Ch. 14 Notes PDF

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CHAPTER 14 NURSING CARE OF THE FAMILY DURING PREGNANCY -

The prenatal period is a time of physical and psychologic preparation for birth and parenthood.

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Prenatal health care enables discovery, diagnosis, and treatment of preexisting maternal disorders and any disorders that develop during the pregnancy, prenatal care is designed to monitor the growth and development of the fetus and to identify abnormalities that will interfere with the course of normal labor and birth.

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First trimester lasts from weeks 1 through 13; the second from weeks 14 through 26; and the third from weeks 27 through 40. A pregnancy is considered to be at term if it advances to 37 weeks or more.

ESTIMATING DOB -

The Naegele rule is a common method for calculating the EDB. Example:

ESTABLISHING A RELATIONSHIP WITH THE FETUS Rubin’s 3 Phases -

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Phase 1: The woman accepts the biologic fact of pregnancy. She has to be able to state, “I am pregnant” and to incorporate the idea of a child into her body and self-image. The woman’s thoughts center around herself and the reality of her pregnancy. The child is viewed as part of herself, not as a separate and unique person. Phase 2: The women accepts the growing fetus as distinct from herself. This is usually done by the 5th month. This differentiation of the child from the woman’s self marks the beginning of the mother-child relationship, which involves not only caring but also responsibility. She puts more attention on her fantasy child. Phase 3: At this point in the attachment process, the woman prepares realistically’ for the birth and parenting of the child. She expresses the thought, “I am going to be a mother” and defines the nature and characteristics of the child. She may, for example, speculate about the child’s sex (if unknown) and personality traits based on patterns of fetal activity.

CARE MANAGEMENT -

Traditional Model: The initial visit usually occurs in the first trimester, with monthly visits through week 28 of pregnancy. Thereafter, visits are scheduled every 2 weeks until week 36 and then every week until birth. Women with low-risk pregnancies may have fewer routine prenatal visits, whereas those at risk for complications may be seen more frequently than the traditional schedule would suggest.

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Centering Pregnancy: A well-known model of group prenatal care that involves three components: health care, education, and peer support.

Initial Visit: - Prenatal Interview: The therapeutic relationship between the nurse and the woman is ideally established during the initial assessment interview. o Reproductive System History and Health History:

Includes physical conditions or surgical procedures that can affect the pregnancy or that can be affected by the pregnancy. For example, a pregnant woman who has diabetes, HTN, or epilepsy requires special care. If a woman has undergone uterine surgery or extensive repair of the pelvic floor, a cesarean birth may be necessary. o

Nutritional History: Nutritional status has a direct effect on the growth and development of the fetus. We want to know about any food allergies, eating disorders, folic acid intake, and the practice of Pica. Gaining too much or not enough needs to be assessed. Pica interferes with the absorption of minerals and nutrients. Expect a decreased Hgb level.

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History of Medication and Herbal Use: Alcohol, tobacco, and other drug usage needs to be assessed. There is no safe level of ETOH usage in pregnancy and can lead to Fetal Alcohol Syndrome in which there is no cure. We want to assess caffeine intake and suggest no more than 200mg/day (12 oz cup of coffee). Opioid abuse can cause increased change of birth defects, neural tube defects (anencephaly and spina bifida), heart defects and abdominal wall defects, premature delivery, miscarriage, and addiction.

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Family History: These data help identify familial or genetic disorders or conditions that could affect the health status of the woman or her fetus. The family history of the woman’s partner is important in identifying risk factors that can affect the fetus.

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Mental Health Screening: As part of routine prenatal care, all women should be assessed and screened for mental health issues.

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History of Abuse: If history of IPV is reported, it is likely to see an increase in IPV over pregnancy.

Lab Work: Urine, cervical, and blood samples are routinely obtained during the initial visit for a variety of recommended screening and diagnostic tests for infectious diseases and metabolic conditions that can affect the mother and/ or developing fetus.

Follow Up Visits: - Interview: briefer and less intensive. -

Physical Examination: The woman’s BP and weight are assessed. During each examination, the nurse must remain alert for supine hypotension—low BP that occurs while the woman is lying on her back. o Progresses with pregnancy as abdominal contents are heavier and laying down compresses the vena cava. Turn to side until symptoms subside and vitals return to normal. o S/S: pallor, dizziness, faintness, breathlessness, nausea, clammy skin, tachycardia.

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Fetal Assessment: Gestational Age: -First uterine evaluation: date, size -Fetal heart first heard: date, method -Date of first feelings of fetal movements -Current fundal height, estimated fetal weight -Current week of gestation by history of LMP and/or ultrasound examination

-Ultrasound Examination -Reliability of dates Health Status: -Assessment of the fetus’s health status often includes consideration of fetal movement. -Absence of fetal movement is correlated with fetal death; women who report decreased fetal movement have an increased risk for an adverse outcome. -Note the extent and timing movements and to report immediately if the pattern changes or if movements decrease. Fundal Height: -The fundal height (measurement of the height of the uterus above the symphysis pubis) is one indicator of fetal growth. From gestational weeks (GWs) 18 to 30, the height of fundus in centimeters is approximately the same as the number of weeks of gestation (±2 GW) if the woman’s bladder is empty at the time of measurement. -

Lab Work: A clean-catch urine specimen is obtained to test for glucose, protein, nitrites, and leukocytes at each visit. o Group B streptococcus (GBS) testing is recommended between 35 -37 weeks of gestation; All pregnant women should have testing, even those who are scheduled for a cesarean delivery because labor can begin or membranes rupture prior to the administration of prophylactic antibiotics. o GBS is tested to determine if it will affect infant at the time of delivery. It is normal flora. Will not treat until in labor because the normal flora will return. GBS positive moms can cause significant respiratory issues in infant. Will treat mom as positive if she has never been tested.

NURSING INTERVENTIONS Education for Self-Management -

Expected maternal and fetal changes Nutrition

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Personal Hygiene: Sweat glands are highly active because of hormonal influences, and women often perspire freely. Is normal.

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Prevention of UTI: Physiologic changes that occur in the renal system during pregnancy cause UTI infections more frequently. UTI’s can be asymptomatic, but common S/S include frequency, urgency, dysuria, dribbling and hesitancy, and gross hematuria. Teach hand hygiene, correct wiping, fluid intake, and do not ignore urge to pee.

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Kegel exercises: strengthen the muse the reproductive organs and improve muscle tone. Exercised muscle can then stretch and contract readily at the time of birth. Practice of pelvic muscle exercises during pregnancy results in fewer complaints of urinary incontinence in late pregnancy and postpartum. “stop the flow”

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Preparation for Breastfeeding: breast implants, inverted nipples (breast shells). The woman is taught to cleanse the nipples with warm water to keep the ducts from being blocked with dried colostrum. Soap, ointments, alcohol, and tinctures should not be applied because they remove protective oils that keep the nipples supple. A bra that fits well and provides support promotes comfort as breasts increase in size during pregnancy.

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Oral health: increased incidence of gingivitis and periodontitis. Encourage moms with N/V to rinse with a solution of baking soda after vomiting to prevent tooth erosion. Suggest a dental visit in 2 nd trimester as there is no more N/V and mom can sit more comfortably.

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Immunizations: Immunization with live or attenuated live is contraindicated during pregnancy because of potential teratogenicity. Live-virus vaccines include those for measles (rubeola and rubella), varicella (chickenpox), and mumps. Vaccines that can be administered during pregnancy include combined tetanus-diphtheria-acellular pertussis (Tdap), recombinant hepatitis B, and influenza (inactivated) vaccines. To provide a maximal maternal antibody response and transfer passive immunity to the infant, Tdap should be administered between 27 and 36 weeks or gestation.

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Recognizing potential complications: One of the most important responsibilities of care providers is to alert the pregnant woman to signs symptoms that indicate a potential complication. These include vaginal bleeding, alteration in fetal movements, symptoms of preeclampsia, rupture of membranes, and preterm labor. o Vaginal Bleeding: impending miscarriage. o Fluid discharge from vagina: premature rupture of membranes. o Decreased or no movement: fetal jeopardy or demise. o Hyperemesis Gravidarum: o Cramping: preterm labor or miscarriage. o Headaches that are severe, frequent, or continuous: preeclampsia, HTN. o Abdominal Pain: HTN, preeclampsia, abruptio placentae. o Weight Gain: preeclampsia.

DAILY FETAL MOVEMENT COUNT: -

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“Kick Count” can be assessed at inexpensive, and simple to understand. During the third trimester, the fetus makes about 30 gross body movements each hour. Count once a day for 60 minutes, count fetal movement two or three times a day for 2 hours, or until 10 movements are counted or count all fetal movements in a 12 hr period each day until a minimum of 10 movements are reached. The situation in which fetal movements cease entirely for 12 hours (fetal alarm signal). A count of fewer than 3 fetal movements within 1 hour warrants further evaluation by a nonstress test (NST) or a contraction stress test (CST) and a complete or modified biophysical profile (BPP). Or if a decrease in pattern.

HYPEREMESIS GRAVIDARUM: -

When vomiting during pregnancy becomes excessive enough to cause weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria, the disorder is termed hyperemesis gravidarum. Hyperemesis gravidarum usually begins during the first trimester, but approximately 10% of women with the disorder continue to have symptoms throughout the pregnancy. Hyperemesis gravidarum is the second most common reason for hospitalization during pregnancy in the United States and requires IV therapy for correction of fluid and electrolyte imbalances. Typically treated with Diclegis which is a single tabled that provides delayed-release effects. Also treated with vitamin B6 and Unisom. Reglan is also given to accelerate gastric emptying and correct gastric dysrhythmias. Once vomiting has stopped, feedings are started in small amounts at frequent intervals. In the beginning, limited amounts of oral fluids and bland foods like crackers, toast, or baked chicken are offered.

DISCOMFORTS RELATED TO PREGNANCY TABLE 14.2...