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Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

MATERNAL-INFANT NURSING CARE PLANS Karla L. Luxner RNC, MSN I- THOMSON LEARNING Africa Australia Canada Denmark Japan Mexico New Zealand Philippines Puerto Rico Singapore Spain United Kingdom United States

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

NOTICE TO THE READER Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain and include information other than that provided to it by the manufacturer. The reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities herein and to avoid all potential hazards. By following the instructions contained herein, the reader willingly assumes all risks in connection with such instructions. The Publisher makes no representation or warranties of any kind, including but not limited to, the warranties of fitness for particular purpose or merchantability, nor are any such representations implied with respect to the material set forth herein, and the publisher takes no responsibility with respect to such material. The publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or part, from the readers' use of, or reliance upon, this material. COPYRIGHT 0 1999 Delmar, a division of Thomson Learning, Inc. The Thomson Learningm is a trademark used herein under license. Printed in the United States of America 2 3 4 5 6 XXX 03 02 01 00 For more information, contact Delmar, 3 Columbia Circle, PO Box 15015, Albany, NY 12212-0515; or find us on the World Wide Web at http://www. delmar. com International Division List Asia Australiflew Zealand: Latin America: Thomson Learning Nelsow Thomson Learning Thomson Learning 60 Albert Street, #15-01 102 Dodds Street Seneca, 53 Albert Complcx South Melbournc, Victoria 3205 Colonia Polanco Singapore 189969 Australia 1 1560 Mexico D. F. Mexico Tel: 65 336 6411 Tel: 61 39 685 4111 Tel: 525-281-2906 Fax: 65 336 7411 Fax: 61 39 685 4199 Fax: 525-281-2656 Japan: UWEurope Middle East Canada: Thomson Learning Thomson Learning Nelsod Thomson Learning Palaceside Building 5F Berkshire House 1120 Birchmount Road 1-1-1 Hitotsubashi, Chiyoda-ku 168-173 High Holbom Scarborough, Ontario Tokyo 1000003Japan London Canada M1K 5G4 Tel: 813 5218 6544 WCl V 7AA United Kingdom Tel: 416-752-9100 Fax: 813 5218 6551 Tel: 44 171 497 1422 Fax: 41 6-752-8 I02 Fax; 44 171 497 1426 ALL RIGHTS RESERVED. No part of this work covered by the copyright hereon may be reproduced or used in any form or by any means-graphic, electronic, or mechanical, including photocopying, recording, taping, Web distribution or information storage and retrieval systems-without the written permission of the publisher. For permission to use material from this text or product contact us by Tel (800) 730-2214; Fax (800) 730-2215; www. thomsonrights. com Library of Congress Cataloging-in-Publication Data ISBN: 1-56930-0992

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

Pregnancy, childbirth, the puerperium, and the newborn transition to extrauterine life are natural physiologic processes. The healthy mother and her infant usually require little in the way of medical intervention during these life events; they may however, benefit greatly from comprehensive nursing care. Maternal-Infant nurs- ing is provided in diverse settings from homes and schools to Third-World clinics, hospitals, and OB Intensive Care Units. Perinatal health promotion and wellness teaching form the foundation of this care and lay the groundwork for healthy families of the future. For the families experiencing a complicated pregnancy or birth, skilled nursing care based on sound scientific knowledge is provided-not instead of, but in addi- tion to health promotion and wellness teaching. Knowledge and respect for cultural variations is essential to modern nursing practice. Perhaps in no other specialty are there so many culturally defined prescriptions and proscriptions as those accompanying pregnancy, birth, and infant care. The nursing process serves as a learning tool for students and as a practice and documentation format for clinicians. Based on a thorough assessment, the nurse formulates a specific plan of care for each individual client. The care plans in this book are provided to facilitate that process, not supplant it. To that end, each care plan solicits specific client data and prompts the nurse to individualize the interventions, consider cul- tural relevance, and to evaluate the client's individual response. The book provides basic nursing care plans for healthy clients during the prenatal, intraparturn, postpartum, and newborn periods. Common perinatal and neonatal complications for each section are then presented with associated care plans. Home visit care plans are included for the prenatal, postpartum, and newborn clients, reflecting current practice. I am grateful to my family, students, nurse colleagues, and the many mothers, fathers, grandmas, and babies who have enriched my understanding and shaped my practice. This book is dedicated to my own mother, Elizabeth Hobart Romaine, who taught me that it could be done. Karla L. Luxner

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

NURSING CARE PLANS Consultants Yondell Masten, RNC, Ph D, WHNP, CNS Professor Texas Tech University Health Sciences Center School of Nursing Lubbock, Texas Dori Bronstein Krolick, RNC, BSN, MS Candidate Operations Manager, Maternal-Child Services Benedictine Hospital Kingston, New York

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

Usinm the Maternal-Infant Nursing Care Plans These plans have been developed to reflect com- prehensive perinatal nursing care for mothers and their infants. The book is divided into four units: Pregnancy, Intrapartum, Postpartum, and Newborn. Each unit begins with an overview of the general physiologic and psychological changes associated with the period. Additional pertinent information is presented in flowchart format. A Care Path for each unit provides an overview of common health care practices during each period. The basic nursing care plans in each unit provide comprehensive care for healthy clients. These should serve as the basic plan for most clients with changes made to address individual situations. For example, designing a client-specific plan of care may include combining nursing diagnoses from the basic care plan and one or more complica- tions. The practitioner should add, delete, and combine diagnoses as dictated by assessment of the individual client. Perinatal and neonatal complications are briefly described, including risk factors and common medical care if indicated. Important relationships are presented in flowcharts to facilitate under- standing of the basis for care. Nursing diagnoses relevant to the complication are cross-referenced when applicable and followed by specific diag- noses common for the condition. Nursing care begins with a comprehensive review and assessment of each individual client. The data is then analyzed and a specific plan of care devel- oped. The format for each nursing care plan in this book is summarized below. Related factors (etiology) for each diagnosis are suggested and the user is prompted to choose the most appropriate for the specific client. Defining characteristics for each actual diagno- sis are listed with prompts to the user to include specific client data from the nursing assessment. Goals are related to the nursing diagnosis and include a time frame for evaluation to be speci- fied by the user. Appropriate outcome criteria specific for the client are suggested for each goal. Nursing interventions and rationales are com- prehensive. They include pertinent continuous assessments and observations. Common thera- peutic actions originating from nursing and those resulting from collaboration with the pri- mary caregiver are suggested with prompts for creativity and individualization. Client and family teaching and psychosocial support are provided with respect for cultural variation and individual needs. Consultation and referral to other caregivers is suggested when indicated. Evaluation of the client's goal and presentation of data related to the outcome criteria is fol- lowed by consideration of the next step for the client. It is hoped that the user will individualize these care plans not only by inserting pertinent client data when prompted, but also find stimulation to include creative interventions not listed here. Nursing diagnoses as approved by the North American Nursing Diagnosis Association (NANDA) taxonomy.

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TABLE OF CONTENTS

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... Unl I :~na ncy.................................................................................................................................................. 1 Basic Care Plan: Prenatal Home Visit...................................................................................................................................... 13 Multiple Gestation................................................................................................................................................................... 21 Threatened Abortion............................................................................................................................................................... 31 Infection.................................................................................................................................................................................. 35 Substance Abuse...................................................................................................................................................................... 41 Gestational Diabetes................................................................................................................................................................ 45 Heart Disease.......................................................................................................................................................................... 51 Pregnancy Induced Hypertension (PIH).................................................................................................................................. 57 Placenta Previa......................................................................................................................................................................... 65 Preterm Labor.......................................................................................................................................................................... 71 Preterm Rupture of Membranes.............................................................................................................................................. 77 At-Risk Fetus........................................................................................................................................................................... 81 Urn II: lnlrapartum............................................................................................................................................. 85 Healthy Pregnancy.,.................................................................................................................................. 3 Adolescent Pregnancy.............................................................................................................................................................. 17 Hyperemesis Gravidarum........................................................................................................................................................ 27 Labor and Birth...................................................................................................................................... 87 Basic Care Plan: Cesarean Birth............................................................................................................................................... 99 Induction & Augmentation................................................................................................................................................... 105 Regional Analgesia................................................................................................................................................................. 111 Failure to Progress.................................................................................................................................................................. 117 Fetal Distress......................................................................................................................................................................... 121 Abruptio Placentae................................................................................................................................................................ 125 Prolapsed Cord...................................................................................................................................................................... 129 Postterm Birth....................................................................................................................................................................... 133 Precipitous Labor and Birth................................................................................................................................................... 137 HELLPl DIC......................................................................................................................................................................... 141 Fetal Demise.......................................................................................................................................................................... 145 Basic Care Plan: Labor and Vaginal Birth............................................................................................... 91 Unit 111: Postpartum........................................................................................................................................... 151 Healthy Puerperium.............................................................................................................................................................. 153 Basic Care Plan: Vaginal Birth............................................................................................................................................... 159 Basic Care Plan: Postpartum Home Visit............................................................................................................................... 169 Episiotomy and Lacerations................................................................................................................................................... 189 Puerperal Infection................................................................................................................................................................ 193 Basic Care Plan: Cesarean Birth............................................................................................................................................. 165 Brmt-Feeding....................................................................................................................................................................... 175 Postpartum Hemorrhage....................................................................................................................................................... 183 Venous Thrombosis............................................................................................................................................................... 197 Hematomas........................................................................................................................................................................... 203 Adolescent Mother................................................................................................................................................................ 207 Parents of the At-Risk Newborn............................................................................................................................................ 219 Postpartum Depression.......................................................................................................................................................... 213

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

iv Unit IU: Newborn.............................................................................................................................................. 227 Healthy Newborn.................................................................................................................................................................. 229 Basic Care Plan: Term Newborn............................................................................................................................................ 233 Basic Care Plan: Newborn Home Visit.................................................................................................................................. 241 Circumcision......................................................................................................................................................................... 247 Preterm Infant....................................................................................................................................................................... 251 Small for Gestational Age (SGA, IUGR)............................................................................................................................... 259 Large for Gestational Age (LGA, IDM)................................................................................................................................. 265 Postterm Infant...................................................................................................................................................................... 269 Birth Injury........................................................................................................................................................................... 273 Hyperbilirubinemia............................................................................................................................................................... 279 Neonatal Sepsis...................................................................................................................................................................... 287 HN....................................................................................................................................................................................... 291 Infant of Substance Abusing Mother..................................................................................................................................... 299.. References...................................................................................................................................................... 311

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

UNIT I: PREGNANCY Healthy Pregnancy Basic Care Plan: Prenatal Home Visit Adolescent Pregnancy Multiple Gestation Hyperemesis Gravidarum Threatened Abortion Infection Substance Abuse Gestational Diabetes Heart Disease Pregnancy Induced Hypertension (PIH) Placenta Previa Preterm Labor Preterm Rupture of Membranes At-Risk Fetus

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Healthy Pregnancy Pregnancy is a normal physiologic process. The goal of health care during pregnancy is to promote and maintain the health of the mother and fetus. Risk assessment, problem identification and incer- vention, and health teaching are important aspects of prenatal care. Physical Changes The placental hormones influence changes in maternal physiology during pregnancy. These hor- mones maintain pregnancy and promote an opti- mal environment for the growing fetus. Physiologic changes include a 50% increase in blood volume, an increased sensitivity to CO2 and a need for higher insulin production. Mechanical changes result from the growing uterus and include pressure on the bladder dur- ing the first and third trimesters, a shifting cen- ter of gravity, and stretching of uterine liga- ments. lab Value Changes Non-Dremant Precnant Hgb (g/d L) 12-16 11-13 Hct (%) 36-48 33-39 Albumin (g/d L) 4. 3 3. 5 Psychological Changes BUN (mg/d L) 10-16 7-10 WBC (mm3) 4000-1 1000 5000-1 5000 Developmental issues and possibly hormone levels influence changes in maternal emotions and out- look. Maternal psychological tasks of pregnancy may include: Acceptance of the fact of pregnancy (first trimester) Acknowledgement of the fetus as a seperate being (second trimester) Preparation for birth and motherhood (third trimester) Fetal Growth and Development Fetal growth and development are monitored at each prenatal visit. The gestational age of the fetus is calculated from the mother's last normal men- strual period. A full-term pregnancy is 40 weeks (plus or minus 2 weeks) from the LNMl? During the first trimester all organ systems develop and the fetus is most vulnerable to ter- atogens. The fetal heart rate (FHT) can be heard with a doppler from 8-12 weeks. Normal FHT's are from 120-160 beats per minutes. Fetal movement (“quickening”) is usually noticed by the mother from 16-10 weeks. Lanugo is fine hair, which covers the fetus from about 20 weeks until the third trimester when it thins and disappears. Vernix caseosa is a thick cheesy secretion that covers and protects the fetal skin from about 26 weeks. This disappears by term except in body creases. Viability depends on maturation of the respira- tory and neurological systems. A fetus born as early as 24 weeks may survive but will require intensive care.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

4 MATERNALINFANT NURSING CARE PLANS h CG (produced by the trophoblast) maintains 1 Corpus luteum (prevents menses) I Placenta Estrogen Progesterone I I J. peripheral vascular resistance Relaxin 4 Collagen changes +joint I mobility I cervical softening \ Fetal growth +protein synthesis Milk p I;pduction I I + maternal insulin L resistance Prostaglandin (risk for gestational diabetes) 1 Possible role during labor Relaxation of smooth muscle uterus arteries GI/GU (syncope, GI discomforts, risk for UTI) Breast gland development + Body temp J/ C02 tolerance (physiologic hyperventilation) + Aldosterone secretion I (physiologic 4 edema)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 5 Prenatal Care Path Week Interview I l St visit Chief c/o Med/OB hx Psychosocial Religious Cultural Concerns h resources Risk assessment v Client concerns L I. c 20 Quickening? 24 28 32 34 Client concerns 86 discomforts. I Physical Exam Ht., Wt., B/P, TPR, reflexes Physical exam Fundal ht. &, FHT if indicated Pelvic exam, adequacy, sizeldates Wt., vital signs, FHT, fundal ht. + I contractions Tests Teaching Referral Other Antibody Substance Services, L PNV, iron I

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PREGNANCY 7 Basic Care Plan: Healthy The nursing care plan is based on a thorough nursing history, assessment, and review of medical and laboratory findings. Specific client-related data should be inserted wherever possible and within parentheses. Nursing Care Plans Health Seeking Behaviors: Prenatal Care Related to: Client's desire for a healthy pregnancy and newborn. Defining Characteristics: Client makes and keeps prenatal care appointment (date). Client states (specify: e. g. ; “I think that I am pregnant; I want to have a healthy baby”). List appropriate subjec- tive/objective data. Outcome Criteria Client will keep all prenatal appointments. Client will call the health care provider for any concerns related to pregnancy. ~ INTERVENTIONS RATIONALES Establish rapport: ensure privacy, listen attentively, and allow adequate time to address client's concerns. Assess reason for seeking care, remain nonjudgmen- tal, use open-ended ques- tions, and observe nonver- bal dues. Assess knowledge level of pregnancy and prenatal care (previous OB hx). Client will feel comfort- able in the care setting and be willing to share con- cerns. Client concerns are the basis of nursing care. Therapeutic techniques help the nurse obtain the most information. Assessment provides data for development of an individualized teaching plan. INTEKVENTIONS RATIONALES Assess client concerns related to pregnanqdpre- natal care: eg., cultural expectations; emotional, family, financial concerns. Observe interaction with significant other, if pre- sent. Describe the components of care with rationales (schedule of care, fetal assessments, lab tests, etc. ). Provide emotional support during invasive or painhl procedures. Modify plan of care based on client requestdneeds (e. g., female physician, teaching session rather than literature for illiterate clients). Provide the name and phone number (specify) for client to call with any questions. Provide written informa- tion about pregnancy. Refer client as needed (WIC, social services, etc. ). Socioeconomic concerns may interfere with the ability to obtain care. Issues may interfere with compliance. Observation provides information about social support. Understanding what to expect allays fear and pro- motes compliance. Most women dislike pelvic exams. Nursing support can decrease discomfort by promoting relaxation. Individualizing the rou- tines of prenatal care shows respect for the client's unique needs and concerns. Often questions will arise outside of appointments. Client will feel comfort- able with a person to con- tact. Written information is available to [he client in her home. Ensures client will obtain needed assistance. Evaluation (Datehime of evaluation of goal) (Has goal been met?not met? partially met?) (Has client kept all prenatal appointments? Give data. ) (Has client called with concerns? Give data. )

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

8 MATERNALINFANT NURSING CARE PLANS (Revisions to care plan? D/C care plan? Continue care plan?) Nutrition, Altered: Less Than Body Requirements Related to: Increased demands of pregnancy, inability to obtainhgesdutilize adequate nutri- ents. Defining Characteristics: Specify: (Client's report- ed daily intake v. requirements for this pregnancy, reported nausea and vomiting, pica), (EGA, Ht, Wt, Hgb and Hct, serum albumin, blood glucose, condition of skin, hair, nails, teeth); list appropri- ate subjective and objective data. Goal: Client will ingest adequate nutrients during pregnancy for maternal and fetal needs (date/ time to evaluate). Outcome Criteria Client reports eating a balanced diet based on the Food Guide Pyramid modified for pregnancy (or prescribed diet). Client takes prenatal vitamins and iron as pre- scribed. Client gains 25 to 35 pounds during pregnancy (2-5 pounds first 12 weeks, 1 pound/week there- after), (+ for multiple gestation). INTERVENTZONS RATIONALES Assess current food intake; 24 hour diet recall; pica; and appetite changes (at each prenatal visit). Assess for nausea and vom- iting (amount, times). Assessment provides base- line data. Pica is the inges- tion of non-food substances (dirt, starch, ice, etc). Assessment provides infor- mation about the client's ability to ingest and absorb nutrients. INTERVENTIONS RATIONALES Assess skin (texture, tur- gor), hair, eyes, mouth, nails for signs of adequate nutrition. Assess weight at each visit and compare with previous weight and expected gains. Remain nonjudgmental about weight gain. Assist client to compare her usual diet with the Food Guide Pyramid rec- ommendations for preg- nancy. Praise positive eating habits and digcuss the rela- tionship with optimal fetal growth and development. Assist client to plan a nutritious diet using the Food Guide Pyramid mod- ified for pregnancy taking into account personal and cultural preferences and financial ability (specify: diabetic, vegetarian, kosher, etc. ). Teach client to avoid high- ly processed foods or those with many artificial addi- tives (clients with PKU need to avoid phenylala- nine). Reinforce need for prenatal vitamins and iron if pre- scribed. Assessment provides infor- mation about general nutrition status. Skin should be smooth and elastic, hair shiny, nails smooth, pink, and not brittle. Assessment provides infor- mation about weight gain and the pattern of gain. Shows respect for client and helps allay fears related to weight gain. Involving the client in assessment and planning encourages compliance. Praise reinforces healthy eating. Understanding the fetal needs provides incen- tive for obtaining opti- mum nutrition. Promotes compliance by recognizing individual variations and includes client in planning. Unprocessed, natural foods contain the most nutrients. Additives may adversely affect the fetus (high phenylalanine levels may cause mental retardation in the fetus of PKU moms). Provides additional nutri- ents that may be dificult to obtain by diet alone.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 9 INTERVENTIONS RATIONALES Reinforce positive nutri-Reinforcement motintes tion habits at each prenatal visit. healthy diet during preg-the client to maintain a nancy. Referral provides addition- al information and support for clients with special dietary needs. Refer to dietitian, as need- ed (e. g., diabetes mellitus, strict vegetarian). Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client report eating a balanced diet based on the Food Guide Pyramid modified for preg- nancy?) (Does client take prenatal vitamins and iron as prescribed?) (What is client weight gain? ) (Revisions to care plan? D/C? Continue?) Injury, Risk for: Muterna UFetal Related to: Exposure to teratogens, complications of pregnancy. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client and her fetus will not experience any injury during pregnancy. Outcome Criteria Client denies any exposure to teratogens. Client denies experiencing any danger signs of pregnancy. Client's B/P remains c 140/90, reflexes same as baseline (specify), urine negative for protein. FHT's remain between 120-160; growth is appro- priate for EGA. INTERVENTIONS RATIONALES Assess maternal risk for exposure to teratogens (at first prenatal visit): envi- ronmental toxins, medica- tionsldrugs, employment, or pets. Assess wt gain, BIP, reflex- es, edema; dip urine for protein and glucose (at each visit) and compare to baseline data. Assess immunity to rubella (history, immunization): Assess fetal well-being at each visit. Ask about fetal movement, listen to FHT for a full minute, measure fundal height, and com- pare to EGA. Perform, or assist with, other fetal assessments as indicated or ordered (spec- ify: CVS, amniocentesis, NST, ultrasound, CST, biophysical profile, etc. ). Teach client to avoid expo- sure to terarogens during pregnancy: medicationddrugs not pre- scribed by the physician, including OTC meds; radiation (including x- rays); cat litter or raw meat; viral infections Assessment provides infor- mation about client risk factors. The fetus is at highest risk from terato- gens during the first 12 weeks when organogenesis takes place. Signs & symptoms of PIH include an increase in BIP of 30/1 Smm Hg or more, sudden $in wt, edema, and proteinuria. Gestational diabetes may cause consistent glycosuria; rubella is a known (eratogen. Complications of pregnan- cy may affect the fetus by interfering with placental function. The stressed fetus may have 4 move- ments or & fundal height. Size-dates discrepancies may indicate IUGR. Testing provides informa- tion about fetus. The fetus may exhibit signs of dis- tress such as decreased FHR variability or late decelerations. Client may be unaware of risks associated with com- monplace exposures. Provides needed inforrna- tion to help prevent harm to the feerus.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

10 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES (rubella); prolonged expo- sure to heat (hot tubs, saunas); alcohol. Teach good body mechan- ics and appropriate exer- cise: not to lie flat on back; wear sensible shoes; keep back straight and feet apart when bendingllifting; usually may engage in nonweight-bearing exer- cises (e. g., swimming, cycling, walking); avoid over-heating. Teach client to wear both lap and shoulder seat belts; lap belt should be worn low. Discuss safe sex practices with client and significant other if available (e. g., risks af STD/HIV, proper use of condoms); address any concerns the couple may have about sex during pregnancy. Teach good hygiene prac- tices: hand washing, wip- ing front to back after using the toilet, daily bathing. Teach warning signs that client should report: severe nausea and vomiting, s/s of infection, vaginal bleed- inglwatery discharge, severe headache, visual dis- turbances, epigastric pain, severe abdominal pain, s/s of preterm labor, marked changes in fetal move- ment. Avoids maternal or fetal injury while allowing the client to continue to par- ticipate in appropriate exercise during pregnancy. The mother and fetus are at highest risk of injury from being thrown from the car in an accident. Client may not know how to protect herself and the fetus. Client and signifi- cant other may have con- cerns about sexuality dur- ing pregnancy. Good hygiene prevents the spread of microorganisms, prevents fecal contamina- tion of vagindurethra. These are sls of serious complications of pregnan- cy: hyperemesis gravi- darum, placenta previa, placental abruption, pregnancy-induced hyper-tension, PROM, preterm labor, fetal distress. Early identification ensures prompt treatment. Provide written reinforce-Written reinforcement ment of teaching topics and verify understanding. enables client to review teaching at home. Verification allows for clar- ification and ensures understanding. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client deny any warning signs?) (What is B/P? reflexes? urine protein?) mat are FHT's? Is fetal growth appropriate for EGA? ) (Revisions to Care Plan? D/C? Continue?) Pain (discomfort) Related to: Physiologic changes of pregnancy. Defining Characteristics: Specify: (client's report of nausea & vomiting, backache, leg cramps etc. Client should rate on a scale of 1 to 10. Appropriate objective data: grimacing, etc. ). Goal: Client will experience less discomfort relat- ed to pregnancy (datejtime goal to be evaluated). Outcome Criteria Client reports a decrease in discomfort to less than (specify on a scale of 1 to 10). Client does not show objective signs of discomfort (grimacing, etc; specify what client had been indi- cating).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 11 INTERVENTIONS RATIONALES Assess client for discomfort at each prenatal visit. Observe for nonverbal signs such as grimacing, guarding, etc. Ask client if she has any discomfort. Ask client to rate the dis- comfort on a scale of 1 to 10 with 1 being the least and 10 the most. Assess what the client usu- ally does to alleviate the discomfort and how effec- tive that has been. Explain the physiologic basis for each discomfort the client identifies and suggest possible interven- tions for each discomfort. Specify: (Nausea and vomiting: Eat frequent small meals, dry carbohydrates or hard candy before rising in the morning. ) (Fatigdfainting: Teach client to obtain 7-8 hours of sleep at night and plan for a rest or nap during the day. Teach to rise slowly when changing position and if she feels faint to sit and lower her head. ) (Urinary frequency: Teach client to void frequently, not to “hold it. ” Teach Kegel exercises and Client may think discom- fort is normal during preg- nancy, or may not wish to complain. Some cultures do not approve of showing discomfort. A rating scale helps the nurse to measure the effec- tiveness of interventions. Provides information about the methods already tried by the client to allevi- ate discomfort. Understanding the physio- logic basis helps to allay fear, an emotion that may increase the discomfort. Keeping the stomach nei- ther empty nor too full and avoiding greasy or highly spiced foods may help. N&V may be related to high h CG levels in early pregnancy; this usually improves by the second trimester. Fatigue may be due to hor- mone changes in first trimester and f demands during last trimester. Postural hypotension may be related to venous pool- ing in the lower extremi- ties from general vascular relaxation. May be caused by pressure on the bladder from the enlarging uterus-more common during first and INTERVENTIONS RATIONALES signslsymptoms of UTI to report: pain, burning, and urgency in addition to fre- quency. ) (Vaginal discharge (leukor- rhea): Assess for infection, STD's; teach client to wear cotton underwear and bathe daily. May wear peri pad if changed frequently. ) (Leg cramps: Assess calci- um intake. Teach client to extend her leg and dorsi- flex the foot of the affected leg to relieve cramp. ) (Heart burn (gastroe- sophageal reflux): Teach client to eat small frequent meals, avoid fatty foods and flat positioning. Instruct to take antacids as prescribed [specify: e. g., Maalox]. ) (Varicose veins: Teach client to change positions frequently, rest with legs elevated, engage in regular exercise and wear support hose without garters. ) (Backache: Needs to be differentiated from preterm labor. Assess for contractions; teach good body mechanics and pelvic rock exercise. Teach client to wear low sturdy shoes and rest with feet elevated. ) (Braxton-Hicks contrac- tions: Teach client to dif- ferentiate from labor: usu-last trimesters. UTI's may cause preterm labor and need to be identified and treated early. Hyperplasia and f vaginal and cervical secretions are the result of hormone changes. Good hygiene may prevent infection. Cramps may be related to possible calcium imbalance or uterine pressure. Progesterone causes J motility and relaxes the cardiac sphincter. Increased uterine pressure causes gas- troesophageal reflux. Antacids neutralize gastric acid. Decreased peripheral vas- cular resistance, f blood volume, and uterine pres- sure may cause venous sta- sis leading to f varicose veins and risk for throm- bus formation. Preterm labor is often felt as lower back pain. In the third trimester the center of gravity shifts which puts added stress on lower back muscles. The uterus contracts throughout pregnancy. Labor contractions usually

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

12 MATERNAL-INFANT NURSING CARE PLANS ~~~ INTERVENTIONS RATIONALES ally painless, don't I' in intensity over time, may decrease if activity changes (walking or resting). Suggest client practice breathing techniques with B-H contractions. Hicks contractions. Notify caregiver for unusual symptoms or severe discomfort. plication. I' over time, becoming more uncomfortable no matter what the client does. Client may feel reas- sured about labor if she practices with Braxton- Unusual or severe discom- fort may indicate a com- Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What does client report the intensity of discom- fort to be on a scale of 1 to lo?) (Describe objective signs of discomfort or change in them [e. g., client is smiling and no longer gri- macing?]) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 13 Basic Care Plan: Prenatal Home Visit Prenatal home visits provide information about the client's home environment and family support system. Additional benefits are client convenience and comfort, which facilitate learning. Nursing Care Plans Basic Care Plan: Healthy Pregnancy (7) Additional Diagnoses and Care Plans Home Maintenance Management: Impaired Related to: (Specify: inadequate finances, lack of understanding, insufficient support systems, etc. ) Defining Characteristics: Specify: (C1' lent states she can't maintain the home-home is dirty, infested, overcrowded, etc. Home has no plumb- ing, heat, window screens, etc. Client states she can't afford basic hygiene needs; has inadequate support systems to help with finances and mainte- nance, etc. ). Goal: Client will maintain a safe, clean, and growth-promoting home environment by (datehime to evaluate). Outcome Criteria Client will identify hygienic needs in the home (specify). Client will obtain financial assistance to maintain home (specify). Client will develop a plan to improve home main- tenance support system (specify). INTERVENTIONS RATIONALES Assess client's understand- ing of the need for a clean, safe, growth-promoting environment for herself and her family. Assess home environment for water supply, plumb- ing, air quality, heating, screens, cleanliness, food preparation area, and bathing facilities. Assess client's plans for newborn care area (sepa- rate room, area of other room, crib, bassinet, etc. ). Assist client to identify needed changes in the home (specify: safety issues, cleanliness, basic services, etc. ). Provide teaching about factors the client doesn't identify (specify). Inform client of communi- ty services and agencies that may offer support in meeting basic home main- tenance needs (specifl). Assist the client to develop a plan to improve and maintain a clean, safe, and growth-promoting home (specify). Make r Fferrals as needed to help client implement plan (specify: Social services, WIC, community agen- cies, etc. ). Assessment provides infor- mation about the client's understanding of basic home maintenance needs. Assessment provides infor- mation about the safety and cleanliness of the home environment for the client and family. Assessment provides infor- mation about the client's knowledge of infant needs and her plans to meet them. Process involves the client in the plan to improve home maintenance. Provides information about basic home mainte- nance needs. Teaching provides infor- mation about available resources. Assistance promotes self- esteem and encourages the client to maintain a healthy environment. Referrals provide addition- al financial or resource assistance to client.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

14 MATERNALINFANT NURSING CARE PLANS Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Has client identified hygienic needs? Specify. ) (Has client obtained financial assistance? Specify. ) (Has client developed a plan to improve support systems? Specify. ) (Revisions to care plan? D/C'care plan? Continue care plan?) Family Coping: Potential for Growth Related to: Family adaptation and preparation for birth of new member of family. Defining Characteristics: Family members describe impact of pregnancy in enhancing growth (speci G: e. g., sibling states “I'm going to be a big brother and help take care of the baby!” etc. ). Family members are involved in prenatal visits and preparations for baby (specify: e. g., husband attends childbirth classes, Grandma plans to baby- sit, etc. ). Goal: Family will continue to cope effectively dur- ing pregnancy by (date/time to evaluate). Outcome Criteria Family will express positive feelings about the pregnancy. Family will be involved in prenatal care and prepa- rations for the new baby (other specifics as appro- priate). INTERVENTXONS RATIONALES Assess family structure and encourage participation in nontraditional family. home visit as appropriate (specify according to ages of children). Client may be part of a Participation during the prenatal period helps the family to bond with the new baby. INTERVENTIONS RATIONALES Assess family members' responses to the pregnan- cy: verbal and nonverbal. Provide information about changes the family may experience due to the preg- nancy and birth (specify for each family member). Provide age-appropriate (specify) information to siblings of new baby: pic- ture~, books, stories, etc. Identify and praise effec- tive coping mechanisms used by the family (speci- fy) * Refer family members to appropriate childbirth edu- cation classes (specify: sib- ling, grandparent, and VBAC classes, etc. ). Family members may need assistance to identify feel- ings and thoughts about the new baby. Information provides anticipatory guidance to help the family adjust to changes they will experi- ence. Enhances the child's self- esteem to be included in the home visit with age- appropriate methods. Identification and praise provides positive reinforce- ment to the family and helps identify skills they already possess. Childbirth education pro- vides additional informa- tion about the childbear- ing process for different age groups. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does family express positive feelings about the pregnancy?) (Is family involved in prenatal care and prepara- tions for the new baby?) (Revisions to care plan? D/C care plan? Continue care plan?) Knowledge D. f;cit: Preparation for Labor and Birth of Newborn Related to: (Specify: first pregnancy, first VBAC, etc. )

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PREGNANCY 15 Defining Characteristics: Client expresses a lack of knowledge about preparing for labor and birth of newborn (specify). Client expresses erroneous ideas about labor and birth of newborn (specify). Goal: Client will obtain knowledge about prepara- tion for labor and birth of newborn (date/time to evaluate). Outcome Criteria Client is able to describe what happens during normal labor and vaginal delivery. Client & significant other prepare a birth plan. INTERVENTIONS RATIONALES Assess client and signifi- cant other's perceptions about what happens dur- ing childbirth. Teach client & significant other about the stages and phases of labor using visual aids: 1st stage: contrac- tions, effacement & dilata- tion, 3 phases (latent, active, transition); 2nd stage: contractions, push- ing, birth; 3rd stage: con- tractions, placenta delivery. Teach client & significant other to differentiate true from false labor: true labor contractions get more intense and closer together over time, are unaffected by position or activity changes. Assessment provides infor- mation about the client's learning needs and possible fears. Understanding the physi- ology of labor and birth decreases fear and inter- rupts the fear +tension + pain syndrome. Decreases the perception of discom- fort and assists the client and significant other to become active participants in the birth. Visual aids enhance verbal and written instruction. Teaching provides needed information about when labor has begun. INTERVENTIONS RATIONALES Inform client when to come to hospital: when her water breaks, when con- tractions are 5 minutes apart for primigravida or regular for a multipara (per caregiver's preference). Teach methods to cope with discomfort (specifjr: breathing relaxation tech- niques, back rub, whirlpool, birthing ball, etc. ). Describe specific pharma- cological pain relief meth- ods that may be available to client (specifjr: IV and- gesia, epidural, intrathecal, local, etc. ). Inform client and signifi- cant other of the routine admission orders for her health care provider (speci- fjr: prep, enema, Iv, blood work, etc. ). Inform client and signifi- cant other that they will need to make decisions at the time of delivery: whether or not to have cir- cumcision for a boy baby, and on a method of feed- ing their baby (breast, bot- tle, and combination). Discuss the benefits of breast-feeding. Verify client and signifi- cant other's understanding of information presented. Provides necessary infor- mation. Clients should be seen after membranes rup- ture to r/o a prolapsed cord. Clients will be more comfortable at home until active labor. Teaching provides infor- mation so client & signifi- cant other can choose the most effective methods to cope with discomfort. Description provides infor- mation to the client before she is in pain. This allows client participation in deci- sion making for pain relief methods prior to onset of labor. Information about what to expect when client is admitted to the hospital helps decrease anxiety. Information provides an opportunity for anticipato- ry guidance related to con- siderations about circumci- sion and the benefits of breast-feeding. Verification insures that client & significant other have accurate information about labor and birth.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

16 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Assist client and significant other to make a birth plan based on the information provided. Instruct the client to share the plan with her provider and the hospital staff on admission (send plan to L&D prior to admission if very differ- ent from routine care). Refer client to written information, childbirth information to interested education classes, and/or clients. her health care provider as indicated for additional A birth plan empowers the client to become a partici- pant in the birth of her baby. It ensures that all participants understand the client's wishes. Referral provides more Evaluation Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client describe what occurs during normal labor and delivery?) (Has client made a birth plan?) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 17 Adolescent Pregnancy The pregnant teenager is at risk for physical, psy- chological, and socioeconomic complications. Early prenatal care that is sensitive to the needs of adolescents can decrease these risks and help the adolescent gain control of her future. Physiologic Risks Poor dietary habits, anemia, substance abuse (including cigarettes), STD's Preterm birth, low birth-weight (LBW) infant Pregnancy-induced hypertension (PIH) Cephalopelvic disproportion (CPD) leading to cesarean delivery (greater risk if under 15 years old) Psychological Issues Striving for identity formation and indepen- dence; authority figures may be seen as a threat to autonomy-may have dificulty asking for help Concerned about confidentiality-may use denial as a major coping mechanism Strong peer influence-may fear isolation and rejection; pregnancy may be seen as a “rite of passage” or cultural norm Concerned with body image: often idealistic regarding pregnancy, relationships, and mother- hood; preoccupied with self May engage in risk-taking behaviors; feels invul- nerable; may be impulsive and unpredictable at times Lack of education leads to decreased career options, low-paying jobs, poverty and depen- dence on the welfare system High divorce rates for adolescent marriages reflect their difficulty in establishing stable fam- ilies; the grandmother may end up caring for the infant Children of adolescent mothers are at risk for developmental delays, neglect, and child abuse as well as adolescent pregnancy themselves Nursing Care Plans Basic Care PLan: Healthy Pregnancy (7) Basic Care Plan: Prenatal Home visit (13) Additional Diaanoses and Care Deci. $ional Conflict Related to: Pregnancy options (specify: marriage, single parenting, adoption, termination of preg- nancy). Defining Characteristics: Client verbalizes uncer- tainty about choices; delays decision making; reports distress (specify: e. g., “I don't know what to do,” “My Dad is gonna kill me”; client doesn't seek prenatal care until second trimester, etc. ). Goal: Client will be able to make an informed decision about pregnancy by (date/rime to evalu- ate). Outcome Criteria Client will list her options as she sees them. Client Socioeconomic Issues Many adolescent mothers drop out of school and never complete their basic education will describe the advantages and disadvantages of each option. Client will relate her fears and anxi- eties about each option. Client will make and fol- low through with a decision.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

18 MATERNAL-INFANT NURSING CARE PLANS INTER~NTIONS RATIONALES Assess client's usual method of making deci- sions (e. g., alone, with help from friends andlor parents, etc. ). Ask client to describe deci- sions she has made in the past that she feels good about. Assess the reason the client is having difficulty making a decision: fear of parent or boyfriend's response, value conflict, lack of information about options. Encourage client to involve her significant others spec- ify: parents, boyfriend, etc. ) in helping her to explore options. Assist client to explore her values about pregnancy and to identie those that are most important to her; remain nonj udgmental. Assist client to list the pos- sible choices she thinks she has (specie: keeping the baby, marriage, living at home, adoption, termina- tion of pregnancy, etc. ). For each option, ask client to explore her fears and anxieties as well as the risks of not making a deci- sion. Assist client to list advan- tages and disadvantages of each option. Provide accu- rate information as needed Assessment helps client to explore how she usually makes major decisions. Intervention shows respect for client as someone capa- ble of making decisions. Assessment reinforces self- esteem and the belief that she can make good deci- sions. Client may feel confused and afraid. Identifying the main concerns helps the client begin to begin the decision-making process. Social support can posi- tively affect the outcome of adolescent pregnancy. Individual, social, and cul- tural values and mores are important to the adoles- cent's growing sense of her own identity. Listing options is the first step in logical decision making. Only the client can decide which options are possible for her. Fears and anxieties may negatively affect the client's ability to think clearly. Denial is a common cop- ing mechanism. Exploring advantages and disadvantages based on accurate information helps the client to see which INTERVENTIONS RATIONALES (e. g., open and closed adoption, education options, GED, abortion, come. etc. ). Encourage and or assist client to seek spiritual advice if this is important to her. Refer to agencies as indicated (teen pregnancy groups, etc. ). Encourage client to make a decision regarding preg- nancy as soon as possible. options are most likely to result in a positive out- Client may have a strong need for spiritual advice and direction. Encouragement reinforces the client's right to make her own decisions. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Has client listed her options? Has client described advantages and disadvantages of each option? Has client related her fears and anxieties? Has client made a decision and is she following through?) (Revisions to care plan? D/C care plan? Continue care plan?) Health Maintenance, Altered Related to: Substance abuse (specify: tobacco, alcohol, marijuana, etc. ); poor dietary habits (specify: high fat diet, inadequate nutrients, etc. ); lack of understanding (specify: sexuality/reproduc- tive health care needs). Defining Characteristics: Client reports smoking cigarettes (specify packdday), drinking, or using other drugs (specify substance and amount). Client reports poor dietary habits (specify f' fat diet, skips meals, drinks soda instead of milk, etc). Client states inaccurate information about sexuali- ty/reproductive needs (specify: e. g., “I don't need

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 19 to see a doctor, I feel fine”). Goal: Client will change behaviors to maintain health by (date/time to evaluate). Outcome Criteria Client will identify unhealthy behaviors. Client will verbalize plan to engage in healthy behaviors (specify: stop smoking, avoid alcohol and other drugs, eat a balanced diet for pregnancy, obtain prenatal care, etc. ). INTERVENTIONS RATIONALES Develop a trusting rela- tionship with client. Remain nonjudgmental. Assess underlying reasons for unhealthy behaviors (consider poor self-esteem, history of abuse, etc. ). Discuss the physiologic risks associated with the behaviors (specify: anemia, preterm birth, LBW or addicted infant, fetal alco- hol syndrome, complica- tions of pregnancy associ- ated with adolescent moth- ers: PIH, CPD, STD's, etc. ). Assist client to plan healthy behaviors (specify: quit smoking, change dietary habits, obtain pre- natal care, etc. ). Praise client for planning and attempts to change behaviors. Trust is necessary for the client to talk about behav- iors that may make her feel guilty. Assessment provides infor- mation about motivation for unhealthy behaviors (may lack knowledge, poverty, addiction, peer pressure, cultural norms, etc. ). Client will be informed of the risks to herself and her baby if she doesn't improve her health maintenance behaviors. Early prenatal care has been shown to decrease the physiologic risks. Client will identify the problem and decide on a plan for change. Praise may reinforce attempts to alter behavior. INTERVENTIONS RATIONALES Assist client to obtain needed resources (specify: WIC, AFDC, social ser- vices etc. ). Poverty may be a factor in poor dietary habits. Lack of transportation may affect ability to obtain pre- natal care. Support programs have been successful in helping clients to overcome addic- tion and maintain healthy lifestyles. Peer groups and resource mothers programs are effective with adoles- cents. Refer client to appropriate supportive services (specify: smoking cessation program, substance abuse programs, 12-step, peer support groups, resource mothers programs, etc. ). Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Has client identified unhealthy behaviors? Specify. ) (Does client verbalize a plan to change unhealthy behaviors? Specify) (Revisions to care plan? D/C care plan? Continue care plan?) Growth and Development, Altered Related to: Physical changes of pregnancy, inter- ruption of the normal psychosocial development of adolescence. Defining Characteristics: Clients younger than 15 have not completed their own skeletal growth (specify: age, ht, wt, and percentile). Client expresses dislike of body image changes (specify). Client reports difficulty in school, with peers, or parent(s) related to the pregnancy and/or plans for the future (specify). Goal: Client will demonstrate adequate growth and age-appropriate psychosocial development

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

20 MATERNALINFANT NURSING CARE PLANS while accomplishing the developmental tasks of pregnancy. Outcome Criteria Client will gain appropriate weight for pregnancy and normal physical growth. Client will make plans to complete at least a high school education. Client reports satisfactory relationship with par- ent(s), significant other, and peers. Client will express acceptance of pregnancy and body changes. INTERVENTIONS RATIONALES Assess client's physical growth at each prenatal visit. Reinforce nutrition teach- ing relating it to the client's growth needs as well as the fetus. Assess the impact of preg- nancy on client's education and future plans for a career. Discuss body image issues and correct misconcep- tions (e. g., “I'll never wear a bikini again”). Encourage client to finish basic schooling and make realistic plans for the future including childcare. Assist client to assess rela- tionships with parent(s), significant other, and peers, and plan ways to improve these if needed. Teach client about the developmental tasks of adolescence (Erikson) and the tasks of pregnancy Assessment provides infor- mation about physical growth. Young adolescents may need more nutrients and calories than usual during pregnancy. Teen pregnancy may adversely affect the devel- opment of a mature identi- ty. The adolescent may fear mutilation or permanent disfigurement from preg- nancy. Lack of education leading to low income becomes a vicious cycle for many teen mothers. Pregnancy may affect rela- tionships. Teens need social interaction in order to develop identity and independence. Teaching may decrease some confusion from con- flicting feelings and desires. INTERVENTIONS RATIONALES Make referrals as indicated (specify: school counselor, social services and financial assistance, home-tutors, member of society. etc. ). Social support will assist the client to become a mature and productive Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Has client gained appropriate weight for preg- nancy and normal growth? Speci+. Does client verbalize a plan to complete her education? Specifjr. Does client report satisfactory relation- ships? Speci@. Does client verbalize acceptance of pregnancy and body changes? Give quote if possible. ) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 21 Multiple Gestation The incidence of multi-fetal pregnancies is increasing due to use of drugs that induce ovula- tion and other infertility technologies such as in vitro fertilization (IVF). The fetuses may either be monozygotic (identical) resulting from one ovum that divides, or dizygotic (fraternal) where more than one ovum is released and fertilized. This can be determined by exami- nation of the placenta(s) and membranes or DNA studies after birth. Monozygotic twins are at greater risk for discordancy (twin-to-twin transfu- sion) and cord entanglement. Physiologic Risks Spontaneous abortion, malformations Preterm birth, LBW Abnormal growth: discordancy, IUGR Increased incidence of PIH Maternal anemia, PP hemorrhage Placenta and cord accidents Abnormal fetal presentation Medical Care Close observation: prenatal visits q 2 weeks until 26 weeks, then weekly. Serial (monthly) ultrasounds to assess growth of each fetus and try to determine if monozygotic or dizygotic fetuses.-NST, BPP, possibly doppler flow studies and amniocentesis to determine L/S ratios. More frequent vaginal exams to rule out preterm effacement and dilatation of cervix. Bed rest may be prescribed from 28-30 weeks (or if cervical changes are noted) until birth. Cesarean birth is planned for about 50% of twin pregnancies, and for almost all with greater numbers of babies due to abnormal pre- sentations. Nursing Care Plans Basic Care Plan: Healthy Pregnancy (7) Increase calorie intake by 300 kcal per fetus per day. (Twin pregnancy should gain 40-45 pounds. ) Basic Care Plan: Prenatal Home Visit (13) Knowledge Deficit: Pretemn Labor Prevention (74) Related to: Inexperience with multiple gestation pregnancy. Defining Characteristics: Client has not experi- enced preterm labor before, is unaware of sensa- tions of PTL. Client is at increased risk for preterm birth: multiple gestation (specify: twins, triplets, etc. ). Impaired Gas Exchange, Risk for: Fetal Related to: Decreased oxygen supply secondary to complications of multiple gestation (specify: (82) ~~ * Increased iron (60-100 mg) and folic acid (1 monozygotic multiple pregnancy, cord entangle- ment, placental insufficiency, twin-to-twin trans- fusion, etc. ). mg) is usually prescribed. Maternal hemoglobin may be checked each trimester. Tests for fetal well-being beginning at 30 weeks

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

22 MATERNALINFANT NURSING CARE PLANS Additional Dlagnoses and Care Anxiety Related to: Fears for well-being of mother and fetus secondary to complicated pregnancy. Defining Characteristics: Client verbalizes anxiety about pregnancy outcome (specify: feels physically threatened, afraid babies will die, can't sleep, etc. ). Client rates anxiety as a (specify) on a scale of 1 to 10 with 1 being no anxiety and 10 being the most. Goal: Client will demonstrate a J( in anxiety by (date and time to evaluate). Outcome Criteria Client will rate anxiety as a (specify) or less on a scale of 1 to 10 with 1 being least, 10 most. Client will appear calm (specify: not crying, no tremors, HR e 100, etc. ). INTERVENTIONS RATIONALES Assess for physical signs of anxiety: tremors, palpita- tions, tachycardia, dry mouth, nausea, or diaphoresis. of anxiety. Assess for mental and emotional signs of anxiety at each visit: nervousness, crying, difficulty with con- centration or memory, etc. Ask client to rate anxiety on a scale of 1 to 10 with 1 being calm and 10 very anxious. Anxiety may cause the “fight or flight” sympathet- ic response. Some cultures prohibit verbal expression Anxiety may interfere with normal mental and emo- tional functioning. Rating allows measure- ment of anxiety level and changes. INTERVENTIONS RATIONALE3 sion, and use touch (if cul- turally appropriate). Ask client how she usually copes with anxiety and dis- cuss if this would be help- ful now. Encourage client to involve significant other(s) in attempts to identify and cope with anxiety. When client is calmer, val- idate concerns and provide client with factual infor- mation about complica- tions of pregnancy and what will be done to lessen the risks (specify: NST, BPP, bedrest, perinatolo- gist, etc. ). Assist client to plan coping strategies for anxiety dur- ing pregnancy. Suggest the following possibilities: breathing and relaxation, creative imagery, music, biofeedback, talking to self, etc. (suggest others). Arrange a tour of the NICU if appropriate. Prepare client and signifi- cant other for what they will see and hear in the unit. Provide information about counseling or support groups as appropriate (specify: groups for parents of multiple gestation, con- genital anomalies, etc. ). These measures may help 4 anxiety levels. Allows identification of adaptive coping mecha- nisms v. maladaptive (e. g. smoking, alcohol, etc). Significant others are also under stress during com- plicated pregnancy. Client may be overly fear ful. Understanding empowers the client to participate in her own cai by understanding the risk and treatment options th, may be offered. Developing a plan to address anxiety promotes sense of control, which enhances coping ability. Familiarity decreases fear of the unknown. Preparation decreases anx ety. Severe anxiety may requi I individual counseling. Support groups provide reassurance and coping strategies. Provide reassurance and support: acknowledge anx- iety, allow time for discus-Severe anxiety may inter- fere with the client's ability to take in information.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 23 Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (How does client rate her anxiety as now? Does client appear calm? Specify: not crying, smiling, pulse 72, etc. ) (Revisions. to care plan? D/C care plan? Continue care plan?) Activity Intolerance Related to: Prescribed bedrest during pregnancy. Defining Characteristics: Client reports (specify: weakness, fatigue, difficulty concentrating, etc. ). Client is physically de-conditioned (specify: has lost weight, short of breath, weak pulse, etc. ). Client reports psychological symptoms (specify: boredom, depression, etc. ). Goal: Client will experience minimal negative effects from enforced bedrest during pregnancy by (datehime to evaluate). Outcome Criteria Client will participate in exercises for bedrest as approved by her care provider. Client will identify 3 activities to combat bore- dom and depression during bedrest. INTERVENTIONS RATIONALES Plan time to spend with client (specify: e. g., 15 minutes q shift if hospital- ized), sit down, listen actively to client's con- cerns. Assess client's perception of the need for bedrest; correct any misunderstand- ings. Reinforce positive oucloo k. Clients report that caring and empathy from nurses is most helpful. Intervention assists client to comply with bedrest. Thinking about helping the baby helps the client to tolerate enforced bedrest. INTERVENTIONS RATIONALES Assess B/P, pulse, breath sounds, and muscle strength (specie time frame). Ask client how she feels physically (e. g., weak, tired, nauseated, s. o. b., etc. ). Assess client's perception of the main stresses of bed, rest (e. g., boredom, role strain, sleep disturbance, etc. ). Assist client to plan 3 activities she can do in bed to cope with the stresses (specify: reading, writing lists, phone calls, music, IT, needlework, etc. ). Teach client to eat 6 small meals a day, rather than 3 large ones. Include 8 glass- es of water a day, increase intake of fiber and fresh fruits and vegetables. Teach client to avoid lying flat on her back: side-lying or high fowlers [if permit- ted) are preferred. Collaborate with client's health provider to have a physiotherapist (PT) teach client exercises that can be done on bedrest. Review and reinforce exer- cises (specify when: e. g., at each visit). Share with caregiver recent research indicating that bedrest is not necessarily beneficial during compli- cated pregnancy. Bedrest results in 4 car- diac output, J, aerobic capacicy, muscle atrophy, 4 GI motility, and fluid and electrolyte changes. Isolation and confinement may lead to emotional and family conflict. Sleep dis- turbances are common as client naps during the day. Planning empowers the client to take control of her situation and plan individualized activities to cope with the stresses of bedrest. Decreased appetite, wt. loss, indigestion, heart- burn, and constipation are common with prolonged bedrest. Supine position may cause uterine compression of the inferior vena cava, which can lead to hypotension and fetal distress. Intervention provides safe exercise to 4 the ill effects of bedrest. Exercises need to be chosen that don't stimulate contractions. Review & reinforcement provide feedback to client about performing exercises correctly. Discussion promotes research-based practice. The nurse acts as a client advocate.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

24 MATERNAL-INFANT NURSING CARE PLANS Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client exercise as prescribed? Describe rou- tine, times, etc. ) (Which 3 activities has client identified to combat the boredom and depression of bedrest?) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 25 mpes of Wins Dizygotic 2 ova / OVm ATION 1 Monozygotic 1 ovum 00 FERTILIZATION 0 0 DMSION TIMING Within 72 hours of fertilization diamnionic, dichorionic 2 placentas (may be fused) -- &tween 4 and 8 days after fertilization diamnionic, monochorionic oneplacenta 0 8 days after fertilization monoamnionic, monochorionic one placenta @/ w @-- 14+ days after fertilization Conjoined twins (Siamese twins) monochorionic, monoamnionic one placenta- diamnionic, dichorionic 2 placentas (may be fused together to look like one) KEY chorion (outer membrane) amnion (inner membrane) placenta+ <-

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PREGNANCY 27 Hyperemesis gravidarum is a rare condition (1% of pregnancies) of severe nausea and vomiting which starts in the first 20 weeks of gestation. The vomiting results in weight loss, dehydration, aci- dosis from starvation, alkalosis from loss of hydrochloric acid, and electrolyte imbalances. The fetus is at risk for IUGR, abnormal development, and death if the condition is not treated. The cause of hyperemesis is unknown. Theories include psychological as well as physiological caus- es. It is diagnosed by its severity (weight loss > 5% of pre-pregnancy weight) and by ruling out other possible causes such as hydatidiform mole, gas- troenteritis, or pancreatitis. Fluid replacement with intravenous therapy: D5LR or D5NS with multivitamins and elec- trolytes Antiemetic drug therapy Possible nasogastic feeding once nausea has decreased, or TPN (total parented nutrition) may be necessary Possible psychiatric consult Nursing Care Plans Health Seeking Behauiors: Prenatal Care (7) Related to: Desire for a healthy pregnancy and newborn. Defining Characteristics: Client keeps all prenatal appointments. Client complies with plan of care for controlling hyperemesis gravidarum. Injury, Risk for: Materna QFetal(9) Related to: Excessive nausea and vomiting during pregnancy. Farnib Coping: Potential for Growth (14) Related to: Family adaptation and assistance with care of mother experiencing hyperemesis gravi- darum. Defining Characteristics: Family members share in household duties normally done by the client (specifjr). Family members assist the client to cope with excessive nausea and vomiting. Anxiety (22) Related to: Fears for maternal and fetal well- being. Defining Characteristics: Client and family express anxiety about fetal tolerance of excessive nausea and vomiting (specify). Client and family express fear for client's health (specify). Client rates anxiety on a scale of 1 to 10 (specify). Addl'tiional Diagnoses and Care Plans Fluid Volume De$cit Related to: Excessive losses and insufficient intake: nausea and vomiting. Defining Characteristics: Client reports nausea & vomiting (use quotes, indicate amounts). 9 serum sodium (other labs as available). Insufficient intake (describe amount/24 hours), weight loss (specify), dry mucous membranes, and 4 skin turgor. Goal: Client will demonstrate fluid balance by (date/time to evaluate).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

28 MATERNAL-INFANT NURSING CARE PLANS Outcome Criteria Client will have intake equal to output. Client's mucous membranes will be moist, skin turgor will be elastic. INTERVENTIONS RATIONALES Assess intake 8r output: measure all fluid intake (P. o., IV, NG, TPN, etc. ) and compare to all output (emesis, urine, NG aspi- rate, diaphoresis, etc. ). (Specify timing: e. g., q 1-24 hours depending on dehydration and fluid rates. ) Assess client's weight on same scale each morning. Assess for signs of dehydra- tion: poor skin turgor, dry mucous membranes and skin, 't urinespecific gravity, 't BUN, 't Hct, vital sign changes: 4 B/P, 't pulse (specify timing). Assess for signs of elec- trolyte imbalance: muscle weakness, cramps, irritabil- ity, irregular heart beat. Monitor electrolyte lab vd- ues. Initiate and maintain IV therapy as ordered (specify: fluids, rate, site, via pump, etc. ). Assess IV rate and site for redness, swelling, and ten- derness at each visit. Change tubing q 24 hours. (If client is on IV therapy Assessment provides infor- mation to determine posi- tive or negative fluid bd- ance. Normal adult intake equals output (usually about 2500 ml in and out in 24 hours). Weight changes provide information on severity of losses. Fluid moves out of the tis- sues to replace losses in the vascular space; urine and blood become concentrat- ed, circulating volume C, and heart rate 'f' to com- pensate. Potassium and magnesium are lost through prolonged vomiting. Potassium plays an important role in the myocardium. Provides fluid replacement until vomiting is under control (specify how fluid ordered will correct deficit). IV infiltration, or infection at the site are possible complications of IV thera- py. Clients may benefit from IV therapy at home. INTERVENTIONS RATIONALES at home, teach client and significant others to main- tain W, run pump, assess site, etc. ) Administer antiemetic medications as ordered (specify: drug, dose, route, and time). Monitor for side effects of medications (specify for each drug). Teach client about common or serious side effects to report. Suggest to client that lying down in a quiet room may relieve the nausea. Provide information about acupressure as a possible additional therapy. Provide support and teach- ing about the risks of dehydration to client and significant others. Evaluation (Specify action of pre- scribed drug related to nausea and vomiting. ) (Specify the problems with each side effect related to the drug and nursing diag- nosis. ) Client may need “permis- sion” to lie down frequent. l Y. Many women report a J, in nausea and vomiting with acupressure wrist bands. The client and significant others will need support t( cope with the demands of hyperemesis. (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Specify client's intake and output in cc'dtime frame. ) (Describe client's skin turgor and mucous mem- branes. ) (Revisions to care plan? D/C care plan? Continue care plan?) Nutrition, Altered Less Than Body Requirements Related to: Inability to ingest or absorb nutrients due to excessive vomiting.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

~~ PREGNANCY 29 Defining Characteristics: Client reports anorexia and vomiting and is unable to eat (specify amount of food client has been able to keep downhime). Client is not gaining appropriate weight or is los- ing weight (specify). Goal: Client will absorb sufficient nutrients for maternal needs and fetal growth by (datehime to evaluate). Outcome Criteria Client will ingest and absorb (specify caloric requirements for this client) kcallday. Client will gain appropriate weight (specify gain and time frame: e. g., 2-4 pounds in first trimester). INTERVENTIONS RATIONALES Assess weight and weight gain at each visit. Assess for physiologic signs of starvation: jaundice, bleeding from mucous membranes, or ketonuria at each visit. Once acute nausea has passed, begin oral intake as tolerated: clear liquids (broth, juices), potato chips, small meals of any desired foods q 2-3 hours. Suggest herbal teas such as ginger, mint, or chamomile. If client is to receive TPN, initiate and titrate accord- ing to physician's orders and nursing protocols (specify). Monitor blood glucose as ordered. Report levels over 120 mg/d L. Provides information about nutritional status. Deficiencies of vitamins C and B-complex, hypothrombinemia, and ketosis may result from insufficient nutrition. Many women report that they can't tolerate water, desire salty foods (chips have f' potassium, folic acid, and vitamin C than saltines), feel better if liq- uids aren't taken with meals. Ginger offers relief for some women; herbal teas may be soothing. TPN can be formulated to provide glucose, lipids, amino acids, electrolytes, minerals, and trace ele- ments. Hyperglycemia may be detrimental to the fetus. 1"I'EWENTIONS RATIONALES Monitor labs for triglyc- erides, cholesterol level & liver function. If client is to receive naso- gastric feedings, insert tube according to nursing pro- tocols. Ensure proper placement (add specifics), use pump. Initiate feedings of pre- scribed product (specify) at 50 cclhour and increase as client tolerates to 75 cclhr (specify amount to be givenlday as ordered). Teach client to maintain infusion if at home, teach to assess tube placement, may also teach to reinsert tube with assistance of sig- nificant others. Maintain strict I&O while on TPN or NG feedings. Refer client to Registered Dietitian and/or support groups as needed (specify). Excessive fats may cause maternal hyperlipidemia, 9 cholesterol. Proper placement of feed- ing tubes prevents aspira- tion of the feeding solu- tion. A pump ensures cor- rect rate with no boluses of glucose. Infusion rates should be adjusted according to the client's feelings of fullness. After client is comfortable, rate may be 'I' to provide specified amounts. Client may need feeding tube for days or weeks until nausea has stopped. Allows client to participate in her care. Provides information to avoid overload. Support groups may offer additional ideas, dietitian can help the client plan an optimum diet. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (List kcal/day that client is receiving. Compare with those needed for this client. ) (What is client's weight gain/loss? Is this appro- priate for goal?) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

30 MATERNAL-INFANT NURSING CARE PLANS Hyneremesis Grauidarum Theoretical Causes + h CG + estrogen psychiatric gastric dysrhythm Excessive Nausea & Vomiting Fluid 86 Electrolyte Dehydration Imb mce J 1 Acid-Base Hypovolemia Imbalance 1 T J, renal function V dysrhythmias J/ placental perfusion J. protein / Starvation J, \ vitamins 1 jaundice bleeding J/ fetal nutrition Fetus IUGR CNS malformation death

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 31 Threatened Abortion Vaginal bleeding during the first half of pregnancy is considered a sign of a threatened spontaneous abortion. About 20-25% of women will experi- ence some bleeding in early pregnancy. About half of these will eventually abort in a matter of days or even weeks. Uterine cramping andor low back pain often accompanies this bleeding. The other causes of early spotting or bleeding may be implantation of the trophoblast, cervical lesions, or polyps disturbed by exercise or intercourse. These conditions usually do not cause pain or cramping. Other serious causes of vaginal bleeding during the first trimester may be ectopic pregnancy or gestational trophoblastic disease. All pregnant women should be taught to report any vaginal bleeding to their health care provider. Medical Care Sterile speculum exam to rlo dilatation of the cervix (inevitable abortion) Bedrest with analgesia if needed Hgb and Hct if bleeding heavily, CBC, blood type and screen levels to assess if conceptus is alive Vaginal ultrasound, serum 13 h CG, progesterone Possible D&C if no living conceptus or missed abortion, followed by examination of the tissue for abnormalities Rh negative mothers who are not sensitized are given Rho Gam after an abortion Anxiety (22) Related to: Possible pregnancy loss. Defining Characteristics: Client verbalizes fears about pregnancy loss (specify). Client is (specify physical signs of anxiety e. g., crying, pale, tremors, etc. ). Fluid Volume Deficit, Risk for (66) Related to: Excessive losses: vaginal bleeding dur- ing pregnancy. Addilional Diagnoses and Care Plans Infiction, Risk For Related to: Internal site for organism invasion sec- ondary to vaginal bleeding during pregnancy. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience infectious process by (datehime to evaluate). Outcome Criteria Client will maintain (specify: oral, tympanic, etc. ) temperature < 100°F. Vaginal discharge will not be foul smelling. INTERVENTIONS RATIONALES Assess for signs of infec- tion (specify how often: e. g., q 4 hrs): temperature (route), pulse, B/P, odor of vaginal discharge, abdomi- nal tenderness. Wash hands thoroughly Effective handwashing with warm water, soap, and friction before and after providing client care. Teach client to wash her- Provides information about the signs of inflam- matory response and infectious processes. removes pathogenic organ- isms from the hands. Prevents transmission of microorganisms.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

32 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES hands before and after using the bathroom, changing peri pads, and before eating, etc. Monitor lab values as obtained: CBC, cultures, etc. Notify caregiver of any abnormal values. Wear clean gloves when changing peri pads for client. Teach client to change peri pad frequently (specify: at least q 2h or when soiled). Teach client to wipe and dean perineum from front to back. Administer antibiotics as ordered (specify: drug, dose, route, times for each drug). Monitor for side effects of each drug (speci- fy). Teach client to always take whole course of antibiotics as prescribed (specify). Teach client signs of infec- tion to report: fever, abdominal tenderness, foul vaginal discharge. Allows early identification of infectious processes and allows prompt treatment. Protects client and nurse from cross-contamination. Decreases dark moist envi- ronment, which enhances growth of microorganisms. Prevents contamination of vagina with fecal microor- ganisms. (Specify action of each antibiotic: e. g., destroys bacterial cell walls. ) Teaching prevents develop- ment of antibiotic resistant bacteria. Provides information the client needs to identify infections early. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's temp? Is vaginal discharge foul smelling?) (Revisions to care plan? D/C care plan? Continue care plan?) Grieving, Anticipatory Related to: Threatened abortion, potential for infant with congenital anomalies (specify). Defining Characteristics: Client and significant other report perceived loss (specify quotes: e. g., “I think I'm going to have a miscarriage,” “We're afraid the baby will be damaged,” etc. ). God: Client and significant other will begin the grieving process. Outcome Criteria Client and significant other identify the meaning of the possible loss to them. Client and significant other are able to express their grief in culturally appropriate ways (specify). INTERVENTIONS RATIONALES Assess the client and sig- nificant other's beliefs about the likelihood of perceived loss. Provide accurate informa- tion (specify: percentages of miscarriage with current condition, viability with these diagnoses, congenital anomalies, etc. ). Assist client and significant other to describe what the perceived loss means to them. Don't offer interpre- tations such as “You can always have another baby,” etc. Allow and support the client and significant other's cultural expressions of grieving (specify: anger, crying, screaming, tearing of clothes, etc. ). Assessment provides infor- mation and allows clarifi- cation. Client and significant other may be overly anx- ious due to being unin- formed about current con- dition or may not realize how serious the situation is. With an early abortion, the client may feel relieved or devastated. Identifying the meaning of this loss for themselves helps to begin the grief process. Different cultures express grief in different ways- the nurse needs to allow and facilitate grief work without being judgmental.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 33 INTERVENTIONS RATIONALES Teach client and signifi- cant other about the nor- mal grief process & stages and what they may experi- ence. Provide written materials if literate. Support client and signifi- cant other in the stage they are in and assist with reali- ty-orientation (specify: “I can see that you are angry, this is a normal way to feel,” or “I can see that you are still hoping things will turn out OK, I am hoping so too”). Allow visitors as client wishes. Explain to client that seda- tion may delay grief work. Ask client and family if there are cultural traditions that they would like to observe. Facilitate as need- ed. Offer to contact the client's clergy or the hospi- tal chaplain if indicated. Knowing that depression, insomnia, crying, and anger are normal reactions will help the family to cope with these feelings. Assists the client and sig- nificant other to work through the process with- out feeling disapproval. Presents reality. Anger may be turned on staff who need to recognize that this is normal. Client advocacy: may wish no visitors or a large sup- port group. Sedation may cloud the events with which the client must cope. Provides information and support for the cultural needs of the family. Religious support may be helpful to some clients. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What do client and significant other describe as the meaning of the possible loss? Use quotes. Describe grief reactions the client and significant other express: crying, anger, being stoic, etc. Relate to culture as indicated. ) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

34 MATERNAL-INFANT NURSING CARE PLANS Missed Abortion death of the conceptous \ without expulsion Complete Abortion expulsion of the complete products of conception; Causes 1st trimester: abnormal development (50%) 2nd trimester: maternal infection, chronic diseases, endocrine defects, autoimmune (antiphospholipid antibodies, HLA) incompetent cervix, uterine defects, environmental toxins Threatened Abortion

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 35 Infect ion Pregnant women are at increased risk of infection due to the hormonal and immune changes that support pregnancy. Infection may affect the fetus by crossing the placenta or ascending the vagina. During the first trimester, infections may result in spontaneous abortion or fetal developmental defects. Later, infections may cause preterm birth, CNS defects, or neonatal infection and sepsis. Prevention of infection is the primary goal. Prenatal screening and identification of risk fac- tors, along with client teaching, can lead to early identification and prompt treatment. Rubella vaccination prior to pregnancy Screening for TORCH infections, Group B streptococcus, and possibly hepatitis and HIV Medications: prophylactic antibiotics, antiviral: zidovudine (AZT), antiinfectives, immune globulins, etc. Fetal screening/ultrasounds to determine effects of infections Nursing Care Plans Anxiev (22) Related to: Effects of prenatal infection on devel- oping fetus. Defining Characteristics: Client expresses concern about the effects of infection on fetus (specify). Client exhibits physical signs of anxiety (specify: e. g., tension, pallor, insomnia, crying, etc. ). Grieving, Anticipatory (32) Related to: Perceived potential loss of fetus, or developmental defects secondary to infection. Defining Characteristics: Client exhibits distress about the perceived loss (specify: e. g., crying, sor- row, anger, guilt, anorexia, etc. ). Decisional Conflict (I 7) Related to: Continuing pregnancy with diagnosis of (specify: HIV, fetal developmental defects, etc. ). Defining Characteristics: Client expresses conflict about continuing pregnancy (specify: uncertainty, questioning of personal values, etc. ). Client delays making a decision. Additional Diagnoses and Care Plans Infection, Risk for Related to: Specify conditions that cause risk (e. g., heart disease, HIV positive, IV drug abuser, histo- ry of recurrent STD's, etc. ). Defining Characteristics: None, since this is a potential diagnosis. Goal: Client will not experience infectious processes by (specify date/time to evaluate). Outcome Criteria Client reports no symptoms of infection (specify: no fever, malaise, respiratory congestion, diarrhea, urinary burning, etc. ). Client describes steps to avoid infection (specify: handwashing, avoiding people with infections, dirty needles, safe sex prac- tices, etc. ).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

36 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Assess for fever, malaise, anorexia, weakness, fatigue, night sweats, respi- ratory congestion, diar- rhea, urinary burning, skin lesions, joint pain, and swollen lymph nodes. Assess client for risk behaviors: IV drug abuse, recurrent STD's. Wash hands before and after caring for client. Teach client to wash fre- quently: before eating, before and after using the bathroom, etc. Teach client to avoid con- tact with people with infections (large crowds, enclosed areas). Use and teach client's fam- ily to use clean gloves if handling body fluids; use masks, eye shields, etc. as indicated. Do not recap needles; clean spills with bleach solution in the home. Monitor lab values as obtained for signs of infec- tion risk (specify: cultures, CBC, ELISA, Western Blot, PCR, HIV culture, CD4, ecc. ). Use protective isolation techniques (gloves, mask, gowns for staff or visitors, etc. ) for clients at high risk due to immune suppres- sion. Assessment provides infor- mation about signs and symptoms of active infec- tious processes and oppor- tunistic infections such as pneumocystis carinii pneu- monia, Kaposi's sarcoma, and lymphoma. Identifies clients at risk for infection. Friction and hot water remove many microorgan- isms from the hands and prevent their transmission. Protects client from infec- tions spread by respiratory droplets. Follows CDC guidelines to prevent transmission of blood-borne pathogens to caregiver or others in the family of client. Provides information about the microorganism causing the infectious process. Interventions protect immune-compromised client from contact with infection. Administer drugs as ordered (specify: drug, dose, route, and times). Administer prophylactic antibiotics prior to dental work, birth, and invasive procedures if ordered. Monitor for side effects of medications (specify for each). Provide emotional support and accurate information about the prognosis for the pregnancy (specify for each infectious agent the client has). Refer client and family as indicated (specify: drug treatment programs, psy- chological counseling, and support groups, etc. ). (Describe action of each drug related to the infec- tious agent. ) Prevents bacterial endo- carditis in client at risk; e. g., hx of rheumatic fever, heart disease. Provides information about client tolerance of the medication. Provides information and support to help the client cope with a diagnosis that may endanger the fetus or herself. Referrals provide addition- al information and assis- tance to client and family. Evaluation (Dadtime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client deny s/s of infection? List s/s. Does client identify how to avoid infection? Use quotes) (Revisions to care plan? D/C care plan? Continue care plan?) Hypertbemia Related to: Physiologic response to infectious process. Defining Characteristics: Increased body temper- ature (specifjr), warm, flushed skin, tachycardia. Goal: Client will have a return to normal body temperature by (specify date/time).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 37 Outcome Criteria Client's temperature will be c 102" F. ~~ ~ INTERVENTIONS RATIONALES Assess temperature (specify route), B/P, pulse, and res- piration every (specify time frame: e. g., q 2-4 hours). Assess client for dehydra- tion: dry skin and mucous membranes, poor turgor, sunken eyes, output z intake, etc. (specify how often). Assess fetal heart tones (specify frequency or maintain on continuous EFM if condition war- rants). Assess for contractions (specify to palpate or mon- itor with EFM for speci- fied amount of time). Provide +fluids either by mouth or IV as ordered (specify: type of fluids, whether isotonic or hypo- tonic, amounts, routes, via pump, times, etc). Teach client to recognize dehydration (thirst, dry mouth, etc. ) and to f' flu- ids early. Monitor lab values as obtained (specify: cultures, etc. ). Administer (or teach client Provides information about temperature changes, vital si n response: with 4 temp, HR +respiration +, B/P may 4 due to hypo- volemia. Assessment provides infor- mation about hydration status. Hyperthermia caus- es fluid loss by metabo- lism, respirations, and diaphoresis. Maternal fever and dehy- dration cause fetal tachy- cardia. Hypovolemia may compromise placental flow and lead to fetal distress. Maternal dehydration is implicated in uterine con- tractions which could lead to preterm labor and birth. Maintains hydration as fluid is lost from hyper- thermia. (Isotonic fluids act as replacement only, hypotonic fluids cause fluid to move across mem- branes and back into the cells if severely dehydrated. ) Prevents complication of preterm labor. Pregnant women have a f' need for fluids. Lab tests may indicate which organism is respon- sible for fever. (Specify action of drug in INTERVENTIONS RATIONALES to take) antipyretics only as ordered by health care provider (specify: drug, route, times, etc. ). antiplatelet activity. ) Keep environmental tem- perature at 72"F, cover client with light blankets, add blankets if chilling that may metabolic occurs. activity. Encourage and provide for rest during illness. reducing temperature- aspirin is contraindicated during pregnancy due to Promotes heat loss to the environment and promotes comfort, reduces chilling Rest 4 metabolic activity. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's temperature?) (Revisions to care plan? D/C care plan? Continue care plan?) Social' Isohtion Related to: Fear of rejection secondary to commu- nicable disease. Defining Characteristics: Client is diagnosed with (specifit: HIV infection, AIDS, herpes, condylo- ma, etc. ). Client reports feeling alone and being unable to make contact with others (specify with quotes). Goal: Client will report + social interaction by (datehime to evaluate). Outcome Criteria Client will identify 2 strategies to tions. Client will verbalize correct information about her condition. social interac-

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

38 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Establish a supportive rela- tionship with client. Ensure privacy. Take time, use good eye contact and therapeutic communica- tion techniques. Teach client accurate infor- mation about the disease: agent, mode of transmis- sion, and treatment options (specify for condy- loma, herpes, HIV/AIDS, etc. ). Teach client how to avoid spread of the infection to others (specify: handwash- ing, condoms, abstinence during outbreaks, etc. ) Verify understanding. Explore misconceptions that the client and other people may have about the infection and how it is spread. Discuss ways to provide accurate information to others and when it would be important to do so (specify for each condi- tion). Ask client to describe her current social network: family, friends, co-workers, neighbors, etc. Explore how client thinks her social network may change related to her diag- nosis. Provide a safe environment and encourage client to express her fears and feel- ings. The client is vulnerable and benefits from the sup- port of the nurse who shows respect and caring for the client as a worthy individual. Provides information with which to counter possible misconceptions about the condition. Empowers the client to care for herself and other people. Identifies myths and mis- information about the infection. Helps to reduce fear of rejection by practicing how to tell others of the infec- tion. Provides baseline informa- tion about client's socid network. Vdidates the client's feel- ings, allows exploration of fears about how others will react to the diagnosis. Empowers the client to work toward changing a situation she dislikes. Assist client to plan 2 strategies to improve inter- action with others during the next week. Encourage client to initiate interaction with one other person she trusts in the next week. Provide simple written materials, videos, etc. which client can use to teach others-help client to practice using the infor- mation. Refer client to support groups as appropriate for this client (specify: HIV support groups, counsel- ing, parenting groups, hobbies, etc. ). Provides a beginning for improving social interac- tion within a specified time frame. Helps the client to be real- istic and practice how to teach others factual infor- mation about the condi- tion. Provides information and support from others who are coping with the same diagnosis. Gives client some options she may think of trying to meet new people who may be supportive. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Describe strategies that client has chosen to improve social interaction. ) (Does client verbalize correct information about her diagnosis?) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 39 Infection Maternal Infection 4 Fetal-Neonatal Exposure Across Placenta Viruses Rubella CMV Herpes HIV Protozoa Toxoplasmosis Spirochete Syphilis 1 Ascending Chorioamnionitis Vaginal Bacteria Group B p-hemolytic streptococcus Bacterial vaghosis Bacteria Group B p-hemolytic streptococcus Gonorrhea Chlamydia Trichamoniasis Viruses Herpes Hepatitis B HIV Neonatal Sepsis

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Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 41 ~ Substance Abuse The use of alcohol, tobacco, and illegal “street drugs” such as marijuana, cocaine (crack), heroin, PCP, and LSD can lead to an increase in perinatal mortality and morbidity. Miscarriage, malnutri- tion, infection, IUGR, placental abruption, still- birth, preterm birth, congenital malformations, and mental retardation may result from maternal substance abuse during pregnancy. All pregnant clients should be assessed for sub- stance use in a caring and nonjudgmental manner. The client may delay seeking prenatal care for fear of reprisal. Clients frequently abuse several sub- stances although they may only admit to one. Definitions Medical Care Psychological Dependence: The substance is used for pleasure or to avoid pain/problems. Results in intense craving and compulsive use. Physical Dependence: The body adapts to the chemical. Results in tolerance (dosage must be increased to produce the same effect) and with- drawal syndrome (uncomfortable physiological symptoms result from discontinuation of the chemical). Addiction: The substance-dependent person continues to use it in order to experience the pleasure AND to avoid the discomfort of with- drawal. Urine toxicology screening: may be done at intervals during pregnancy Fetal well-being screening: ultrasounds, NST, BPP, etc.-high risk pregnancy Referral to Alcoholics Anonymous, addiction counseling, or psychiatric consult if indicated Heroin may not be discontinued abruptly as it will lead to decreased placental blood flow; methadone maintenance therapy may be used for women addicted to narcotics though it does cross the placenta Nursing Care Plans Basic Care Plan: Prenatal Home Visit (13) Health Maintenance, Altered (8) Related to: Lack of understanding about effects of substance abuse during pregnancy. Lack of readi- ness to change behaviors detrimental to self and fetus. Defining Characteristics: Client continues sub- stance abuse during pregnancy. Client exhibits emotional fragility; behavior disorders; symptoms of abuse (specify). Knowledge Dejcit: Preterm Labor Prevention (74) Related to: Inexperience or lack of understanding about the connection between substance abuse and preterm labor. Defining Characteristics: Maternal substance abuse (specify) during pregnancy. Client expresses incorrect information about substance abuse or preterm labor (specif): e. g., 'X seven month baby does better than a nine month baby. ”) Gas Exchange, Impaired Risk fir: Fetal (82) Related to: Placental insufficiency secondary to substance abuse (specify).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

42 MATERNAL-INFANT NURSING CARE PLANS Additional Diagnoses and Care Plans Growth and Development, Risk for Altered: Fetal Related to: Maternal substance abuse (specify) and J( nutrition. Defining Characteristics: Inadequate maternal weight gain (specify). Evidence of SGA fetus or fetal IUGR (specify fetal sizdgestational age); con- genital defects (specify). God: Fetus will experience appropriate growth and development during pregnanq. Outcome Criteria Client's fundal height will be within 2 cm of value for gestational age between 18 and 30 weeks. Fetal growth and development appears appropriate on ultrasound-no fetal anomalies identified. INTERVENTIONS RATIONALES Assess fundal height (spec- ify frequency: e. g., each visit, each week, etc. ). Assess maternal nutrition and weight gain (specify frequency). Reinforce nutrition teaching. Assess fetal heart tones by EFM (specify frequency). Teach mother to count and chart fetal movements and review (specify fre- quency). Perform tests for fetal well- being as ordered (specify: e. g., NST, OCT, BPP, etc. ) report nonreassuring results to caregiver. From approximately 18 to 30 weeks, hndal height in cms equals gestational age. Substance abuse may lead to poor nutrition and inadequate weight gain. Provides information on fetal well-being. The severely affected fetus may show a decrease in movement. Provides information about fetal well-being. Ensures health care provider is aware of testing results. RATIONALES INTEKVENTIONS : Monitor results of fetal testing (specify: Doppler flow studies; ultrasounds: fetal growth, physical anomalies, amniotic fluid volume (AFV). Amniocentesis: congenital anomalies, L-S ratio, phos- phatidylglycerol levels, etc. ). Explain all testing and results to client in terms she can understand. Teach client about the pos- sible/actual fetal effects of her substance abuse (speci- fy). Encourage client to abstain from substance abuse and praise efforts to do so. Refer client for substance abuse counseling or sup- port groups (specify) if unable to stop on her own. Notify NICU, pediatri- cian, perinatologist, and/or neonatologist of fetal con- dition and plans for deliv- ery- Evaluation Provides information about fetal warning signs: decreased cord blood flow, decreased AFV; cardiac or neurological anomalies may accompany alco- holism; L-S ratio of 2:1 or more and/or PG presence indicate fetal maturity. Allows client to participate in care of her fetus. Client may be unaware of detrimental fetal effects of substance abuse. Provides reinforcement for client attempts to abstain. Provides additional encouragement and assis- tance to client trying to stop using substances. Promotes multi-discipli- nary involvement in deci- sions regarding fetal care and delivery. (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is fundal heighdgestational age?) (What are results of ultrasound? growth? develop- ment? anomalies?) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

____~_____ PREGNANCY 43 Coping, Inefective hdividkd Related to: Substance abuse behavior in response to stress. Defining Characteristics: Client reports substance abuse (specify: alcohol, tobacco, cocaine, amounts, years of use, etc. ). Client states she uses substance to cope with stress (speci+, use quotes). Goal: Client will cope effectively with stress with- out substance use by (datehime to evaluate). Outcome Criteria Client will identify stresses that lead to addictive behaviors. Client will plan ways to avoid stress in personal life. Client will use effective coping strategies to deal with unavoidable stress. INTERVENTIONS RATIONALES Establish rapport by con- veying a nonjudgmental and caring attitude while presenting reality. Assist client to identify all substances she abuses, and approximate amounts used -allow time, suggest others if client hesitates. Teach client about the effects of the substances she uses on herself and her fetus. Describe how each affects fetus and mother. Offer to assist client to develop more effective coping mechanisms. Assist client to explore original reasons for sub- stance abuse and any relapses if she has tried to stop. Clients who are substance abusers may have learned to be manipulative to avoid negative conse- quences. Client may attempt to avoid admitting to all sub- stances which are used or the amounts used. Provides information about the negative conse- quences of each substance. Reassures client she is not alone and is worthy of the attention of the nurse. Provides information about history and stimuli for substance abuse. INTERVENTIONS RATIONALES Assist client to identify current stress in her life, which accounts for contin- uing substance abuse For each stress identified, help client to plan a way to avoid the stress if possi- ble. Teach effective coping techniques: relaxation, exercise, meditation, etc. Encourage client to identi- fy potential sources of emotional support (speci- fy: family, significant other, support groups, etc. ). Praise client for attempts to stop substance abuse and encourage continued attempts if she has a relapse. Refer to appropriate pro- fessional support (specify: Alcoholics Anonymous, Narc0 tics Anonymous, psychiatric nurse coun- selors, or others as ordered: e. g., psychiatrist, in-patient psychia. tric unit, etc. ). Evaluation Provides information about stresses in the client's current life. Avoidance of “trigger” situ- ations will make it easier to avoid using the sub- stance. Teaching provides infor- mation about possible effective coping strategies for handling stress. Social support influences the client's ability to effec- tively cope with stresses. Provides positive reinforce- ment. Clients may have many relapses before final- ly being able to stop sub- stance abuse. The client may need more assistance than the nurse is prepared to offer. Support groups such as AA are often successfd in helping clients to quit substance abuse. (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (List stresses client has identified) (List ways client has decided to avoid specific stresses. ) (Describe coping strategies client has decided to use to cope with unavoidable stresses. ) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

44 MATERNAL-INFANT NURSING CARE PLANS Associated Factors social attitudes/envirnt stress, occupation (access) low self-esteem, poor coping skills, lack of knowledge familial substance abuse frequently uses combination of substances, amounts used signs/sympto?ns delay in seeking cm hx of spontaneous abortion stillbirth, LBW infants malnutrition, dental decay sinusitis, chronic URI's cellulitis (track marks) infections, poor personal hygiene Maternal Substance Use + alcohol tobacco cocaine (crack) heroin PCP, LSD, others Fetal-Neonatal Effects spontaneous abortion chromosome breakage congenital heart defects spinal anomalies intestinal atresia limb anomalies brain anomalies GU malformations perinatal death Fetal Alcohol Syndrome developmental delays mental retardation Maternal Effects Cocaine: cardiac dysrhythmias myocardial infaretion, stroke, seizure placental abruption, sudden death Growth LBW IUGR Fl T

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

-PREGNANCY 45 Gestational Diabetes Diabetes mellitus is a metabolic disorder caused by inadequate insulin production. Insulin is a hor- mone that moves glucose from the blood into the cells for energy use or storage. Diabetes mellitus is broadly classified as Type I (insulin dependent, IDDM) or Type I1 (non-insulin dependent, NIDDM), depending on the severity of the deficit. Gestational diabetes mellitus (GDM) results from the inability to meet the need for increased insulin production during pregnancy. The mother's body stores more glucose during the first half of preg- nancy and later, the placental hormone h PL (h CS) works to resist maternal insulin, allowing more glucose to be available for the fetus. GDM may be controlled by diet alone or may require insulin injections. Risk Factors Native American, Hispanic, or African- American heritage Family hx of diabetes Previous GDM Previous unexplained stillbirth Previous infant > 9. 5 pounds Maternal obesity Maternal age > 30 Perinatal Complications Pre-eclampsideclampsia Bacterial infections Macrosomic infant Polyhydraminos Preterm birth Stillbirth (IDDM only) Congenital anomalies: heart defects, neural tube defects (IDDM only) Neonatal RDS, polycythemia, hyperbilirubine- mia Mediical Care Dietary control: 30-35 kcallkg of ideal body weighdday ADA diet with no concentrated sweets Blood glucose monitoring Medication: insulin (human)-oral hypo- glycemic medications are contraindicated (ter- atogenic) Urine testing for glucose and ketones MSAFP at 16-18 weeks Fetal movement counts NST weekly from 28-32 weeks Ultrasound for anomalies, AFV, and fetal growth patterns maturity cesarean delivery Possible: OCT, BPP, amniocentesis for lung Possible induction at 38-39 weeks andlor Nursing Care Plans Fluid' Volume Dt$cit, Risk for (31) Related to: Osmotic dehydration secondary to hyperglycemia. Anxiev (22) Related to: Threat to biologic integrity secondary to complicated pregnancy. Threat to well-being of fetus secondary to maternal illness.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

46 MATERNALINFANT NURSING CARE PLANS Defining Characteristics: Client expresses appre- hension about self and fetal well-being (specify). Client exhibits physical tension ( heart rate, B/P, etc. ). Gas Exchange, Impaired Risk for: Feta J Related to: Placental vascular changes secondary to poor glycemic control. (84 Additional Diagnoses and Care Plans Injury: Risk fir Materna WFetal Related to: Fluctuations in internal environment: hyperglycemia or hypoglycemia, Defining Characteristics: None, since this is a potential diagnosis. Goal: Mother and fetus will not experience any injury from hyper-, hypoglycemia by (date/time to evaluate). Outcome Criteria Client maintains fasting blood glucose between 80-105 mg/d L, and urine is negative for ketones. Fetal growth is appropriate for gestational age. Fetus moves at least 10 times in 2-hour count. INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Assess urine for glucose and ketones (specify tim- ing). Review client's home testing record at each pre- natal visit. ing is ketoacidosis. Monitor client's compli- ance with diet (specify: e. g., 2500 kcal ADA w/o concentrated sugar divided into 3 meals and 3 snacks daily). Monitor client's self-Appropriate insulin administration of human administration maintains insulin SC as ordered normal blood glucose lev- (specify: type, timing, & els w/o causing hypo- dosage). glycemia: may be adminis- tered by insulin pump or injection. Excess blood glucose spills into urine. Inability to use glucose leads to f fat and protein metabolism result- GDM may be controlled by diet alone if client com- plies. This diet provides steady blood glucose levels throughout the day. Teach client to record daily “kick counts” after 28 weeks: After a meal, when baby is active, sit comfort- ably and count fetal move- ment until 10 “kicks” have been recorded. Call health provider if JI fetal move- ment, fewer than normal kicks, or c 10 in 2 hours. Fetal movement counts are an inexpensive way to pro- vide daily information about fetal well-being without being invasive. A decrease in fetal movement may indicate distress. Allows client to be a par- ticipant in her care. Explain purpose of MSAFP test at 16-1 8 weeks to r/o fetal neural tube defects. NTD. Fetuses of mothers with IDDM and poor glycemic control are at 'I' risk for Assess client's blood glu- cose and Hb A,-, as ordered (specify method and timing: e. g. FSBG, GTT, post-prandial, q. i. d., q. d., weekly, etc. ). Review client's home test- ing records at each visit. Provides information about glycemic control during pregnancy: blood glucose > 105 mg/d L fast- ing or 120 mg/d L 2 hour post-prandial may require insulin administration. If Hb A1-, is > 8. 5, fetus is at f risk for congenital anomalies. Monitor fetal testing as ordered (specify: BPP, ultrasound, fetal echocar- diogram amniocentesis). rity. Assess client for signs of PIH at each prenatal visit (B/P, wt gain, proteinuria, edema, and reflexes). Provides information about fetal growth, com- plications, and lung matu- Client with diabetes is at higher risk for PIH.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

~~~ PREGNANCY 47 Perform weekly NST's as ordered from 28-32 weeks (or more frequently-speci- fy), CST or OCT as ordered. Measure fundal height at each visit, compare to pre- vious value, and correlate to estimated gestational age. Coordinate referrals as ordered (specify: perinatol- ogist, endocrinologist, dia- betic nurse educator, dietitian etc. ). INTERVENTIONS RATIONALES Definiing Characteristics: (Specify: new diagnosis of GDM). Client (and significant other) verbalize lack of knowledge about diabetes during pregnan- cy-request information about pathophysiology, Reactive NST is reassuring sign of fetal well-being. Nonreactive NST needs. ^ further assessment such as CST or OCT. Macrosomic fetus is at risk for birth trauma, shoulder dystocia and may need cesarean delivery. Coordination of referrals insures continuity of care and communication between multiple health care providers. treatment, prognosis, self-care options (specify, use quotes). Goal: Client and significant other will verbalize knowledge about gestational diabetes by (dateltime to evaluate). Outcome Criteria Client and significant other will verbalize an understanding of glycemic control during her pregnancy: diet, exercise, BG, and urine testing (insulin administration). Client and significant other demonstrate skills needed for control of diabetes during pregnancy (specify: e. g., blood glucose monitoring, urine dipsticks, SC insulin administration, etc. ). INTERWNTIONS RATIONALES Evaluation (Dateltime of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's fasting blood glucose? What is fetal growth pattern relative to gestational age? How often is fetal movement felt in 2 hours?) (Revisions to care plan? D/C care plan? Continue care plan?) Knowledge Deficit Related to: Lack of information about diabetes mellitus during pregnancy. Provide a comfortable environment for learning, invite client to include sig- nificant others, allow ade- quate time for questions. Assess client and signifi- cant other's knowledge of diabetes mellitus and abili- ty to learn needed skills. Describe maternal and fetal pathophysiology of GDM in simple terms: use visual aids and written materials; verify under- standing. Teach client and signifi- cant other about the physi- ologic rationale for the diet Facilitates learning of corn- plex content; significant others may provide sup- port and reinforce learning at home. Provides baseline data for planning education about diabetes and self-care- individualizes content to client learning level. Basic information the client needs to understand the condition and assess her physiologic responses. Understanding the physi- ology will enhance cornpli- ance and allow the client

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

48 MATERNAL-INFANT NURSING CARE PLANS- INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES plan prescribed (specify: e. g., 2400 cal ADA, divid- ed into 3 meals and 3 snacks, etc. ). Instruct client and signifi- cant other in proper use of blood glucose monitoring equipment. Demonstrate and have client perform a return demonstration. Teach client to perform urine testing for glucose and ketones: observe client's ability to read results accurately. (If insulin is prescribed: Instruct client and signifi- cant other in insulin administration: include storage, drawing up accu- rate 'dosage, rolling vial to mix, draw up clear (Regular) insulin before cloudy (NPH) if mixing types, SC technique, rota- tion of sites-allow client to demonstrate skill at next dosage. ) Teach client to engage in regular nonstrenuous exer- cise such as walking or swimming and to adjust diet according to activity level. Teach client and signifi- cant other the sls of hypo- glycemia (BG < 70 mg/d L) and how to treat it: Immediately eat some sim- ple carbohydrate-glass of fruit juice, honey, etc. Follow this with 15 gm of a complex carbohydrate such as a slice of toast or to modify her diet based on activity levels and BG testing. Ensures client understands procedure and can perform skills correctly. Ensures client is capable of testing urine and under- stands how to read results. Teaching promotes safe and accurate insulin administration technique- enhances self-esteem to master this skill. Exercise promotes utiliza- tion of dietary CHO and may 4 insulin need. May need to f CHO intake before vigorous activity or 4 insulin if ill. Promotes recognition of condition and allows fast treatment to avoid compli- cations. Empowers the client and significant other to recognize and handle situation. Simple CHO BG levels quickly but is metabolized quickly so needs to be followed with crackers and peanut butter, wait 15 minutes and retest BG. Teach client and signifi- cant other the sls of hyper- glycemia, the dangers of diabetic ketoacidosis, and to check BG and notify health care provider (administer insulin). Instruct client to report any signs of illness or infection to caregiver as diet or insulin needs may change quickly. Instruct client to keep a record of all BG and urine testing, insulin administra- tion, diet, and activity lev- els. Review record with client at prenatal visits. Provide written reinforce- ment of all teaching topics, reassure client that you will return to review con- tent (specify when). Suggest writing down questions. Refer client to other resources as needed (speci- fy: American Diabetic Association, support groups, etc. ). longer-lasting CHO to maintain blood levels. Promotes recognition and fast treatment to avoid DKA. Clients with GDM are at greater risk of infection, which may result in DKA. Written record provides information about client's individual responses. Allows client to modify self-care as needed. Provides alternative source of information, reinforces content and ensures client's questions will be answered. Resources provide addi- tional information and support. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Do client and significant other verbalize under- standing of: diet, exercise, BG, and urine testing (insulin administration?)

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PREGNANCY 49 (Did client and significant other demonstrate blood glucose monitoring, urine dipsticks, SC insulin administration, etc?) (Revisions to care plan? D/C care plan? Continue care plan?)

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50 MATERNAL-INFANT NURSING CARE PLANS polyuria polyphagia & amino acids polydipsia 9 ketones PLACENTA Maternal v + fattyhs & amino acids + need for insulin (glucose storage 8a fetal use) (h PL + insulin resistance) insufficient production of insulin in beta cells of pancreas + 4 J/ insulin 1 Inability of glum& to enter cells for energy metabolism or storage / I

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

Heart Disease Medlical Care Heart disease is the number four cause of mater- nal mortality after hypertension, hemorrhage, and infection. Rheumatic fever is declining as a cause of heart disease but advances in treatment of con- genital defects means that more of these women are now likely to become pregnant. Pregnancy increases the workload of the heart. Cardiac output is increased from 15-25Yo by 8 weeks of gestation and peaks at 30-50% by mid- pregnancy. The left ventricle has an increased workload, pulse rates increase, and there is a decrease in peripheral and pulmonary vascular resistance. The diseased heart has a decreased car- diac reserve and may have difficulty adapting to these changes. Diagnostics: echocardiogram, chest x-ray, elec- trocardiogram, auscultation for murmurs, pos- sible cardiac catheterization Medications: vitamins and iron, flu vaccine, Heparin (coumadin is teratogenic), thiazide diuretics, furosemide, cardiac glycosides (digi- talis:), prophylactic antibiotics for dental or sur- gical invasive procedures and for delivery Close monitoring to avoid excessive weight gain (24# goal), anemia, fluid retention, PIH, and infection Plan for low forceps vaginal delivery with epidural anesthesia delivery with possible invasive hemodynamic Hospitalization for Class I11 or IV prior to monitoring Nursing Care Plans Clients with Class I and I1 heart disease have a potential for good pregnancy outcome. Those with Class I11 or IV are at risk for serious compli- cations and may be advised to avoid pregnancy. Anxiety (22) Related to: Actual or perceived threat to biologic integrity secondary to effects of pregnancy on pre- Class I-Uncompromised: Physical activity is not limited by angina or symptoms of cardiac insufficiency Class I1-Slightly Compromised: Comfortable at rest but normal activity causes fatigue, palpi- tations, dyspnea, or angina Class 111-Markedly Compromised: Comfortable at rest but less than ordinary activ- ity causes excessive fatigue, palpitation, dysp- nea, or angina Class IV-Severely Compromised: Unable to perform any activity without discomfort; may experience angina or signs of cardiac insuffi- ciency while at rest existing heart disease. Defining Characteristics: (Specify: client states feeling, nervous; anxious, anticipates misfortune. Client exhibits physiologic signs of anxiety: trem- bling, palpitations, pallor, etc. ). Client reports cognitive signs of anxiety: unable to concentrate, confusion, etc. ). Infiction, Risk fir (35) Related to: Underlying heart disease and decreased cardiac reserve. Activity Intolerance (26) Related to: Fatigue, insufficient oxygenation for normal activity.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

52 MATERNAL-INFANT NURSING CARE PLANS Defining Characteristics: (Specify: client reports weakness and fatigue. Client exhibits shortness of breath, dyspnea, tachypnea with activity [specify level]. Specify changes in pulse and B/P with activity. ) Additlonal Diagnoses and Care Plans Decreased Cardiac Output Related to: Inability of the heart to adapt to hemodynamic changes of pregnancy secondary to mechanical, electrical, or structural alterations. Defining Characteristics: Client reports (specify: fatigue, syncope, angina at rest, with normal activ- ity, with exertion. Specify: J( B/P, ECG changes, f pulse, J( peripheral pulses, 4 urine output, 4 CW, etc. ). Goal: Client will maintain adequate cardiac out- put during pregnancy (datehime to evaluate). Outcome Criteria Client will maintain stable B/P (Specify: e. g. sys- tolic > 100 mm Hg), pulses regular rhythm, rate < 100, urine output > 30 cc/hr. INTERVENTIONS RATIONALES Assess B/P (specify sites) and apical pulse for 1 minute noting rate and rhythm, assess peripheral pulses (specify frequency). (Assess CVP or Swan Ganz readings if applicable provides information [specify timing]-monitor for complications: trauma, infection, emboli, dys- rhythmias, pneumothorax, tion about pulmonary etc. ) pressures. Systolic B/P < 100 mm Hg, pulse > 100 or irregular with J, peripheral pulses, may indicate & C. O. Central venous pressure about circulating blood volume; Swan Ganz catheter provides informa-INTERVENTIONS RATIONALES Assess for changes in pulse and respirations associated with activity change (speci- fy frequency). Compare to previous findings. Assess for ECG changes if applicable [specify timing]. Assess urine output (speci- fy frequency: e. g., qh, q shift). Teach client to report if output estimated at c 30 cc/hr. Assess fetal well-being (specify frequency: e. g., continuous, q shift, weekly etc. ) FHR, reactivity, fetal movement counts, fundal height, etc. Monitor lab values and test results: potassium, cal- cium, ECG, echocardio- gram, amniocentesis, etc. Administer drugs such as digitalis, i3-blockers, and calcium channel blockers, as ordered (specify: drug, dose, route, and times). For digoxin, assess apical pulse for 1 min and hold dose if HR < 60-notify M. D. Monitor serum K+ levels. Assess for therapeutic and adverse effects of each drug (specify: e. g., s/s digitalis toxicity: anorexia, nausea, vomiting, bradycardia, and dysrhythmias). J, C. O. results in tachy- cardia and tachypnea (res- pirations > 24) with f activity. Worsening condi- tion indicates cardiac decompensation. Dysrhythmias may cause J, C. O. or be sympto- matic of & cardiac func- tion. Provides information about adequacy of C. O. relative to renal blood flow and the effect on renal function. Assessment provides infor- mation about adequacy of cardiac output and utero- placental blood flow, fetal oxygenation, and nutri- tiodgrowth. Assessment provides infor- mation about electrolytes critical for cardiac func- tion; cardiac pathology; fetal maturity. Digitalis (cardiac glyco- side) increases the strengt-h of the myocardial contrac- tion while decreasing the rate and workload of the heart (specify action of each drug relative to car- diac output) & K+ increases risk of digitalis toxicity. Assessment provides infor- mation about the desired effect and early recognition of complications of drug therapy.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

INTERVENTIONS RATIONALES Assess social support and include family andlor sig- nificant other in teaching about condition and care. Teach client med. adminis- tration (specify: e. g., for digitalis need to teach to take apical pulse) and adverse effects to report (signs of digitalis toxicity). Teach client to rest in bed for 10 hours at night and for 30 minutes after meals. Teach client to lie in left lateral position and to sit with feet elevated. Teach client use of anti- embolism stockings if pre- scribed: teach to roll on, check pulses, color of toes, and sensation. Teach client and family of need to limit activity to no more than light house- work, not to climb stairs, and to avoid emotional stress (bedrest if ordered). Teach client and signifi- cant other warning signs of cardiac decompensation to report immediately: pro- gressive severe dyspnea, '?' fatigue, tachycardia, palpi- tations, or syncope, chest pain on exertion. Refer to support groups if available, social service agencies, etc. (specie). Client will need good social support for lifestyle changes needed during '?' risk pregnancy. Teaching provides infor- mation to ensure safe administration of cardiac drugs. Resting decreases workload on the heart. These posi- tions facilitate venous return and renal and uteroplacental perfusion. Anti-embolism stockings prevent venous stasis and provide mechanical stimu- lation for venous return. Limiting activity decreases cardiac workload-extent of limitations depends on degree of cardiac disease: Class I11 or IV may need complete bed rest. Teaching allows for prompt treatment to pre- vent further complications such as CHF or dysrhyth- mias. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What is client's B/P? Is systolic > 100 mm Hg? What is client's pulse rate and rhythm? Is rate < loo? What is client's urine output? Is output > 30 cdhr?) (Revisions to care plan? D/C care plan? Continue care plan?) Fluid hlurne Excess Related to: Compromised regulatory systems sec- ondary to heart disease and 9 circulating volume of pregnancy. Defining Characteristics: Client reports dyspnea, shortness of breath, edema (specify where, how much: e. g., dependent, periorbital, +2, +3... pit- ting). Intake > output (specify), I' wt. gain greater than expected for gestation (specifjr). Goal: Client will not exhibit excess fluid reten- tion by (datehime to evaluate). Outcome Criteria Client will report 6 dyspnea. Client will have J( edema (specify: e. g., < +2 dependent). Urine out- put will approximately equal intake. Weight gain will bc: no more than (specify based on gestation). INTERVENTIONS RATIONALES Referrals may provide social or financial support. Weigh client (at each pre- natal visit) and compare to expected gain for gesta-tion. tion. Assess for edema (at each visit): dependent, sacral (if Unexplained weight gain is an early sign of fluid reten- Increased fluid volume of pregnancy and gravity may

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

54 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES lying), fingers (check rings), facial, and perior- bital. Rate extent (+I, +2, etc. ). Compare to previous findings. Assess skin turgor and stri- ae gravidarum (stretch marks) development (at each visit). Assess for other signs of PIH (at each visit): B/P, hyperreflexia, epigastric pain, and visual distur- bances. Assess urine for protein. Assess for cough, respira- tions noting rate and ease. Auscultate lungs noting any rales (crackles), rhonchi, or wheezes (at each visit). Assess for jugular (neck) vein distention (at each visit). Assess intake and output and urine specific gravity (specify time frame). Teach client to assess intake and output at home and to report urine output c 30 cclhr. Administer diuretics as ordered early in the day (specify: drug, dose, route, times) and assess results (teach client to self-admin- ister diuretics if indicated). Monitor lab results as obtained. Note serum albumin, sodium and potassium levels. account for dependent edema (physiologic edema of pregnancy). Increased fluid retention in the extravascular spaces causes taut skin. Striae may develop rapidly as skin stretches. Clients with heart disease are at higher risk of devel- oping PIH. Cough, dyspnea, & tachypnea (> 24) are signs of 4 oxygenation possibly caused by pleural effusions resulting from FVE. Jugular distention is an indication of systemic venous congestion. Oliguria indicates 4 renal perfusion, which activates the renin-angiotensin- aldosterone system causing Na+, K+, and H20 reten- tion and I' sp. gr. of urine. (Describe how specific drug works to cause diure- sis. ) Teaching client about medications enables her to participate in her care and assess for therapeutic or adverse effects. Monitoring labs provides information on fluid and electrolyte balance. INTERVENTIONS RATIONALES Assist client to plan a diet f' in iron and protein & essential nutrients with no added salt. Explain ratio-nale for diet changes. Teach client to position herself with head & shoul- ders raised and a wedge under right hip to tilt uterus to the left. Instruct client and signifi- cant other to noti6 physi- cian if client experiences I' dyspnea, tachypnea, a “smothering” feeling, cough, or hemoptysis. Evaluation Low protein, I' sodium contributes to fluid reten- tion. Iron is needed for hemoglobin. Understanding the ratio- nale helps the client to comply. Upright position facilitates breathing, and left uterine displacement increases renal and uteroplacental blood flow and fetal perfu- sion. Instruction allows for prompt treatment to avoid complications from con- gestive heart failure. (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Does client report 4 dyspnea?) (Describe edema, does urine output approximately equal intake? What was client's wt gain?) (Revisions to care plan? D/C care plan? Continue care plan?) Essue Pe+ion, Altered placental cardiopulmonary Related to: Changes in circulating blood volume, secondary to heart disease. Defining Characteristics: Specify: (pallor, cyanosis, 4 B/P [specify normal and present B/P], I' capillary refill time [specify how many seconds], 4 Sa O, levels [specify], anemia [specify Hgb & Hct), fetal IUGR, and/or late decelerations on EFM). God: Client will experience adequate cardiopul-

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 55 monary and placental tissue perfusion by (datehime to evaluate). Outcome Criteria Client's B/P will be > (specify: e. g., 100/60 mm Hg). Sa O, will be > 95%. Fetal growth will be appropriate for gestational age. FHR will be 110-160 with average variability and no late decel- erations. INTERVENTIONS RATIONALES Assess BIP and pulses, skin color and temperature, mucous membrane color, capillary refill time, Sa O, (if available), clubbing of fingersltoes, and level of consciousness (LOC) (state how often). Assess fetal growth com- pared to expected rate, and monitor FHT for rate (1 10-1 GO), variability, and accelerations or decelera- tions. Perform NST or OCT as ordered (state when to assess fetal well- being). Assess client for anemia: monitor labwork as obtained (e. g., H&H). Provide oxygen via face mask or nasal cannula at (specie rate) as ordered. Administer cardiac glyco- side medications (or oth- ers) as ordered (specify: drug, dose, route, time). Monitor for therapeutic and adverse effects. Assessment provides infor- mation about circulation: C. O., oxygenation at the capillary level, chronicity of hypoxemia, oxygenation of the CNS. Assessment provides infor- mation on placental hnc- tion. Changes in baseline FHR with loss of variabili- ty or late decelerations indicate J, oxygenation or placental perfusion. Tissue oxygenation is dependent on adequate hemoglobin levels. Provides supplemental oxygen to tissues. Cardiac glycosides pro- mote C. O. by slowing and strengthening contraction of the myocardium (speci-e action of other drugs). Prevents complications of drug therapy. Teach client to rest in left lateral position or semi- fowler's with a wedge under right hip and to change position at least q 2h. Provide egg crate mattress and extra pillows for client on bedrest. Provide ROM as needed (specify timing). Assess skin condition dur- ing bath noting any red- dened areas. Teach client to avoid tight or restrictive clothing. Teach cli. ent to do daily “kick cormts” of fetal movement. Reinforce measures to ensure optimal oxygena- tion: diet, iron and vita- mins, and no smoking. Rest and positioning facili- tate placental perfusion. Position change prevents skin breakdown from con- tinuous pressure on one area. Interventions prevent development of pressure sores from J, tissue perfu- sion over bony promi- nences. Tight clothing may further J, circulation. Provides information on feral oxygenation. Reinforcement supports the client in making lifestyle changes to improve tissue perhsion. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Specify client's B/P What is Sa O, level? Is fetal growth appropriate for gestational age? What is baseline FHR? Are there any accelerations or decelerations?) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

56 MATERNALINFANT NURSING CARE PLANS + C. O. (30-50%) J/ pulmonary 86 peripheral vascular resistance JC B/P, + P, + stroke volume Heart Disease obstruction abnormal openings \L C. O. J. perfusion sympathetic coronary stimulation arteries . t peripheral 4 J/ 02 vasoconst,tiction r 1 tachycardia (@or 1 + need for 02 (tachypnea) \ \ + venous return \ J. renal perfusion 4 + renin, angiotensin, aldosterone, ADH + +H2O 86 Na+ 9 circulating volume + Cardiomyopat hy A Right ventricle weakness 4 + systemic venous congestion 1 jugular vein distension he patomegaly 'P edema sudden weight \ +venous 1 engorgement Left ventricle weakness + pulmonary pre sure 1 pulmonstry edema J/ 02 fatigue n \ Congestive Heart Failure 4-J tachypnea rales I hemoptysis cough

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

~ PREGNANCY 57 Pregnancy Induced Pregnancy induced hypertension (PIH) is defined as persistent B/P readings of 140/90 mm Hg or higher (or an elevation of more than 30 mm Hg systolic or more than 90 mm Hg diastolic over baseline B/P) which develops during pregnancy. Pre-eclampsia is diagnosed when the hypertension is combined with proteinuria (of 300 mg/L or more in a 24 hour specimen) and or pathological edema. The edema is generalized, not dependent, and can be assessed in the hands and face. Pre- eclampsia is further divided into mild and severe. Severe pre-eclampsia is diagnosed when the dias- tolic B/P is > 110 mm Hg or the client experiences persistent 2+ or more proteinuria (or > 4 g/L in 24 hours). Ominous signs of severe pre-eclampsia are severe headache, visual disturbances, and epi- gastric pain. These signs may indicate impending eclampsia. Eclampsia is PIH that progresses to maternal con- vulsions. High maternal and fetal mortality and morbidity is associated with eclampsia. PIH usually develops in the third trimester. An exception to this is found in molar pregnancies when severe PIH can develop during the first 20 weeks. The cause of PIH is unknown with theo- ries including immunologic factors and abnormal prostaglandin synthesis. The only known cure is delivery. Risk Factors nulliparity. maternal age < 18 family hx of PIH or > 35 large uterine mass: hydatidiform mole, multiple gestation, fetal hydrops (Rh sensitization), dia- betes mellitus African-American heritage, hx chronic renal or vascular disease Comglications complications are the result of vasospasm and vascular damage congestive heart failure cerebral: edema, ischemia, seizures, hemor- rhagdstroke + coma, death pulmonary edema portal hypertension +liver rupture retinal detachment coagialopathy: HELLP, DIC fetal hypoxia and malnutrition: IUGR, fetal placental abruption d' istress Mild pre-eclampsia (B/P < 140/90, no IUGR): bedrest, evaluation twice a week B/P sustained > 140190: hospitalization, bed- rest Severe pre-eclampsia (B/P 160/ 1 10, proteinuria, edema, ominous s/s: severe headache, visual dis- turbances, epigastric pain, oliguria): hospitaliza- tion,, stabilization, and delivery (induction or cesarean) Medications-Mg S04 IV or IM (prevents con- vulsions) and hydralazine (Apresoline) P. o., or IV (lower B/P). Cervical ripening if indicated,

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

58 MATERNAL-INFANT NURSING CARE PLANS pitocin induction, possibly betamethasone IM (induce fetal lung maturity) Laboratory tests: H&H, platelets, serum creati- nine, BUN, liver enzymes, coagulation studies, 24 hour urine for protein and creatinine clear- ance Fetal testing: u/s, fetal size, NST, OCT, BPR AFV, amniocentesis for lung maturity Nursing Care Plans Anxiety (22) Related to: Actual or perceived threat to biologic integrity of mother and fetus secondary to compli- cation of pregnancy. Defining Characteristics: Client expresses feelings of apprehension or nervousness (specify). Client exhibits physical signs of tension or anxiety (speci- G: e. g., trembling, diaphoresis, insomnia, etc. ). Activity Intolerance (23) Related to: Prescribed bedrest secondary to hyper- tensive complication of pregnancy. Defining Characteristics: Client exhibits increased B/P > 15 mm Hg with activity. Client reports weakness, fatigue (specify) after bedrest. Gas Exchange, Impaired Risk for: Fetal (82) Related to: Placental separation secondary to vas- cular damage and hypertension. Additional Diagnoses and Care Plans Injury, Risk for: Materna UFetal Related to: Tonic-clonic convulsions. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client and fetus will not experience injury from convulsions by (datehime to evaluate). Outcome Criteria Client does not exhibit tonic-clonic convulsions, FHR remains between 1 10-160 without late decelerations. INTERVENTIONS RATIONALES Assess maternal B/P, P, R (specify frequency: e. g., q 5-1 5 min, qh). Assess DTRs (specify fre- quency) and compare to baseline prenatal DTR's: 0 = no reflexes +I = hyporeflexia +2 = normal DTR +3 = brisk DTR +4 = very brisk, with clonus Assess for signs of worsen- ing condition (specify tim- ing): headache, N&V, visual disturbances, or epi- gastric pain. Provide decreased sensory stimulation: dim lights, provide a quiet atmos- phere, limit visitors to sig- nificant other. Initiate and monitor Mg S04 administration IV via pump or IM (Z-track) as ordered (specify dose) Assessment provides infor- mation about escalation of hypertension, which may precede convulsions. Hyperreflexia, especially with clonus, indicates cere- bral irritation, which may precede convulsions. Mg SO, toxicity may first be suspected with absent DTR's. Assessment provides infor- mation on increased CNS irritability and portal hypertension-ominous signs indicating imminent convulsions. Interventions decrease cerebral stimulation. sig- nificant other may provide reassurance and comfort. Mg SO, is a CNS depres- sant that J, acerylcholine release at motor neurons preventing convulsions.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 59 ~~ INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES with % solution). Report respiration < 12 and d/c Mg S04-support respira- tion. Inform client of expected side effects of N adminis- tration: feeling of warmth. Maintain strict bedrest. Keep side rails up (X4) and padded (with bath blankets), keep oral airway at bedside. Monitor magnesium levels as obtained: 6-8 mg/100 ml = thera- peutic range 8-10 mg/100 ml-patellar DTR disappears 12+ mg/IOO ml = respira- tory depression Monitor hourly urine out- put and inform physician if < 30 cclhr. Keep calcium gluconate and a syringe at the bed- side for emergency use. Administer antihyperten- sive medications as ordered (specify: e. g., hydralazine) and per protocol (e. g., give IVP slowly over I minute, assess BIP q 2-3 minutes etc. ). Implement continuous EFM and assess for changes in feral well-being. (specify frequency of docu- mentation). May cause resp. depres- siodarrest. Teaching prepares client for expected sensations to avoid anxiety. Interventions prevent injury from tonic-clonic movements. Airway is available to maintain air- way during seizure. Monitoring levels provides information on therapeutic range and helps avoid magnesium toxicity or res- piratory arrest. The kidneys excrete Mg S04-intervention prevents toxic accumula- tion. Calcium reverses respirato- ry depression caused by magnesium toxicity. Describe action of specific medications (e. g., hydralazine 4 B/P by direct action on arterial smooth muscle. Fetal monitoring provides information about baseline rate or late decelerations. Convulsions may interrupt placental perfusion or lead to placental abruption. Inform client and signifi- cant other about all proce- dures and medications provided. If client has a convulsion: insert the airway if possi- ble, protect client from injury, note duration and activity during seizure, assess aiiway and fetal well-being after seizure, perform vaginal exam. Stay with client and have some- one else notify the physi- cian. Keep other caregivers (specitjr: e. g., perinatolo- gist, neonatologist) informed of client and fetus condition. Information decreases anx- iety about unfamiliar ther- apies. Interventions protect the client from injury; provide information about CNS activity during convulsion and fetal response; cervix may become completely dilated during a seizure. Informing the caregivers ensures continuity of care and allows a team approach to ensure mater-nal/fetal well-being. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Has client had a convulsion? What is FHR base- line? Any late decelerations?) (Revisi'ons to care plan? D/C care plan? Continue care plan?) Fluid blurne Deficit Related to: Fluid shift to the extravascular space secondary to J( plasma protein and colloid osmot- ic pressure. Defining Characteristics: Edema (describe e. g., 3+ pitting, periorbital etc. ), abnormal weight gain (specify), J( urine output (described), f hemat- ocrit (specify) s/s pulmonary edema (specify: cough, rales, etc. ).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

GO,MATERNAL-INFANT~ NURSING-RE PLANS Goal: Client will maintain intravascular fluid vol- ume by (datehime to evaluate). Outcome Criteria Client will exhibit decreased edema (specif): e. g., 2+ or less), increased urine output (specify hourly amount), hematocrit will return to normal for pregnancy (specify: e. g., < 40%). INTERVENTIONS RATIONALES Assess for edema (specify frequency): +1 = slight pedal and pretibial edema +2 = marked dependent edema +3 = edema of hands, face, periorbital area, sacrum +4 = anasarca with ascites Position client on her left side, maintain strict bedrest. Suggest client remove jewelry and give to significant other. Insert foley catheter (as ordered) and measure strict hourly intake and output, check urine specific gravi- ty, and dip urine for pro- tein. Maintain IV fluids via pump as ordered (specify fluid type and rate: e. g., LR at 60 cc/hr). Assess site (specify frequency) for red- ness, edema, or tenderness. (Assess & monitor hemo- dynamics via CVP line or Swan Ganz catheter if Assessment provides infor- mation on the extent of the fluid shift from intravascular to extravascu- lar spaces. Provides infor- mation about improve- ment of condition. Left lateral positioning facilitates renal and placen- tal perfusion. Jewelry may become constrictive with edema. Retention catheter pro- vides information about urine output and fluid bal- ance. Output e 30 mllhr or sp. gravity > 1. 040 indi- cates severe hypovolemia. IV provides venous access and carefd fluid replace- ment. Pump protects against accidental fluid overload. Assessment pro- vides information about IV infiltration or infection. Assessment provides accu- rate measurement of intravascular fluid volume.-~~~ ~~ INTERVENTIONS RATIONALES inserted. Norms: CVP-R atrium: 5-1 5 mm Hg; pul- monary artery wedge pres- sure PAW-8-12 mm Hg. ) Auscultate lungs (specify frequency). Note any changes: e. g., development of a cough or rales that don't clear after 2-3 deep breaths. Notify caregiver. Explain all procedures and rationales to client and sig- nificant other. events. Complications include trauma, infection, emboli, and cardiac dysrhythmias. Assessment provides infor- mation about the develop- ment of pulmonary edema. Explanation decreases anx- iety about unfamiliar Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Describe edema, hourly urine output, and latest hematocrit level) (Revisions to care plan? D/C care plan? Continue care plan?) Tissue Perjkion, Altered Cerebrul, Hepatic, Renal, Phcental, Pekpberal Related to: Vasospasm, coagulopathies secondary to vascular endothelial damage. Defining Characteristics: Client reports (specify: severe headache, blurred vision or “seeing spots,” nausea, epigastric pain, C fetal movement). (Specify: hyperreflexia [specify], oliguria [specify], proteinuria, IUGR, fetal distress, fetal demise, 6 platelets, J( AST and ALT, bleeding gums, petichiae, etc. ). Goal: Client and fetus will experience adequate tissue perfusion by (datehime to evaluate).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 61 Outcome Criteria Client will deny any headache, visual distur- bances, or epigastric pain. Client will have platelet count > 100,000/mm3, liver enzymes (AST & ALT), WNL (specify for lab), fetal heart rate will remain between 11 0-160 without late decelera- tions. INTERVENTIONS RATIONALES Assess temp (q 2 h), B/P, P, R (q 15-30 minutes or specify). Assess LOC, monitor for severe headaches and hyperreflexia (specify fre- quency). Assess for nausea and vom- iting, epigastric pain, or jaundice. Monitor lab work for liver enzymes (AST [SGOT] and ALT [SGPT]). Assess intake and urine output via foley catheter, monitor urine sp. gravity and proteinuria. Monitor lab work as obtained: BUN, serum creatinine, and uric acid. Mollitor fetal growth pat- tern using fundal height, serial ultrasound measure- ments (if provided). Provide continuous EFM if indicated. Monitor FHR for 'I' or JI baseline, wan- dering baseline, 4 vari- ability, or late decelera- tions. Assess client's skin condi- tion, color, temperature, turgor, and edema (specify frequency). Assessment provides ongoing information about physiologic changes. Assessment provides infor- mation about neurological perfusion and irritation. Assessment and monitor- ing provide information about hepatic perfusion, distention, portal hyper- tension, and liver damage. Assessment provides infor- mation about rend perfu- sion, GFR, and damage to glomerular endothelium. Assessment provides infor- mation about placental perfusion and transfer of nutrients to the fetus. Continuous EFM provides information about JI pla- centa perfusion and impaired gas exchange to the fetus. Assessment provides infor- mation about client's peripheral perfusion. INTERVENTIONS RATIONALES Monitor client for HELLP syndrome: hemolysis, f liver enzymes, and JI platelets. Monitor client for the development of dissemi- nating intravascular coagu- lation (DIC): easy bruis- ing, epistaxis, bleeding gums, hematuria, petechi- ae, or conjunctival hemor- rhages. Administer acetaminophen as ordered for elevated temperature. Monitor for signs of infection. Keep client's caregiver informed of client's status and new information as obtained. Transfuse blood products and coagulation factors as ordered per agency proto- col. Provide emotional support to client and family. Explain all equipment and procedures. Arrange for health care providers to meet with client and fami- ly to discuss plans. Arrange for significant other (fami- ly) to tour NICU if indi- cated. HELLP syndrome may be associated with severe pre- eclampsia. Clients with HELLP syn- drome may progress to develop DIC, which may result in spontaneous hem- orrhage. Infection or fever reduces platelets further. Aspirin is thrombocy- topenic. Acetaminophen does not affect platelets. Client's condition may deteriorate quickly. Delivery is indicated with HELLP regardless of EGA. Intervention provides replacement of necessary blood and clotting compo- nents. Illness and the potential for a poor outcome may frighten client and family. Knowledge decreases anxi- ety related to unfamiliar events and equipment. Evalu. ation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client deny any headache, visual distur-

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

62 MATERNAL-INFANT NURSING CARE PLANS bances, or epigastric pain? What is the platelet count? Are liver enzymes (AST and ALT) WNL (speci Q for lab)? What is FHR? Are there any late decelerations?) (Revisions to care plan? D/C care plan? Continue care plan?) Diversionary Activity Deficit Related to: Isolation and inability to engage in usual activity secondary to prolonged bed- rest/hospitalization. Defining Characteristics: Client reports boredom, depression (specify with quotes), flat affect, com- plaining, or appears disinterested. Goal: Client will engage in diversionary activities as condition permits by (datehime to evaluate). Outcome Criteria Client will plan and participate in 3 appropriate activities within limitations imposed by illness. INTERVENTIONS RATIONALES Assess desired activities and limitations imposed by physician's order, or client condition. Plan to spend quality time with client (specifj: e. g., 1 hour each day). Explain rationales for limi- tations to client and signif- icant other. Assist client and significant other to develop a list of diversionary activities allowed in the plan of care. Suggest additional activi- ties client may not think Assessment provides infor- mation about client's desires and their congruen- cy with the medical regi- men. Validates client's concerns and worth as a person. Understanding rationale for limits improves com- pliance. Intervention involves client and significant other in plan of care. Suggestions provide options for diversionary INTERVENTIONS RATIONALES of: e. g., books on tape, music therapy, computer activities (Internet if avail- able) and games, needle- work, scrapbooks, etc. Suggest that client and family may like to decorate the hospital room with pictures, cards, window painting, etc. Allow client to make deci- sions regarding timing of routine care whenever pos- sible (e. g., bathe in the evening rather than morn- ing). Encourage visitors (includ- ing children) if client's condition allows. Suggest scheduling visits through- out the day and evening- allow flexible hours. For clients with a small social support network, suggest having pastoral care or a volunteer come visit client. Consider allowing a favorite pet to visit in client's room. Suggest an outing on a stretcher if condition allows and physician agrees. Suggest an occupational therapy referral for client (or play therapist if avail- able, for an adolescent). activities-stimulates thinking about additional ideas. Suggestions promote per- sonalization of the envi- ronment and provide diversionary activity for the client. Decision making promotes a sense of control over daily activities. Visitors provide social sup- port. Scheduling avoids having all visitors come at once. Suggestion promotes social diversion for clients who have few visitors. Pet visits may help meet client's emotional needs and provide diversion. A change of scenery may provide stimulation and diversion for client. Referrals promote age- appropriate diversionary activity. Evaluation (Datehime of evaluation of goal)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 63 ~~ (Has goal been met? not met? partially met?) (Has client planned and participated in diversionary activities? Specify,) (Revisions to care plan? D/C care plan? care plan?) at least 3 Continue

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

64 MATERNAL-INFANT NURSING CARE PLANS Premnancy Induced Hypertension (PIHI /I' blood pressure 3. circulating volume /I' extravascular fluid lacen P IUGR 3. fetal 02 a cerebral edema ischemia headache f abruptio-seizure coma fetal intracranial distress hemorrhage 3. organ perfusion vaylar damage I I retinal kidneys- edema 1 visual oliguria listurbance Na+ retention proteinuria letachment I cv A \ 3. plasma proteins 4 pulmonary peripheral edema-edema CHF I renal tubular necrosis I * acute renal r I vdscular and liver hematologic Tern hemolysis 1 periportal microangiopathic necrosis platelet adherence hemorrhagic I fibrin deposition subcapsular HELLP hematoma syndrome I liver fetal maternal death f--------------death

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 65 Placenta previa is an abnormally low implantation of the placenta in relation to the internal cervical 0s. As the cervix softens, late in the second trimester and then dilates, the placenta is pulled away, opening the blood-filled intervillous spaces and possibly rupturing placental vessels. The result is bleeding which may be mild or torrential. Often the first episode of bleeding is mild and resolves spontaneously. As pregnancy progresses however, the cervical changes increase, and bleeding becomes more profuse. The classic sign of placenta previa is painless, bright red vaginal bleeding. Placenta previa is classified as: Total previa-the placenta completely covers the internal 0s Partial previa-the placenta covers a part of the internal cervical 0s Marginal previa-the edge of the placenta lies at the margin of the internal 0s and may be exposed during dilatation Low-lying placenta-the placenta is implanted in the lower uterine segment but does not reach to the internal 0s Low-lying placentas or previas diagnosed by ultra- sound early in pregnancy often resolve as the uterus and placenta both grow. This is called pla- cental migration. Previas noted after 30 weeks ges- tation are less likely to migrate and more likely to cause significant hemorrhage. Risk Factors advanced maternal age multiparity previous uterine surgery large placenta (multiple gestation, erythroblasto- maternal smoking sis) Medilcal Care Ultrasound exams to determine migration of an early-diagnosed previa or classification of the previa as total, partial, marginal, or low-lying h0m. e on bedrest if she can get to a hospital quickly With a small first bleed, client may be sent If bleeding is more profuse, client is hospitalized on tied rest with Bm, IV access; labs: H&H, urinalysis, blood group & type and cross-match for 2 units of blood on hold, possible transfu- sions; goal is to maintain the pregnancy until fetal maturity No vaginal exams are performed except under special conditions requiring a double set-up for immediate cesarean birth should hemorrhage result Low-lying or marginal previas may be allowed to deliver vaginally if the fetal head acts as a tamponade to prevent hemorrhage 4 Cesarean birth, often with a vertical uterine incision, is used for total placenta previa Nursing Care Plans Actiuity Intolerance (23) Related to: Enforced bedrest during pregnancy secondary to potential for hemorrhage. Defining Characteristics: Specify: (e. g., client exhibits weakness, palpitations, dyspnea, confu- sion, etc. ).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

66 MATERNAL-INFANT NURSING CARE PLANS Impaired Gas Exchange, Risk for: Fetal Related to: Disruption of placental implantation. (82) Diversionary Activity Deficit (62) Related to: Inability to engage in usual activities secondary to enforced bedrest and inactivity dur- ing pregnancy. Defining Characteristics: Specify: (e. g., client states she is bored or depressed about bedrest. Client exhibits flat affect, appears inattentive, yawning, is restless, etc. ). Additional Diagnoses and Care Plans Fluid Volume Deficit: Maternal Related to: Active blood loss secondary to disrupt- ed placental implantation. Defining Characteristics: Describe bleeding episode (amount, duration, painless/painful, abdomen sofi/hard), 4 B/P, 9 P & R 4 urine output (specify values), pale, cool skin, 9 capil- lary refill (specify). Goal: Client will exhibit improved fluid balance by (date/time to evaluate). Outcome Criteria Client will experience no further vaginal bleeding; pulse < 100; B/P > (specify for individual client); capillary refill < 3 seconds. ~~ ~~ INTERVENTIONS RATIONALES ~ INTERVENTIONS RATIONALES Assess hourly intake and output. Assess B/P and P (specify frequency) and note changes. Monitor FHR. Assess abdomen for ten- derness or rigidity-if pre- sent, measure abdomen at umbilicus (specify frequen- cy) * Assess temperature (speci- fv: e. g., q 2-4h). Assess Sa02, skin color, temperature, moisture, tur- gor, and capillary refill (specify frequency). Assess for changes in LOC; note complaints of thirst or apprehension. Provide supplemental humidified oxygen as ordered via face mask or nasal cannula at 10-12 Llmin. Initiate IV fluids as ordered (specify the fluid type & rate). Assess color, odor, consis- tency, and amount of vagi- nal bleeding: weigh pads (1 g = 1 cc). Provides information about active bleeding v. old blood, tissue loss, and degree of blood loss. Position client supine with hips elevated if ordered or left lateral position if stable (specify). Provides information about maternal and fetal physiologic compensation for blood loss. Assessment provides infor- mation about possible infection, placenta previa, or abruption. Increasing abdominal girth suggests active abruption. Assessment provides infor- mation about development of infection. Warm, moist, bloody environment is ideal for growth of microorganisms. Assessment provides infor- mation about blood vol- ume, O2 saturation, and peripheral perfixion. Assessment provides infor- mation about cerebral per- fusion. Intervention increases available oxygen to satu- rate decreased hemoglobin. IV replacement of lost vas- cular volume. Position decreases pressure on placenta and cervical 0s. Left lateral position improves placental perfu- sion. Lab work provides infor- mation about degree of blood loss; prepares for possible transfusion.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 67 INTERVENTIONS RATIONALES Monitor lab work as obtained: H&H, Rh & type, cross-match for 2 units RBC's, urinalysis, etc. Arrange portable ultra- sound as ordered. Determine if client has any objections to blood trans- fusions-inform physician. Administer blood transfu- sions as ordered with client consent per agency proce- dure. Monitor closely for trans- fusion reaction following agency policy and proce- dures (specify). Provide emotional support; keep client and family informed of findings and continuing plan of care. Administer prenatal vita- mins and iron as ordered; provide a diet high in iron: lean meats, dark green leafy vegetables, eggs, whole grains. (Prepare client for cesarean birth if ordered: e. g., severe hemorrhage, abrup- tion, complete previa at term, etc. ) Ultrasound provides infor- mation about the cause of bleeding. Client may have religious beliefs related to accepting blood products. Provides replacement of blood components and volume. Potentially life-threatening allergic reaction may result from incompatible blood. Support and information decrease anxiety and help client and family to antici- pate what might happen next. Diet and vitamins replace nutrient losses from active bleeding to prevent anemia -iron is a necessary com- ponent of hemoglobin. Cesarean birth may be necessary to resolve the hemorrhage or prevent fetal or maternal injury. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (When was last bleeding noted? What is client's B/P, P, capillary refill time?) (Revisions to care plan? D/C care plan? Continue care plan?) Fear Related to: Threat to maternal and/or fetal sur- vival secondary to excessive blood loss. Defining Characteristics: Specify (Client states she is frightened [quotes]; client is crying, trem- bling, eyes are dilated. Client complains of muscle tension, dry mouth, palpitations, inability to con- centrate, etc. ). Goal: Client will exhibit decreased fear by (datehime to evaluate). Outcome Criteria Client will identify her fears and methods to cope with each. Client will report a decrease in fearful- ness. INTERVENTIONS RATIONALES Provide adequate time for discussion and a calm environment. Validate: the perception that the client, family are feeling fearful. Assist d. ient and family to identify specific fears. Listen actively to client and family's perception of threat. Provide accurate and hon- est information about client's condition and expected plan of care. Assist client and family to identi+ ways to cope with Calm environment and unhurried discussion pro- mote a decrease in anxiety. Validation provides infor- mation about client's behavior. Assistance allows identifi- cation of frightening thoughts. Active listening promotes understanding of client and family's perceptions. Fears may be based on unrealistic imaginings or misunderstanding. Planning a response to cope with situation may alleviate feelings of help-

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

68 MATERNALINFANT NURSING CARE I?-S INTERVENTIONS RATIONALES fears (e. g., preparation for getting to the hospital quickly should bleeding begin). Suggest and teach relax- ation techniques, creative visualization, etc. Assess degree of fearhlness after discussion. Validate client's feelings and plan for further discussion as needed. Arrange for other health providers to talk with client as appropriate (spec- i+ e. g., pastoral care, NICU staff, etc. ). lessness. Interventions promote relaxation and a sense of control. Evaluates effectiveness of teaching and discussion. Provides continual sup- port. Increased information may help client and family to feel calmer about possible outcomes. Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (List fears client verbalized. Does client report a decrease in fearfulness?) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 69 Placenta Previa painless vaginal bleeding ultrasound J complete previa marginal previa partial previa low-lying placenta bleeding stops fetus stable 1 bedrest observe bleeding dbntinues bleeding restarts cesarean birth vaginal or cesarean birth

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Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 71 Preterm Labor A term pregnancy lasts from 38 to 42 weeks after the LNMP Preterm labor refers to progressive uterine contractions, after 20 weeks and before 38 weeks gestation, that result in cervical change (effacement and dilatation). Preterm is a descrip- tion of fetal age, not maturity or size. Preterm birth is the number one cause of neonatal morbidity and mortality. Preterm birth may result from preterm labor, spontaneous preterm rupture of membranes, or the baby may be delivered early because of severe maternal or fetal illness. Infants born between 24 and 34 weeks have the highest incidence of complications. Complications may result in permanent physical and mental disabili- ties. Advances in neonatal intensive care have resulted in greatly improved outcomes for infants born after 34 weeks of gestation. The exact cause of preterm labor is unknown as is the exact mechanism that begins term labor. All pregnant women should be assessed for risk fac- tors and monitored carefully during pregnancy. Risk Factors Previous preterm labor or birth Infection: maternal or fetal 6 Chronic maternal illnesses: heart disease, kidney disease, diabetes mellitus Uterine or cervical anomalies or scarring, DES Pregnancy factors: multiple gestation, 'l' amni-exposure, trauma, abdominal surgery otic fluid (hydramnios), PIH, placenta previa or abruption, SROM Low socioeconomic status Frequent prenatal visits and assessments for clients at risk Horne uterine monitoring, decreased activity, bedrest, P. o., tocolytics, subcutaneous terbu- taline pump Hospitalization, hydration, antibiotics as indi Toccolytics: Mg SO,, i3-adrenergic receptor ago nists (ritodrine, terbutaline), others: pro,staglandin inhibitors, calcium channel blockers cated Testing: urinalysis, B-strep, fetal fibronectin, Betamethasone to 'l' fetal lung maturity Cervical cerclage for incompetent cervix amniocentesis: L/S ratio, phosphatidylglycera Nursing Care Plans Anxiety (22) Related to: Threat to fetal well-being secondary preterm labor/SROM. Defining Characteristics: Specify: (e. g., client i: tremblling, eyes dilated, shaking, crying, etc. Client verbalizes anxiety about fetal well-being) Activity Intolerance (23) Related to: Prescribed bedrest or decreased acti7 secondary to threat of preterm labor. Defining Characteristics: Specify: (e. g., client reports feelings of weakness, fatigue, shortness c breath, etc. ).

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

72 MATERNAL-INFANT NURSING CARE PLANS Diversionary Activity Deficit (62) Related to: Inability to engage in usual activities secondary to attempts to avoid preterm labor and birth. Defining Characteristics: Specify: (e. g., client reports feelings of boredom or depression related to bedrest or lack of activity). and Care Plans Injury, Risk for: Matema WFetaal Related to: Risk for preterm birth. Adverse effects of drugs used to prevent preterm birth. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client and fetus will not experience preterm birth or injury from drugs used to stop preterm labor by (date/time to evaluate). Outcome Criteria Contractions will stop. FHR will remain 1 10-1 60 with accelerations. Client's B/P will remain > 100/70 (or specify for client), pulse < 120 (or specify), respirations > 14, DTR's 2+ (or specify for client). INTERVENTIONS RATIONALES Position client on left side as much as tolerated. Change to right side if client becomes uncomfort- able-avoid supine posi- tion. Explain all procedures and equipment to client and Positioning hcilitates uteroplacental perhsion. Supine position causes compression of the inferior vena cava by the heavy uterus, 4 blood flow to the heart and 4 B/P and placental perfusion. Client and significant other may be experiencing 1NTEIWI"IONS RATIONALES ~ ~ ~~~ significant other. Provide high anxiety and need accurate information while repeated explanations. providing emotional sup- port. Place external fetal moni- tor on client; also assess uterine contractions by palpation to determine fre- quency, intensity, and labor contractions. duration (specify frequen-External tocodynamometer does not provide informa- tion on contraction inten- sity, may not show preterm cy) * Assess FHR for baseline rate, variability, accelera- tions, or decelerations (specify frequency). Perform sterile vaginal exam if indicated (as ordered)-limit exams. Place client on cardiac monitor if ordered. Obtain baseline vital signs. Monitor for tachycardia or dysrhythmias. Start an IV with designat- ed fluids (specify) at ordered rate (specify) via IV pump. Provide bolus if ordered then reduce rate as ordered (specify). Prepare piggyback IV tocolytic medication as ordered or per policy (specifjl: e. g., drug strength, dose, IV solu- tion). Piggyback tocolytic to mainline IV and begin inhion via pump at des-Assessment provides infor- mation about fetal well- being. Vaginal exam provides information about fetal presentation and labor progress-excessive exams may introduce infection or stimulate labor. Beta-adrenergic agonists (ritodrine, terbutaline) may cause hypotension from relaxation of smooth muscle resulting in tachy- cardia and additional stress on the heart. Provides venous access, hydration, and a port for piggyback medications. Careful preparation of tocolytic drugs ensures the proper dose will be given. Piggyback allows the drug to be discontinued while maintaining venous access. Pump ensures the client receives the right dose.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

INTERVENTIONS RATIONALES ignated rate (specify load- ing dose and titration). Teach client about side effects of the drugs; (speci- fy: Mg SO, causes feelings of warmth, flushing; terbu- taline or ritodrine may cause J, BIP, tachycardia (mom and baby), feeling “jittery,” possible N&V). Monitor maternal vital signs, breath sounds, and DTR's as ordered or per protocol for drug (specify). Monitor hourly I&O- notify physician if output < 30 cclhr. Assess skin tur- gor, mucous membranes (specify frequency). Apply TED hose if ordered. Discontinue tocolytic and notify physician if signs of complications develop (specify: for 8-adrenergics, chest pain, > G PVC'sihr, s. o. b., maternal HR z 140, FHR > 200, etc. ; for Mg S04, respirations < 12, absent DTRH, etc. ). Monitor labs as obtained noting potassium and glu- cose levels if g-adrenergics are used, magnesium level if Mg S0, is used (speci- fy). Keep antidotes to medica- tions at bedside (specify: calcium gluconate for Teaching prepares client for unfamiliar sensations, J, anxiety for client. Monitoring provides infor- mation about response to drug. Monitoring provides infor- mation about fluid bal- ance. Adequate renal func- tion is necessary for excre- tion of the drugs. Compression stockings facilitate venous return from extremities. Discontinuing the drug prevents serious complica- tions from tocolytic med- ications: cardiac dysrhyth- mias, pulmonary edema, and respiratory depression. Monitoring labs provides information about compli- cations of drug therapy: h yperglycemia, hypokalemia, and magne- sium toxicity. Antidotes reverse the action of drugs (specify for drug used). INTEKVENTIONS RATIONALES Mg SO,, beta-blockers may be used for 8-adrenergic tocolytics). Administer p. 0. tocolytics as ordered (specify: when, drug, dose, and time). Provide and monitor results of fetal testing as ordered. : amniocentesis for US ratio, PG's, NST, etc. Administer betamethasone IM as ordered (specify: dose, timing). Explain rationale to parents. Arrange for a NICU nurse to talk with client and family about preterm infants and the NICU environment. Ensure that all involved health care providers are kept informed of client's status. (Describe action of p. 0. tocolytic. ) Allows client to be maintained without IV meds. Fetal testing provides information on fetal matu- rity and well-being. Glucocorticoids may be given between 28-34 weeks and delivery delayed for 24-48 hours in an attempt to hasten fetal lung maturity. Consultation provides anticipatory information to client at risk for preterm birth. An informed health care team ensures readiness and continuity. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (Have contractions stopped? Is FHR between 110-1. 60 with accelerations? What are client's v/s: B/P, P, R, and DTR's?) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

74 MATERNALINFANT NURSING CARE PLANS Knowledge Dejcit: Preterm Labor Prevention Related to: Unfamiliarity with preterm labor (signs/symptoms, and prevention). Defining Characteristics: Client reports that she doesn't know the s/s of preterm labor (specify with quote). Client is at risk for preterm labor (specify: substance abuse, multiple gestation, IDDM, etc. ). Goal: Client will verbalize 9 knowledge about preterm labor by (datehime to evaluate). Outcome Criteria Client will describe s/s of preterm labor (specify: regular contractions, lower back pain, pelvic pres- sure, cramps, etc. ). Client will describe steps to take to avoid preterm labor (specify: drink 2-3 quartdday, void q 2h, stop smoking, report early s/s UTI, etc. ). INTERVENTIONS RATIONALES Assess client's risk factors for preterm labor, educa- tion level, and ability to understand teaching (pro- vide interpreter if needed). Provide a comfortable quiet setting for teaching- invite family to participate in session(s). Assess client's understand- ing of the risks of preterm labor and birth for her baby. Correct any misconcep- tions and provide informa- tion on fetal lung develop- ment. Assessment provides infor- mation to guide planning an individualized teaching program to ensure client understanding. Interventions decrease dis- tractions and promote learning; family may rein- force teaching and help client comply. Some clients may believe that preterm infants have few problems or that 7 month babies do better than 8 month gestations (old wives tale). Accurate information encourages compliance. INTERVENTIONS RATIONALES Help client to identify Braxton-Hicb contrac- tions she may be experi- encing: if she says she doesn't have any, ask her the baby ever “balls up” (or other terms to help understanding) and if - explain that this is a con- traction. Teach client to palpate Braxton-Hicks contrac- tions at the fundus, mov- ing fingertips around. Teach to time frequency of contractions from the start of one contraction to the beginning of the next. Praise efforts. Teach client to lie down on her left side 2 or 3 times a day and palpate for contractions noting fetal movements (“kick counts”) and to keep a journal of findings. Teach client other sls of preterm labor to report: dull low back pain, pelvic pressure, abdominal cramping with or without diarrhea, or an increase in vaginal discharge (especial- ly if watery or bloody); other sls of infection. Teach client s/s of urinary tract infections to report: frequency, urgency or burning on urination. Teach to wash hands and wipe from front to back after using the bathroom. Assistance empowers the client to recognize mild uterine contractions. Many women are unaware that Braxton-Hicks are contrac-tions even if they are not painful. Teaching promotes self- care and assessment skills. The fundus is the thickest part of the uterus where contractions are most easi- ly felt. Teaching promotes aware- ness of sensations of con- tractions and fetal move- ment. Journal provides a written record of activity. Teaching empowers client to recognize subtle signs of preterm labor. Client may not experience contrac- tions as such. Urinary tract infections may precede preterrn labor. Hand washing and wiping front to back prevents fecal contamination of urethra or vagina.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 75 INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Instruct client to drink a glass of water or juice every hour, or 2-3 quadday and to void at least every 2h while awake. Teach client to avoid overexertion, heavy lifting, or staying in one position for long periods (sitting or standing). Have employer contact physician if this is a problem. Instruct client to avoid nipple stimulation and possibly avoid sexual inter- course or to use condoms as advised by caregiver. Teach proper administra- tion of p. 0. tocolytics if ordered (specify: drug, dose, route, times, etc. ). Teach side effects to call physician for (specify). Arrange for additional teaching if terbutaline pump and/or home uter- ine monitoring is to be used. Encourage client to stop smoking if indicated-refer to support group or smok- ing cessation program. Instruct client that if she feels an unusual increase in contractions to drink a large glass of water and lie down on her left side. If pattern continues for 20- 30 minutes or becomes more intense to call the Dehydration or a distend- ed bladder may increase uterine irritability/activity. Teaching helps client avoid ligament and muscle strain, changing position facilitates circulation, uteroplacental perhsion, and venous return. Instruction avoids activity that may cause the release of oxytocin from posterior pituitary gland. Semen contains prostaglandins that may affect uterine activity. (Describe action of specific drug as it relates to uterine activity. Specify why these side effects are dangerous. ) Additional instruction pro- vides information the client needs if these modalities are ordered. Smoking has been impli- cated in preterm labor. Instruction allows client to have some control over evaluation of preterm labor. ~~ physician or go to the hos- pital for evaluation. Praise client and family for ability to comply with instructions and reinforce ance. that each day labor is held off is another day for her baby's lungs to mature. Provide pamphlets, books, videos, :and refer client and family to support groups if available. Provides encouragement and incentive for compli- Reinforces teaching, may provide additional coping ideas. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (What signs of preterm labor can client identify? What steps to avoid preterm labor does client ver- balize?:) (Revisions to care plan? D/C care plan? Continue care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

76 MATERNAL-INFANT NURSING CARE PLANS Preterm labor SROM chorioamnionitis maternal svstemic overdistended uterus multiple gestation hydraminos incompetent cervix uterine anomalies complications of preg;nancv PIH previa abruption anomalies Unknown Causes

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 77 Preterm Rupture of Preterm rupture of the fetal membranes describes ruptured membranes before 38 weeks of gestation. The term refers to the gestational age of the fetus at the time of rupture. Premature rupture of membranes (PROM) describes membrane rupture before the onset of labor. 'PROM may occur with either term or preterm gestations. The terminolo- gy for ruptured membranes with no labor before 38 weeks gestation would be preterm premature rupture of membranes or PPROM. Like preterm labor, the exact cause of preterm rupture of membranes is unknown. Infection, which may not be clinically apparent, is often implicated and is also one of the most serious complications. Comalications Gross rupture early in pregnancy: deformities (amputation) from adhesion of amnion (amni- otic bands) to fetal parts, musculoskeletal defor- mities from fetal compression, pulmonary hypo plasia tum endometritis Infection: chorioamnionitis, maternal postpar- Abnormal presentation (breech, transverse lie) Prolapsed cord Possible abruption Severe decelerations during labor from cord compression Risk Factors Materna Vfetal infection. Overdistended uterus: multiple gestation, poly- hydraminos Preterm labor and factors that cause preterm labor Incompetent cervix Maternal trauma Medical Care Confirmation of rupture of membranes: nitrazine test; sterile speculum exam to visualize fluid and cervix; ferning test of fluid Determination of gestational age of fetus: LNMP, ultrasound measurements, and possible amniocentesis to determine L/S ratio and pres- ence of PG Expectant management: monitor for infection and contractions-may discharge to home on bedrest with BRP after stabilization Urinalysis and daily CBC Vaginal cultures for gonorrhea, group B strepto- coccus; possible antibiotic therapy if positive; if infe:ction is evident, the fetus is delivered by induction or cesarean Serial fetal testing: daily NST, Biophysical Profiles (BPP), ultrasound estimation of amni- otic fluid index (AFI), possible weekly amnio- centesis for lung maturity May give glucocorticoids (betamethasone) to enhlance fetal lung maturation-may use tocolytics to prevent birth for 24 to 48 hours after administration

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

78 MATERNALINFANT NURSING CARE PLANS . If fetus is mature, may carefully induce labor after waiting 12 hours for labor to ensue natu- rally Nursing Care Plans Anxiety (22) Related to: Threat to maternal or fetal well-being secondary to risk for infection or preterm birth. Defining Characteristics: Specify: (Client reports increased worry and anxiety. Client exhibits difi- culty remembering information, crying, etc. ). Activity Intolerance (23) Related to: Enforced bedrest during complicated pregnancy. Defining Characteristics: Specify: (Client reports feeling weak or tired; decreased muscle tone, con- stipation, etc. ). Diversionary Activity Deficit (62) Related to: Inability to engage in usual activity due to enforced bedrest. Defining Characteristics: Client reports boredom, depression (specify). Client exhibits withdrawal, sleeps more than usual, etc. (specify). Injury, Risk for: Materna UFetal(72) Related to: Tocolytic drugs used to delay birth for administration of glucocorticoids. Additional Diagnoses and Care Plans Infiction, Risk for: Maternal/Fetal Related to: Site for organism invasion secondary to preterm rupture of fetal membranes. Defining Characteristics: None, since this is a potential diagnosis. Goal: Client and fetus will not experience infec- tion related to preterm rupture of membranes by (datehime to evaluate). Outcome Criteria Client's temperature will be < 39. 5" F, amniotic fluid will remain clear with no offensive odor. INTERVENTIONS RATIONALES Confirm rupture by testing external fluid (no vaginal exams) with nitrazine paper. Note date and time of rupture. Apply external fetal moni- tor; assess fetal well-being and palpate for uterine contractions (specify fre- quency of monitoring). Assist caregiver with sterile speculum exam, ferning test, and vaginal cultures- monitor the lab results. Obtain specimens for CBC and urinalysis as ordered (specify: e. g., daily CBC)-monitor the lab results. Administer antibiotics as ordered (specify drug, dose, route, time). Provide accurate informa- tion and emotional sup- port to client and family. Allow time for questions. Assess client's temperature q 2-4 hours (specify). Notify caregiver if > 99. 5" F. Positive nitrazine test pro- vides documentation of rupture date and time. Vaginal exam might intro- duce microorganisms. Assessment provides infor- mation about fetal well- being and preterm labor. Interventions provide information about mem- brane status and possible infection. Laboratory studies provide information about possible inflammation and infec- tious processes. (Specify action of individ- ual drug. ) Client and family may be anxious and confused about prognosis for their baby. Assessment provides infor- mation about the develop- ment of infection.

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

PREGNANCY 79 INTERVENTIONS RATIONALES (What is client's temperature? Is fluid clear with no foul odor?) (Revisions to care plan? D/C care plan? Continue Thick foul-smelling fluid may indicate chorioam-Monitor color, amount, and odor of vaginal dis- charge. Notify caregiver if increased amount, color changes, or foul odor is noted. Maintain client on bedrest with BRP (shower) if ordered. Assistlinstruct client in good hygiene practices: hand washing technique, perineal care. If client wants to wear a peri pad for leakage, instruct her to change it at least every 2 hours. Monitor fetal well-being: perform daily NST's as ordered, note presence of variable decelerations; arrange other testing as ordered (specify: e. g., BPP, amniocentesis for L/S ratio and PG, ultrasound for AFI). If client is to be discharged to home, teach her to read a thermometer accurately, to take her temperature every 4 hours, remain on bedrest with BW, avoid sexual intercourse, and notify her physician for: temp > 99. 5" F, uterine tenderness/contractions, 9 leakage, or foul-smelling discharge. nionitis; increased fluid loss may put the fetus at risk for cord prolapse. Bedrest may decrease the amount of active fluid loss. Teaching helps prevent the spread of microorganisms from the environment to the genital area. Moist, warm peripad provides a favorable environment for organism growth. Monitoring provides infor- mation about fetal stress, which may result from sepsis; cord compression, maturity, and amount of amniotic fluid. Teaching promotes safety and self-care. Some clients have difficulty reading a regular thermometer, signs of infection may necessi- tate delivery. Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) care plan?)

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf

80 MATERNALINFANT NURSING CARE PLANS Preterm Rupture of Membranes Membrane Rupture < 38 weeks . c + nitrazine test + ferning test Calculation of Gestational Age Monitor fo Infection J 5-\ c 34 weeks s/s of infection > 34 weeks No labor No s/s infection No labor No s/s infection I 1 1 1 Ekpec. tant Expectant management Delivery management or (steroids) Induction after Fetal testing 12 hours without labor PG present

Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf