

a. Goal: prevent isoimmunization in women who are Coombs’ negative

  • Postabortion—if no evidence of Rh sensitization (antibody formation) in the mother who is Rh negative, administer RhoGAM.
  • Prenatal—if no evidence of sensitization, administer RhoGAM at 28 weeks of gestation, as ordered, to all women who are Rh negative.
  • Postpartum—if no evidence of sensitization, administer RhoGAM within 72 hours of birth to women who are Rh negative and who gave birth to a baby who is Rh positive.

Give RhoGAM to:

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

1. Mother who is Rh negative who gives birth to neonate who is Rh positive.

2. Mother who is Rh negative after spontaneous or induced abortion (>8 weeks).

3. Mother who is Rh negative after amniocentesis or chorionic villus sampling (CVS).

4. Mother who is Rh negative between 28 and 32 weeks of gestation.

b. Goal: health teaching.

  • Explain, discuss that RhoGAM suppresses antibody formation in susceptible woman who is Rh negative carrying fetus that is Rh positive. Note: Cannot reverse sensitization if already present.
  • Required during and after each pregnancy with fetus who is Rh positive.

6. Evaluation/outcome criteria:

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

a. Successfully carries pregnancy to term.

b. No evidence of Rh isoimmunization.

c. Birth of viable infant.

D. Disorders affecting fluid-gas transport in fetus: tuberculosis

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

1. Pathophysiology: Mycobacterium tuberculosis primarily is spread as an airborne aerosol from infected → non-infected individuals, through the lung. Initial TB infection usually → latent or dormant infection in hosts with normally functioning immune systems. M. tuberculosis is a slow-growing obligate aerobe and a facultative intracellular parasite.

2. Etiology:

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

a. Symptoms of tuberculosis in pregnancy are vague and nonspecific. Fatigue, shortness of breath, sweating, and tiredness can all be attributed to the pregnancy.

b. Reluctance of health-care professionals to perform a chest x-ray on a woman who is pregnant due to fear of harming the fetus → delay in diagnosis.

3. Assessment:

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

a. Heaf and Mantoux skin tests (as reliable as in women who are non-pregnant).

b. Same as for women who are non-pregnant: sputum examination, and culture and scans.

4. Nursing care plan/implementation:

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

a. Goal: prevent spread of disease.

  • Initial treatment regimen: isoniazid (INH), rifampin (RIF), and ethambutol (EMB).
  • Pyridoxine (vitamin [latex]B_6[/latex]) recommended for women who are pregnant and taking INH.
  • Routine use of pyrazinamide (PZA) should be avoided because of inadequate teratogenicity data.
  • Avoid: streptomycin (which interferes with development of the ear; may cause congenital deafness).

b. Goal: health teaching.

  • Explain, discuss transmission of disease, importance of completion of medication regimen.
  • Because small concentration of antituberculosis drugs in breast milk do not produce toxicity in the newborn who is nursing, breastfeeding should not be discouraged for a woman who is HIV seronegative and is planning to take (or is taking) INH or other anti-TB medications.

c. Goal: TB treatment for women who are HIV infected and pregnant.

  • If have a positive M. tuberculosis culture or suspected TB disease, treat without delay.
  • Rifamycin.
  • Although routine use of pyrazinamide not recommended if pregnant (due to inadequate teratogenicity data), benefits for women who are HIV infected and pregnant outweigh potential pyrazinamide-related risks to fetus.

E. Disorders affecting fluid-gas transport in fetus: hepatitis B (HBV)

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

1. Pathophysiology: Hepatitis B is one of the most highly transmitted forms of hepatitis from mother to child around the world, especially in developing countries. Hepatitis B virus (HBV) is highly contagious; the risk that newborn infant will develop hepatitis B is 10% to 20% if the mother is positive for the hepatitis B surface antigen (HBsAg); and as high as 90% if she is also positive for the HBeAg (hepatitis Be antigen).

2. Etiology: Usually, hepatitis B is passed on during delivery with exposure to the blood and fluids during the birth process.

3. Assessment:

a. Blood: highest concentration.

b. Semen, vaginal secretions, wound exudates: lower concentration.

c. Hepatitis B surface antigen = active infection.

4. Nursing care plan/implementation:

a. Goal: prevent spread of disease.

  • Hepatitis B immune globulin (HBIG) to infant at birth.
  • Hepatitis B vaccine at 1 week, 1 month, 6 months after birth.

b. Goal: health teaching.

  • Explain, discuss transmission of disease, importance of completion of vaccination regimen.
  • Centers for Disease Control and Prevention (CDC) has recommended that all newborn infants be vaccinated for hepatitis B.
  • The risk of HBV infection in children is not only from perinatal transmission from mothers who are HBV infected, but also from close contact with household members and caregivers who have acute or chronic HBV infection.
  • Ensure that all infants born to mothers who are HBsAg positive receive timely and appropriate immunoprophylaxis with HBIG and hepatitis B vaccine.
  • Discontinue interferon therapy during pregnancy (effect on fetus is unknown).

F. Disorders affecting nutrition: diabetes mellitus

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

1. Pathophysiology: increased demand for insulin exceeds pancreatic reserve → inadequate insulin production; enzyme (insulinase) activity breaks down circulating insulin → further reduction in available insulin; increased tissue resistance to insulin; glycogenolysis/gluconeogenesis → ketosis.

2. Etiology: increased metabolic rate; action of placental hormones (see following), enzyme (insulinase) activity.

3. Normal physiological alterations during pregnancy that may affect management of the woman who is diabetic, or precipitate gestational diabetes in women who are susceptible:

a. Hormone production:

  • Human placental lactogen (HPL).
  • Progesterone.
  • Estrogen.
  • Cortisol.

b. Effects of hormones:

  • Decreased glucose tolerance.
  • Increased metabolic rate.
  • Increased production of adrenocortical and pituitary hormones.
  • Decreased effectiveness of insulin (increased resistance to insulin by peripheral tissues).
  • Increased gluconeogenesis. Increased size and number of islets of Langerhans to meet increased maternal needs.
  • Increased mobilization of free fatty acids. Decreased renal threshold, increased glomerular filtration rate; glycosuria common.
  • Decreased [latex]CO_2[/latex]-combining power of blood; higher metabolic rate increases tendency to acidosis.

c. Effect of pregnancy on diabetes:

  • Nausea and vomiting—predispose to ketoacidosis.
  • Insulin requirements—relatively stable or may decrease in first trimester; rapid increase during second and third trimesters; rapid decrease after birth to prepregnant level.
  • Pathophysiological progression (nephropathy, retinopathy, and arteriosclerotic changes) may appear; existing pathology may worsen.

4. Effect of poorly controlled diabetes on pregnancy—increased incidence of:

a. Infertility.

b. UTI.

c. Vaginal infections (moniliasis).

d. Spontaneous abortion.

e. Congenital anomalies (three times as prevalent).

f. Preeclampsia/eclampsia.

g. Polyhydramnios.

h. Preterm labor and birth.

i. Fetal macrosomia—cephalopelvic disproportion (CPD).

j. Stillbirth.

5. Assessment: gestational diabetes (mellitus)

a. History:

  • Family history.
  • Previous infant 9 lb or more.
  • Unexplained fetal wastage—abortion, stillbirth, or early neonatal death.
  • Obesity with very rapid weight gain.
  • Polyhydramnios (excessive amniotic fluid).
  • Previous infant with congenital anomalies.
  • Increased tendency for intense vaginal or urinary tract infections.
  • Previous history of gestational diabetes.

b. Symptoms: “3 Ps”—polydipsia, polyphagia, polyuria—and weight loss.

c. Abdominal assessment:

  • Fetal heart rate.
  • Excessive fundal height.
    (a) Polyhydramnios.
    (b) Large-for-gestational-age (LGA) fetus. Note: With vascular pathology, small-for-gestational-age (SGA) fetus.

d. Medical diagnosis—procedures:

  • 50-gm oral glucose tolerance test (GTT): woman ingests 50 gm oral glucose solution; 1 hour later plasma glucose obtained. If 140 mg/dL, 3-hour oral GTT ordered.
  • Abnormal 3-hour GTT: two or more of
    the following findings are diagnostic of
    gestational diabetes:
    (a) Fasting blood sugar (FBS) ≥95 mg/dL.
    (b) One hour ≥180 mg/dL.
    (c) Two hours ≥155 mg/dL.
    (d) Three hours ≥140 mg/dL.
  • Diabetic classification criteria:
    (a) Type 1—autoimmune disease in which the body’s immune system destroys pancreatic beta cells; ↓ production of insulin; need additional insulin. About 10% with diabetes are type 1.
    (b) Type 2— ↑ insulin resistance despite adequate insulin production; treatment may include: diet, exercise, weight loss, oral drugs to stimulate release of insulin; or insulin injections. About 90% with diabetes are type 2.
    (c) Gestational—occurs in about 3% of all pregnancies. GTT administered at 24 to 28 weeks’ gestation; two abnormal values indicate diagnosis of gestational diabetes. About 40% of women with gestational diabetes will develop type 2 diabetes within 5 years.

e. Woman with known diabetes—all classes.

  • Knowledge and acceptance of disease and its management:
    (a) Signs and symptoms of hyperglycemia/hypoglycemia.
    (b)Appropriate behaviors (e.g., skim milk for symptoms of hypoglycemia).
  • Skill and accuracy in monitoring serum glucose (dextrometer use).
  • Skill and accuracy in preparing and administering insulin dosage; site rotation; subcutaneous injection in abdomen.
  • Close monitoring—prenatal status assessment every 2 weeks until 30 weeks, then weekly until birth. Alert to signs of emerging problems (need for insulin adjustment, polyhydramnios, macrosomia).
  • Other—as for any woman who is pregnant.

6. Analysis/nursing diagnosis:

a. Knowledge deficit related to pathophysiology, interactions with pregnancy, management (e.g., insulin administration).

b. Altered nutrition, more or less than body requirements, related to weight gain.

c. High-risk pregnancy: high risk for infection, ketosis, fetal demise, fetal macrosomia, cephalopelvic disproportion, polyhydramnios, preterm labor and birth, congenital anomalies.

7. Nursing care plan/implementation:

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

a. Goal: health teaching.

  • Pathophysiology of diabetes, as necessary; effect of pregnancy on management.
  • Signs and symptoms of hyperglycemia, hypoglycemia; appropriate management of symptoms.
  • Hygiene—to reduce probability of infection.
  • Exercise—needed to control serum glucose levels, to regulate weight gain, and for feeling of well-being.
  • Need for close monitoring during pregnancy.
  • Insulin regulation:
    (a) Requirements vary through pregnancy: first trimester—may decrease with some periods of hypoglycemia due to fetal drain; second trimester—increased need for insulin; third trimester—needs may be triple prepregnant dose; acidosis more common in late pregnancy (precipitated by emotional stress, infection).
    (b)Serum glucose testing—dextrometer, blood glucose, or other.
    (c) Preparation and self-administration of insulin injection, as necessary.
    (d)Prompt reporting of fluctuating serum glucose levels.
  • Diagnostic testing/hospitalization:
    (a) Nonstress test.
    (c) Amniocentesis.

b. Goal: dietary counseling.

  • Optimal weight gain—about 24 lb.
  • Needs 25 to 35 calories/kg of ideal body weight (1800–2600 calories).
  • Protein—18% to 25% (2 gm/kg, or about 70 gm daily).
  • Carbohydrates: 50% to 60% in complex form (milk, bread).
  • Fats—25% to 30% unsaturated.
  • No fruit juice; no cold cereal; carbohydrates limited.

c. Medical management: hospitalize woman for:

  • Regulation of insulin (oral hypoglycemics contraindicated in early pregnancy, due to teratogenicity; cross placental barrier).
  • Control of infection.
  • Determination of fetal jeopardy or indications for early termination of pregnancy.

8. Evaluation/outcome criteria:

a. Understands and accepts diagnosis of diabetes.

b. Actively participates in effective management of diabetes and pregnancy.

c. Maintains serum glucose levels within acceptable parameters (e.g., 70–120 mg/dL).

  • Monitors serum glucose levels accurately (dextrometer, blood glucose).
  • Prepares and self-administers insulin appropriately.
  • Complies with dietary regimen.

9. Antepartal hospitalization

a. Assessment:

  • Medical evaluation—procedures:
    (a) Serum glucose levels (↓ 120 mg/dL).
    (b) Sonography for fetal growth: biophysical profile (BPP) evaluates fetal physical well-being and volume of amniotic fluid.
    (c) Nonstress testing/contraction stress testing.
    (d) Amniocentesis for fetal maturity. Note: Lecithin/sphingomyelin (L/S) ratio may be elevated in women who are diabetic; phosphatidylglycerol [PG] more accurate for women who are diabetic.
  • Nursing assessment:
    (a) Daily weight, vital signs, FHR q4h, I&O.
    (b) Fundal height and Leopold’s maneuver on admission.

b. Nursing care plan/implementation: Goal: emotional support to reduce anxiety and tension, which contribute to insulin imbalance.

  • Explain all procedures.
  • Assist with tests for fetal status.
  • Prepare for possibility of preterm or cesarean birth.

10. Anticipatory planning—management of labor

a. Assessment: continuous.

  • Signs and symptoms of hyperglycemia, hypoglycemia. Hourly blood sugar measurements.
  • Electronic fetal monitoring—to identify signs of fetal distress.
  • Other—as for any woman in labor.

b. Nursing care plan/implementation: Goal: safeguard maternal/fetal status.

  • Position: lateral Sims’—to reduce compression of inferior vena cava and aorta due to polyhydramnios or LGA baby. (Supine hypotensive syndrome results from compression; reduced placental perfusion increases incidence of fetal hypoxia/anoxia.)
  • Medical management—varies widely.
    (a) Timing—amniocentesis to determine PG and phosphatidylinositol levels (estimate fetal pulmonary surfactant).
    (b) Insulin added to intravenous infusion of 0.9 NaCl and titrated to maintain serum glucose approximately 100 mg/dL. 5% to 10% D/W IV needed to prevent hypoglycemia that may lead to maternal ketoacidosis; hyperglycemia may result in newborn hypoglycemia.
    (c) Ultrasound to identify macrosomia >4050 gm.

11. Anticipatory planning—management of postpartum

a. Factors influencing serum glucose levels:

  • Loss of placental hormones that degrade insulin.
  • Lower metabolic rate. Woman requiring large doses of insulin may need to triple caloric intake and decrease insulin by one-half.

b. Assessment:

  • Observe for:
    (a) Hypoglycemia.
    (b) Infection.
    (c) Preeclampsia/eclampsia (higher incidence in women who are diabetic).
    (d) Hemorrhage (associated with polyhydramnios, macrosomia, induction of labor, forceps birth, or cesarean birth).
  • Monitor healing of episiotomy/abdominal incision.

c. Nursing care plan/implementation:

  • Medical management: insulin calibration—requirement may drop to one-half or two-thirds pregnant dosage on first postpartum day if woman is on full diet (due to loss of human placental lactogen and conversion of serum glucose to lactose).
  • Nursing management
    (a) Goal: euglycemia. Blood glucose, insulin as ordered.
    (b)Goal: avoid trauma, reduce risk of UTI. Avoid catheterization, where possible.
    (c) Goal: health teaching. Nipple care—to prevent fissures and possible mastitis.
    (d) Goal: reduce serum glucose and insulin needs. Encourage/support breastfeeding → antidiabetogenic effect. Note: If acetonuria occurs, stop breastfeeding while physician readjusts diet/insulin balance; may pump breasts to maintain lactation. If hypoglycemic, adrenalin level rises → decreased milk supply and let-down reflex.

12. Anticipatory guidancedischarge plan/implementation

a. Goal: counseling. Reinforce recommendations of physicians/genetic counselors.

  • Risk of infant inheriting gene for diabetes is greater if mother has early-onset, insulin-dependent disease.
  • Increased risk of congenital disorders.

b. Goal: family planning.

  • Oral contraceptives are controversial because they decrease carbohydrate tolerance; may be cautiously prescribed for women with no vascular disease and who are nonsmokers. Intrauterine device (IUD) contraindicated because of impaired response to infection. Barrier contraceptives (diaphragm or condoms with spermicides) recommended.
  • Tubal ligation: if mother has vascular involvement (i.e., retinopathy or nephropathy), increased risk with later pregnancies.

c. Goal: health teaching.

  • Self-care measures.
  • Importance of eating on time, even if infant must wait to breastfeed or bottle feed.
  • Importance of adequate rest and exercise to maintain insulin/glucose balance.
  • Organize schedule to care for infant, other children, and her diabetes. Allow time for self.

d. Evaluation/outcome criteria:

  • Successfully completes an uneventful pregnancy, labor, and birth of a newborn who is normal and healthy.
  • Makes informed judgments regarding parenting, family planning, management of her diabetes.

G. Disorders affecting psychosocial-cultural behaviors: substance abuse

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

1. Assessment: woman who is pregnant and abuses substances

a. Medical history

  • Infections: HIV-positive status, AIDS, STIs, hepatitis, cirrhosis, cellulitis, endocarditis, pancreatitis, pneumonia.
  • Psychiatric illness: depression, paranoia, irritability.
  • Trauma related to violence.

b. Obstetric history

  • Spontaneous abortions.
  • History of abruptio placentae.
  • Preterm labor.
  • Preterm rupture of membranes.
  • Fetal death.
  • Low-birth-weight (LBW) infants.
  • Tremors/seizures.

c. Current pregnancy

  • Preterm labor contractions.
  • Hypoactivity or hyperactivity in fetus.
  • Poor or decreased weight gain.
  • STI.
  • Undiagnosed vaginal bleeding.
  • Drugs being used and methods of self-administration.

d. Psychosocial history

  • Attitudes re: pregnancy.
  • Current support system: lacking.
  • Current living arrangements; lifestyle.
  • History of psychiatric illness.
  • History of physical, sexual abuse.
  • Involvement with legal system.

e. Physical examination

f. Commonly abused substances

  • Nicotine.
  • Alcohol (fetal alcohol syndrome [FAS] or fetal alcohol effects [FAE]).
  • Marijuana.
  • Stimulants—cocaine, crack, ice, methamphetamine.
  • Opiates—heroin, methadone, Darvon, codeine, Vicodin, OxyContin.
  • Sedatives, hypnotics.
  • Caffeine.
  • Ecstasy.

g. Neonatal outcomes

  • LBW, small heads.
  • Irritable, difficult to console.
  • Disorganized suck-swallow reflex.
  • Impaired motor development.
  • Congenital anomalies: genitourinary, gastrointestinal, limb anomalies.
  • Cerebral infarctions.
  • Breastfeeding allowed; thought to ease infant withdrawal.
  • Poor, slow weight gain; failure to thrive.

2. Analysis/nursing diagnosis:

a. Altered nutrition: less than body requirements—poor weight gain related to poor nutrition.

b. Altered nutrition: less than body requirements—slow fetal growth related to slow gain in weight.

c. Altered placental function related to high risk for abruptio placentae.

d. Noncompliance with health-care protocols related to persistent drug use.

e. Altered parenting related to psychological illness (substance dependence).

3. Nursing care plan/implementation:

a. Early identification of substance abuse.

b. Stabilize physiological status.

c. Fetal surveillance.

d. Urge consistent obstetric care.

e. Refer for social services.

4. Evaluation/outcome criteria:

a. Seeks out and uses social services and drug treatment program.

b. Abstains from illicit substances during pregnancy.

c. Successfully completes an uneventful pregnancy, labor, and birth of normal healthy infant.




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