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

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: GROWTH AND DEVELOPMENT

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

 Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Biological Foundations of Reproduction

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

General overview: This review of the structures, functions, and important assessment characteristics of the reproductive system provides essential components of the database required for accurate nursing judgments. Comparing normal characteristics and established patterns with nursing assessment findings assists in identifying client needs and in planning, implementing, and evaluating appropriate goal-directed nursing interventions.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Female Reproductive Anatomy and Physiology

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

I. THE FEMALE PELVIS

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

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

  • Two hip bones (right and left innominate: sacrum, coccyx).
  • False pelvis—upper portion above brim, supportive structure for uterus during last half of pregnancy.
  • True pelvis—below brim; pelvic inlet, mid-plane, pelvic outlet. Fetus passes through during birth.

II. PELVIC MEASUREMENTS

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

  • Diagonal conjugate—12.5 cm or greater is adequate size; evaluated by examiner.
  • Conjugate vera—11 cm is adequate size; can be measured by x-ray (not commonly performed).
  • Obstetric conjugate—measured by x-ray (not commonly performed).
  • Tuber-ischial diameter—9 to 11 cm indicates adequate size; evaluated by examiner.

III. FEMALE EXTERNAL ORGANS

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

  • Mons veneris—protects symphysis.
  • Labia majora—covers, protects labia minora.
  • Labia minora—two located within labia majora.
  • Clitoris—small erectile tissue.
  • Hymen—thin membrane at opening of vagina.
  • Urinary meatus—opening of urethra.
  • Bartholin glands—producers of alkaline secretions that enhance sperm motility, viability.

IV. FEMALE INTERNAL REPRODUCTIVE ORGANS

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

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

  • Vagina—outlet for menstrual flow, depository of semen, lower birth canal.
  • Cervix—cone-shaped neck of the uterus that protrudes into the vagina.
  • Uterus—muscular organ that houses fetus during gestation.
  • Fallopian tubes—two tubes stretching from cornua of uterus to ovaries; transport ovum.
  • Ovaries—two oval-shaped structures that produce ovum and hormones (estrogen and progesterone).
  • Breasts—two mammary glands capable of secreting milk for infant nourishment.

V. MENSTRUAL CYCLE

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

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

A. Reproductive hormones

1. Follicle-stimulating hormone (FSH)—secreted during the first half of cycle; stimulates development of graafian follicle; secreted by anterior pituitary.

2. Interstitial cell-stimulating hormone, luteinizing hormone (ICSH, LH)—stimulates ovulation and development of corpus luteum; secreted by pituitary.

3. Estrogen—assists in ovarian follicle maturation; stimulates endometrial thickening; responsible for development of secondary sex characteristics; maintains endometrium during pregnancy. Secreted by ovaries and adrenal cortex during cycle and by placenta during pregnancy.

4. Progesterone—aids in endometrial thickening; facilitates secretory changes; maintains uterine lining for implantation and early pregnancy; relaxes smooth muscle. Secreted by corpus luteum and placenta.

5. Prostaglandins—substances produced by various body organs that act hormonally on the endometrium to influence the onset and continuation of labor. A medication that may be used to facilitate onset of second-trimester abortion; also used to efface the cervix before induction of labor in term pregnancies.

B. Ovulation—maturation and release of egg from ovary; generally occurs 14 days before beginning of next menses.

C. Menstruation—vaginal discharge of blood and fragments of the endometrium; cyclic; occurs in response to dropping levels of estrogen and progesterone.

D. Fertilization—impregnation of ovum by sperm.

E. Implantation—fertilized ovum attaches to uterine wall for growth.

F. Menopause—normally occurring cessation of menses with gradual decrease in amount of flow and increase in the time between periods at end of fertility cycle; average age is 51 to 52. Early menopause rare but may be influenced by hypothyroidism, surgical ovarian removal, overexposure to radiation. Treatments during menopause for symptom relief: hormone replacement therapy, isoflavanoids, vitamins B and E for hot flashes, vaginal creams for dyspareunia (painful intercourse), and calcium for osteoporosis. Alternative treatments include herbal supplements and soy.

G. Spinnbarkeit—stretchable, thin cervical mucus present at ovulation.

VI. ASSESSMENT OF REPRODUCTIVE TRACT/REPRODUCTIVE HEALTH:

A. Health history

  1. Menarche: onset and duration.
  2. Menstrual problems.
  3. Contraceptive use.
  4. Pregnancy history.
  5. Fertility problems.
  6. Lifestyle choices that may have an impact on health and reproductive decision making.

B. Physical examination

1. External, internal reproductive organs.

2. Breast examination.

3. Mammography—every 1 to 2 years for women beginning age 40; annually beginning age 50; earlier and more frequently if have risk factors for breast cancer:

  • Mother, daughter, or sister had breast cancer.
  • Menses before age 11, or menopause before age 45 or after age 55.
  • Previous benign needle biopsies.
  • Birth of first child greater than 30 years old.
  • High-fat diet, obesity.
  • Obesity after menopause.
  • Alcohol intake of 2 to 5 drinks per day.
  • Nulliparous.
  • Personal history of cancer.
  • Defects in certain genes (BRCA1, BRCA2, HER).

4. Pap smear—First Papanicolaou (Pap) smear at age 18 or earlier if sexually active; then annually until three consecutive normal Paps. After three consecutive normal Paps, physician discretion is recommended.

5. Tests for sexually transmitted infections (STIs).

VII. ANALYSIS/NURSING DIAGNOSIS:

A. Health-seeking behaviors related to health promotion.

B. Health-seeking behaviors related to menopause.

VIII. NURSING CARE PLAN/IMPLEMENTATION:

A. Discuss anatomy and physiology of reproductive tract.

B. Review menstruation, ovulation, fertilization.

C. Explain need for periodic Pap smears, annual gynecological examinations, including mammography.

D. Discuss lifestyle choices and sexuality issues that might affect health.

IX. EVALUATION/OUTCOME CRITERIA:

A. Woman displays basic understanding of anatomy and physiology.

B. Woman understands cycle and contraception.

C. Woman regularly seeks preventive care and performs monthly breast self-examination (BSE).

Health Promotion and Maintenance; Nursing Care of the Childbearing Family: Decision Making Regarding Reproduction

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

General overview: During the reproductive years, the woman who is sexually active often faces the decision to postpone, prevent, or terminate a pregnancy. The nursing role focuses on assisting her to make an informed decision consistent with individual needs.

I. FAMILY PLANNING

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

A. Assessment:

1. Determine interest in and present knowledge of methods of family planning.

2. Identify factors affecting choice of method: cultural and religious objections, contraindications for individual methods, motivation/ability to follow chosen method successfully, financial considerations, and sexual orientations.

B. Analysis/nursing diagnosis: knowledge deficit regarding family planning methods/options

C. Nursing care plan/implementation: Goal: health teaching to facilitate informed decision making, selection of option appropriate to individual needs, desires.

1. Describe, explain, discuss options available and appropriate to the woman. Include information on advantages and disadvantages of each option (Contraception and Sterilization).

2. Demonstrate, as necessary, method selected.

3. Quick health teaching reminders for missed oral hormone preparations:

  • Woman should take one pill at the same time every day for 21 (or 28) days.
  • If woman misses one pill, she should take it as soon as she remembers it; she should then take the next one at the usual time.
  • If woman misses two or more pills in a row in the first 2 weeks of her cycle, she should take two pills for 2 days and use a backup method of contraception for the next 7 days.
  • If woman misses two pills in the third week, or three or more pills anytime:
    (1) A Sunday starter should keep taking pills until the next Sunday, then start a new pack that Sunday. She should use a backup method of contraception for the next 7 days.
    (2) A day 1 starter should throw out the rest of the pack and start a new pack that day. She should use a backup method of contraception for the next 7 days.
  • 28-day pill pack: If woman misses any of the seven pills that do not have any hormones, she should throw out the pills missed and keep taking one pill a day until the pack is empty. She does not need a backup method of contraception.

 

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Health Promotion and Maintenance; Nursing Care of the Childbearing Familysceenshot

 

4. Alert woman to discontinue use of oral hormone contraceptive preparations and report any of the following signs of potential problems to the physician STAT:ACHES”*

AAbdominal pain: possible problem with the liver or gallbladder.
CChest pain or shortness of breath: possible clot within lungs or heart.
HHeadaches (sudden or persistent): possibly caused by stroke (brain attack) or hypertension.
EEye problems: possible vascular incident or hypertension.
SSevere leg pain: possible thromboembolic process.

5. Signs of potential problems related to IUD use: “PAINS”*

P—Period (menstrual) late, abnormal spotting or bleeding.
AAbdominal pain, pain during coitus (dyspareunia).
IInfection, abnormal vaginal discharge.
NNot feeling well; fever or chills.
SString missing (nonpalpable on vaginal self-examination, or not seen on speculum examination).

6. Toxic Shock Syndrome (TSS)

a. Signs/symptoms:

(1) Fever of sudden onset—over 102°F (38.9°C).

(2) Hypotension—systolic pressure 90 mm Hg; orthostatic dizziness; disorientation.

(3) Rash—diffuse, macular erythroderma (resembling sunburn).

(4) Sore throat; severe nausea, vomiting.

(5) Copious vaginal discharge.

b. Instructions for prevention:

(1) General

  • Avoid use of tampons, cervical caps, and diaphragms during the postpartum period (6 weeks).
  • Do not use any of the above if you have a history of TSS.
  • Call physician if you experience sudden onset of a high fever, vomiting, diarrhea, or skin rash.
  • Insert clean tampons and contraceptive devices with clean hands.
  • Remove within prescribed time limits.

(2) Tampons

  • Change tampons every 3 to 6 hours.
  • Do not use super-absorbent tampons.
  • For overnight protection, substitute other products such as sanitary napkins or mini-pads.

(3) Diaphragm or cervical cap

  • Avoid use during your menstrual period.
  • Remove within 8 hours after intercourse (diaphragm must be removed no later than 24 hours; the cap, no later than 48 hours).

D. Evaluation/outcome criteria:

1. Woman avoids or achieves a pregnancy as desired.

2. Woman expresses comfort and satisfaction with method selected.

II. INFERTILITY

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

A. Definition: inability to conceive after 1 year of unprotected intercourse.

B. Pathophysiology: contributing factors—hormonal deficiencies, reproductive system disorders, congenital anomalies, male impotence, sexual knowledge deficit, debilitating disease.

C. Assessment:

1. History—general health, reproduction, social history.

2. Maternal diagnosis

  • Basal body temperature (BBT) (Basal body temperature chart).
  • Endocrine studies.
  • Huhner test (postcoital).
  • Rubin’s test (tubal patency).
  • Hysterosalpingogram (tubal patency).

3. Male diagnosis—history, physical examination, laboratory studies (e.g., semen analysis).

D. Analysis/nursing diagnosis: altered sexuality, altered family process related to infertility.

E. Nursing care plan/implementation:

1. Provide emotional support.

2. Explain testing procedures for diagnosis.

3. Assist with referral process.

Health Promotion and Maintenance; Nursing Care of the Childbearing Family

 

F. Evaluation/outcome criteria:

1. The couple conceives, or,

2. If the couple does not conceive, they accept referral for help with adoption, other reproductive alternatives, or childlessness.

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III. INTERRUPTION OF PREGNANCY—also known as elective, voluntary, or therapeutic abortion. Once the diagnosis of pregnancy and the length of gestation are established, the woman faces the decision to interrupt or to maintain the pregnancy (Interruption of Pregnancy (Elective/Voluntary Abortion)).

A. Decision-making stage:

1. Assessment:

a. Health history:

  1. Determine woman’s feelings about the pregnancy, reasons for considering abortion, level of maturity; if decision was already made before she came to clinic, how was decision made? Does she have a support system?
  2. Identify factors influencing/complicating her decisions (religious beliefs, cultural mores, peer and family pressures).
  3. Information needs.

b. Physical examination.

c. Laboratory tests: blood type, Rh, hemoglobin, hematocrit, urinalysis, pregnancy test, antibody titer, other tests dependent on her health status.

2. Analysis/nursing diagnosis:

a. Ineffective coping related to emotional conflicts associated with need for decision to continue/terminate pregnancy.

b. Altered family process related to intrafamily conflict associated with need for/decision to continue/terminate pregnancy.

c. Anticipatory grieving related to loss of pregnancy/child.

d. Altered self-concept, self-esteem disturbance related to possible guilt feelings associated with pregnancy/termination.

e. Knowledge deficit related to available options.

3. Nursing care plan/implementation:

a. Goal: emotional support to minimize impact on self-image and self-esteem.

  1. Maintain accepting, nonjudgmental attitude.
  2. Encourage verbalization of feelings, perceptions, and values.
  3. Support woman’s decision.

b. Goal: health teaching to facilitate informed decision making.

  1. Explain and discuss available options as
    applicable (see Interruption of Pregnancy (Elective/Voluntary Abortion)).
  2. Describe procedure selected and what to
    expect after procedure.

c. Goal: minimize impact on intrafamily relations, family process. Where applicable, encourage open communication between deciding partners.

4. Evaluation/outcome criteria:

a. Woman states she understands all information necessary to give consent.

b. Woman expresses comfort and satisfaction with the decision.

B. Preoperative period

1. Assessment:

a. Reassess woman’s emotional and physical status and current feelings regarding decision.

b. Determine woman’s current knowledge/understanding of authorization form, anticipated procedure, and consequences (informed consent).

c. Monitor woman’s physiological and (if awake) psychological response to procedure.

2. Analysis/nursing diagnosis:

a. Anxiety/fear related to procedure, potential complications.

b. Knowledge deficit related to ongoing procedure, sights, sounds, and sensations experienced.

3. Nursing care plan/implementation:

a. Goal: provide opportunity to reconsider decision regarding termination of pregnancy.

  1. Check to ensure all required permission (informed consent) forms have been signed/filed.
  2. Refer to physician if woman is ambivalent or insecure in decision.

b. Goal: reduce anxiety/fear related to procedure.

  1. Explain all anticipated preoperative, operative, and postoperative care.
  2. Assist with procedure; if woman is awake, explain what is happening and what she may be experiencing.

c. Goal: emotional support to facilitate effective coping.

  1. Encourage verbalization of feelings, fears, concerns.
  2. Support woman’s decision.

4. Evaluation/outcome criteria: woman does not experience physiological or psychological problems during procedure.

C. Postoperative period

1. Assessment:

a. Monitor physiological response to procedure (vital signs, blood loss, uterine cramping).

b. Determine psychological response (happy, relieved; guilt feelings, lowered self-esteem).

c. Determine desire for family planning information.

d. Determine need for Rho(D) immune globulin, rubella vaccination

2. Analysis/nursing diagnosis:

a. Pain related to procedure.

b. High risk for infection related to lack of knowledge of post-abortal self-care.

3. Nursing care plan/implementation:

a. Goal: provide and explain postoperative care.

  1. Administer intravenous (IV) fluids.
  2. Administer medications prn for discomfort.
  3. Administer oxytocic medications for uterine atony, prn.
  4. If mother is Rh-negative, 8 or more weeks of gestation, and laboratory tests indicate no current sensitization (i.e., she is Coombs’ negative):
    (a) Explain rationale for post-abortion administration of Rho (D antigen) immune globulin (RhoGAM). (b) Administer RhoGAM, as ordered.
  5. Provide and explain perineal care.

b. Goal: health teaching to facilitate active participation in own health maintenance, informed decision making, provide predischarge anticipatory guidance (also provide in written form with attention to woman’s level of reading skill and understanding, and in her native language whenever possible):

  1. Immediately report any cramping, excessive bleeding, signs of infection.
  2. Provide name and telephone number of person to call if she has questions.
  3. Schedule a post-abortal checkup.
  4. Discuss contraception, if woman indicates interest; or give her place and name to call for information later.
  5. Discuss resumption of tampon use (3 days to 3 weeks as ordered) and sexual intercourse (1 to 3 weeks as ordered).
  6. Discuss need to avoid douching.

4. Evaluation/outcome criteria:

a. Woman returns for post-abortal appointment.

b. Woman suffers no adverse physical sequelae to the procedure.

c. Woman suffers no adverse psychological sequelae to the procedure.

d. Woman is successful in achieving her goal of either contraception or conception at the time she desires.

5. Postabortion psychological impact:

a. Majority—relieved and happy.

b. Small number (5% to 10%)—negative feelings, such as guilt or low self-esteem.

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FURTHER READING/STUDY:

Resources:

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