NCP Elective Termination

Elective Termination
Therapeutic abortion may be done to safeguard the woman’s health, or a voluntary abortion may be a woman’s reproductive decision.
CLIENT ASSESSMENT DATA BASE
Circulation
Preexisting maternal health problems placing client at risk
Ego Integrity
Pregnancy often unplanned; may be result of incest/rape.
May express concern about decision and future expectations.
Possible feelings of abandonment, i.e., loss of contact with male partner.
Stress factors may include inadequate finances, cultural/religious conflicts, and individual plans for the future.
May have strong feelings/beliefs regarding abortion that may be in conflict with present situation (e.g., conception is result of incest or rape); lack of support, or family/other pressures to have abortion.
Food/Fluid
Severe nausea and vomiting
Safety
History of pelvic inflammatory disease, STDs, or exposure to contagious diseases, such as rubella
Exposure to toxic/teratogenic agents
Sexuality
Lack of, or inadequate use of, birth control measures.
Menstrual history may include problems such as endometriosis, heavy flow, or irregular periods.
Uterus may be in extreme flexion or version.
Absence of adnexal masses (rules out ectopic pregnancy).
Vaginal bleeding may be present.
Social Interaction
Possible lack of support systems or conflict within the family/couple.
Teaching/Learning
Family history of genetic conditions.
Client’s perception of reasons for pregnancy termination, influencing factors, and anticipated effects may/may not be clear; alternatives may not have been considered/discussed or explored.
DIAGNOSTIC STUDIES
Complete Blood Count (CBC), Blood Type, and Rh Determination: Identifies individual needs.
Urine or Radioimmunoassay of Serum for Human Chorionic Gonadotropin (HCG): Verifies pregnancy.
Papanicolaou Smear: Rules out dysplasias.
Gonorrheal Culture, Rapid Plasma Reagin (RPR): Determine presence of STD.
Ultrasonography: May be done to confirm the pregnancy, to date the pregnancy, or to localize the placenta, if there is some discrepancy between uterine size and estimated date of birth.
Genetic Testing/Screening: Identifies affected fetus, which may be reason for decision to terminate pregnancy.
NURSING PRIORITIES
  1. Evaluate biopsychosocial status.
  2. Promote/augment coping strategies.
  3. Provide emotional support.
  4. Prevent postprocedural complications.
  5. Provide appropriate instruction/information.
DISCHARGE GOALS
  1. Free of complications following procedure
  2. Coping effectively with situation
  3. Specific therapeutic needs and concerns understood
NURSING DIAGNOSIS:                                                               Decisional Conflict, risk for
Risk Factors May Include:                                                               Unclear personal values/beliefs, lack of experience or interference with decision making, lack of relevant sources of information or information from multiple or divergent sources, support system deficit
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Acknowledge feelings of anxiety/distress related
CRITERIA—CLIENT WILL:                                                     to making difficult decision.
Verbalize confidence in the decision to terminate the pregnancy.
Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.
Display relaxed manner and/or calm demeanor, free of physical signs of distress.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Ascertain circumstances of conception and                                           Allows the nurse to determine whether the
response of family/significant other. Encourage                                    client/couple has explored alternatives. The
client to talk about the issues and process used                                      decision to terminate a pregnancy may have been
to problem-solve and make decision                                                      based on an inability to problem-solve or a lack of
regarding termination.                                                                             support and resources.
Note expressions of indecision and                                                        May indicate ambivalence about decision and
dependence on others.                                                                            need for further information and discussion.
Assist client to look at alternatives and use                                            Helps client to reinforce reasons for decision and
problem-solving process to validate decision.                                       to be comfortable that this is the course she wants
Involve significant others as appropriate.                                               to pursue.
Provide explanations about the procedure                                              Lack of knowledge about the procedures,
desired by the client, pre-procedural and                                               reproduction, or self-care may contribute to the
post-procedural tests, examinations, and follow-up.                              client’s/family’s inability to cope positively with this
event, which may be behaviorally manifested by the
client canceling appointments or verbalizing
ambivalence. By eliminating fear of the unknown and
by reinforcing reasons for and appropriateness of
decision, ongoing verbalization can foster positive
decision making.
Evaluate the influence of family and significant                                    Conflict can arise within the client herself as well
other(s) on the client.                                                                              as within the family. Allows the nurse to encourage
positive forces or provide support where it is lacking.
Remain with the client during examinations and                                   Physical presence of nurse can help client feel
the procedure. Provide both physical and                                              accepted and reduce stress.
emotional support.
Act as a liaison and lend support to significant                                      Helps reduce stress and encourages significant
other(s).                                                                                                   other(s) to be supportive of the client.
Collaborative
Review safe options available based on gestation.                                 Assists client in making informed decision.
Obtain/review informed consent.                                                           Depends on agency guidelines. No procedure
should be performed unless the client freely
consents to it.
Refer for additional counseling or resources,                                         Some clients may be more affected by the decision
if needed.                                                                                                 and may require additional support and/or
education or genetic counseling.
NURSING DIAGNOSIS:                                                               Knowledge deficit [Learning Need], regarding reproduction, contraception, self-care, Rh factor
May Be Related To:                                                                        Lack of exposure/recall or misinterpretation of information
Possibly Evidenced By:                                                                   Request for information, statement of misconception, inaccurate follow-through of instructions, development of preventable events/complications
DESIRED OUTCOMES/EVALUATION                                    Verbalize accurate information about the
CRITERIA—CLIENT WILL:                                                     reproductive system.
Explain proper use of desired contraceptive methods.
Demonstrate appropriate follow-through with treatment and aftercare.
Receive Rho(D) immune globulin within 72 hr of termination, if appropriate.
Verbalize the implications of the Rh factor for planning future pregnancies or for receiving blood transfusions.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess level of client knowledge, and provide                                       Knowledge is essential to prevention of future
information about reproduction. Use charts                                           unplanned pregnancies. Written and visual
and diagrams.                                                                                          materials are more concrete and easily understood.
Discuss alternative methods of contraception.                                        Client needs information to be able to choose a
method that is right for her. Ovulation may occur
before menses resume, so contraception needs to be
considered at this time.
Give specific instructions, preferably written,                                       Client may have a method of contraception
about the contraceptive chosen.                                                              prescribed prior to discharge. Because of the anxiety
and stress associated with the termination, verbal
information may not be retained.
Reinforce postabortion instructions concerning                                     The stress/anxiety caused by the procedure can
the use of tampons and resumption of sexual                                         diminish the client’s ability to retain information.
activity, exercise, and prescribed antibiotics,                                         Written instructions can be reviewed when
if applicable. Provide written instructions.                                             necessary. Note: Specific time frames vary according
to practitioner.
Provide information about the implications of Rho                               The client may not be aware of her blood type or
(D)-negative blood and the need for RhIgG                                           the implications for future pregnancies if she is
administration.                                                                                         Rho(D)-negative. Understanding may promote
positive self-care, enhance cooperation, and help
prepare client for future pregnancies.
Identify signs/symptoms to be reported to                                             Prompt evaluation/intervention may prevent or
healthcare provider.                                                                                limit complications.
Collaborative
Verify Rh-negative status and administer RhIgG.                                 For the Rho(D)-negative client, RhIgG prevents
Give 50 mg for early abortion; otherwise, dosage                                 anti-Rh-positive antibody formation, so that
is the same as for delivery or fetal hemorrhage in                                 negative effects on future pregnancies are avoided.
the nonsensitized client.                                                                          Microdoses are given for early abortions, and this
dose is sufficient up to 12 weeks’ gestation. Fetal
RBCs may be noted as early as 38 days after
conception.
NURSING DIAGNOSIS:                                                               Spiritual Distress (distress of the human spirit), risk for
Risk Factors May Include:                                                             Perception of moral/ethical implications of therapy
Possibly Evidenced By:                                                                   [Not applicable; the presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Discuss beliefs/values about spiritual issues.
CRITERIA—CLIENT WILL:
Verbalize acceptance of self/decision.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Note comments indicating feelings of guilt,                                          There may be conflict with family/significant
negative self-concept/self-esteem, and ethical                                       other(s) regarding the morality of the client’s
or religious value conflicts.                                                                     decision, which can create confusion for the client.
Discuss alternatives to abortion with the client                                      A decision based on a rational choice is less likely
and significant other(s), if present. Maintain                                         to result in conflict.
nonjudgmental attitude.
Assist with problem solving within the client’s                                     The ability to project the consequences of a
ethical and religious framework.                                                            decision or to explore alternatives may be hampered
by anxiety and emotion.
Support the client’s decision.                                                                  Client may have few, if any, support systems
available at this time and may need a nonjudgmental
resource.
Explain the grief response that may occur.                                             Client may not expect to feel loss.
Stress the importance of follow-up visits.                                              There may be delayed psychological reactions, which
can be assessed at the follow-up visit along with the
physical status.
Collaborative
Refer to clergy/spiritual advisor, or                                                        Some clients may need additional counseling
professional counseling. (Refer to CP: The High-                                 before and after abortion to help them resolve
Risk Pregnancy; ND: Coping, Individual/                                              feelings of conflict or guilt.
Family, ineffective.)
NURSING DIAGNOSIS:                                                               Anxiety [specify level]
May Be Related To:                                                                        Situational/maturational crises, unmet needs, unconscious conflict about essential values/beliefs
Possibly Evidenced By:                                                                   Increased tension, apprehension, fear of unspecific consequences, sympathetic stimulation, focus on self
DESIRED OUTCOMES/EVALUATION                                    Recognize the presence of anxiety.
CRITERIA—CLIENT WILL:
Identify the cause of anxiety.
Begin to use positive coping strategies to adjust to the situation.
Report anxiety reduced to a manageable level.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Acknowledge the client’s anxiety. Encourage                                       client may need assistance in recognizing
ventilation of feelings.                                                                            reactions.
Be empathic and nonjudgmental.                                                            Conveys a caring attitude.
Provide instruction in breathing and                                                      Holding the breath and tightening the muscles
relaxation techniques.                                                                             may influence physiological responses (BP, pulse,
and respiration). Tense muscles may interfere with
the procedure.
Explain procedures before they are performed,                                     A physical presence is reassuring and can increase
and stay with the client to provide                                                          cooperation and promote a sense of security.
concurrent feedback.
Have a support person remain with the                                                  The presence of a familiar person can help reduce
client, particularly if she is undergoing a                                               anxiety and promote relaxation and coping.
second-trimester procedure requiring
induction of labor.
NURSING DIAGNOSIS:                                                               Pain/[Discomfort]
May Be Related To:                                                                        Aftereffects of procedure/drug effect
Possibly Evidenced By:                                                                   Report of discomfort, distraction behaviors,
changes in muscle tone, autonomic responses/change in vital signs
DESIRED OUTCOMES/EVALUATION                                    Identify/use methods that provide relief.
CRITERIA—CLIENT WILL:
Report discomfort is minimized and/or controlled.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Explain to client the nature of discomfort expected.                              Knowledge helps the client to cope with reality.
Cramping pain during, and for 1 wk after, a first-
trimester termination is expected. Clients treated
with prostaglandins may experience nausea,
vomiting, and diarrhea.
Determine the extent/severity and location of                                        Although some discomfort is expected, severe
discomfort.                                                                                              cramping and abdominal tenderness may indicate
complications.
Provide instruction in relaxation and                                                      May help break the cycle of fear, tension, and pain;
breathing techniques.                                                                              provide distraction; and enhance coping.
Collaborative
Administer narcotic/nonnarcotic analgesics,                                          These drugs promote relaxation, decrease pain
sedatives, and antiemetics, as indicated.                                                 awareness, and control side effects of treatment (drug
therapy).
Provide information about the use of                                                     Specific instructions about the use of any drugs
prescription or nonprescription analgesics.                                            increases awareness of safe use and side effects.
NURSING DIAGNOSIS:                                                               Injury, risk for maternal
Risk Factors May Include:                                                             Surgical procedure/anesthesia
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Recognize and report signs/symptoms of
CRITERIA—CLIENT WILL:                                                     complications.
Institute appropriate corrective measures.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Monitor and assess blood loss. Count and                                             Bleeding is normally like a heavy menstrual
weigh or estimate peripads.                                                                    period. Excessive loss (more than 1 large pad per
hour for 4 hr) may indicate retained tissue or uterine
perforation.
Monitor vital signs, noting increased pulse rate,                                    Changes in vital signs are often a late sign of
severe headache, or flushed face.                                                           hypovolemic shock from blood loss. If hypertonic
saline solution is used in second-trimester procedure
and is inadvertently injected into the circulatory
system, convulsions and death can occur.
Note dyspnea, wheezing, or agitation.                                                    Prostaglandins may cause vasoconstriction or
bronchial constriction.
Evaluate level of discomfort.                                                                  Abdominal pain, tenderness, and severe cramping
may indicate retained tissue or uterine perforation.
Instruct client to report symptoms indicating                                         Clients are in the healthcare facility for a short
complications (e.g., temperature 100.4° F (40.0°C)                               time. Complications, including bleeding and
or greater, chills, malaise, abdominal pain or                                         infection, may be manifested days or weeks after
tenderness, severe bleeding, heavy flow with clots,                               the procedure.
foul-smelling and/or greenish vaginal discharge).
Provide information about person to contact in                                     A specific phone number encourages contact; can
case of emergency.                                                                                  save time and anxiety.
Stress importance of returning for a follow-up                                      Follow-up is necessary to assess healing. A repeat
examination.                                                                                            pregnancy test is sometimes done after early first-
trimester procedures to assure procedure was
complete.
Collaborative
Assist with/review results of ultrasonography                                       Helps in confirming gestational age and the size of
before procedure as indicated.                                                                products of conception.
Determine cervical status before procedure.                                          Aids in softening cervix; may be inserted 24–48 hr
Assist as needed with insertion of Laminaria                                        before procedure.
tent or prostaglandin (lamicel) gel.
Assist with any additional treatment or                                                  IV therapy may need to be instituted, with or
procedures necessary to control complications.                                      without oxytoxics. Additional surgery (D & C or
hysterectomy) may be needed to control bleeding.
(Refer to CP: Labor: Induced/Augmented.)
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NCP Dysfunctional Labor Dystocia

Dysfunctional Labor/Dystocia
Dystocia refers to difficult labor which is usually due to uterine dysfunction, fetal malpresentation/abnormality, or pelvic abnormality.
(Refer to CPs: Labor: Stage I—Latent Phase; Labor: Stage I—Active Phase.)
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Report of fatigue, lack of energy
Lethargy, decreased performance
Circulatory
BP may be elevated.
May have received magnesium sulfate (MgSO4) for pregnancy-induced hypertension.
Elimination
Bowel or bladder distension may be evident.
Ego Integrity
May be extremely anxious, fearful
Pain/Discomfort
May have received narcotic or peridural anesthesia early in labor process.
May have noted false labor at home.
Infrequent or irregular contractions, mild to moderate in intensity (fewer than three contractions in a 10-min period).
May occur prior to the onset of labor (primary latent-phase dysfunction) or after labor is well established (secondary active-phase dysfunction).
Latent Phase of Labor May Be Prolonged: 20 hr or longer in nullipara (average is 81⁄2 hr), or 14 hr in multipara (average is 51⁄2 hr).
Myometrial resting tone may be 8 mm Hg or less, and contractions may measure less than 30 mm Hg or may occur more than 5 min apart; or resting tone may be greater than 15 mm Hg, with contractions rising to 50–85 mm Hg with increased frequency and decreasing intensity.
Safety
May have had external version after 34 weeks’ gestation in attempt to convert breech to cephalic presentation.
Fetal descent may be less than 1 cm/hr in nullipara or less than 2 cm/hr in multipara (protracted descent), or no progress over 1 or more hr for nullipara or for 30 min in multipara after complete cervical dilation (arrest of descent).
Vaginal examination may reveal fetus to be in malposition (i.e., breech; chin, face, or brow position).
Cervix may be rigid/“not ripe.”
Dilation may be less than 1.2 cm/hr in primipara or less than 1.5 cm/hr for multipara, in active phase (protracted active phase), or absence of cervical changes over a 2-hr period (secondary arrest of labor).
Failure to deliver within 2 hr, or 3 hr with regional anesthesia for primipara, or 1 hr/2hr with regional anesthesia for multipara (prolonged stage II).
Sexuality
May be primigravida or grand multipara.
Uterus may be overdistended owing to hydramnios, multiple gestation, a large fetus, or grand multiparity.
May have identifiable uterine tumors.
DIAGNOSTIC STUDIES
Prenatal Testing: May have confirmed polyhydramnios, large fetus, or multiple gestation.
Nonstress Test/Contraction Stress Test (NST/CST): Assesses fetal well-being.
X-ray Pelvimetry or Ultrasound: Evaluates pelvic architecture, fetal presentation, position, and formation.
Fetal Scalp Sampling: Occasionally done to detect or rule out acidosis.
NURSING PRIORITIES
  1. Identify and treat abnormal uterine pattern.
  2. Monitor maternal/fetal physical response to contractile pattern and length of labor.
  3. Provide emotional support for the client/couple.
  4. Prevent complications.
NURSING DIAGNOSIS:                                                               Injury, risk for maternal
Risk Factors May Include:                                                             Alteration of muscle tone/contractile pattern, mechanical obstruction to fetal descent, maternal fatigue
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Accomplish cervix dilation at least 1.2 cm/hr for
CRITERIA—CLIENT WILL:                                                     primipara, 1.5 cm/hr for multipara in active phase, with fetal descent at least 1 cm/hr for primipara, 2 cm/hr for multipara.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Review history of labor, onset, and duration.                                         Helpful in identifying possible causes, needed
diagnostic studies, and appropriate interventions.
Uterine dysfunction may be caused by an atonic or a
hypertonic state. Uterine atony is classified as
primary when it occurs before the onset of labor
(latent phase) or secondary when it occurs after well-
established labor (active phase).
Note timing/type of medication(s). Avoid admin-                                 A hypertonic contractile pattern may occur in
istration of narcotics or of epidural block anesthetics                            response to oxytocin stimulation; sedation/
until cervix is 4 cm dilated.                                                                     analgesia given too early (or in excess of needs) can
inhibit or arrest labor.
Evaluate current level of fatigue, as well as activity                              Excess maternal exhaustion contributes to
and rest prior to onset of labor.                                                               secondary dysfunction, or may be the result of
prolonged labor/false labor.
Assess uterine contractile pattern manually                                           Dysfunctional contractions prolong labor,
(palpation) or electronically via external, or internal                             increasing the risk of maternal/fetal complications.
monitor with internal uterine pressure catheter                                      A hypotonic pattern is reflected by frequent, mild
(IUPC).                                                                                                   contractions measuring less than 30 mm Hg via IUPC
or “soft as chin” per palpation. A hypertonic pattern
is reflected by increased frequency, an elevated
resting tone per palpation or greater than 15 mm Hg
via IUPC, and possibly decreased intensity of
contractions. Note: Intensity of contractions cannot be
measured by external monitor.
Note condition of cervix. Monitor for signs of                                      A rigid or unripe cervix will not dilate, impeding
amnionitis. Note elevated temperature or WBC;                                   fetal descent/labor progress. Development of
odor and color of vaginal discharge.                                                       amnionitis is directly related to length of labor, so
that delivery should occur within 24 hr after rupture
of membranes.
Note effacement, fetal station, and fetal presentation.                            These indicators of labor progress may identify a
contributing cause of prolonged labor. For example,
breech presentation is not as effective a wedge for
cervical dilation as is vertex presentation.
Graph cervical dilation and fetal descent against                                   May be used on occasion to document progress/
time (i.e., Friedman curve).                                                                    prolongation of labor.
Place client in lateral recumbent position and                                        Relaxation and increased uterine perfusion may
encourage bedrest or sitting position/ambulation,                                  correct a hypertonic pattern. Ambulation may
as tolerated.                                                                                             assist gravitational forces in stimulating normal labor
pattern and cervical dilation.
Encourage client to void every 1–2 hr. Assess for                                 A full bladder may inhibit uterine activity and
bladder fullness over symphysis pubis.                                                  interfere with fetal descent.
Assess degree of hydration. Note amount and type                               Prolonged labor can result in a fluid-electrolyte
of intake. (Refer to ND: Fluid Volume risk for deficit.)                         imbalance as well as depletion of glucose reserves,
resulting in exhaustion and prolonged labor with
increased risk of uterine infection, postpartal
hemorrhage, or precipitous delivery in the presence
of hypertonic labor.
Review bowel habits and regularity of evacuation.                                Bowel fullness may inhibit uterine activity and
interfere with fetal descent.
Remain with client if possible, arrange for presence                             Reduction of outside stimuli may be necessary to
of doula as appropriate; provide quiet environment                               allow sleep after administration of medication to
as indicated.                                                                                             client in the hypertonic state. Also helpful in
reducing level of anxiety, which can contribute to
both primary and secondary uterine dysfunction.
Have emergency delivery kit available.                                                  May be needed in the event of a precipitous labor
and delivery, which are associated with uterine
hypertonicity.
Palpate abdomen of thin client for presence of                                      In obstructed labor, a depressed pathological ring
pathological retraction ring between uterine segments.                         (Bandl’s ring) may develop at the juncture of lower
(These rings are not palpable through the vagina,                                  and upper uterine segments, indicating impending
or through the abdomen, in the obese client).                                         uterine rupture.
Investigate reports of severe abdominal pain. Note                               May indicate developing uterine tear/acute
signs of fetal distress, cessation of contractions,                                    rupture necessitating emergency surgery. Note:
presence of vaginal bleeding.                                                                  Hemorrhage is usually occult since it is
intraperitoneal with hematomas of the broad
ligament.
Collaborative
Prepare client for amniotomy, and assist with the                                  Rupture of membranes relieves uterine
procedure, when cervix is 3–4 cm dilated.                                             overdistension (a cause of both primary and
secondary dysfunction) and allows presenting part to
engage and labor to progress in the absence of CPD.
Note: Active management of labor (AML) protocols
may support anmniotomy once presenting part is
engaged to accelerate labor/help prevent dystocia.
Use nipple stimulation to produce endogenous                                      Oxytocin may be necessary to augment or institute
oxytocin, or initiate infusion of exogenous oxytocin                             myometrial activity for hypotonic uterine pattern.
(Pitocin) or prostaglandins. (Refer to CP: Labor:                                  It is usually contraindicated in hypertonic labor
Induced/Augmented.)                                                                              pattern because it can accentuate the hypertonicity,
but may be tried with amniotomy if latent phase is
prolonged and if CPD and malpositions are ruled
out.
Administer narcotic or sedative, such as morphine,                               May help distinguish between true and false labor.
pentobarbital (Nembutal), or secobarbital (Seconal),                            With false labor, contractions cease; with true
for sleep as indicated.                                                                              labor, more effective pattern may ensue following
rest. Morphine helps promote heavy sedation and
eliminate hypertonic contractile pattern. A period of
rest conserves energy and reduces utilization of
glucose to relieve fatigue.
Prepare for forceps delivery, as necessary.                                             Excessive maternal fatigue, resulting in ineffective
bearing-down efforts in stage II labor, necessitates
use of forceps.
Assist with preparation for cesarean delivery, as                                   Immediate cesarean birth is indicated for Bandl’s
indicated, e.g., malposition, CPD, or Bandl’s ring.                                ring or fetal distress due to CPD. Note: Once labor
(Refer to CP: Cesarean Birth.)                                                                is diagnosed, if delivery has not occurred within
12 hr, and amniotomy and oxytocin have been
used appropriately, then a cesarean delivery is
recommended by some protocols.
NURSING DIAGNOSIS:                                                               Injury, risk for fetal
Risk Factors May Include:                                                             Prolonged labor, fetal malpresentations, tissue hypoxia/acidosis, abnormalities of the maternal pelvis, CPD
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Display FHR within normal limits, with good
CRITERIA—FETUS WILL:                                                        variability, no late decelerations noted.
CLIENT WILL:                                                                              Participate in interventions to improve labor pattern and/or reduce identified risk factors.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess FHR manually or electronically. Note vari-                               Detects abnormal responses, such as exaggerated
ability, periodic changes, and baseline rate. If in free-                           variability, bradycardia, and tachycardia, which
standing birth center, check FHTs between contrac-                              may be caused by stress, hypoxia, acidosis, or
tions using Doptone. Count for 10 min, break for                                  sepsis.
5 min, and count again for 10 min. Continue this
pattern throughout the contraction to midway
between it and the following contraction.
Note uterine pressures during resting and con-                                      Resting pressure greater than 30 mm Hg or
tractile phases via intrauterine pressure catheter, if                               contractile pressure greater than 50 mm Hg
available.                                                                                                 reduces or compromises oxygenation within
intervillous spaces.
Identify maternal factors such as dehydration,                                       Sometimes, simple procedures (such as turning
acidosis, anxiety, or vena caval syndrome.                                            client to lateral recumbent position) can increase
circulating blood and oxygen to uterus and placenta
and may prevent or correct fetal hypoxia.
Note frequency of uterine contractions. Notify                                      Contractions occurring every 2 min or less do not
physician if frequency is 2 min or less.                                                  allow for adequate oxygenation of intervillous
spaces.
Assess for malpositioning using Leopold’s maneuvers                         Determining fetal lie, position, and presentation
and findings on internal examination (location of                                  may identify factor(s) contributing to
fontanelles and cranial sutures). Review results of                                dysfunctional labor.
ultrasonography.
Monitor fetal descent in birth canal in relation to                                  Descent that is less than 1 cm/hr for a primipara,
ischial spines.                                                                                          or less than 2 cm/hr for a multipara, may indicate
CPD or malposition.
Arrange transfer to acute care setting if malposition                              Risk of fetal/neonatal injury or demise increases
is detected in client in free-standing birth center                                   with vaginal delivery if presentation is other than
without adequate surgical/high-risk neonatal                                         vertex.
capabilities.
Prepare client for the most expedient method of delivery                      Such presentations increase the risk of CPD, owing
if fetus is in brow, face, or chin presentation.                                         to a larger diameter of the fetal skull entering the
pelvis (11 cm in brow or face presentation, 13 cm in
chin presentation, versus 9.5 cm for vertex
presentation), often necessitating assisted delivery
via forceps or vacuum, or cesarean delivery because
of failure to progress and ineffective labor pattern.
Assess for deep transverse arrest of the fetal head.                                Failure of the vertex to rotate fully from an OP to an
occiput OA position may result in a transverse
position, arrested labor, and the need for cesarean
delivery.
Have client assume hands-and-knees position, or                                  These positions encourage anterior rotation by
lateral Sims’ position on side opposite that to which                             allowing fetal spine to fall toward the client’s
fetal occiput is directed, if fetus is in OP position.                                 anterior abdominal wall (70% of fetuses in OP
position rotate spontaneously).
Note color and amount of amniotic fluid when                                      Excess amniotic fluid causing uterine overdis-
membranes rupture.                                                                                tention is associated with fetal anomalies.
Meconium-stained amniotic fluid in a vertex
presentation results from hypoxia, which causes
vagal stimulation and relaxation of the anal
sphincter. Noting characteristics of amniotic fluid
alerts staff to potential needs of newborn, e.g.,
airway/ventilatory support.
Observe for visible cord prolapse when membranes                              Cord prolapse is more likely to occur in breech
rupture, and occult cord prolapse as indicated by                                  presentation, because the presenting part is not
variable decelerations on monitor strip, especially if                             firmly engaged, nor is it totally blocking the os, as
fetus is in breech presentation.                                                                in vertex presentation.
Note odor and change in color of amniotic fluid                                    Ascending infection and sepsis with accompanying
with prolonged rupture of membranes.                                                   fetal tachycardia may occur with prolonged rupture
of membranes.
Collaborative
Administer antibiotic to client, as indicated.                                           Prevents/treats ascending infection and will protect
fetus as well.
If fetus fails to rotate from OP to OA position (face                              Delivering the fetus in a posterior position results
to pubis), prepare for delivery in posterior position.                              in a higher incidence of maternal lacerations.
Alternatively, apply vacuum extractor as indicated.                               Vacuum extractor may be used to rotate and expedite
delivery of fetus.
Prepare for cesarean delivery of breech presentation                             Vaginal delivery of an infant in breech position is
if fetus fails to descend, labor progress ceases, or                                  associated with injury to the fetal spinal column,
CPD is identified.                                                                                    brachial plexus, clavicle, and brain structures,
increasing neonatal mortality and morbidity. Risk of
hypoxia caused by prolonged vagal stimulation with
head compression, and trauma such as intracranial
hemorrhage, can be alleviated or prevented if CPD is
identified and surgical intervention follows
immediately.
NURSING DIAGNOSIS:                                                               Fluid Volume risk for deficit
Risk Factors May Include:                                                             Hypermetabolic state, vomiting, profuse diaphoresis, restricted oral intake, mild diuresis associated with oxytocin administration
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Maintain fluid balance, as evidenced by moist
CRITERIA—CLIENT WILL:                                                     mucous membranes, appropriate urine output, and palpable pulses.
Be free of complications.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Keep accurate intake/output, test urine for ketones,                               Decreased urine output and increased urine
and assess breath for fruity odor.                                                            specific gravity reflect dehydration. Inadequate
glucose intake results in a breakdown of fats and
presence of ketones.
Monitor vital signs. Note reports of dizziness with                                Increased pulse rate and temperature, and
change of position.                                                                                  orthostatic BP changes may indicate decrease in
circulating volume.
Assess lips and oral mucous membranes and degree                             Dry oral mucous membranes/lips and decreased
of salivation.                                                                                            salivation are further indicators of dehydration.
Note abnormal FHR response.                                                               May reflect effects of maternal dehydration and
(Refer to ND: Injury, risk for fetal.)                                                       decreased perfusion.
Encourage oral fluids as appropriate.                                                      Clear liquids such as fruit juices and broths provide
not only fluids but also calories for energy
production. Note: PO fluids are not recommended if
surgical intervention is contemplated.
Collaborative
Review laboratory data, e.g.: Hb/Hct, serum                                         Increased Hct suggests dehydration. Serum
electrolytes, and serum glucose.                                                             electrolyte levels detect developing imbalances;
serum glucose levels detect hypoglycemia.
Administer fluids intravenously.                                                             Parenteral solutions containing electrolytes and
glucose can correct or prevent maternal and fetal
imbalances and may reduce maternal exhaustion.
NURSING DIAGNOSIS:                                                               Coping, Individual, ineffective
May Be Related To:                                                                        Situational crisis, personal vulnerability, unrealistic expectations/perceptions, inadequate/exhausted support systems
Possibly Evidenced By:                                                                   Verbalizations and behavior indicative of inability to cope (loss of control, inability to problem-solve and/or meet role expectations), irritability, reports of tension/fatigue
DESIRED OUTCOMES/EVALUATION                                    Verbalize understanding of what is happening.
CRITERIA—CLIENT WILL:
Identify/use effective coping techniques.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Determine progress of labor. Assess degree of pain                              Prolonged labor with resultant fatigue can reduce
in relation to dilation/effacement.                                                            the client’s ability to cope/manage contractions.
Increasing pain when the cervix is not dilating/
effacing can indicate developing dysfunction.
Extreme pain may indicate developing anoxia of
the uterine cells.
Acknowledge reality of client’s reports of pain/                                    Discomfort and pain may be misunderstood in the
discomfort.                                                                                              presence of lack of progression that is not recognized
as a dysfunctional problem. Feeling listened to and
supported can help client relax, reducing discomfort
and enhancing ability to cope with situation.
Determine anxiety level of client and partner. Note                              Excess anxiety increases adrenal activity/release of
evidence of frustration.                                                                           catecholamines, causing endocrine imbalance. Excess
epinephrine inhibits myometrial activity. Stress also
depletes glycogen stores, reducing glucose available
for adenosine triphosphate (ATP) synthesis, which is
needed for uterine contraction.
Discuss possibility of discharge of client to home                                 Too early admission fosters a sense of longer/
until active labor is established.                                                              prolonged labor for client. Client may be able to relax
better in familiar surroundings. Provides opportunity
to divert/refocus attention and to attend to tasks
that may be contributing to level of
anxiety/frustration.
Provide comfort measures and reposition client/                                    Reduces anxiety, promotes relaxation and sense of
encourage ambulation as appropriate. Demonstrate/                              control, assisting client to cope positively with the
encourage use of relaxation techniques, including                                 situation.
patterned breathing.
Provide encouragement for client/couple efforts                                   May be useful in correcting misconception that
to date.                                                                                                     client is overreacting to labor or is somehow to blame
for alteration of anticipated birth plan.
Give factual information about what is happening.                                Reduces the “unknowns” to assist with reduction of
anxiety and provides data necessary to make
informed decisions.
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NCP Diabetes Mellitus Pre-pregnancy Gestational

Diabetes Mellitus Prepregnancy/Gestational
This disorder of carbohydrate metabolism of variable severity may be preexisting (pregestational insulin-dependent diabetes mellitus [IDDM] or non–insulin-dependent diabetes mellitus [NIDDM]), or may develop during pregnancy (gestational diabetes mellitus [GDM]).
(This plan of care is to be used in conjunction with the Trimesters and the High-Risk Pregnancy.)
CLIENT ASSESSMENT DATA BASE
circulation
Pedal pulse and capillary refill of extremities may be diminished or slowed (with diabetes of long duration).
Edema, elevated BP (PIH).
Elimination
May have history of pyelonephritis, recurrent UTI, nephropathy
Polyuria
Food/Fluid
Polydipsia, polyphagia.
Nausea and vomiting.
Obesity; excessive or inadequate weight gain (client with GDM is usually obese; client with IDDM is not usually obese before pregnancy).
Abdominal tenderness.
May report episodes of hypoglycemia, glycosuria.
Safety
Skin integrity/sensation of arms, thighs, buttocks, and abdomen may be altered from frequent injections of insulin.
Visual impairment/retinopathy may be present.
History of symptoms of infection and/or positive cultures for infection, especially urinary or vaginal.
Sexuality
Fundal height may be higher or lower than normal for gestational age (hydramnios, inappropriate fetal growth).
History of large for gestational age (LGA) neonate, hydramnios, congenital anomalies, unexplained stillbirth.
Social Interaction
Socioeconomic concerns/factors can increase risk of complications.
Inadequate or lack of committed support system (may adversely affect diabetic control).
Teaching/Learning
Client’s own birth weight may have been 9 lb or more.
May report recent problems/change in stability of diabetic control.
Family history of diabetes, GDM, PIH, infertility problem; LGA infant, history of neonatal death(s), stillbirth, congenital anomalies, spontaneous abortion, hydramnios, macrosomia (greater than 4000 g or 9 lb at birth).
DIAGNOSTIC STUDIES
Glucose Tolerance Test (GTT): Elevated above 140 mg/dL at 24–28 weeks’ gestation. Clients with specific risk factors are screened at first prenatal visit. (If screening result is positive,
3-hr glucose challenge or oral glucose tolerance test [OGTT] test done to make diagnosis.)
Glycosylated Hemoglobin (HbA1c): Reveals glucose control over previous 4–8 wk. Levels greater than 8.5%, especially before pregnancy, puts the fetus at risk for congenital anomalies.
Random Serum Glucose Level: Determines immediate diabetic control.
Urine Ketone Levels: Determines nutritional state.
Glycosylated Albumin: Reflects glucose control over last several days as possible screening test for GDM.
Urine Culture: Identifies asymptomatic UTI.
Vaginal Culture: May be positive for Candida albicans (Monilia infection).
Protein and Creatinine Clearance (24 hr): Verify level of kidney function, especially in diabetes of long duration.
Thyroid Function Tests: Establish baseline and/or identify coexisting hypothyroidism or hyperthryoidism.
Hemoglobin (Hb)/Hematocrit (Hct): May reveal anemia.
Triglycerides and Cholesterol Levels: May be elevated.
Estriol Level: Indicates level of placental function.
Electrocardiogram (ECG): May reveal altered cardiovascular function in diabetes of long duration.
Nonstress Test (NST): May demonstrate reduced fetal response to maternal activity.
Serial Ultrasonography: Determines presence of macrosomia or IUGR.
Contraction Stress Test (CST), Oxytocin Challenge Test (OCT): Positive results indicate placental insufficiency.
Amniocentesis: Ascertains fetal lung maturity using lecithin to sphingomyelin (L/S) ratio or presence of phosphatidylglycerol (PG).
BPP Criteria: Assesses fetal well-being/maturity.
NURSING PRIORITIES
  1. Determine immediate and previous 8-wk diabetic control.
  2. Evaluate ongoing client/fetal well-being.
  3. Achieve and maintain normoglycemia (euglycemia).
  4. Provide client/couple with appropriate information.
NURSING DIAGNOSIS:                                                               Nutrition: altered, risk for less than body requirements
Risk Factors May Include:                                                             Inability to ingest/utilize nutrients appropriately
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Gain 24–30 lb prenatally, or as appropriate for
CRITERIA—CLIENT WILL:                                                     prepregnancy weight.
Maintain fasting serum glucose levels between 60–100 mg/dL and 1 hr postprandial no higher than 140 mg/dL.
Be free of signs/symptoms of ketoacidosis.
Verbalize understanding of individual treatment regimen and need for frequent self-monitoring.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Weigh client each prenatal visit. Encourage client                                Weight gain is the key index for deciding caloric
to periodically monitor weight at home between                                   adjustments.
visits.
Assess caloric intake and dietary pattern using                                      Aids in evaluating client’s understanding of
24-hr recall.                                                                                             and/or adherence to dietary regimen.
Review/provide information regarding any                                           Metabolism and fetal/maternal needs change
required changes in diabetic management;                                             greatly during gestation, requiring close
e.g., switch from oral agents to insulin, use                                           monitoring and adaptation. Research suggests
of Humulin insulin only, self-monitoring of                                          antibodies against insulin may cross the placenta,
serum glucose levels at least 4 times/day                                               causing inappropriate fetal weight gain. The use of
(e.g., before breakfast and 2 hr after each meal),                                   human insulin decreases the development of these
and reducing/changing time for ingesting                                              antibodies. Reducing carbohydrates to less than
carbohydrates.                                                                                         40% of the calories ingested decreases the degree of
the postprandial glucose peak of hyperglycemia.
Because pregnancy produces severe morning
carbohydrate intolerance, the first meal of the day
should be small, with minimal carbohydrates.
Review importance of regularity of meals and                                      Small, frequent meals avoid postprandial
snacks (e.g., 3 meals/3 or 4 snacks) when taking                                   hyperglycemia and fasting/starvation ketosis.
insulin.                                                                                                    Note: Bedtime snack should contain both protein and
complex carbohydrates to prevent nighttime
hypoglycemia.
Note presence of nausea and vomiting, especially                                 Nausea and vomiting may result in carbohydrate
in first trimester.                                                                                      deficiency, which may lead to metabolism of fats and
development of ketosis.
Assess understanding of the effect of stress on                                      Stress can elevate serum glucose levels, creating
diabetes. Provide information about stress                                             fluctuations in insulin needs.
management and relaxation. (Refer to CP: The
High-Risk Pregnancy.)
Teach client finger-stick method for self-monitoring                            Insulin needs for the day can be adjusted based on
of glucose. Have client demonstrate procedure.                                     periodic serum glucose readings. Note: Values
obtained by reflectance meters may be 10%–15%
lower/higher than plasma values.
Recommend monitoring urine for ketones on                                        Insufficient caloric intake is reflected by ketonuria,
awakening and when a planned meal or                                                 indicating need for an increase of carbohydrates or
snack is delayed.                                                                                     addition of an extra snack in the dietary plan (e.g.,
recurrent presence of ketonuria on awakening may
be eliminated by a 3 am glass of milk). Presence of
ketones during second half of pregnancy may reflect
“accelerated starvation” as diminished effectiveness
of insulin results in a catabolic state during fasting
periods (e.g., skipping meals), causing maternal
metabolism of fat. Adjustment of insulin
frequency/dosage/type must then be considered.
Review/discuss signs and symptoms and                                               Hypoglycemia may be more sudden or severe in
significance of hypoglycemia or hyperglycemia.                                   first trimester, owing to increased usage of glucose
and glycogen by client and developing fetus, as well as
low levels of the insulin antagonist human placental
lactogen (HPL). Ketoacidosis occurs more frequently
in second and third trimesters because of the increased
resistance to insulin and elevated HPL levels.
Sustained or intermittent pulses of hyperglycemia are
mutagenic and teratogenic for the fetus during the first
trimester; may also cause fetal hyperinsulinemia,
macrosomia, inhibition of lung maturity, cardiac
dysrhythmias, neonatal hypoglycemia, and risk of
permanent neurological damage. Maternal effects of
hyperglycemia can include hydramnios, UTI and/or
vaginal infections, hypertension, and spontaneous
termination of pregnancy.
Instruct client to treat symptomatic hypoglycemia,                               Using large amounts of simple carbohydrates to
if it occurs, with an 8-oz glass of milk and to repeat                              treat hypoglycemia causes serum glucose values to
in 15 min if serum glucose levels remains                                             overshoot. A combination of complex
below 70 mg/dL.                                                                                     carbohydrates and protein maintains normoglycemia
longer and helps maintain stability of serum glucose
throughout the day.
Collaborative
Participate in/coordinate multispecialty care                                         Provides opportunity to review management of
conference as appropriate.                                                                      both pregnancy and diabetic condition, and to plan
for special needs during intrapartum and postpartum
periods.
Discuss dosage, schedule, and type of insulin                                        Division of insulin dosage considers maternal
(e.g., usually 4 times/day: 7:30 am—NPH;                                           basal needs and mealtime insulin-to-food ratio,
10 am—regular; 4 pm—NPH; 6 pm—regular).                                      and allows more freedom in meal scheduling.
Total daily dosage is based on gestational age,
current maternal body weight, and serum glucose
levels. A mix of NPH and regular human insulin
helps mimic the normal insulin release pattern of the
pancreas, minimizing “peak/valley” effect of serum
glucose level. Note: Although some providers may
choose to manage clients with GDM with oral agents,
insulin is still the drug of choice.
Adjust diet or insulin regimen to meet                                                   Prenatal metabolic needs change throughout the
individual needs.                                                                                     trimesters, and adjustment is determined by weight
gain and laboratory test results. Insulin needs in the
first trimester are 0.7 unit/kg of body weight.
Between 18 and 24 weeks’ gestation, it increases to
0.8  unit/kg; at 34 weeks’ gestation, 0.9 unit/kg, and
1.0 unit/kg by 36 weeks’ gestation.
Refer to registered dietitian to individualize diet                                   Diet specific to the individual is necessary to
and counsel regarding dietary questions.                                                maintain normoglycemia and to obtain desired
weight gain. In-depth teaching promotes
understanding of own needs and clarifies
misconceptions, especially for client with GDM.
Note: New recommendations (Peterson & Peterson,
1992) set dietary needs at 25 kcal/kg dependent on
the client’s current pregnant weight.
Monitor serum glucose levels (FBS, preprandial,                                  Incidence of fetal and newborn abnormalities is
1 and 2 hr postprandial) on initial visit, then as                                     decreased when FBS levels range between 60 and
indicated by client’s condition.                                                               100 mg/dL, preprandial levels between 60 and 105
mg/dL, 1-hr postprandial remains below 140 mg/dL,
and 2-hr postprandial is less than 120 mg/dL.
Ascertain results of HbA1c every 2–4 wk.                                            Provides accurate picture of average serum glucose
control during the preceding 60 days. Serum glucose
control takes 6 wk to stabilize.
Prepare for hospitalization if diabetes is not controlled.                         Infant morbidity is linked to maternal
hyperglycemia-induced fetal hyperinsulinemia.
NURSING DIAGNOSIS:                                                               Injury, risk for fetal
Risk Factors May Include:                                                             Elevated maternal serum glucose levels, changes in circulation
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Display normally reactive NST and negative OCT
CRITERIA—FETUS WILL:                                                        and/or CST.
Be full-term, with size appropriate for gestational age.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Determine White’s classification for diabetes;                                      Fetus is at less risk if White’s classification is A, B,
explain classification and significance to                                               or C. The client with classification D, E, or F who
client/couple.                                                                                           develops kidney or acidotic problems or PIH is at
high risk. As a means of determining prognosis for
perinatal outcome, White’s classification has been used
in conjunction with (1) evaluation of diabetic control
or lack of control and (2) presence or absence of
Pederson’s prognostically bad signs of pregnancy
(PBSP), which include acidosis, mild/severe toxemia,
and pyelonephritis. The National Diabetes Data Group
Classification, which includes diabetes mellitus (type I,
insulin-dependent; type II, non–insulin-dependent),
impaired glucose tolerance, and gestational diabetes
mellitus, has not yet had prognostic significance in
predicting perinatal outcomes.
Note client’s diabetic control before conception.                                   Strict control (normal HbA1c levels) before conception
helps reduce the risk of fetal mortality and congenital
anomalies.
Assess fetal movement and FHR each visit                                           Fetal movement and FHR may be negatively
as indicated. (Refer to CP: Third Trimester,                                          affected when placental insufficiency and maternal
ND: Injury, risk for fetal.) Encourage client to                                      ketosis occur.
periodically count/record fetal movements
beginning about 18 weeks’ gestation, then
daily from 34 weeks’ gestation on.
Monitor fundal height each visit.                                                            Useful in identifying abnormal growth pattern
(macrosomia or IUGR, small or large for gestational
age [SGA/LGA]).
Monitor urine for ketones. Note fruity breath.                                       Irreparable CNS damage or fetal death can occur as
result of maternal ketonemia, especially in the third
trimester.
Provide information and reinforce procedure                                        Decreased fetal/newborn mortality and morbidity
for home blood glucose monitoring and                                                 complications and congenital anomalies are associated
diabetic management. (Refer to NDs: Knowledge                                 with optimal FBS levels between 70 and 96 mg/dL,
Deficit [Learning Need]; Nutrition: altered,                                           and 2-hr postprandial glucose level of less than
risk for less than body requirements.)                                                     120 mg/dL. Frequent monitoring is necessary to
maintain this tight range and to reduce incidence
of fetal hypoglycemia or hyperglycemia.
Monitor for signs of PIH (edema, proteinuria,                                       About 12%–13% of diabetic individuals develop
increased blood pressure).                                                                      hypertensive disorders owing to cardiovascular
changes associated with diabetes. These disorders
negatively affect placental perfusion and fetal status.
Provide information about possible effect of diabetes                           Helps client to make informed decisions about
on fetal growth and development.                                                           managing regimen and may increase cooperation.
Review procedure and rationale for periodic NSTs                               Fetal activity and movement are good predictors
(e.g., weekly NST after 30 weeks’ gestation, twice-                              of fetal wellness. Activity level decreases before
weekly NST after 36 weeks’ gestation).                                                 alterations in FHR occur.
Discuss rationale/procedure for carrying out                                         CST assesses placental perfusion of oxygen and
periodic OCT/CST beginning at 30–32 weeks’                                     nutrients to fetus. Positive results indicate
gestation, depending on diagnosis of IDDM or GDM.                          placental insufficiency, in which case fetus may
(Refer to CP: Third Trimester; ND: Injury,                                           need to be delivered surgically.
risk for fetal.)
Review procedure and rationale for amniocentesis                                When maternal/placental functioning is impaired
using L/S ratio and presence of PG. (Refer to CP:                                 before term, fetal lung maturity is criterion used to
Second Trimester; ND: Injury, risk for fetal.)                                        determine whether survival is possible. Hyper-
insulinemia inhibits and interferes with surfactant
production; therefore, in the diabetic client, testing for
presence of PG is more accurate than using L/S ratio.
Collaborative
Assess HbA1c every 2–4 wk, as indicated.                                            Incidence of congenitally malformed infants is
increased in women with high HbA1c level (greater
than 8.5%) early in pregnancy or before conception.
Note: HbA1c is not sensitive enough as a screening
tool for GDM.
Assess glycolysated albumin level at 24–28 weeks’                              Serum test for glycolysated albumin reflects
gestation, especially for client in high-risk category                              glycemia over several days and may gain
(history of macrosomic infants, previous GDM,                                    acceptance as screening tool for GDM because it
or positive family history of GDM). Follow with                                  does not involve potentially harmful glucose
OGTT if test results are positive.                                                            loading as does OGTT.
Verify AFP levels are obtained at 14–16 weeks’                                   Although AFP screen is recommended for all
gestation.                                                                                                 clients, it is especially important in this population
because the incidence of neural tube defects is greater
in diabetic clients than in nondiabetic clients,
particularly if poor control existed before pregnancy.
Prepare for ultrasonography at 8, 12, 18, 28, and                                  Ultrasonography is useful in confirming gestation
36–38 weeks’ gestation, as indicated.                                                     date and helps to evaluate IUGR.
Perform NST and OCT/CST, as appropriate.                                         Assesses fetal well-being and adequacy of placental
perfusion.
Review periodic creatinine clearance levels.                                          There is a slight parallel between renal vascular
damage and impaired uterine blood flow.
Obtain sequential serum or 24-hr urinary specimen                              Although estriol levels are not used as often now,
for estriol levels after 30 weeks’ gestation.                                            falling levels may indicate decreased placental
functioning, leading to possibility of IUGR and
stillbirth.
Assist as necessary with BPP assessment.                                             Provides a score to assess fetal well-being/risk. The
criteria include NST results, fetal breathing
movements, amniotic fluid volume, fetal tone, and
fetal body movements. For each criterion met, a score
of 2 is given. A total score of 8–10 is reassuring, a
score of 4–7 indicates need for further evaluation and
retesting, and a score of 0–3 is ominous.
Assist with preparation for delivery of fetus                                          Helps ensure positive outcome for neonate.
vaginally or surgically if test results indicate                                         Incidence of stillbirths increases significantly with
placental aging and insufficiency.                                                           gestation more than 36 wk. Macrosomia often causes
dystocia with cephalopelvic disproportion (CPD).
NURSING DIAGNOSIS:                                                               Injury, risk for maternal
Risk Factors May Include:                                                             Changes in diabetic control, abnormal blood profile/anemia, tissue hypoxia, altered immune response
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes in actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Remain normotensive.
CRITERIA—CLIENT WILL:                                                     Maintain normoglycemia, free of signs/symptoms of ketoacidosis.
Be free of complications (e.g., infection, placental separation).
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Note White’s classification for diabetes. Assess                                    Client classified as D, E, or F is at higher risk for
degree of diabetic control (Pederson’s criteria).                                     complications, as is client with PBSP.
(Refer to ND: Injury, risk for fetal.)
Assess client for vaginal bleeding and                                                   Vascular changes associated with diabetes place
abdominal tenderness.                                                                            client at risk for abruptio placentae.
Monitor for signs and symptoms of preterm labor.                                Overdistension of uterus caused by macrosomia or hydramnios may predispose client to early labor.
Assist client in learning home monitoring of                                         Allows greater accuracy than urine testing because
blood glucose, to be done a minimum of                                               renal threshold for glucose is lowered during
4 times/day. (Refer to NDs: Nutrition: altered,                                      pregnancy. Facilitates tighter control of serum
risk for less than body requirements; Knowledge                                  glucose levels.
deficit [Learning Need].)
Request that client check urine for ketones daily.                                  Ketonuria indicates presence of starvation state,
which may negatively affect the developing fetus.
Identify for hypoglycemic episodes occurring at home.                        Hypoglycemic episodes occur most frequently in the
first trimester, owing to continuous fetal drain on
serum glucose and amino acids, and to low levels of
HPL. In the presence of hypoglycemia, vomiting may
lead to ketosis.
Identify for episodes of hyperglycemia.                                                  Diet/insulin regulation is necessary for
normoglycemia, especially in second and third
trimesters, when insulin requirements often double
(may quadruple in third trimester).
Assess for and/or monitor presence of edema.                                       Because of vascular changes, the diabetic client is
(Refer to CP: Pregnancy-Induced Hypertension;                                   prone to excess fluid retention and PIH. The
ND: Fluid Volume deficit.)                                                                     severity of the vascular changes before pregnancy
influences the extent and time of onset of PIH.
Determine fundal height; check for edema of                                        Hydramnios occurs in 6%–25% of pregnant
extremities and dyspnea.                                                                        diabetic clients; may possibly be associated with
increased fetal contribution to amniotic fluid, because
hyperglycemia increases fetal urine output.
Assess for, and review with client, signs and                                         Early detection of UTI may prevent pyelonephritis,
symptoms if UTI.                                                                                   which is thought to contribute to premature labor.
Determine nature of any vaginal discharge.                                           If glycosuria is present, client is more likely to develop
monilial vulvovaginitis, which is caused by Candida
albicans and may result in oral thrush in newborn.
Monitor client closely if tocolytic drugs are                                          Tocolytic drugs may elevate serum glucose and
used to arrest labor.                                                                                 insulin levels.
Collaborative
Monitor serum glucose levels each visit.                                                Detects impending ketoacidosis; helps determine
times of day during which client is prone to
hypoglycemia.
Obtain HbA1c every 2–4 wk, as indicated.                                            Allows accurate assessment of glucose control for
past 60 days.
Assess Hb/Hct on initial visit, then during second                                 Anemia may be present in client with vascular
trimester and at term.                                                                              involvement.
Instruct in insulin administration, as required.                                       Insulin requirements are decreased in first
Ensure that client is adept at self-administration,                                   trimester, then double and may even quadruple as
either subcutaneously (SC) or with pump,                                             the pregnancy progresses. Highly motivated and
depending on client’s needs or care setting.                                           capable clients may do well with a continuous
subcutaneous insulin infusion pump to more
naturally meet insulin needs.
Obtain urinalysis and urine culture; administer                                     Helps prevent or treat pyelonephritis. Note: Some
antibiotic as indicated.                                                                             antibiotics might be contraindicated because of
danger of teratogenic effects.
Obtain culture of vaginal discharge, if present.                                      Candida vulvovaginitis can cause oral thrush in the
newborn.
Collect specimens for total protein excretion,                                        Progressive vascular changes may impair renal
creatinine clearance, BUN, and uric acid levels.                                    function in clients with severe or long-standing
diabetes.
Schedule ophthalmologic examination during                                       Owing to severe vascular involvement,
first trimester for all clients, and in second and                                     background retinopathy may progress during
third trimesters if client is class D, E, F.                                                pregnancy. Laser coagulation therapy may improve
client’s condition and reduce optic fibrosis.
Prepare client for ultrasonography at 8, 12, 18, 26,                               Determines fetal size using biparietal diameter,
and 36–38 weeks’ gestation as indicated.                                               femur length, and estimated fetal weight. Client is at
increased risk for CPD and dystocia due to
macrosomia.
Start IV therapy with 5% dextrose; administer                                      Glucagon is a naturally occurring substance that
glucagon SC if client is hospitalized with insulin                                  acts on liver glycogen and converts it to glucose,
shock and is unconscious. Follow with protein-                                     which corrects hypoglycemic state. (Note:
containing fluids/foods, e.g., 8 oz skim milk                                         Hypertonic glucose [D50] administered IV may
when client is able to swallow.                                                               have negative effects on fetal brain tissue because of
its hypertonic action.) Protein helps sustain
normoglycemia over a longer period of time.
NURSING DIAGNOSIS:                                                               Knowledge deficit [Learning Need], regarding diabetic condition, prognosis, and self care treatment needs
May Be Related To:                                                                        Lack of exposure to information, misinformation, lack of recall, unfamiliarity with information resources
Possibly Evidenced By:                                                                   Questions, statement of misconception, inaccurate follow-through of instructions, development of preventable complications
DESIRED OUTCOMES/EVALUATION                                    Participate in the management of diabetes during
CRITERIA—CLIENT WILL:                                                     pregnancy.
Verbalize understanding of the procedures, laboratory tests, and activities involved in controlling diabetes.
Demonstrate proficiency in self-monitoring and insulin administration.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess client’s/couple’s knowledge of disease                                      Clients with either preexisting diabetes or GDM
process and treatment, including relationships                                       are at risk for ineffective glucose uptake within the
between diet, exercise, illness, stress, and                                              cells, excess utilization of fats/proteins for energy,
insulin requirements.                                                                               and cellular dehydration as water is drawn from the
cell by a hypertonic concentration of glucose within
the serum. Pregnancy alters insulin requirements
drastically and necessitates more intense control,
requiring the client/couple to take a very active role.
Informed decisions can be made only when there is a
clear understanding of both the disease process and
the rationale for management.
Discuss importance of home serum glucose                                          Frequent blood glucose measurements allow client
monitoring using reflectance meter, and the need                                  to recognize the impact of her diet and exercise on
for frequent readings (at least 4 times/day),                                           serum glucose levels and promote tighter control
as indicated. Demonstrate procedure, then                                             of glucose levels.
observe return demonstration by the client.
Review reasons why oral hypoglycemic medications                            Although insulin does not cross the placenta, oral
should be avoided, even though they may have                                     hypoglycemic agents do and are potentially
been used by the class A client, to control diabetes                               harmful to the fetus, necessitating a change in
before pregnancy.                                                                                   diabetic management. Although some clinical sources report use of    oral agents in clients with GDM, this is not recommended during               pregnancy.
Provide information about action and adverse                                       Prenatal metabolic changes cause insulin
effects of insulin. Assist client to learn administration                          requirements to change. In the first trimester,
by injection, insulin pump, or nasal spray                                              insulin requirements are lower, but they double
(experimental technique) as indicated.                                                    and then may quadruple during second and third
trimesters.
Explain normal weight gain to client. Encourage                                  Total gain in the first trimester should be 2.5–
home monitoring between visits.                                                            4.5 lb, then 0.8–0.9 lb/wk thereafter. Caloric
restriction with resulting ketonemia may cause fetal
damage and inhibit optimal protein utilization. (Refer
to ND: Injury, risk for fetal.)
Provide information about need for regular daily                                  Regular exercise may decrease insulin
mild exercise program (regularly, 20 min after                                      requirements, while radical fluctuations in
meals). Warn against exercising if glucose                                            physical activity can adversely affect glucose
exceeds 300 mg/dL.                                                                                control. Client should exercise after meals to help
prevent hypoglycemia and to stabilize glucose
excursion, unless excessive elevation of glucose is
present, in which case exercise promotes
ketoacidosis.
Provide information regarding the impact of                                         Increased knowledge may decrease fear of the
pregnancy on the diabetic condition and                                                unknown, may increase likelihood of
future expectations.                                                                                 participation, and may help reduce fetal/maternal
complications. About 70% of clients diagnosed with
GDM will develop NIDDM within 15 yr.
Discuss how client can recognize signs of infection.                             Important to seek medical help early to avoid
Caution client not to treat self with OTC                                               complications. Choice of self-treatment may be
vaginal creams.                                                                                       inappropriate/mask infection.
Recommend client maintain a diary of home                                         When reviewed by healthcare practitioner(s),
assessment of serum glucose levels, insulin                                           client’s diary can assist with evaluation and
dosage, diet, exercise, reactions, general feelings                                  alteration of therapy.
of well-being, and any other pertinent thoughts.
Provide contact numbers for health team members.                               Client needs to be assured that questions will be
answered and problems dealt with immediately on a
24-hr–day basis.
Review Hb/Hct levels. Provide dietary information                               Anemias are of greater concern in clients with pre-
about sources of iron and the need for                                                   existing diabetes because elevated glucose levels
iron supplements.                                                                                    replace oxygen in the Hb molecule, resulting in
reduced oxygen-carrying capacity.
Assist client/family to learn glucagon administration.                           Presence of symptoms of hypoglycemia
Instruct client to follow with protein source, such                                 (diaphoresis, tingling sensation, palpitations) with
as 8 oz of milk, then recheck glucose level in 15 min.                           a serum glucose level under 70 mg/dL requires
prompt intervention. Use of glucagon in combination
with milk can increase the serum glucose level
without the risk of rebound hyperglycemia.
Glucagon is also useful during periods of morning
sickness/vomiting when food intake is curtailed and
serum glucose levels fall.
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NCP Deviations in Growth Pattern

Deviations in Growth Patterns
Deviations in intrauterine growth patterns not only increase the risk of morbidity and mortality in the early newborn period, but may also have long-term implications for altered growth and development and for altered CNS function and learning disabilities in childhood.
This general plan of care is designed to facilitate optimal nursing management of the infant with deviations in intrauterine growth and is to be used in conjunction with the CPs: The Neonate at Two Hours to Two Days of Age, and The Preterm Infant, as appropriate. Growth deviations are classified as SGA, intrauterine growth retardation/restriction (IUGR), and LGA.
SGA/IUGR: Any newborn whose birth weight falls at or below the 10th percentile on classification charts, considering local factors (e.g., ethnicity, altitude).
LGA/Macrosomic: Any newborn whose birth weight is at or above the 90th percentile on classification charts, considering local population at any week in gestation (with special attention to determining appropriate gestational age), or who at birth weighs more than 4000 g (8 lb 13 oz).
NEONATAL ASSESSMENT DATA BASE
SGA Infant
Activity/Rest
Activity level may be excessive, with vigorous cry/hungry suck attributable to chronic intrauterine hypoxia.
MATERNAL FACTORS
Excessive/strenuous exercise program
Circulation
Maternal Factors
Resides at high altitude
Heart/lung disease; bleeding, severe anemia or sickle cell anemia; chronic hypertension or PIH
Elimination
Abdomen may appear scaphoid or concave.
Maternal Factors
Pyelonephritis, chronic renal disease
Food/Fluid
All body parts may be below expected size for gestational age but in proportion/symmetrical to each other (suggests a chronic or prolonged problem throughout gestation).
Disproportionate weight as compared to length and head circumference (appears long and thin with normal head circumference) suggests episodic vascular insufficiency in third trimester.
Sunken abdomen; absence of subcutaneous tissue.
Decreased muscle mass, especially in the cheeks, buttocks, and thighs.
May demonstrate metabolic instability associated with hypoglycemia/hypocalcemia.
Maternal Factors
Small stature
Malnutrition/poor nutritional intake (chronic or during third trimester); history of eating disorders
Advanced diabetes mellitus (class D or above); PKU
Neurosensory
Skull suture and fontanels appear widened; bulging of fontanels caused by inadequate bone growth may be evident.
Small head with protruding forehead, sunken nasal bridge, short upturned nose, thin upper lip, receding chin (indicative of fetal alcohol syndrome [FAS]).
Muscle tone may appear tight with flexion of upper and lower extremities, minor joint/limb abnormalities, and restricted movement (suggests FAS).
Wide-eyed appearance (associated with chronic hypoxia in utero).
Chromosomal syndromes.
Respiration
Signs of respiratory distress may be present (especially in presence of meconium aspiration syndrome [MAS], polycythemia, or infection).
Mucus may be green-tinged.
Maternal Factors
Heavy smoker
Safety
Dry, cracked, and peeling skin present, with loose skin fold; sparse scalp hair.
Meconium staining may be evident with greenish stains on fingernails and at base of umbilical cord.
Umbilical cord may have single artery and/or be thin, slightly yellow, dull, dry.
Congenital anomalies/malformations or infection may be present.
Maternal Factors
Irradiation and use of medications with teratogenic side effects (e.g., antimetabolites, anticonvulsants, trimethadione)
Collagen disease; maternal infections such as rubella, syphilis, cytomegalovirus, toxoplasmosis; uterine tumors
Sexuality
Females tend to be smaller than males at birth.
Maternal Factors
Adolescent or advanced maternal age (younger than age 16 or older than age 40)
Primiparity, grand multiparity
Placenta previa/separation, insufficiency, infarction, fibrosis, thrombosis, hemangioma, abnormal cord insertion and single umbilical artery with vascular anastomoses (twin-to-twin)
Chromosomal abnormalities, chronic intrauterine infections, congenital anomalies, multifetal pregnancy, inborn errors of metabolism
Social Interaction
Maternal Factors
Low socioeconomic class
Other child(ren) at home with history of FTT
May have previous or current involvement with Department of Social Services
Teaching/Learning
May be premature (and/or member of multifetus pregnancy)
Maternal Factors
Poor/incomplete formal education
Alcoholism, drug abuse
Lack of prenatal care
LGA Infant
Activity/Rest
Difficulty maintaining quiet, alert state; slower to arouse
Circulation
Skin color ruddy (associated with polycythemia), jaundice (indicative of hyperbilirubinemia)
May have congenital anomalies such as transposition of the great vessels, Beckwith-Wiedemann syndrome, or erythroblastosis fetalis
Food/Fluid
Macrosomia; excess fat deposits and reddened complexion; increased body size proportional (except in infant of diabetic mother [IDM], whose weight may appear disproportionately large for length)
May demonstrate metabolic instability associated with hypoglycemia/hypocalcemia, may have feeding problems
Weight may be 4000 g (8 lb 13 oz) or more (dependent on gestational age)
Maternal Factors
Inappropriate/overnutrition, excessive pregravid weight and/or weight gain >35 lb
Large stature
Diabetes mellitus (class A, B, or C)
Neurosensory
Large amount of scalp hair
May display hypotonia/hypertonia; decreased reflex functioning
Respiration
Signs of respiratory distress may be present if stress of delivery has induced meconium aspiration/asphyxiation, if delivered by cesarean section, or if infection present.
Safety
Birth injury(s) may be present, e.g., bruising, caput succedaneum, cephalhematomas; facial/phrenic nerve paralysis, brachial palsy; fractured clavicles, intracranial bleeding/depressed skull fracture(s); bulging fontanel indicative of neurological problems, depressed fontanel suggestive of dehydration.
Intrapartal/delivery events may reveal fetal distress, meconium-stained amniotic fluid, oligohydramnios, late/variable decelerations, scalp pH levels7.20, resuscitative measures.
Evidence of congenital malformations may involve the heart, CNS, kidney, lungs, GI tract.
Long, hard nails extending beyond ends of toes and fingers.
Absence of vernix caseosa/lanugo; desquamation or epidermis.
Sexuality
Higher incidence in males
Maternal Factors
Birth of previous LGA infant
Cesarean birth because of cephalopelvic disproportion or oxytocin-induced labor related to diabetes/fetal distress/prolonged pregnancy
Multiparity
Social Interactions
Slow to orient to maternal face/voice (generally improves within 48 hr)
Teaching/Learning
May be preterm/postterm by clinical assessment
May be postterm (42 wk or more) because of postconceptional bleeding, leading to a miscalculation of dates/prolonged pregnancy associated with menstrual cycle longer than 28 days.
Diagnostic Studies
Dextrostix Glucose Estimations: Less than 40 mg/dl in LGA infant or 25 mg/dl in SGA infant during first 3 days indicates hypoglycemia.
Serum Glucose: Verifies Dextrostix value <40 mg/dl in LGA infant,25 mg/dl in SGA infant.
Chest X-Ray and ABGs: Help determine cause/severity of respiratory distress if present, e.g., pneumonia, MAS, RDS.
CBC: May reveal central venous Hct elevated above 65%; central venous Hb 20 g/dl associated with polycythemia/hyperviscosity.
WBC Count: May be elevated or depressed.
Platelet Count: May be depressed if mother was pre-eclamptic or if infant was born with a congenital viral infection.
Coagulation Studies (prothrombin time [PT], partial thromboplastin time [PTT], fibrinogen, fibrin split products [FSP]): May indicate DIC, especially in the presence of polycythemia or asphyxia.
Blood Type for ABO Group, Rh Factor, and Crossmatch: Plasma exchange may be necessary if Rh incompatibility exists.
Serum Electrolytes (including ionized calcium): Assesses for hypocalcemia (level 7 mg/dl [3.5 mEq/L] or less in first 3 days of life); inappropriate antidiuretic hormone secretion, and instability related to metabolic complications.
Bilirubin: May be elevated secondary to polycythemia and resorption of bleeding associated with birth injury, e.g., intracranial hemorrhage, cephalhematoma.
Urinalysis on/after Second Voided Specimen, Including Specific Gravity and Sugar/Acetone: Assesses homeostasis, renal involvement.
Bacterial and Viral Cultures: Rule out/diagnose infectious process.
Electrocardiography (ECG), Echocardiography, Ultrasonography, Angiography, and Genetic Studies: As appropriate with suspected FAS, congenital defects, and/or complications.
NURSING PRIORITIES
  1. Maintain physiological homeostasis.
  2. Prevent and/or treat complications.
  3. Identify/minimize effects of birth trauma.
  4. Provide family with appropriate information/strategies for meeting short- and long-term needs associated with growth deviation.
NURSING DIAGNOSIS:                                                               GAS EXCHANGE, impaired
May Be Related To:                                                                        Alveolar capillary membrane changes (decreased surfactant levels, retained pulmonary fluid, meconium aspiration), altered oxygen supply (diaphragmatic paralysis/phrenic nerve paralysis, increased intracranial pressure)
Possibly Evidenced By:                                                                   Restlessness/irritability; inability to move secretions, tachypnea, cyanosis, hypoxia
DESIRED OUTCOMES/EVALUATION                                    Display spontaneous, unassisted regular
CRITERIA—NEONATE WILL:                                                 respiratory effort with rate of 30–50/min; and ABGs WNL.
Be free of apnea and complications of hypoxia/lung disease.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Review history for abnormal prenatal growth                                        Low-birth-weight infant or infant with IUGR
patterns and/or reduced amounts of amniotic                                         suffers chronic intrauterine asphyxia, resulting in
fluid, as detected by ultrasonography/fundal                                         hypoxia/malnutrition. Fetal contribution to the
changes.                                                                                                  amniotic pool is reduced in the stressed infant.
Macrosomia can be related to maternal diabetes,
prolonged pregnancy, heredity, and inappropriate
nutrition. Macrosomia in IDM results from excess
release of growth hormone (thyroid stimulation),
increasing the number of cells and/or organ size
throughout the body.
Note type of delivery and intrapartal events                                          Infant with chronic hypoxia will be more
indicative of hypoxia.                                                                             susceptible to acidosis/respiratory
depression/persistent fetal circulation (PFC) after
delivery. Cesarean birth increases risk of excess
mucus because thoracic compression by the birth
canal does not occur as in a vaginal delivery.
Note time/onset of breathing and Apgar scores.                                    The infant with intrapartal asphyxia may present
Observe ensuing respiratory patterns.                                                     with a delayed onset of respirations and altered
respiratory pattern. Apgar scores aid in evaluation of
the degree of depression or asphyxia of the newborn
at birth and are directly correlated with serum
pH/degree of infant acidosis.
Assess respiratory rate, depth, effort. Observe                                       Infant with altered growth is more susceptible to
and report signs and symptoms of respiratory                                        respiratory distress associated with chronic asphyxia
distress, distinguishing from symptoms associated                                in SGA infant, inadequate surfactant levels in IDM,
with polycythemia.                                                                                  perinatal asphyxia, aspiration of meconium or
amniotic fluid, and PFC. Diminished lung
compliance may occur as a result of polycythemia.
Auscultate breath sounds regularly.                                                        Presence of crackles/rhonchi reflect respiratory
congestion and need for intervention.
Suction nasopharynx/endotracheal tube as                                             Ensures patency of airway, removes excess mucus.
needed, after first providing supplemental oxygen.                               Supplemental oxygen reduces hypoxic effect of
procedure.
Auscultate apical pulse; note presence of cyanosis.                               Tachypnea, bradycardia, and cyanosis may occur in
response to altered oxygen levels.
Prevent iatrogenic complications associated with                                  Such complications increase metabolic demands
cold stress, metabolic imbalance, and caloric                                        and oxygen needs.
insufficiency.
Ensure availability of resources in the event                                          Equipment for oxygenation, suction, intubation,
complications occur.                                                                               assisted ventilation, resuscitation, and chest tube
placement must be readily available in the event of
severe/prolonged respiratory distress.
Collaborative
Monitor transcutaneous oxygen/pulse                                                    Identifies therapy needs/effectiveness.
oximeter readings.
Monitor laboratory studies, as indicated:
Serum pH;                                                                                          Detects possible metabolic acidosis occurring from
inadequate oxygen intake/respiratory acidosis and
anaerobic metabolism with acid end products. Note:
Normal pH values range from 7.35–7.44; HCO3 is
19–22 mEq/L (bicarbonate reflects buffering capacity
of the blood).
ABGs;                                                                                                Indicate degree of hypoxia/hypercapnia, as well as
therapy needs/effectiveness. Note: Normal newborn
arterial Po2 ranges from 50–70 mm Hg, arterial Pco2
from 35–45 mm Hg.
Hct.                                                                                                     Polycythemia, which occurs in 50% of SGA infants
related to excess RBC production in response to
chronic intrauterine hypoxia, typically increases
capillary/venous Hct levels to greater than 60%, with
resultant respiratory distress associated with
diminished lung compliance.
Administer warm, humidified oxygen; provide                                     Corrects/prevents hypoxia, hypercapnia, and
assisted ventilation, as indicated.                                                            respiratory acid-base imbalances.
Review chest x-rays.                                                                               May confirm meconium aspiration pneumonia,
common in SGA or postterm infant, or RDS, in IDM.
Provide chest physiotherapy, as indicated.                                             Percussion and postural drainage promote
mobilization of secretions, enhancing airway patency
and gas exchange, especially in the presence of MAS.
Note: Contraindicated in preterm infant.
Administer medications as indicated:
Sodium bicarbonate;                                                                           Corrects metabolic imbalances/acidosis resulting
from prolonged respiratory acidosis.
Xanthine derivatives, e.g., aminophylline,                                         Sympathomimetic bronchodilators may be useful
theophylline;                                                                                   in treating apnea of prematurity.
Tolazoline HCl (Priscoline);                                                               Potent vasodilator that relaxes smooth muscle to
maximize circulatory effort/oxygenation in cases of
meconium aspiration/PFC.
Dopamine.                                                                                          May be required to counteract hypotensive effect of
Priscoline administration.
NURSING DIAGNOSIS:                                                               NUTRITION: altered, less than body requirements
May Be Related To:                                                                        Decreased nutritional stores, increased insulin production and/or hyperplasia of the pancreatic beta cells
Possibly Evidenced By:                                                                   Weight deviation from expected; decreased muscle mass/fat stores, electrolyte imbalance
DESIRED OUTCOMES/EVALUATION                                    Ingest and digest adequate nutrients for weight
CRITERIA—NEONATE WILL:                                                 gain (or to prevent weight loss of 2% or more).
                                                                                                           Display serum glucose >40 mg/dl, and other associated laboratory studies WNL.
PARENT(S) WILL:                                                                        Identify/treat/prevent short- and long-term complications of malnutrition.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Compare weight in relation to gestational age                                       Identifies presence, degree, and risk of altered
and size. Document on growth chart. Weigh daily.                                growth pattern. LGA infant with excess extracellular
fluid experiences a postdelivery diuresis, resulting in
a loss of up to 15% of birth weight. SGA infant may
have already lost weight in utero or may suffer from
reduced fat/glycogen stores.
Maintain thermoneutral environment, including                                    The SGA infant does not have adequate adipose
use of incubator/radiant warmer, as indicated.                                       tissue for insulation and has a large body surface
Monitor heat controls, temperature of infant and                                   area compared to body weight. Brown adipose
environment frequently, noting hypothermia/                                        tissue stores may be inadequate to maintain
hyperthermia.                                                                                          thermoregulation. Both hypothermia and
hyperthermia increase metabolic demands,
necessitating increased intake in an already
compromised infant. Note: Thermal instability may
be iatrogenically induced by improperly operated
heating equipment used to maintain thermogenesis
in dysmature infant. (Refer to CP: The Preterm Infant;
ND: Thermoregulation, ineffective.)
Initiate early and frequent feedings and                                                 Assists in maintaining fluid/electrolyte balance
advance as tolerated.                                                                               and meeting caloric needs to support metabolic
process. Helps prevent hypoglycemia associated with
inadequate body stores in SGA infant or continued
pancreatic secretion of insulin in IDM.
Assess tolerance to feedings. Note stool color,                                      Advances in amount and caloric composition of
consistency, and frequency; presence of reducing                                 feedings are dependent on tolerance. Evidence of
substances; abdominal girth; vomiting, and                                           reducing substances (increased glucose) in stool
gastric residuals.                                                                                     suggests inability to digest formula because of
obstruction and/or disease process present. Note:
Poor sucking reflex and recurrent vomiting or
persistent regurgitation may be seen in FAS,
requiring further evaluation/intervention. (Refer to
CP: The Infant of an Addicted Mother.)
Monitor intake and output. Calculate daily                                            Provides information about actual intake in
caloric and electrolyte consumption.                                                      relation to estimated needs for use in readjustment of
dietary prescription.
Assess hydration level, noting fontanels, skin                                       Increased metabolic demands of the SGA infant
turgor, urine specific gravity, condition of                                             may increase fluid requirements. Hyperglycemic
mucous membranes, and weight fluctuations.                                        states may produce diuresis in the infant. IV
administration of fluids may be required to meet
increased demands but must be conscientiously
managed to avoid fluid excess.
Monitor Dextrostix levels immediately after birth                                 Hypoglycemia may occur after birth because of
and routinely until serum glucose is stabilized.                                      limited glucose stores in the SGA infant and from
hyperplasia/continued release of insulin in the LGA
infant. Symptoms in the SGA infant usually appear
between 24 and 72 hr of age, but may begin as early as
3 hr or as late as 7 days; the IDM may be symptomatic
within 1–3 hr of birth. Hyperglycemia may result from
inappropriate infusion of solutions containing glucose.
Observe for signs of hypoglycemia, e.g., tachypnea                              Because glucose is a major source of fuel for the
and irregular respirations, apnea, lethargy, flaccidity,                           brain, deficits may cause permanent CNS damage.
cyanosis, temperature fluctuations, diaphoresis,                                    Hypoglycemia significantly increases morbidity
poor feeding, jitteriness, high-pitched cry, tremors,                               and mortality rates, and severity of long-term
eye rolling, seizure activity.                                                                    effects is dependent on duration of such episodes.
Untreated symptomatic infants have a higher
incidence of neurological abnormalities and/or lower
mean IQ later in childhood than treated infants.
Note signs of hypocalcemia, e.g., neuromuscular                                  Peak incidence of early hypocalcemia is during
irritability (tremors, twitching, seizing, clonus),                                    first 48–72 hr of life and is often related to
hypotonia, vomiting, high-pitched cry, cyanosis,                                  temporary abdominal distension, neonatal
apnea, and cardiac dysrhythmias with prolonged                                  hypoparathyroidism in premature infant, or
Q-T interval.                                                                                            prenatal asphyxia in SGA infant or IDM. Late
hypocalcemia (at 6–10 days) may be caused by
ingestion of milk formulas containing a higher ratio
of phosphorus to calcium.
Discuss long-term complications of malnutrition                                  Chronic protein deficiencies in the SGA infant
in SGA infant and obesity in LGA infant; review                                  make child prone to learning difficulties and
importance of protein during phase II of brain                                       cerebral dysfunction, characterized by short
growth.                                                                                                    attention span, poor fine-motor coordination,
hyperactivity behavior problems, and speech defects.
Excess fat cells in the LGA/macrosomic infant may
create lifelong problems associated with obesity (e.g.,
diabetes, cardiovascular disease, stroke). Adequate
protein during hyperplasia/hypertrophy phase of
brain growth during the first 6 mo of life helps to
overcome insults that occurred in early gestational
period of brain development.
Collaborative
Monitor laboratory studies as indicated:
Serum glucose;                                                                                   Hypoglycemia may occur as early as 1–3 hr after
birth. In the SGA infant, glycogen reserves are
quickly depleted and gluconeogenesis is inadequate
because of reduced stores of muscle protein and fat,
while the IDM has decreased ability to release
glucagon and catecholamines needed to stimulate
glucagon breakdown/facilitate release of glucose.
Calcium;                                                                                              Frequency of screening is dependent on this risk
group, i.e., IDM, intrapartal asphyxia, or preterm
infants. Levels 7 mg/dl require further
evaluation/intervention.
Sodium, potassium, chloride, phosphorus,                                        Electrolyte instability may be a consequence of
and magnesium;                                                                             deviations in growth, inadequate placental transfer,
or altered maternal mineral balance. Note:
Hypomagnesemia/hyperphosphatemia are usually
associated with hypocalcemia.
BUN, creatinine, serum/urine osmolality,                                         Detects altered kidney function associated with
urine electrolytes;                                                                           reduced nutrient stores and fluid levels resulting
from acute malnutrition/asphyxia.
Triglyceride/cholesterol levels, and liver                                           Useful in determining nutritional deficits and
function tests.                                                                                 therapy needs/effectiveness.
Establish intravascular access as indicated.                                            IV access allows for fluid and electrolyte
administration. Intra-arterial access allows for ease in
obtaining samples for monitoring laboratory values.
Administer glucose-containing solutions/                                              The severely compromised infant with deviations in
parenteral nutrition.                                                                                 intrauterine growth may be unable to consume
adequate fluids and nutrients via an enteral route. IV
glucose (i.e., infusion of D5W) may be required when
serum glucose cannot be maintained at or above 40
mg/dl, or seizure activity occurs.
Provide electrolyte supplementation as indicated,                                 Metabolic instability in the SGA/LGA infant may
e.g., 10% calcium gluconate.                                                                  necessitate supplements to maintain homeostasis,
especially calcium, sodium, and occasionally
magnesium.
NURSING DIAGNOSIS:                                                               TISSUE PERFUSION, risk for altered
Risk Factors May Include:                                                             Interruption of arterial or venous blood flow (hyperviscosity associated with polycythemia)
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Maintain normal vital signs, with adequate
CRITERIA—NEONATE WILL:                                                 peripheral pulses and Hct WNL.
Be free of complications associated with polycythemia.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Note risk factors for/presence of polycythemia.                                     Maternal fetal or infant transfusion (during gestation
or at birth), twin gestation (twin-to-twin transfusion),
chronic fetal distress associated with maternal PIH,
placenta previa; chromosomal anomalies, endocrine
disorders; and residing at altitudes over 5000 ft place
the infant at risk for developing increased blood
volume. Polycythemia resulting from increased
erythropoietin production in response to chronic
intrauterine hypoxia may occur in both the SGA/LGA
infant. In many cases, infants of diabetic mothers are
polycythemic. Although the pathophysiology of the
hyperviscosity is not fully understood, it may be
related to decreased extracellular fluid volume or
increased bone marrow stimulation associated with
hypoxia.
Monitor temperature, intake/output, and urine                                       Prevention or correction of dehydration decreases
specific gravity. Note skin turgor, condition of                                      the risks of hyperviscosity.
mucous membranes, and fontanels.
Observe skin color for ruddiness or pallor. Note                                   Helps detect/promotes prompt intervention to
presence of hyperthermia, respiratory distress,                                      prevent possible complications of polycythemia,
hypertension or hypotension, tachycardia,                                             e.g., myocardial, cerebral, and renal ischemia;
decreased pulses, oliguria, hematuria, or altered                                    cardiopulmonary congestion; hyperbilirubinemia;
neurological findings.                                                                             thromboembolism, and convulsions.
Collaborative
Monitor central/peripheral Hct/Hb and bilirubin.                                  Indicates degree of polycythemia/hyperviscosity.
Send blood for type, crossmatch, and Rh. (Refer to                               Hyperbilirubinemia often results from
CP: Newborn: Hyperbilirubinemia.)                                                       polycythemia (central Hct is >65%; Hb is 22 g/dl) as
excess RBCs break down.
Establish intravascular access, preferably through                                 Provides for fluid administration to correct
umbilical catheterization.                                                                         hyperviscosity and exchange transfusion, if
necessary.
Prepare for/assist with exchange transfusion                                         Fresh frozen plasma, 5% albumin or 9% saline,
as indicated.                                                                                             replaces infant’s blood in equal amounts, thereby
diluting infant’s remaining blood volume to
prevent/correct polycythemia and hyperviscosity.
Usually 10% of the infant’s blood volume is
removed/exchanged at one time.
Monitor for complications of procedure, including                               Provides for early detection/intervention.
transfusion reactions, overload (CHF), catheter
complications, cardiac dysrhythmias, hypovolemia,
anemia, and hepatitis.
NURSING DIAGNOSIS:                                                               INJURY, risk for
Risk Factors May Include:                                                             Altered growth patterns, delayed CNS/neurological development, abnormal blood profile, immature immune response
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Be free of complications.
CRITERIA—NEONATE WILL:
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Inspect all LGA infants for birth injuries. Note                                     Because of disproportion between fetal size and
bulging/tense fontanels; muscle spasticity,                                            maternal pelvis, LGA infants have a high
twitching, or flaccidity; high-pitched, weak,                                          incidence of birth injuries/trauma, such as
constant cry; tremors or seizure activity; changes                                  IICP/CNS damage, cervical/brachial plexus palsy,
in pupil size/reaction; or asymmetrical chest                                         fractured clavicle/humerus, diaphragmatic
movement.                                                                                               paralysis, and cephalhematoma.
Observe invasive sites, urine/stool, NG drainage,                                  Early recognition promotes timely intervention.
and pulmonary secretions for signs of bleeding.                                    Septicemia, congenital syphilis, cytomegalic
Note petechiae/bruising, changes in                                                       inclusion disease, and rubella may result in DIC,
responsiveness/activity level or muscle                                                 resulting in pulmonary, cerebral, or IVH.
tone, nystagmus, opisthotonic posturing, or
convulsions.
Measure occipital frontal circumference, as                                           Hydrocephalus may develop following IVH.
indicated.
Monitor vital signs. Observe peripheral capillary                                  Hypotension, bradycardia, apnea, hypothermia,
refill and color and temperature of skin.                                                delayed capillary refill, and pallor reflect developing
shock related to blood loss, requiring prompt
assessment/intervention.
Assess home situation for abusive relationships.                                    Maternal abuse during pregnancy is a significant risk
factor for development of SGA infant. Releasing
infant into potentially unsafe environment increases
risk of abuse/neglect and FTT.
Monitor for signs and symptoms of infection (e.g.,                               Poor resistance to infection, cracks in epidermis,
changes in temperature, color, muscle tone and                                     and possible exposure to infectious agents in utero
activity, feeding tolerance, cardiopulmonary status;                              place the SGA/postterm infant at risk for
or presence of petechiae, rash, jaundice).                                               infection, which may be life-threatening, especially if
not detected in its earliest phases. (Refer to CP: The
Preterm Infant; ND: Infection, risk for.)
Discuss with parents the potential of conditions that                             Enhances early identification and promotes
may have long-term sequelae, such as birth injury                                optimal management of long-term effects of
or fetal malnutrition hypoxia (significant role in                                   injury/condition.
late or subnormal CNS functioning), which may
result in convulsions or altered reflex responses.
Collaborative
Monitor laboratory studies as indicated:
CBC with differential;                                                                         Dropping Hct may reflect hemorrhage; a shift of the
differential may suggest infection.
Coagulation studies: PTT/activated PTT                                           Alterations in clotting times, presence of FSP
(APTT), PT, fibrinogen levels, FSP, platelets;                              reflect developing coagulopathies.
Blood type, crossmatch, and Rh factor;                                              Blood replacement may be required.
Bacterial viral cultures and sensitivities.                                            Verifies presence, etiology, severity of infectious
process.
Provide supplemental oxygen, CPAP, and/or                                        Aids in correcting hypoxia, acidemia, and
mechanical ventilation, as needed. (Refer to ND:                                  hypotension; reduces risk of IVH/increased ICP.
Gas Exchange, impaired.)
Administer blood products, albumin, and                                              Replaces losses/enhances circulating volume; may
coagulants, as necessary.                                                                        help control bleeding.
Administer anticonvulsants (e.g., phenobarbital),                                  May be necessary to quiet cerebrum and reduce
as indicated.                                                                                             electrical stimuli that precipitate seizure activity.
Assist with diagnostic studies, as indicated, e.g.,                                   Bloody spinal fluid indicates IVH. Scans are useful
lumbar puncture, CT, or ultrasound scan.                                              in identifying site/extent of cerebral hemorrhage.
Refer family to appropriate community resources/                                Provides support/guidance for dealing with
support groups.                                                                                       possible long-term effects of condition.
NURSING DIAGNOSIS:                                                               INFANT BEHAVIOR, risk for disorganized
May Be Related To:                                                                        Functional limitations related to growth deviations (restricting neonate’s opportunity to seek out, recognize, and interpret stimuli), electrolyte imbalance, and psychological stress, immaturity or CNS damage (low threshold for stress), low energy reserves, poor organizational ability, limited ability to control environment
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Exhibit organized behaviors that allow the
CRITERIA—NEONATE WILL:                                                 achievement of optimal potential for growth and development as evidenced by modulation of physiological, motor, state, and attentional-interactive functioning.
PARENT(S)/CAREGIVER(S) WILL:                                         Recognize individual infant cues.
                                                                                                           Identify appropriate responses (including environmental modifications) to infant cues.
Verbalize readiness to assume caregiving independently.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Determine infant’s capacity for stimulation,                                          Allows provision of stimuli consistent with
noting behavioral responses involving gross and                                   infant’s capabilities and with cues reflecting
fine motor movement, presence of irritability,                                       sensory overload.
restlessness, crying, eye contact, and facial
expressions.
Provide stimuli consistent with chronological and                                 Size of the infant with deviations in growth may
developmental capabilities.                                                                     be a false indicator of capacity for stimulation.
Monitor environmental stimulation. Minimize/                                      Control of stressors can reduce infant’s energy
remove inappropriate or hazardous stimuli.                                           demands, aiding in maintenance of homeostasis
(promotes rest, weight gain).
Provide parents with information regarding the                                     Parents who are informed of their newborn’s
newborn’s capabilities/needs.                                                                  capabilities can provide appropriate stimulation to
optimize the newborn’s development.
Encourage parental involvement in identification                                  Fosters continued support of the infant’s capacities
of coping strategies/deficits of infant, including                                    in the acute care setting and transition to home.
control of behavioral state and temperament.                                         Identifies role for parents in providing coregulation
to the infant.
Promote ongoing assessment of neurodevelopmental                            Prevents/minimizes complications and optimizes
gains/deficits. Plan future interventions accordingly.                             growth and development.
Collaborative
Suggest/refer to early stimulation program if                                         Optimizes infant development/interactional skills
available/indicated.                                                                                  (affective, cognitive, social).
Refer for long-term neurodevelopmental                                               Sequelae of morbidity associated with deviations
assessment and intervention as indicated.                                               in intrauterine growth may affect long-term coping.
(Refer to CP: The Preterm Infant; ND: Infant Behavior, risk for disorganized.)
NURSING DIAGNOSIS:                                                               KNOWLEDGE deficit [Learning Need], parent(s), regarding condition, prognosis, and treatment needs
May Be Related To:                                                                        Lack of exposure, misinterpretations, unfamiliarity with resources
Possibly Evidenced By:                                                                   Verbalization of problem, misconception, request for information
DESIRED OUTCOMES/EVALUATION                                    Identify newborn’s short- and long-term needs.
CRITERIA—PARENT(S) WILL:                                               List available resources.
Participate in discharge planning.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Provide appropriate anticipatory guidance                                             Malnutrition in SGA infant may result in
regarding implications of growth deviations.                                         subnormal CNS/intellectual development as well as
hearing/speech deficits. LGA infant is susceptible to
malnutrition problems associated with obesity. (Refer
to ND: Nutrition: altered, less than body
requirements.)
Review short- and long-term needs for care of                                      Provides information for parents to understand
the SGA/LGA infant. Assist with follow-up in                                      need for ongoing physical, neurodevelopmental,
discharge planning.                                                                                 and psychosocial assessment needed for long-term
follow-up. (Refer to CP: The Parents of a Child with
Special Needs; NDs: Knowledge deficit [Learning
Need]; Family Coping: ineffective, risk for
compromised.)
Identify community/governmental resources                                         Presence of specific needs such as feeding
as appropriate.                                                                                         problems, resolving complications, or congenital
anomalies require ongoing monitoring and problem
solving to foster optimal growth and development.
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NCP Circumsicion

Circumcision
Circumcision is a surgical procedure in which the prepuce (foreskin) of the penis is separated from the glans, and a portion is excised. This elective procedure is performed in the United States based on parental choice for reasons related to hygiene, religion, tradition, social norms, and culture. It is usually performed at 12–24 hr of age or when the infant is considered physically stable. Frequency of this procedure has declined in recent years to approximately 62%.
NEONATAL ASSESSMENT DATA BASE
Circulation
Vital signs WNL, no signs of cold stress
Administration of vitamin K
Food/Fluid
Weight at least 2500 g (5 lb 8 oz)
Safety
Temperature WNL
Free of congenital anomalies; no family history of bleeding disorders or history of “proud flesh” scar formation (especially in black families)
Sexuality
Infant full-term (based on Dubowitz criteria)
Genitalia normal, with no evidence of hypospadias or epispadias; testes descended, and scrotal sac free of hydrocele; prepuce, still developing at birth, normally nonretractable
DIAGNOSTIC STUDIES
CBC: Rules out presence of anemia.
Clotting Studies: Identify coagulation problems.
NURSING PRIORITIES
  1. Provide parents with sufficient information to make an informed choice.
  2. Promote comfort and healing.
  3. Identify and minimize postoperative complications.
  4. Instruct parent(s) in proper care of circumcised infant.
discharge criteria
  1. Void appropriately past procedure.
  2. Free of complications.
  3. Parent(s) understand care needs and signs/symptoms requiring further evaluation.
NURSING DIAGNOSIS:                                                               KNOWLEDGE deficit [Learning Need], regarding surgical procedure, prognosis,
and treatment
May Be Related To:                                                                        Lack of exposure, misinterpretation, unfamiliarity with information resources
Possibly Evidenced By:                                                                   Request for information, verbalization of concerns/misconceptions, inaccurate follow-
through of instructions
DESIRED OUTCOMES/EVALUATION                                    Make informed decision.
CRITERIA—PARENT(S) WILL:                                               Demonstrate proper technique of care following procedure.
Verbalize understanding of signs of complications.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Ascertain parents’ understanding of the                                                 Provides a basis for discussion and identifies need
procedure. Determine cultural/religious influences.                               for further information. While cultural/religious
beliefs may dictate circumcision be performed, some
studies have shown that many women do not know
the meaning of the word or whether their husbands
are circumcised.
Review information about the advantages and                                       The routine practice of circumcision has been
disadvantages of circumcision.                                                               questioned, and the position of the American
Academy of Pediatrics (1989) is that there are both
potential medical benefits and advantages as well as
disadvantages and risks. Proponents believe that
circumcision may reduce risk of cancer of the penis
and prostate in men and of the cervix in women; that it
has prophylactic effects against a number of diseases,
including herpes; that it facilitates hygiene; and that an
uncircumcised boy may feel different from his peers.
Opponents believe that the cancer link is not proved
by scientific studies and that hygiene is more of a
factor in cancer prevention than is circumcision; that
the long-term effects of pain and stress are not known;
and that complications are a significant concern.
Discuss anticipated infant behaviors following                                      Changes in sleep patterns, fussiness, and/or
procedure.                                                                                               refusal of feedings usually persist for 2–3 hr
following procedure. However, studies indicate that
elevated cortisol levels associated with stress of the
procedure can interfere with the newborn’s ability to
regulate sleep-wake cycles for some time following
circumcision.
Note any special requests made by parents.                                           Parents may want to be present during the procedure
or may have specific religious or cultural preferences.
Provide information about the healing process                                      Prevents complications associated with infection;
and proper care (e.g., cleaning, diapering,                                             promotes infant’s comfort. Refer to ND: Pain
positioning, use of petroleum gauze dressing or                                    [acute]. Note: If plastic bell method is used to
bacterial ointment). Discuss the need to check                                      cover the glans, petroleum gauze is not needed.
infant frequently to prevent gauze from drying
out and sticking to site of circumcision. Suggest
soaking gauze with warm, sterile water before
removing it.
Discuss potential complications, e.g., hemorrhage,                               Ensures prompt identifications and treatment of
infection, or other signs warranting notification of                                problems.
healthcare provider.
NURSING DIAGNOSIS:                                                               PAIN [acute]
May Be Related To:                                                                        Trauma to/edema of tender tissues
Possibly Evidenced By:                                                                   Crying, irritability, changes in sleep pattern, refusal to eat
DESIRED OUTCOMES/EVALUATION                                    Appear relaxed, appropriately consolable.
CRITERIA—NEONATE WILL:                                                 Resume normal sleeping and eating patterns.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Provide pacifier (dipped in sugar, if desired),                                        Provides distraction and sense of reassurance to
stroke lightly, and talk gently to infant                                                   soothe the infant.
during procedure. Observe infant response.
Remove infant from restraints immediately                                           A sense of uneasiness occurs because of
following procedure. Calm infant by holding,                                       positioning and restraint. Acute pain occurs at the
cuddling, dressing, and talking to him.                                                  time of surgical procedure, because the foreskin
Encourage parents to feed and cuddle infant.                                         contains numerous nerve endings. Change of
position, freedom of movement, and tactile activities
refocus infant’s attention and comfort infant. Feeding
may promote relaxation. Note: Infant’s turning head
away, increased restlessness, hiccuping suggest
overstimulation, which may further distress the
infant.
Apply petroleum jelly and gauze dressing loosely                                 Protects against adherence to diaper and direct
around glans, as appropriate. Leave in place for                                    contact with urine.
at least 24 hr.
Position infant on side or back, not on abdomen.                                  Prevents friction or pressure on the penis. Plastic
Loose diaper or use no diaper at all for 24–72 hr                                   rim remains in place for 5–7 days. Plastic bell falls
following procedure. Note continued placement                                   off by itself when glans is healed. Note: Removal
of plastic rim following circumcision with plastic                                 of the bell by the healthcare provider may be
bell.                                                                                                         required.
Avoid use of soaps on penis; clean with clear water.                             Soap may cause irritation, increasing discomfort, and
may cause plastic bell to fall off prematurely.
Protect the surgical site from alcohol when caring                                Alcohol may cause stinging, adding to infant’s
for umbilicus.                                                                                          discomfort.
Apply a small amount of bland or petroleum-based                              Prevents the area from sticking to diaper.
ointment on the affected area or on the dressing
that may be covering the site at each diaper
change or at least 4–5 times a day for 24–48 hr.
Note infant’s behavior following procedure.                                          Acute pain following the procedure may last
approximately 30 min, whereas discomfort related to
trauma, edema, and irritation from clothing may last
for up to 7 days until healing is completed.
Collaborative
Assist with dorsal penile nerve block with 1%                                      Although it is not used routinely, anesthesia
lidocaine without epinephrine or chloroprocaine                                    abolishes the pain and distress manifested in the
(Nesacine).                                                                                              unmedicated infant by changes in hormone levels
and cardiovascular system, vigorous crying, attempts
to wriggle from restraints, and trembling. Nesacine
has a faster onset of action. Note: Risk of nerve
damage exists if injection is not carefully
placed, and the risks of elevated blood levels of
lidocaine are as yet unstudied.
Apply topical agents, e.g., EMLAcream                                                Topical agent applied 1-2 hr before procedure may be
(lidocaine and prilocaine) to penis.                                                        as effective as nerve block without associated risks.
Administer acetaminophen drops as indicated.                                       Helps ease acute pain, enhances effects of calming
behaviors.
NURSING DIAGNOSIS:                                                               URINARY ELIMINATION, altered
May Be Related To:                                                                        Tissue injury/inflammation, or development of urethral fistula
Possibly Evidenced By:                                                                   Edema, difficulty voiding
DESIRED OUTCOMES/EVALUATION                                    Void within 6–8 hr following circumcision.
CRITERIA—NEONATE WILL:                                                 Establish normal elimination pattern.
PARENT(S) WILL:                                                                        Prevent/minimize edema.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Record time of first voiding following procedure.                                 Trauma to the urinary meatus from the procedure
Note amount and adequacy of stream and                                              may result in delayed voidings, blocked urinary
presence of hematuria.                                                                            passage, or interrupted stream.
Loosely diaper the newborn and position on                                          Reduces pressure on affected site.
side or back.
Avoid placing petroleum jelly over the meatus.                                     Excessive amounts of petroleum jelly may block
meatus, requiring greater effort to empty bladder.
Place warm, wet washcloth over the bladder area                                  Relaxes musculature and may encourage voiding.
if voiding has not occurred within 6–8 hr
following procedure.
Notify healthcare provider if infant fails to void                                    Failure to void may indicate urethral fistula,
within 12 hr following procedure.                                                          necessitating further evaluation.
NURSING DIAGNOSIS:                                                               INJURY, risk for hemorrhage
Risk Factors May Include:                                                             Decrease in clotting factors immediately after birth (do not return to prebirth levels until the end of the 1st wk); previously unidentified problems with bleeding and clotting
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Be free of injury; no evidence of hemorrhage.
CRITERIA—NEONATE WILL:
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Delay surgical procedure until at least 12–24 hr                                    Postponing circumcision from the time
following birth.                                                                                       immediately following birth to 12 or more hr
following birth helps prevent complications
associated with physiological instability, cold stress,
undetected congenital anomaly, and illness.
Observe infant every hour for first 12 hr after                                       Aids in early detection of persistent bleeding.
the procedure.                                                                                         Note: Excessive blood loss may be an initial indicator
of bleeding/coagulation problems, such as
hemophilia.
Apply gentle, direct pressure to bleeding site,                                       Promotes vasoconstriction to stop bleeding.
using a sterile gauze pad.
Apply sterile petroleum gauze dressing to site                                       Acts as a pressure dressing to control bleeding and
immediately following procedure and with                                            prevent surgical site from adhering to the diaper,
each diaper change, if plastic bell method is not                                    which could cause further irritation or loss of
used. Moisten gauze with water if it adheres                                         stable clot.
to surgical site.
Collaborative
Apply Gelfoam to bleeding areas.                                                          Gelfoam acts as a local hemostatic agent to promote
platelet adhesion and clotting.
Assist with placement of suture(s), as needed.                                       May be necessary to control bleeding.
NURSING DIAGNOSIS:                                                               INFECTION, risk for
Risk Factors May Include:                                                             Immature immune system, invasive procedure/tissue trauma, environmental exposure
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes and actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Display timely healing of circumcision site within
CRITERIA—NEONATE WILL:                                                 1 wk.
Be free of signs of infection.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Clean penis gently with warm, sterile water or                                      Removes urine/feces from penis; helps promote
dilute hydrogen peroxide, and apply fresh sterile                                  healing. Note: Excessive scrubbing may irritate the
petroleum gauze with each diaper change.                                             site and provide entry for bacteria.
Note appearance of whitish yellow exudate                                           Exudate is usually noted 24–48 hr following
around the glans. Do not remove.                                                           procedure. It is a normal sign of the granulation
process and eventually disappears on its own.
Observe penis for signs of infection at each diaper                                Early detection of infection can prevent
change, (e.g., erythema or purulent exudate).                                        generalized sepsis from occurring.
Ensure that plastic bell is still firmly attached,
if used.
Collaborative
Obtain culture of exudate, if present.                                                     Identifies pathogens, appropriate treatment choices.
Monitor results of laboratory studies, e.g., CBC.                                   Helps confirm presence or resolution of infectious
process.
Administer local or systemic antibiotic, as indicated.                            Treats infection; prevents systemic involvement.
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NCP Cesarean Birth

Cesarean Birth
Cesarean birth is an alternative to vaginal birth only when the safety of the mother and/or fetus is compromised.
CLIENT ASSESSMENT DATA BASE
Activity/Rest
Fatigue may be present.
Circulation
Hypertension (escalating PIH)
Hypotension, ashen color, cool/clammy skin (uterine rupture)
Ego Integrity
May view anticipated procedure as a sign of failure and/or as a negative reflection on abilities as a female
May actually fear intervention/view surgery as life-threatening
Irritable/emotional tension, (emotional response to prolonged labor; physiological response to PIH)
Food/Fluid
Excessive weight gain, nausea/vomiting, generalized edema (PIH)
Pain/Discomfort
Prolonged/dysfunctional contractile pattern (dystocia).
Uterine tenderness may be present; severe abdominal pain (uterine rupture).
Right upper quadrant (RUQ)/epigastric pain (PIH).
Headache (PIH).
Neurosensory
Visual disturbance/scotomata (spots in visual field) (PIH)
Seizure activity (eclampsia)
Hyperreflexia, clonus (PIH)
Safety
Elevated temperature (infectious process/dehydration).
Active STD (e.g., herpes).
Severe Rh incompatibility.
Prolapsed cord.
Fetal distress.
Impending delivery of premature fetus.
Fetal macrosomia (estimated >4000 g).
Unsuccessful external cephalic version to rotate breech presentation, or transverse lie.
Membranes may have been ruptured for 24 hr or longer.
Sexuality
CPD; tumor/neoplasm obstructing the pelvis/birth canal
Multiple pregnancies or gestations (overdistended uterus)
Substantial vaginal bleeding (placenta previa/abruptio placentae)
Previous cesarean delivery with classical incision; previous uterine or cervical surgery
Teaching/Learning
Presence of maternal complication/risk factors, such as severe PIH, diabetes, renal or cardiac disease, or ascending infection; prenatal abdominal trauma; maternal age >35 yr.
Procedure may or may not be planned, affecting client’s preparation and understanding of procedure.
Failed induction.
Maternal age.
DIAGNOSTIC STUDIES
Complete Blood Count (CBC), Blood Typing (ABO) and Cross-match, Coombs’ test: Preoperative screening tests.
Urinalysis: Determines albumin/glucose levels.
Cultures: Identify presence of herpes simplex virus type II.
X-ray Pelvimetry: Determines CPD, flexion of head in breech position.
Amniocentesis: Assesses fetal lung maturity.
Ultrasonography: Locates placenta; determines fetal growth, lie, and presentation, as well as fetal anomalies/malformations favoring cesarean delivery.
Nonstress Test (NST) or Contraction Stress Test (CST): Assesses fetal response to movement/stress of uterine contractions.
Continuous Electronic Monitoring: Validates fetal status/uterine activity.
NURSING PRIORITIES
  1. Promote maternal/fetal well-being.
  2. Provide client/couple with necessary information.
  3. Support client’s/couple’s desires to participate actively in birth experience.
  4. Prepare client for surgical procedure.
  5. Prevent complications.
NURSING DIAGNOSIS:                                                               Knowledge deficit [Learning Need], regarding surgical procedure, expectations, postoperative regimen
May Be Related To:                                                                        Lack of exposure/unfamiliarity with information, misinterpretation
Possibly Evidenced By:                                                                   Request for information, statement of misconcep-tion, exaggerated behaviors
DESIRED OUTCOMES/EVALUATION                                    Verbalize understanding of indications for
CRITERIA—CLIENT WILL:                                                     cesarean birth.
Recognize this as an alternative childbirth method to obtain healthiest outcome possible.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess learning needs.                                                                            This birth method is discussed in prepared childbirth
classes, but many clients fail to retain the information
because it has no personal significance at the time.
Clients having a repeat cesarean delivery may not
clearly remember or understand the details of their
previous delivery. Note: Some facilities provide
cesarean preparation classes for those undergoing
planned procedure.
Note stress level and whether procedure was                                         Identifies client’s/couple’s readiness to
planned or unplanned.                                                                             incorporate information.
Provide accurate information in simple terms, clarify                           Stress of the situation can interfere with client’s
misconceptions. Encourage couple to ask questions                              ability to take in/comprehend information needed
and verbalize their understanding.                                                          to make informed decisions. Provides an opportunity
to evaluate client’s/couple’s understanding of
situation. Note: Native Americans may fear
procedure based on history of unwanted sterilization
associated with consent for surgery.
Review indications necessitating alternative birth                                 Currently approximately one in five or six
method.                                                                                                   deliveries is a cesarean birth; and although one of
CDC’s goals for Healthy America 2000 is to reduce
the rate to 15% or less, the procedure should be
viewed as an alternative, not an abnormal situation,
to enhance maternal/fetal safety and well-being.
Describe preoperative procedures in advance, and                                Information allows client to anticipate events and
provide rationale as appropriate.                                                             understand reasons for interventions/actions.
Provide postoperative teaching; including demon-                                Provides techniques to prevent complications
stration of leg exercises, coughing/deep breathing;                               related to venous stasis and hypostatic
splinting technique; and abdominal tightening                                      pneumonia, and to decrease stress on operative
exercises.                                                                                                 site. Abdominal tightening decreases discomfort
associated with gas formation and abdominal
distension.
Discuss anticipated sensations during delivery and                               Knowing what to expect and what is “normal”
recovery period.                                                                                      helps prevent unnecessary concern.
NURSING DIAGNOSIS:                                                               Anxiety [specify level]
May Be Related To:                                                                        Situational crisis, threat to self-concept, perceived/actual threat of maternal and fetal well-being, interpersonal transmission
Possibly Evidenced By:                                                                   Increased tension, distress, apprehension, feelings of inadequacy, sympathetic stimulation, restlessness
DESIRED OUTCOMES/EVALUATION                                    Verbalize fears for the safety of client and infant.
CRITERIA—CLIENT/COUPLE WILL:
Discuss feelings about cesarean birth.
Appear appropriately relaxed.
Use resources/support system effectively.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess psychological response to event and avail-                                 The greater the client perceives the threat, the
ability of support system(s).                                                                   greater the level of her anxiety.
Note cultural influences/expectations.                                                     Some cultures (e.g., Latin, Mexican/Arab-American)
may view surgical intervention as detrimental to the
client’s well-being or may believe client will be
stigmatized as a “weak woman” (e.g., Puerto Rican).
Ascertain whether procedure is planned or                                            With unplanned cesarean birth, the client/couple
unplanned.                                                                                               usually has no time for physiological or
psychological preparation. Even when planned,
cesarean birth can create apprehension in the
client/couple owing to an actual or perceived
physical threat to the mother and infant related to the
condition necessitating the procedure and to the
surgery itself.
Stay with client, and remain calm. Speak slowly.                                  Helps to limit interpersonal transmission of
Convey empathy.                                                                                    anxiety, and demonstrates caring for the
client/couple.
Reinforce positive aspects of maternal and fetal                                    Focuses on likelihood of successful outcome and
condition.                                                                                                helps to bring perceived/actual threat into
perspective.
Encourage client/couple to verbalize and/or                                          Helps to identify negative feelings/concerns and
express feelings (cry).                                                                             provides opportunity to cope with ambivalent or
unresolved feelings/grief. The client may also feel an
emotional threat to her self-esteem, owing to her
feelings that she has failed, that she is weak as a
woman, and that her expectations have not been met.
Partner may question own abilities in assisting client
and providing needed support.
Support/redirect expressed coping mechanisms.                                    Enhances basic and automatic coping mechanisms,
increases self-confidence and acceptance, and reduces
anxiety. Note: Some client actions may be viewed as
ineffective (e.g., screaming and throwing things) and
need to be redirected to enhance client’s sense of
control.
Discuss past childbirth experience/expectations,                                   Client may have distorted memories of past
as appropriate.                                                                                         delivery or unrealistic perceptions of abnormality of
cesarean birth that will increase anxiety.
Provide period of privacy, if possible. Reduce                                      Allows client/couple opportunity to internalize
environmental stimuli, such as the number of people                            information, marshal resources, and cope effectively.
present, as indicated by client’s desires.
NURSING DIAGNOSIS:                                                               Self Esteem, risk for situational low
Risk Factors May Include:                                                             Perceived “failure” at a life event
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Identify and discuss negative feelings.
CRITERIA—CLIENT WILL:
Verbalize confidence in herself and in her abilities.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Determine client’s usual feelings about self and                                    Diagnosis of a change in self-concept is based on
pregnancy. Note cultural influences.                                                      knowledge of past perceptions and experiences.
Cesarean birth, whether planned or unplanned, has
the potential to alter the way the client feels about
herself. The client sees that the birth plan has been
altered and that surgical intervention is needed to
deliver the infant, whereas most women are able to
deliver without any such intervention.
Encourage verbalization of feelings.                                                      Identifies areas to be addressed. Clients’ reactions
vary and may be difficult to diagnose in the
preoperative period. Feelings of negative self-image
related to disappointment in the birth experience
may interfere with postpartal activities related to
successful breastfeeding and infant care.
Encourage questions and provide information/                                      Enhances understanding and clarifies
reinforce previous learning.                                                                    misconceptions.
Refer to cesarean birth as an alternative method                                    Terms such as “C-section” and “normal delivery”
of childbirth.                                                                                            may reinforce client’s perception that the cesarean
birth is different and unnatural, and client may view
self as inadequate/flawed or weak.
Provide verbal communication of assessment and                                 When a problem of self-esteem arises for the client,
interventions. Written information can be provided                              it may become more severe in the postpartal
at a later time.                                                                                          period. During the preoperative period, client is
focusing on the here and now and may not be ready
to read or deal with additional information.
Identify other couples/resources to be referred                                      At this crucial time, the nature of the situation
to after delivery.                                                                                      usually does not allow opportunity to talk with
others who have shared the same experience.
However, these activities may be beneficial in the
future to help with resolution of feelings/
perceptions.
Collaborative
Encourage partner’s presence at the delivery                                         Provides support for the client, promotes parental
as desired.                                                                                               bonding, and provides additional input to the client’s
recall of the birth experience, because memory lapses
are more common during periods of crisis. Note:
Cultural expectations may prevent participation of
father in birth process, necessitating attendance by a
female family member.
Encourage the client/couple to participate in                                         Provides reinforcement of the birth experience and
delivery-room bonding activities (e.g., breastfeeding                            deemphasizes the surgical nature of the delivery.
and holding the infant) as able.
NURSING DIAGNOSIS:                                                               Powerlessness
May Be Related To:                                                                        Interpersonal interaction, perception of illness-related regimen, lifestyle of helplessness
Possibly Evidenced By:                                                                   Verbalization of lack of control, lack of participation in care or decision making, passivity
DESIRED OUTCOMES/EVALUATION                                    Verbalize fears and feelings of vulnerability.
CRITERIA—CLIENT/COUPLE WILL:
Express individual needs/desires.
Participate in decision-making process whenever possible.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess factors contributing to sense of powerlessness.                          Unplanned (and sometimes planned) cesarean birth
may be characterized by the client’s/couple’s sense
of loss of control over the birth experience. The client
becomes subjected to the procedures and equipment
used in illness. For those clients experiencing their
first hospitalization, which involves fear of the
unknown, powerlessness becomes a major stress
factor.
Present options in care when possible (e.g., choice                               Allows the client/couple to have some sense of
of anesthesia, IV placement, and use of mirror).                                    input/control over the situation.
Identify client’s/couple’s expectations and desires                                Provides opportunity to accommodate needs and
regarding the delivery experience.                                                          promote positive experience.
Provide personal space and time alone for the couple                           Creates sense of control and lets couple have time
prior to surgery, if possible. Remain with client                                    to talk about their situation. Leaving client alone
if partner is absent.                                                                                  may result in feelings of abandonment and increased
level of anxiety.
Provide information, and discuss client’s/couple’s                                Reduces stress caused by misconceptions/
perceptions.                                                                                             unfounded fears as well as fear of the unknown.
NURSING DIAGNOSIS:                                                               Pain [acute], risk for
Risk Factors May Include:                                                             Increased/prolonged muscle contractions, psychological reactions
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Verbalize reduced discomfort/pain.
CRITERIA—CLIENT WILL:
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess location, nature, and duration of pain,                                        Indicates the appropriate choice of treatment. The
especially as it relates to the indication for cesarean                              client awaiting imminent cesarean birth may
birth.                                                                                                        experience varying degrees of discomfort, depending
on the indication for the procedure, e.g., failed
induction, dystocia.
Eliminate anxiety-producing factors (e.g., loss of                                  Levels of pain tolerance are individual and are
control), provide accurate information, and                                           affected by various factors. Excessive anxiety in
encourage presence of partner.                                                               response to the emergency situation may enhance
discomfort because fear, tension, and pain are
interrelated and impact client’s ability to cope.
Instruct in relaxation techniques; position for                                        May assist in reduction of anxiety and tension,
comfort as possible. Use Therapeutic Touch, as                                    promote comfort and enhance sense of well-being.
appropriate.
Collaborative
Administer sedative, narcotics, or preoperative                                     Promotes comfort by blocking pain impulses.
medication as indicated.                                                                          Potentiates the action of anesthetic agents.
NURSING DIAGNOSIS:                                                               Infection, risk for
Risk Factors May Include:                                                             Invasive procedures, rupture of amniotic membranes, break in the skin, decreased Hb, exposure to pathogens
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Be free of infection.
CRITERIA—CLIENT WILL:
Achieve timely wound healing without complications.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Review history for preexisting conditions/risk                                      Underlying maternal conditions, such as diabetes
factors. Note time of rupture of membranes.                                          or hemorrhage, potentiate the risk of infection or
poor wound healing. Risk of chorioamnionitis
increases with the passage of time, placing mother
and fetus at risk. Presence of infectious process may
increase fetal risk of contamination.
Assess for signs/symptoms of infection (e.g.,                                        Rupture of membranes occurring 24 hr prior to
elevated temperature, pulse, WBC; abnormal odor/                              surgery may result in chorioamnionitis prior to
color of vaginal discharge, or fetal tachycardia).                                    surgical intervention and may impair wound healing.
Provide perineal care per protocol, especially once                               Reduces risk of ascending infection.
membranes have ruptured.
Collaborative
Carry out preoperative skin preparation; scrub                                      Reduces risk of skin contaminants entering the
according to protocol.                                                                             incision, reducing risk of postoperative infection.
Obtain blood, vaginal, and placental cultures, as                                   Identifies infecting organism and degree of
indicated.                                                                                                 involvement.
Note Hb and Hct, and estimated blood loss during                                Risk of postdelivery infection and poor healing is
surgical procedure.                                                                                  increased if Hb levels are low and blood loss is
excessive. Note: Greater blood loss is associated with
classic incision than with lower uterine segment
incision.
Administer parenteral broad-spectrum antibiotic                                   Prophylactic antibiotic may be ordered to prevent
preoperatively.                                                                                         development of an infectious process, or as
treatment for an identified infection, especially if
the client has had prolonged rupture of membranes.
Note: Research suggests administration of antibiotic
up to 2 hr before start of procedure provides the most
protection from infection.
(Refer to CP: Labor: Stage I—Latent Phase; ND: Infection, risk for maternal.)
NURSING DIAGNOSIS:                                                               Gas Exchange, risk for impaired fetal
Risk Factors May Include:                                                             Altered blood flow to placenta and/or through umbilical cord
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Display optimal FHR.
CRITERIA—FETUS WILL:
Manifest normal variability on monitor strip.
Reduce frequency of late or prolonged variable decelerations.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Note presence of maternal factors that negatively                                 Reduced circulating volume or vasospasms within
affect placental circulation and fetal oxygenation.                                 the placenta reduce oxygen available for fetal uptake.
Continue monitoring FHR, noting beat-to-beat                                     Owing to hypoxia, fetal distress may occur; may
changes or decelerations during and following                                      be manifested by reduced variability, late
contractions.                                                                                            decelerations, and tachycardia followed by
bradycardia. Note: Infection from prolonged rupture
of membranes also increases FHR.
Note presence of variable decelerations; change                                   Compression of cord between birth canal and
client’s position from side to side.                                                          presenting part may be relieved by position changes.
Note color and amount of amniotic fluid when                                      Fetal distress in vertex presentation is manifested
membranes rupture.                                                                                by meconium staining, which is the result of a vagal
response to hypoxia.
Auscultate FHR when membranes rupture.                                            In the absence of full cervical dilation, occult or
visible prolapse of the umbilical cord may necessitate
cesarean birth.
Monitor fetal heart response to preoperative                                          Narcotics usually reduce FHR variability and may
medications or regional anesthesia.                                                        require administration of naloxone (Narcan)
following delivery to reverse narcotic-induced
respiratory depression. Maternal hypotension in
response to anesthesia commonly causes transient
fetal bradycardia, reduced variability, and sleep.
Collaborative
Apply internal lead, and monitor fetus electronically                            Provides more accurate measurement of fetal
as indicated.                                                                                             response and condition.
Provide supplemental oxygen to mother via mask.                                Maximizes oxygen available for placental uptake.
Administer IV fluid bolus prior to initiation                                          Optimizes uteroplacental perfusion, helps prevent
of epidural/spinal anesthesia.                                                                  hypotensive response.
Assist physician with elevation of vertex, if required.                           Position changes may relieve pressure on cord.
Arrange for presence of pediatrician and neonatal                                 owing to underlying maternal condition(s) and/or
intensive care nurse in delivery room for both                                       alternative birth process, infant may be preterm or
scheduled and emergency cesarean births.                                             may experience altered responses, necessitating
immediate care/resuscitation.
NURSING DIAGNOSIS:                                                               Injury, risk for maternal
Risk Factors May Include:                                                             Traumatized tissue, delayed gastric motility, altered mobility, effects of medication/decreased sensation
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                       Be free of injury.
CRITERIA—CLIENT WILL:
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Remove prosthetic devices (e.g., contact lenses,                                   Reduces risk of accidental injury.
dentures/bridges) and jewelry.
Determine time and content of last meal. Report                                   If client has eaten just before surgical procedure,
information to anesthesiologist. Ensure availability                              risks of vomiting and aspiration increase,
and functioning of resuscitation equipment.                                           and general anesthesia may be contraindicated.
Restrict oral intake once decision for cesarean                                      Reduces possibility of aspiration from vomiting.
birth is made.
Review labor record, noting voiding frequency,                                    May indicate urine retention or reflect fluid
output, appearance, and time of last voiding.                                         imbalance or dehydration in client who has been in
prolonged labor.
Monitor urine output and color following insertion                               Reflects hydration level, circulatory status, and
of indwelling catheter. Note any blood-tinged urine.                             possible bladder trauma associated with surgical
procedure.
Assist with positioning for anesthesia; support legs                              Essential for placement of anesthesia. Client
in postoperative transfer to stretcher. Note client’s                                with epidural or spinal anesthesia may incur
response during and after anesthesia. (Refer to CP:                               weakness/decreased sensation of lower
Care Following Cesarean Birth [4 Hours to 4 Days].)                           extremities. Idiosyncratic responses to anesthesia
can occur, such as anaphylaxis or respiratory
paralysis if anesthetic block rises too high.
Keep accurate instrument and sponge counts at                                     Ensures that all equipment and sponges are
critical times during closure, according to hospital                                accounted for and not accidentally left in client’s
protocol.                                                                                                  body.
Collaborative
Obtain urine specimen for routine analysis, protein,                              Client is at increased risk if infectious process or
and specific gravity. Ensure that laboratory results                               hypertensive state is present.
are available before surgery is started.
Insert indwelling catheter to continuous gravity                                    Reduces risk of bladder injury during surgical
drainage system either just before surgical procedure                           procedure.
or in the operating room, as indicated.
Administer preprocedural medication (e.g., atropine).                           Reduces oral secretions, limiting risk of aspiration.
NURSING DIAGNOSIS:                                                               Cardiac Output, risk for decreased
Risk Factors May Include:                                                             Decreased venous return, alteration in systemic vascular resistance
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Remain normotensive, with blood loss less than
CRITERIA—CLIENT WILL:                                                     800 ml.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Note length of labor, if applicable. Assess for                                       Decreased intake and/or increased fluid losses
dehydration or excess intrapartal fluid losses.                                       lead to reduced circulating volume and cardiac
output.
Remove nail polish on fingernails/toenails.                                            Allows clear visualization of nailbeds for assessing
circulatory status.
Monitor respirations, BP, and pulse before, during,                              Hypotension is an anticipated side effect of
and after administration of anesthesia.                                                   regional anesthesia (e.g., epidural or spinal
anesthesia) because such anesthesia relaxes smooth
muscles within vascular walls, affecting circulating
volume and reducing placental perfusion.
Place towel or wedge under client’s hip.                                                Shifts uterus off inferior vena cava and increases
venous return. Compression caused by obstruction of
the inferior vena cava and aorta by the gravid uterus
in a supine position may cause as much as a 50%
decrease in cardiac output.
Note change in behavior or mental status, cyanosis                               Oxygen deficits are manifested first by changes in
of mucous membranes.                                                                           mental status, later by cyanosis.
Collaborative
Administer supplemental oxygen via mask, as                                      Increases oxygen available for maternal and fetal
indicated.                                                                                                 uptake. Note: Nasal cannula is not recommended
because of excessive oxygen loss to environment.
Initiate IV infusion of electrolyte solution.                                            Expands circulatory volume, especially prior to
Administer bolus, as indicated.                                                               administration of epidural/spinal anesthesia;
provides route for emergency medication in the event
of a complication.
Note alteration in vital signs; assist anesthetist as                                  Excess fluid losses and hemorrhage during labor
needed. Estimate and record blood losses.                                             and the intraoperative period may reduce cardiac
output and promote vasoconstriction with shunting
of blood to major organs. Diminished cardiac output
and shock are manifested by decreased BP, increased
or thready pulse, and cool/clammy skin.
Administer whole blood, plasma expanders,                                          Replaces fluid losses, increases circulating blood
cryoprecipitate, platelets, or packed cells as indicated.                          volume, and increases oxygen-carrying capacity.
(Refer to CP: Postpartal Hemorrhage; ND: Fluid
Volume deficit [isotonic].)
Prepare and administer oxytocin (Pitocin) infusion.                              Once delivery of infant and placenta is completed,
Pitocin aids myometrium contraction and reduces
blood loss from exposed endometrial blood vessels.
NURSING DIAGNOSIS:                                                               Sensory/Perceptual alterations, [overload]
May Be Related To:                                                                        Multiple environmental stimuli, increased number of personnel, excessive noise level, psychological stress
Possibly Evidenced By:                                                                   Exaggerated emotional response, irritability, muscle tension
DESIRED OUTCOMES/EVALUATION                                    Verbalize understanding of need for increased
CRITERIA—CLIENT WILL:                                                     level of activity.
Appear appropriately relaxed.
Maintain focus, tuning out extraneous distractions.
 
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess environment for factors causing sensory                                    Identifies factors, which may or may not be
overload.                                                                                                 controllable. Cesarean birth necessitates many
medical and nursing activities necessary to ensure
the health of mother and infant. Client tends to focus
on the procedures being performed and the
conversations going on in the room. The birth
experience may be compromised by invasive
technology, tending to shift the focus from the birth
of the infant to the surgical procedure.
Provide information about the surgical routine,                                     Knowledge about procedures, instruments, and
including sounds, lights, dress, and instruments.                                    alarms can help decrease anxiety, puts perceived
“chaos” in perspective.
Decrease noise levels, limit conversations, and use                               Client may be keenly aware of sounds.
equipment/alarms judiciously.                                                                Conversation, noise from equipment, and alarms
may confuse client/cause unnecessary anxiety.
Maintain eye contact, especially when wearing mask.                           Acknowledges presence of client/couple, conveys
feeling of caring.
Include client/couple in operating room conver-                                    Ignoring the client can increase fear, which
sation or silence, using concerned communication.                                detracts from a positive birth experience.
Eliminate unnecessary personnel from the                                             Avoids intrusions into personal space, which
environment.                                                                                           could increase anxiety. Individuals who are not
involved in care of the client may detract from the
intimacy of the birth experience.
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NCP Care Following Cesarean Birth 4 hours to 3 days post partum

CARE FOLLOWING CESAREAN BIRTH (4 HOURS TO 3 DAYS POSTPARTUM)
CLIENT ASSESSMENT DATA BASE
Review prenatal and intraoperative record, and the indication(s) for cesarean delivery.
Circulation
Blood loss during surgical procedure approximately 600–800 ml
Ego Integrity
May display emotional lability, from excitation, to apprehension, anger, or withdrawal.
Client/couple may have questions or misgivings about role in birth experience.
May express inability to deal with current situation.
Elimination
Indwelling urinary catheter may be in place; urine clear amber.
Bowel sounds absent, faint, or distinct.
Food/Fluid
Abdomen soft with no distension initially.
Mouth may be dry.
Neurosensory
Impaired movement and sensation below level of spinal epidural anesthesia
Pain/Discomfort
May report discomfort from various sources, e.g., surgical trauma/incision, afterpains, bladder/abdominal distension, effects of anesthesia
Respiratory
Lung sounds clear and vesicular
Safety
Abdominal dressing may have scant staining or may be dry and intact.
Parenteral line/saline lock when used, is patent, and site is free of erythema, swelling, and tenderness.
Sexuality
Fundus firmly contracted and located at the umbilicus.
Lochia flow moderate and free of excessive/large clots.
DIAGNOSTIC STUDIES
CBC, Hb/Hct: Assesses changes from preoperative levels and evaluates effect of blood loss in surgery.
Urinalysis (UA); Urine, Blood, Vaginal, and Lochial Cultures: Additional studies are based on individual need.
NURSING PRIORITIES
  1. Promote family unity and bonding.
  2. Enhance comfort and general well-being.
  3. Prevent/minimize postoperative complications.
  4. Promote a positive emotional response to birth experience and parenting role.
  5. Provide information regarding postpartal needs.
DISCHARGE GOALS
  1. Family bonding initiated
  2. Pain/discomfort easing
  3. Physical/psychological needs being met
  4. Complications prevented/resolving
  5. Positive self-appraisal regarding birth and parenting roles expressed
  6. Postpartal care understood and plan in place to meet needs after discharge
NURSING DIAGNOSIS:                                                               PARENT/INFANT ATTACHMENT, altered
May Be Related To:                                                                        Developmental transition/gain of a family member, situational crisis (e.g., surgical intervention, physical complications interfering with initial acquaintance/interaction, negative self-appraisal)
Possibly Evidenced By:                                                                   Hesitancy to hold/interact with infant, verbalization of concerns/difficulty coping with situation, not dealing with traumatic experience constructively
DESIRED OUTCOMES/EVALUATION                                    Hold infant, as maternal and neonatal conditions
CRITERIA—CLIENT WILL:                                                     permit.
                                                                                                           Demonstrate appropriate attachment and bonding behaviors.
Begin to actively engage in newborn care tasks, as appropriate.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Encourage client to hold, touch, and examine                                        The first hours after birth offer a unique
the infant, depending on condition of client                                           opportunity for family bonding to occur because
and the newborn. Assist as needed.                                                        both mother and infant are emotionally receptive to
cues from each other, which initiate the attachment
and acquaintance process. Assistance in first few
interactions or until IV line is removed helps client
avoid feelings of discouragement or inadequacy.
Note: Even if client has chosen to relinquish her
child, interacting with the newborn may facilitate the
grieving process.
Provide opportunity for father/partner to touch                                     Helps facilitate bonding/attachment between
and hold infant and assist with infant care as                                         father and infant. Provides a resource for the
allowed by situation.                                                                               mother, validating the reality of the situation and the
newborn at a time when procedures and her physical
needs may limit her ability to interact.
Observe and record family-infant interactions,                                      Eye-to-eye contact, use of en face position, talking
noting behaviors indicative of bonding and                                           in a high-pitched voice, and holding infant closely
attachment within specific culture.                                                         are associated with attachment in American culture.
On first contact with the infant, a mother manifests a
progressive pattern of behaviors, whereby she
initially uses fingertips to explore the infant’s
extremities and progresses to using the palm before
enfolding the infant with her whole hand and arms.
Discuss need for usual progression and interactive                                Helps client/couple understand significance and
nature of bonding. Reinforce normalcy of variation of                          importance of the process and provides
response from one time to another and among                                       reassurance that differences are to be expected.
different children.
Note verbalizations/behaviors suggesting                                              The arrival of a new family member, even when
disappointment or lack of interest/attachment.                                        wanted and anticipated, creates a transient period of
disequilibrium, requiring incorporation of the new
child into the existing family.
Allow parents the opportunity to verbalize negative                              Unresolved conflicts during the early parent-infant
feelings about themselves and the infant.                                               acquaintance process may have long-term negative
effects on the future parent-child relationship.
Note circumstances surrounding cesarean birth,                                    Parents need to work through meaning attributed
parents’ self-appraisal and perception of birth                                       to stressful events surrounding childbirth and
experience, their initial reaction to infant, and                                       orient themselves to reality before they can focus
their participation in birth experience.                                                    on infant. Effects of anesthesia, anxiety, and pain can
alter the client’s perceptual abilities during and
following surgical intervention.
Encourage and assist with breastfeeding, dependent                             Early contact has a positive effect on duration of
on client’s choice and cultural beliefs/practices.                                     breastfeedings; skin-to-skin contact and initiation of
maternal tasks promotes bonding. Some cultures
(e.g., Hispanic, Navajo, Filipino, Vietnamese) may
refrain from breastfeeding until the milk flow is
established.
Welcome family and siblings for brief visit as soon                              Promotes family unity, and helps siblings begin
as maternal/newborn condition permits. (Refer to                                 process of positive adaptation to new roles and
CP: The Client at 4 Hours to 2 Days Postpartum;                                  incorporation of new member into family
ND: Family Coping: potential for growth.)                                            structure.
Provide information, as desired, about infant’s                                      Helps couple to process and evaluate necessary
safety and condition. Support couple as needed.                                    information, especially if initial acquaintance period
has been delayed.
Initiate contact between client/couple and infant as                               Reduces anxiety that may be associated with
soon as possible. If infant is sent to neonatal                                         handling infant, fear of unknown, and/or
intensive care unit, establish line of communication                             assuming the worst regarding infant status.
between nursery staff and client/couple. Take
pictures of neonate and allow for visits when
client’s physical status permits. (Refer to CP:
The Parents of a Child with Special Needs.)
Answer client’s questions regarding protocol                                        Information relieves anxiety that may interfere
of care during early postdelivery period.                                                with bonding or result in self-absorption rather than
inattention to newborn.
Collaborative
Notify appropriate healthcare team members                                        Inadequate bonding behaviors or poor interaction
(e.g., nursery staff or postpartal nurse) of                                              between client/couple and infant necessitates
observations as indicated.                                                                       support and further evaluation. Note: In some
cultures, e.g., Native American, the father may
practice a period of ritual avoidance beginning
immediately after the birth. (Refer to CP: The Client
at 4 Hours to 2 Days Postpartum; ND: Parenting, risk
for altered.)
Prepare for ongoing support/follow-up after                                          Many couples have unresolved conflicts regarding
discharge, e.g., visiting nurse services, community                               initial parent-infant acquaintance process that may
agencies, and parent support group.                                                       require resolution after discharge.
NURSING DIAGNOSIS:                                                               PAIN [acute]/[DISCOMFORT]
May Be Related To:                                                                        Surgical trauma, effects of anesthesia, hormonal effects, bladder/abdominal distension
Possibly Evidenced By:                                                                   Reports of incisional pain, cramping (afterpains), headache, abdominal bloating, breast tenderness; guarding/distraction behaviors, facial mask of pain
DESIRED OUTCOMES/EVALUATION                                    Identify and use appropriate interventions to
CRITERIA—CLIENT WILL:                                                     manage pain/discomfort.
                                                                                                           Verbalize lessening of level of pain.
Appear relaxed, able to sleep/rest appropriately.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Determine characteristics and location of                                              Client may not verbally report pain and
discomfort. Rate severity on a 0–10 scale.                                             discomfort directly. Comparing specific
Note verbal and nonverbal cues, such as                                                characteristics of pain aids in differentiating
grimacing, rigidity, and guarding or                                                       postoperative pain from developing complications
restricted movement.                                                                               (e.g., ileus, bladder retention or infection, wound
dehiscence).
Provide information and anticipatory guidance                                     Promotes problem solving, helps reduce pain
regarding causes of discomfort and appropriate                                     associated with anxiety and fear of the unknown,
interventions.                                                                                           and provides sense of control.
Evaluate BP, pulse, and behavior changes (e.g.,                                    In many clients pain may cause restlessness and an
distinguish between restlessness associated with                                   increase in BP and pulse. Administration of
excessive blood loss from that resulting from pain).                              analgesics may lower BP.
Note uterine tenderness and presence/                                                    During the first 12 hr postpartum, uterine
characteristics of afterpains; postoperative                                            contractions are strong and regular, and they
infusion of oxytocin.                                                                               continue for the next 2–3 days, although their
frequency and intensity are reduced. Factors
intensifying afterpains include multiparity, uterine
overdistension, breastfeeding, and administration of
ergot and oxytocin preparations.
Reposition client, reduce noxious stimuli, and                                       Relaxes muscles, and redirects attention away
offer comfort measures, e.g., back rubs. Encourage                              from painful sensations. Promotes comfort, and
use of breathing and relaxation techniques and                                      reduces unpleasant distractions, enhancing sense
distraction (stimulation of cutaneous tissue) as                                      of well-being.
learned in childbirth preparation classes.
Encourage presence and participation of partner
as appropriate.
Initiate deep-breathing exercises, incentive                                           Deep breathing enhances respiratory effort.
spirometry, and coughing using splinting                                              Splinting reduces strain and stretching of
procedures, as appropriate, 30 min after                                                incisional area and lessens pain and discomfort
administration of analgesics.                                                                   associated with movement of abdominal muscles.
Coughing is indicated when secretions or rhonchi are
auscultated.
Encourage early ambulation, use of rocking chair                                 Decreases gas formation and promotes peristalsis
or left side-lying position, as appropriate.                                              to relieve discomfort of gas accumulation, which
Recommend avoidance of gas-forming foods or                                   often peaks on 3rd day after cesarean birth.
fluids, e.g., beans, cabbage, carbonated beverages,
whole milk, very hot or very cold beverages,
or use of straws for drinking. (Refer to ND:
Constipation.)
Recommend use of left lateral recumbent position.                               Allows gas to rise from descending to sigmoid colon,
facilitating expulsion.
Inspect perineum for hemorrhoids. Suggest                                           Aids in regression of hemorrhoids and vulvar
application of ice for 20 min every 4 hr, use of                                     varicosities by promoting venous return and
witch hazel compresses, and elevation of pelvis                                    localized vasoconstriction, reducing associated
on pillow, as appropriate.                                                                        edema, discomfort, and itching.
Palpate bladder, noting fullness. Facilitate periodic                               Return of normal bladder function may take 4–7
voiding after removal of indwelling catheter.                                         days, and overdistension of bladder may create
feelings of urgency and discomfort.
Investigate reports of headache, especially following                            Leakage of CSF through the dura mater into the
subarachnoid anesthesia. Avoid medicating client                                 extradural space reduces volume needed to
before nature and cause of headache are determined.                            support brain tissue, causing the brain stem to fall
Note character of headache (e.g., deep location                                     onto the base of the skull when client is in an
behind the eyes, with pain radiating to both temples                             upright position. PIH may result in cerebral
and occipital area; relieved in supine position but                                 edema, necessitating other interventions. (Refer to
increased in sitting or standing position) to                                            CP: The Client at 4 Hours to 2 Days Postpartum;
distinguish from headache associated with anxiety                               ND: Fluid Volume, risk for excess.)
or PIH.
Encourage bedrest in flat-lying position, increase                                 Reduces severity of headache by increasing fluid
fluids, offer caffeinated beverage, assist as needed                                available for production of CSF and limiting
with client and infant care, and apply abdominal                                   position shifts of the brain. Severe headache may
binder when client is upright, in presence of                                          interfere with client’s ability to carry out
postspinal headache. Notify physician or                                               self/infant care. Ongoing headache may require
anesthesiologist, as indicated.                                                                 more aggressive therapy.
Inspect breast and nipple tissue; assess for                                            At 24 hr postpartum, breasts should be soft and
presence of engorgement and/or cracked nipples.                                  nontender, with nipples free of cracks or reddened
areas. Breast engorgement, nipple tenderness, or
presence of cracks on nipple (if client is lactating)
may occur 2–3 days postpartum and require prompt
intervention to facilitate continuation of
breastfeeding and prevent more serious
complications.
Encourage wearing of supportive bra.                                                    Lifts breasts inward and upward, resulting in a more
comfortable position and decreasing muscle fatigue.
Provide information to the lactating client about                                   These measures can help the lactating client
increasing the frequency of feedings, applying                                      stimulate the flow of milk and relieve stasis and
heat to breasts before feedings, proper positioning                                engorgement. Use of “football hold” directs
of the infant, and expressing milk manually.                                         infant’s feet away from abdomen. Pillow helps
(Refer to CP: The Client at 4 Hours to 2 Days                                       support infant and protects incision in sitting or
Postpartum; ND: Breastfeeding [specify].)                                            side-lying position.
Suggest that client initiate feedings on nontender                                  Initial suckling response is strong and may be
nipple for several feedings in succession if only                                    painful. Starting feeding with unaffected breast
one nipple is sore or cracked.                                                                  and then proceeding to involved breast may be less
painful and enhance healing.
Apply ice to axillary area of breasts if the client is                                Use of supportive bra and ice suppresses lactation
not planning to breastfeed. Recommend use of                                     by mechanical means and are the preferred
well-fitting supportive bra, and avoidance of                                         method for cessation of lactation. Discomfort lasts
excess exposure of breasts to heat, or stimulation                                  approximately 48–72 hr but eases or ceases with
of breasts by infant, sexual partner, or client                                         avoidance of nipple stimulation.
until suppression process is completed
(approximately 1 wk).
Collaborative
Assist with bolus dose of morphine sulfate                                            Provides approximately 24-hr period of pain
(Duramorph) via epidural prior to removal of                                        control, at the end of which oral medications are
epidural catheter.                                                                                     usually appropriate.
Administer analgesics every 3–4 hr, progressing                                   Promotes comfort, which improves psychological
from IV/IM (e.g., meperidine [Demerol],                                              status and enhances mobility. Use of medication
butorphanol [Stadol], nalbuphine [Nubain]) to                                      with limited ability to cross into milk allows
oral route (e.g., oxycodone-acetaminophen                                           lactating mother to enjoy feeding without adverse
[Percocet], oxycodone-aspirin [Percodan]).                                           effects on infant.
Medicate lactating client 45–60 min before
breastfeeding.
Review/monitor use of patient-controlled                                              PCA using meperidine or morphine may be used to
analgesia (PCAs) as indicated.                                                                provide rapid pain relief without excessive side
effects/oversedation. Enhances sense of control,
general well-being, and independence.
Administer antiflatulent, e.g., Mylicon. Provide                                    Occasionally necessary to relieve gas buildup.
rectal/nasogastric (NG) tube as indicated.
Assist as needed with saline injection or                                                Effective for relief of severe spinal headache. The
administration of “blood patch” over site of                                          blood patch procedure, which has a 90%–100%
dural puncture. Keep client in horizontal                                               success rate, creates a blood clot, which produces
position following the procedure.                                                           pressure and seals the leak.
NURSING DIAGNOSIS:                                                               SELF ESTEEM, situational low
May Be Related To:                                                                        Perceived failure at a life event, maturational transition, perceived loss of control in current situation
Possibly Evidenced By:                                                                   Verbalization of negative feelings about self in situation (e.g., helplessness, shame/guilt), evaluates self as unable to handle situation, difficulty making decisions
DESIRED OUTCOMES/EVALUATION                                    Discuss concerns related to her/his role in and
CRITERIA—CLIENT/COUPLE WILL:                                    perception of the birth experience.
                                                                                                           Verbalize understanding of individual factors that precipitated current situation.
Express positive self-appraisal.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Determine client’s/couple’s emotional                                                   Both members of the couple may have a negative
response to cesarean birth.                                                                      emotional reaction to the surgical intervention. An
unplanned cesarean birth may have a negative effect
on the client’s self-esteem, leaving her feeling that she
is inadequate and has failed as a woman. The father
or partner, especially if he was unable/unwilling to
be present at the cesarean delivery, may feel that he
abandoned his partner and did not fulfill his
anticipated role as emotional supporter during the
childbirth process. Even though a healthy baby may
be the outcome, parents often grieve and feel a sense
of loss at missing out on the anticipated vaginal birth.
Determine client’s level of anxiety and source                                      Cesarean birth may be viewed by the client/
of concern. Encourage client/couple to verbalize                                  couple as a failure at a life event, and this may
unmet needs and expectations. provide                                                  have a negative impact on the bonding/parenting
information regarding the normalcy of such feelings.                            process. Note: Emergency cesarean birth may create
problems for care of siblings because of unexpected
prolonged hospital stay. Father may encounter
conflicts in spending time with client/infant and
meeting needs of siblings.
Review client’s/couple’s participation and role                                     Refocuses client’s/couple’s attention to help them
in birth experience. Identify positive behaviors                                     view pregnancy in its totality and to see that their
during prenatal and antepartal process.                                                  actions have contributed to an optimal outcome. May
help to avoid guilt/placing of blame. Note: Grief
response may be lessened if both mother and father
were able to share in experience of delivery.
Encourage presence/participation of partner in all                                 Provides emotional support; may encourage
that is going on.                                                                                      verbalization of concerns.
Emphasize similarities between vaginal and                                          Client may alter her perception of cesarean birth
cesarean birth. Convey positive attitude, and                                         experience as well as her perception of her own
manage postpartal care as close as possible to                                       wellness or illness based on the professional’s
care provided to clients following vaginal birth.                                    attitudes. Similar care conveys the message that
cesarean birth is a necessary alternative to vaginal
delivery, focusing on the optimal outcome rather
than on the birth process.
Assist client/couple in identifying usual coping                                     Helps facilitate positive adaptation to new role;
mechanisms and developing new coping strategies                               reduces feelings of inadequacy.
if needed. (Refer to CP: The Client at 4 Hours to
2 Days Postpartum; ND: Coping, Individual, risk
for ineffective.)
Provide accurate information about client/                                             Fantasies caused by lack of information or
infant status.                                                                                            misunderstanding may increase sense of
helplessness/loss of control.
Collaborative
Refer client/couple for professional counseling                                     Client who is unable to resolve grief or negative
if reactions are maladaptive.                                                                    feelings may need further professional help.
NURSING DIAGNOSIS:                                                               INJURY, risk for
Risk Factors May Include:                                                             Biochemical or regulatory functions (e.g., orthostatic hypotension, development of PIH or eclampsia), effects of anesthesia, thromboembolism, abnormal blood profile (anemia/excessive blood loss, rubella sensitivity, Rh incompatibility), tissue trauma
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Demonstrate behaviors to reduce risk factors
CRITERIA—CLIENT WILL:                                                     and/or protect self.
Be free of avoidable complications.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Review prenatal and intrapartal record for                                             Presence of risk factors, such as myometrial
factors that predispose client to complications.                                      fatigue, uterine overdistension, prolonged
Note Hb level and operative blood loss.                                                oxytocin stimulation, general anesthesia,
anemia/excessive blood loss, or prenatal
thrombophlebitis renders the client more susceptible
to postoperative complications.
Monitor BP, pulse, and temperature. Note cool,                                    Elevated BP may indicate developing or
clammy skin; weak, thready pulse; behavior                                         continuing hypertension, necessitating MgSO4 or
changes; delayed capillary refill; or cyanosis.                                        other antihypertensive treatment. Hypotension
(Refer to CP: Postpartal Hemorrhage.)                                                   and tachycardia may reflect dehydration and
hypovolemia. Pyrexia may indicate infection.
Encourage early ambulation and exercise, except                                  Enhances circulation and venous return of lower
in client who received subarachnoid anesthesia                                     extremities, reducing risk of thrombus formation,
who may remain flat for 6–8 hr without use                                          which is associated with stasis. Although
of pillow or raising head, as indicated by                                               recumbent position after subarachnoid anesthesia
protocol and return of sensation/muscle control.                                   is debatable (no research to date supports
(Refer to ND: Pain [acute]/[Discomfort].)                                              effectiveness), it may aid in prevention of CSF
leakage and resultant headache.
Assist client with initial ambulation. Provide                                        Orthostatic hypotension may occur when
adequate supervision in shower or sitz bath.                                          changing from supine to upright position on initial
Leave call bell within client’s reach.                                                      ambulation, or it may result from vasodilation caused
by the heat of the shower or sitz bath.
Have client sit on floor or chair with head between                               Helps maintain or enhance circulation and
legs, or have her lie down in a flat position, if she                                 delivery of oxygen to brain.
feels faint. Use ammonia capsule (“smelling salts”).
Assess for hyperreflexia, RUQ/epigastric pain,                                     Danger of eclampsia due to PIH exists for up to 72
headache, or visual disturbances. Maintain                                            hr postpartum, although literature suggests the
seizure precautions, and provide quiet environment                              convulsive state has occurred as late as the 5th day
as indicated. (Refer to CP: The Client at 4 Hours to                              postpartum.
2 Days Postpartum; ND: Fluid Volume, risk for
excess; CP: Pregnancy-Induced Hypertension;
ND: Injury, risk for.)
Note effects of MgSO4, if administered. Assess                                   Absence of patellar reflex and respiratory rate
patellar response and monitor respiratory rate.                                       below 12/min indicates toxicity and a need to reduce
or discontinue drug therapy.
Inspect incision regularly; note signs of delayed or                               Excessive strain on the incision or delayed healing
altered healing (e.g., lack of approximation).                                         may render client prone to tissue separation and
possible hemorrhage.
Inspect lower extremities for signs of                                                    Elevated fibrin split products (possibly released
thrombophlebitis (e.g., redness, warmth, pain/                                       from placental site), reduced mobility, trauma,
tenderness). Note presence or absence of Homans’                               sepsis, and extensive activation of blood clotting
sign. (Refer to CP: Postpartal Thrombophlebitis.)                                  following delivery predispose the client to the
development of thromboembolism. Homans’ sign
may be present with deep venous thrombus, but may
be absent with superficial phlebitis. In addition,
plasma losses, elevated platelet counts, and
relaxation of blood vessels from anesthesia increase
risk for thrombophlebitis.
Encourage leg/ankle exercises and early ambulation.                            Promotes venous return; prevents stasis/pooling in
lower extremities, reducing risk of phlebitis.
Evaluate client’s rubella status on prenatal chart                                   Vaccination helps prevent teratogenic effects in
(>1:10 titer indicates susceptibility). Assess client                                subsequent pregnancies. Administration of
for allergies to eggs or feathers; if present,                                            vaccine in the immediate postpartal period may
vaccine is contraindicated. Provide written and                                     cause side effects of transient arthralgia, rash, and
oral information, and obtain informed consent for                                 cold symptoms during incubation period of 14–21
vaccination after reviewing side effects, risks, and                                days. Allergic anaphylactic or hypersensitivity
the necessity to prevent conception for 2–3 mo                                     response may occur, necessitating administration
following the vaccination.                                                                       of epinephrine.
Collaborative
Administer MgSO4 by infusion pump, as indicated.                              Helps reduce cerebral irritability in presence of PIH
or eclampsia. (Refer to CP: The Client at 4 Hours to 2
Days Postpartum; ND: Fluid Volume, risk for excess.)
Apply support hose or elastic wrap to legs when                                   Reduces venous stasis, enhancing venous return
risk or symptoms of phlebitis are present.                                              and reducing risk of thrombus formation.
Administer anticoagulant; evaluate coagulation                                    Although usually not required, may help prevent
factors, and note signs of failure to clot. (Refer                                     further development of thrombus.
to CP: Postpartal Thrombophlebitis.)
Administer RhIgG IM within 72 hr postpartum,                                    Dose of 300 mg is usually sufficient to promote
as indicated for Rh-negative mother who has                                        lysis of fetal Rh-positive RBCs that may have
not been previously sensitized and who delivers                                   entered maternal circulation during delivery and
an Rh-positive infant with negative result on                                         that may potentially cause sensitization and
direct Coombs’ test on cord blood. Obtain Betke-                                 problems of Rh incompatibility in subsequent
Kleihauer smear if significant fetal-maternal                                         pregnancies. Presence of 20 ml or more of Rh-
transfusion is suspected at delivery.                                                       positive fetal blood in maternal circulation
necessitates higher dose of RhIgG. Note: If drug is
not administered within 72 hr of delivery, a window
of opportunity exists for up to 2 wk, although the
degree of effectiveness may be reduced.
NURSING DIAGNOSIS:                                                               INFECTION, risk for
Risk Factors May Include:                                                             Tissue trauma/broken skin, decreased Hb, invasive procedures and/or increased environmental exposure, prolonged rupture of amniotic membranes, malnutrition
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Demonstrate techniques to reduce risks and/or
CRITERIA—CLIENT WILL:                                                     promote healing.
                                                                                                           Display wound free of purulent drainage with initial signs of healing (i.e., approximation of wound edges), uterus soft/nontender, with normal lochial flow and character.
Be free of infection, be afebrile, have no adven-titious breath sounds, and void clear amber urine.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Encourage and use careful hand washing                                               Helps prevent or retard spread of infection.
technique and appropriate disposal of soiled
underpads, perineal pads, and contaminated
linen. Discuss with client the importance of
continuing these measures after discharge.
Review prenatal Hb/Hct; note presence of                                             Anemia, obesity, diabetes, prolonged labor
conditions/risk factors that predispose client                                         (especially with membranes ruptured) prior to
to postoperative infection.                                                                       cesarean delivery, corticosteroid therapy,
malnutrition, smoking, and chronic lung disease
increase the risk of infection and delayed healing.
Assess client’s nutritional status. Note appearance                                Client who is 20% below normal weight, or who is
of hair, fingernails, skin, and so forth. Determine                                  anemic or malnourished, is more susceptible to
prepregnancy weight and prenatal weight gain.                                     postpartal infection and may have special dietary
needs.
Encourage oral fluids and diet high in protein,                                      Prevents dehydration; maximizes circulation and
vitamin C, and iron.                                                                                urine flow. Protein and vitamin C are needed for
collagen formation; iron is needed for Hb synthesis.
Inspect abdominal dressing for exudate or oozing.                                A sterile dressing covering the wound in the first
Remove dressing, as indicated.                                                               24 hr following cesarean birth helps protect it from
injury or contamination. Oozing may indicate
hematoma, loss of suture approximation, or wound
dehiscence, requiring further intervention. Removing
the dressing allows incision to dry and promotes
healing.
Note operative record for use of drain and nature                                  Moist environment is an excellent medium for
of incision. Clean wound and change dressing                                      bacterial growth; bacteria can travel by capillary
when wet.                                                                                                action through the wet dressing to the wound. Note:
Incision into the lower uterine segment heals more
rapidly than classic incision and is less likely to
rupture in subsequent pregnancies.
Inspect incision, evaluate healing process, noting                                 These signs indicate wound infection, usually
localized redness, edema, pain, exudate, or loss                                    caused by streptococci, staphylococci, or
of approximation of wound edges.                                                         Pseudomonas species. Note: Wound infections are
usually clinically apparent 3–8 days after the
procedure.
Assist as needed with removal of skin sutures or clips.                         Incision is usually sufficiently healed to remove
sutures on the 4th or 5th day following surgical
procedure.
Encourage client to take warm showers daily.                                       Showers, usually allowed after the 2nd postoperative
day, promote hygiene and may stimulate circulation
and healing of wound. Note: In some cultures,
showers/tub baths are avoided until lochial flow
ceases or longer, as dictated.
Assess temperature, pulse, and WBC count.                                          Fever after the 3rd postoperative day, leukocytosis,
and tachycardia suggest infection. Elevation of
temperature to 101°F (38.3°C) within the first 24 hr is
highly indicative of infection; an elevation to 100.4°F
(38.0°C) on any 2 of the 1st 10 days postpartum is
significant.
Assess location and contractility of uterus; note                                    Following cesarean birth, the fundus remains at
involutional changes or presence of extreme                                         the level of the umbilicus for up to 5 days, when
uterine tenderness.                                                                                  involution begins, accompanied by an increase in
lochial flow. Delayed involution increases the risk of
endometritis. Development of extreme tenderness
signals possible retained placental tissue or infection.
Note amount and odor of lochial discharge or                                       Lochia normally has a fleshy odor; however, in
change in normal progression from rubra to serosa.                              endometritis, the discharge may be purulent and
foul-smelling, and may fail to demonstrate normal
progression from rubra to serosa to alba.
Maintain sterile, closed injury drainage system                                     Prevents introduction of bacteria when indwelling
with drainage bag in dependent position.                                               catheter is used and avoids urinary reflux, reducing
risk of infection.
Provide perineal and catheter care, per protocol.                                   Helps eliminate medium of bacterial growth;
promotes hygiene.
Note frequency/amount and characteristics of urine.                             Urinary stasis increases the risk of infection. Cloudy
or malodorus urine indicates presence of bacteria.
Promote rest and encourage use of semi-Fowler’s                                 Rest reduces metabolic process, allowing oxygen
position once anesthesia precautions are completed.                              and nutrients to be used for healing. Semi-Fowler’s
position promotes flow of lochia and reduces pooling
in uterus, and maximizes respiratory function.
Inspect IV site for signs of erythema or tenderness.                               Indicates local infection, requiring removal of catheter
and possibly restarting the IV line in another site.
Evaluate condition of nipples, noting presence of                                 The development of nipple fissures/cracks
cracks, redness, or tenderness. Recommend routine                              potentiates risk of mastitis.
examination of breasts. Review proper care and
infant feeding techniques. (Refer to ND: Pain
[acute]/[Discomfort].)
Assess lung sounds and respiratory ease or effort.                                 Rhonchi indicative of retained secretions should
Note crackles/rhonchi, dyspnea, chest pain, fever,                                not be present, yet breath sounds may be
or mucopurulent sputum.                                                                        diminished for the first 24 hr after surgery. Absence
of lung sounds indicates consolidation or lack of air
exchange, suggesting atelectasis or possibly
pneumonia. Note: Atelectasis usually occurs in the
first 72 hr after the procedure, whereas pneumonia
typically develops after 72 hr.
Institute turning, coughing, and deep-breathing                                     Improves depth of respirations and alveolar expansion;
routines with splinting of incision every 2–4 hr                                     clears secretions that could block bronchioles.
while awake. Note productive cough.                                                    Productive cough indicates client is clearing
bronchial secretions effectively. Splinting prevents
excessive strain on incision, reducing discomfort and
enhancing client’s participation in activity.
Collaborative
Administer oxytocin or ergot preparation. (Note:                                  Maintains myometrial contractility, thereby
Oxytocin infusion is often ordered routinely for                                    retarding bacterial spread through walls of uterus;
4 hr following surgery.)                                                                          aids in expulsion of clots/membranes.
Monitor laboratory test results, such as BUN and                                  In the client who has had PIH, kidney or vascular
24-hr urine, for total protein, creatinine clearance,                                involvement may persist, or it may appear for the
and uric acid, as indicated.                                                                      first time during the postpartal period. As steroid
levels decrease following delivery, renal function,
evidenced by BUN and creatinine clearance, begins
to return to normal within 1 wk; anatomic changes
(e.g., dilation of ureters and renal pelvis) may take up
to 1 mo to return to normal.
Administer prophylactic antibiotic infusion,                                          Decreases likelihood of postpartal endometritis as
with first dose usually administered                                                       well as complications such as incisional abscesses
immediately after cord clamping and two                                              or pelvic thrombophlebitis.
more doses 6 hr apart.
Demonstrate/encourage use of incentive spirometer.                             Promotes sustained maximal respiration, inflates
alveoli, and prevents atelectasis.
Obtain sputum specimen as indicated by changes                                 Identifies specific pathogens and appropriate
in color or odor of sputum, presence of congestion,                              therapy.
and temperature elevation.
Review chest x-rays, as indicated.                                                          Confirms presence of infiltrate(s) or atelectasis.
Obtain blood, vaginal, and urine cultures, if                                          Bacteremia is more frequent in client whose
infection is suspected.                                                                             membranes were ruptured for 6 hr or longer than in
client whose membranes remained intact prior to
cesarean birth.
Administer specific antibiotic for identified                                          Necessary to effectively eradicate organism.
infectious process.
NURSING DIAGNOSIS:                                                               FLUID VOLUME, risk for deficit
Risk Factors May Include:                                                             Period of restricted oral intake, presence of nausea/vomiting, excessive blood loss during surgery
Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION                                    Maintain fluid volume at a functional level as
CRITERIA—CLIENT WILL:                                                     evidenced by individually adequate urinary output, stable vital signs, moist mucous membranes, and Hb/Hct within normal limits.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Review prenatal and intrapartal/surgical                                                 Data helpful in evaluating current fluid status and
records for Hb level, operative blood loss, fluid                                    potential for diuresis.
replacement, presence of edema.
Monitor BP, pulse, status of mucous membranes,                                 Hypotension, tachycardia, and dry mouth may
capillary refill; note presence of cyanosis.                                             reflect dehydration and hypovolemia but may not
occur until circulating blood volume has decreased
by 30%–50%, at which time signs of peripheral
vasoconstriction may be noted.
Inspect dressing for excessive bleeding. Outline,                                  Surgical wounds with a drain may saturate a
date drainage on dressings (if not changed). Notify                               dressing; however, oozing is usually not expected
physician of continued oozing.                                                               and may suggest developing complications.
Note character and amount of lochial flow and                                     Lochial flow should not be heavy or contain clots;
consistency of fundus. Gently massage                                                  fundus should remain firmly contracted at the
fundus as indicated.                                                                                 umbilicus. A boggy uterus results in increased flow
and blood loss. Note: As a rule, lochial flow is usually
decreased by second postoperative day, thus
“normal” amount of flow expected after vaginal
delivery would be suspect for this client.
Monitor fluid intake and urine output. Note                                           Kidney function is a key index to circulating blood
appearance, color, concentration, and specific                                       volume. As output decreases, specific gravity
gravity of urine.                                                                                      increases, and vice versa. Bloody urine or urine
containing clots signifies possible bladder trauma
associated with surgical intervention.
Encourage adequate oral fluids (e.g., 6–8 glasses/day).                         Preferred route for replacement once nausea is
resolved/peristalsis returns. Adequate intake allows
for timely removal of IV.
Collaborative
Replace fluid losses intravenously, as indicated.                                    Average blood loss is usually 600–800 ml, but
prenatal physiological edema, which mobilizes
postpartum, alleviates need for large fluid volume
replacement. A total of 3 L of fluid infused
intravenously in the intraoperative and early
postoperative (24-hr) period is recommended. Note:
If epidural anesthesia is used, more fluids are usually
required.
Monitor postoperative Hb/Hct; compare with                                        Client with Hct of 33% or greater and increased
preoperative levels.                                                                                 plasma associated with pregnancy can usually
tolerate actual blood loss of up to 1500 ml without
difficulty. A significant change in volume may
necessitate replacement with blood products,
although iron replacement may be preferred.
Increase oxytocin infusion if uterus is relaxed and/                               Stimulates myometrial contractility and reduces
or lochia is heavy.                                                                                   blood loss. Oxytocin is usually added to infusion
intraoperatively after delivery of the infant’s
shoulders and is maintained into the early
postoperative period.
NURSING DIAGNOSIS:                                                               CONSTIPATION
May Be Related To:                                                                        Decreased muscle tone (diastasis recti, excess analgesia or anesthesia), effects of progesterone, dehydration, prelabor diarrhea, lack of intake, perineal/rectal pain
Possibly Evidenced By:                                                                   Reported abdominal/rectal fullness or pressure, nausea, less than usual amount of stool, straining at stool, decreased bowel sounds
DESIRED OUTCOMES/EVALUATION                                    Demonstrate return of intestinal motility, as
CRITERIA—CLIENT WILL:                                                     evidenced by active bowel sounds and the passing of flatus.
                                                                                                           Resume usual/optimal elimination pattern within 4 days postpartum.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Auscultate for presence of bowel sounds in all                                      Determines readiness for oral feedings, and
four quadrants every 4 hr following cesarean birth.                               possible developing complication, e.g., ileus. Usually,
bowel sounds are not heard on the 1st day after
surgical procedure, are faint on the 2nd day, and are
active by the 3rd day.
Palpate abdomen, noting distension or discomfort.                                Indicates gas formation and accumulation or possible
paralytic ileus.
Note passing of flatus or belching.                                                         Indicates return of motility.
Encourage adequate oral fluids (e.g., 6–8 glasses/                                 Roughage (e.g., fruits and vegetables, especially
day) once oral intake resumes. Recommend                                          with seeds and skins) and increased fluids provide
increased dietary roughage and fruits and                                              bulk, stimulate elimination, and prevent
vegetables.                                                                                               constipated stool. Note: Food or fluid offered before
return of peristalsis may contribute to paralytic ileus.
Encourage leg exercises and abdominal tightening;                              Leg exercises tighten abdominal muscles and
promote early ambulation.                                                                      improve abdominal motility. Progressive ambulation
after 24 hr promotes peristalsis and gas expulsion,
and alleviates or prevents gas pains.
Identify those activities that client can use at home                               Helps in re-establishing normal evacuation pattern
to stimulate bowel action.                                                                       and promotes independence.
Collaborative
Administer analgesics 30 min before ambulation.                                  Facilitates ability to ambulate; however, narcotics, if
used, may reduce bowel activity.
Provide stool softener or mild cathartic.                                                 Softens stool, stimulates peristalsis, and helps re-
establish bowel function.
Administer hypertonic or small soap suds enema.                                 Promotes bowel evacuation and relieves gaseous
distension.
Insert or maintain NG tube as indicated.                                                 May be necessary to decompress the stomach and
relieve distension associated with paralytic ileus.
NURSING DIAGNOSIS:                                                               KNOWLEDGE deficit [LEARNING NEED], regarding physiological changes, recovery period, self care, and infant care needs
May Be Related To:                                                                        Lack of exposure/recall, misinterpretation, unfamiliarity with resources
Possibly Evidenced By:                                                                   Verbalized concerns/misconceptions, hesitancy in or inadequate performance of activities, inappropriate behaviors (e.g., apathy)
DESIRED OUTCOMES/EVALUATION                                    Verbalize understanding of physiological changes,
CRITERIA—CLIENT WILL:                                                     individual needs, expected outcomes.
Perform necessary activities/procedures correctly and explain reasons for the actions.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Assess client’s readiness and motivation for                                          The postpartal period can be a positive experience
learning. Assist client/couple in identifying needs.                                if opportune teaching is provided to foster maternal
growth, maturation, and competence. However, the
client needs time to move from a “taking in” to a
“taking hold” phase, in which her receptiveness and
readiness is heightened and she is emotionally and
physically ready for learning new information to
facilitate mastery of her new role. Although basic
information may be provided/reviewed the 1st day,
the client is usually receptive to learning more in-
depth material by the 2nd or 3rd day postpartum.
Initiate written teaching plan using standardized                                   Helps assure completeness of information parents
format, checklist, or clinical pathway. Document                                  receive from staff members and reduces client
information given and client’s response.                                                confusion caused by dissemination of conflicting
advice or information.
Assess client’s physical status. Plan group or                                        Discomfort associated with incision or afterpains,
individual sessions following administration of                                     or bowel/bladder discomfort, is usually less
medication or when client is comfortable and rested.                            severe by the 2nd or 3rd postoperative day, allowing
the client to concentrate more fully and be more
receptive to learning.
Note psychological state and response to cesarean                                Anxiety related to ability to care for herself and
birth and mothering role. (Refer to ND: Self                                         her child, possible disappointment over the birth
Esteem, situational low.)                                                                        experience, or concerns regarding her separation
from the infant may have a negative impact on
client’s learning abilities and readiness.
Provide information related to normal physiological                             Helps client to recognize normal changes from
and psychological changes associated with cesarean                             abnormal responses that may require treatment.
birth and needs associated with the postpartal period.                           Client’s emotional state may be somewhat labile at
this time and often is influenced by physical well-
being. Anticipating such changes may reduce the
stress associated with this transition period that
necessitates learning new roles and taking on new
responsibilities. Note: Client has had a major
abdominal surgical procedure requiring at least 6–8
wk for physiological recovery, but client may not feel
fully recovered for up to 6 mo.
Stress importance of adequate rest, fluid/dietary                                   Promotes healing, facilitates recovery, protects
intake, and necessity for specific activity limitations                             incision—reducing risk of dehiscence.
(e.g., avoidance of lifting and driving).
Review self-care needs (e.g., perineal care, incisional                           Facilitates autonomy, helps prevent infection, and
care, hygiene, voiding). Encourage participation in                               promotes healing. By turning on her side, using
self-care, as client is able. Demonstrate method of                                her arms to lift herself to a sitting position, and
getting out of a flat bed without the use of siderails.                              pushing with her hands to lift buttocks off the bed to
a standing position, client can continue to ease stress
on incision after discharge.
Discuss prescribed exercise program.                                                    A progressive exercise program can usually be
started once abdominal discomfort has eased (by
approximately 3–4 wk postpartum). Helps tone
musculature, increases circulation, produces a
trimmer figure, and enhances feelings of general
well-being. Client should be advised not to lift objects
heavier than the infant for approximately 2 wk, and
to bend at knees when lifting baby.
Identify signs/symptoms requiring notification                                     Prompt evaluation and intervention may
of healthcare provider (e.g., fever, dysuria,                                            prevent/limit development of complications (e.g.,
increase in amount of lochial flow or return to                                      hemorrhage, infection, delayed healing).
bright red lochial exudate, or separation of
suture line).
Demonstrate techniques of infant care. Observe                                    Assists parents in mastery of new tasks.
return demonstration by client/couple. (Refer to
CP: The Neonate at 2 Hours to 2 Days of Age; ND:
Knowledge deficit [Learning Need].)
Review information regarding appropriate choice                                 Promotes independence and optimal feeding
for infant feeding (e.g., physiology of breastfeeding,                            experience. When bottle feeding, it is important to
diet, positioning, breast and nipple care, and                                         feed the infant alternately on the right and left side
removal of infant from breast; formula types/                                        to promote eye development. Slight dehydration
preparation, infant position during bottle feeding,                                 or physical or emotional trauma may delay onset
burping techniques).                                                                                of lactation for the client who has undergone a
cesarean birth.
Discuss plans for home management: assistance                                   Client who has undergone cesarean birth may
with housework, physical layout of house, infant                                  need more assistance when first home than the
sleeping arrangements.                                                                            client who has given birth vaginally. Stairs and the
use of low cradles or bassinets may cause difficulties
for the postoperative client.
Determine availability of support system(s), plans                                Helps to identify individual needs, necessity of
after discharge.                                                                                        home visitation, and provides opportunity to correct
misconceptions/unrealistic expectations. Promotes
problem solving.
Provide numbers for appropriate telephone contacts.                            Provides ready resources to answer questions.
Identify available community resources; e.g., visiting                           Promotes independence and provides support for
nurse/home care services, Public Health Service,                                  adaptation to multiple changes.
WIC program, La Leche League, Mothers of Twins.
Discuss resumption of sexual intercourse and plans                              Intercourse may be resumed as soon as it is
for contraception. Provide information about                                        comfortable for the client and healing has
available methods, including advantages and                                        progressed, generally 4–6 wk postpartum. Couple
disadvantages. (Refer to CP: 1 Week Following                                    may need clarification regarding available
Discharge; ND: Knowledge deficit [Learning Need].)                          contraceptive methods and the fact that pregnancy
could occur even prior to the 4–6-wk visit.
Provide or reinforce information related to follow-                               Postpartum evaluations for the client who has
up postpartal examination.                                                                      undergone cesarean delivery may be scheduled at 3
wk rather than 6 wk because of increased risk of
infection and delayed healing.
NURSING DIAGNOSIS:                                                               URINARY ELIMINATION, altered
May Be Related To:                                                                        Mechanical trauma/diversion, hormonal effects (fluid shifts and/or increased renal plasma flow), effects of anesthesia
Possibly Evidenced By:                                                                   Increased bladder filling/distension, changes in amount/frequency of voiding
DESIRED OUTCOMES/EVALUATION                                    Resume usual/optimal voiding patterns following
CRITERIA—CLIENT WILL:                                                     catheter removal.
Empty bladder with each void.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Note and record amount, color, and                                                       Oliguria (output less than 30 ml/hr) may be
concentration of urinary drainage.                                                          caused by excess fluid loss, inadequate fluid
replacement, or antidiuretic effects of infused
oxytocin.
Test urine for albumin and acetone. Distinguish                                    Catalytic process associated with uterine
between proteinuria associated with PIH and                                        involution may result in normal proteinuria (1+)
that associated with normal processes (Refer to                                     for the first 2 days postpartum. Acetone may
CP: The Client at 4 Hours to 2 Days Postpartum;                                  indicate dehydration associated with prolonged
ND: Fluid Volume, risk for excess.)                                                      labor and/or delivery.
Provide oral fluid, e.g., 6–8 glasses per day,                                          Fluids promote hydration and renal function, and
as appropriate.                                                                                         help prevent bladder stasis.
Palpate bladder. Monitor fundal height and location                             Renal plasma flow, which increases by 25%–50%
and amount of lochial flow.                                                                    during the prenatal period, remains elevated in the
1st wk postpartum, resulting in increased bladder
filling. Bladder distension can be assessed by degree
of uterine displacement; causes increased uterine
relaxation and lochial flow.
Note signs and symptoms of UTI (e.g., cloudy color,                            Presence of indwelling catheter predisposes client
foul odor, burning sensation, or frequency) following                           to introduction of bacteria and UTI. (Refer to ND:
catheter removal.                                                                                     Infection, risk for.)
Use methods to facilitate voiding after catheter                                     Client should void within 6–8 hr following
removal (e.g., run water in sink, pour warm water                                catheter removal, yet may have difficulty
over perineum).                                                                                       emptying bladder completely.
Instruct client to perform Kegel exercise daily after                              Performing Kegel exercise 100 times/day increases
effects of anesthesia have subsided.                                                       circulation to perineum, aids in healing and recovery
of tone of pubococcygeal muscle, and prevents or
reduces stress incontinence.
Collaborative
Maintain IV infusion for 24 hr following surgery,                                 Usually, 3 L of fluid, including lactated Ringer’s
as indicated. Increase infusion rate if output is                                      solution, is adequate to replace losses and
30 ml/hr or less.                                                                                      maintain renal flow/urine output.
Remove catheter per protocol/as indicated.                                            Generally, catheter may be safely removed between
6–12 hr postpartum; but for convenience it may
remain in client until the morning after surgery.
Monitor laboratory test results, such as BUN and                                  In the client who has had PIH, kidney or vascular
24-hr urine for total protein, creatinine clearance,                                 involvement may persist, or it may appear for the
and uric acid, as indicated.                                                                      first time during the postpartal period. As steroid
levels decrease following delivery, renal function,
evidenced by BUN and creatinine clearance, begins
to return to normal within 1 wk; anatomic changes
(e.g., dilation of ureters and renal pelvis) may take up
to 1 mo to return to normal.
NURSING DIAGNOSIS:                                                               SELF CARE deficit [specify type/level]
May Be Related To:                                                                        Effects of anesthesia, decreased strength and endurance, physical discomfort
Possibly Evidenced By:                                                                   Verbalization of inability to participate at level desired
DESIRED OUTCOMES/EVALUATION                                    Demonstrate techniques to meet self-care needs.
CRITERIA—CLIENT WILL:                                                     Identify/use available resources.
ACTIONS/INTERVENTIONS                                   RATIONALE
Independent
Ascertain severity/duration of discomfort.                                             Intense pain affects emotional and behavioral
Note presence of postspinal headache.                                                   responses, so that the client may be unable to focus
on self-care activities until her physical needs for
comfort are met. Intense headache associated with
upright position requires modification of activities
and additional assistance to meet individual needs.
Assess client’s psychological status.                                                      Physical pain experience may be compounded by
mental pain that interferes with client’s desire and
motivation to assume autonomy.
Note cultural expectations/practices.                                                       Some cultures, (e.g., Mexican/Arab-American,
Haitian, Russian) require the new mother to observe
a specified period of bed rest/activity restrictions
during which other female members of her family
may provide care.
Determine type of anesthesia, and associated                                        Epidural anesthesia (especially following bolus
orders or protocol regarding positioning/                                               dose of duramorph) may cause generalized
ambulation.                                                                                              weakness, creating safety concerns, and requires
careful assessment before sitting upright/getting out
of bed. Clients who have undergone spinal
anesthesia may be directed to lie flat and without
pillow for several hours following administration of
anesthesia.
Reposition client every 1–2 hr; assist with                                             Helps prevent surgical complications such as
pulmonary exercises, ambulation, and leg exercises.                             phlebitis or pneumonia, which may occur when
discomfort levels interfere with client’s normal
repositioning/activity.
Offer assistance as needed with hygiene (e.g.,                                       Improves self-esteem; increases feelings of well-
mouth care, bathing, back rubs, and perineal care).                               being.
Offer choices when possible (e.g., selection of                                      Allows some autonomy, even though client
juices, scheduling of bath, destination during                                        depends on professional assistance. Note: Some
ambulation).                                                                                            cultures restrict bathing/showers for a
predetermined length of time after delivery or until
cessation of lochial flow.
Collaborative
Administer analgesic agent every 3–4 hr, as needed.                             Reduces discomfort, which could interfere with
ability to engage in self-care.
Convert IV line to saline lock, as appropriate.                                       Permits unrestricted movement of extremities,
thereby allowing client to function more
independently, regardless of ongoing intermittent
IV therapy (e.g., antibiotics).
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NCP Cardiac Conditions

Cardiac Conditions

During pregnancy blood volume increases as much as 50% above the nonpregnant level and is accompanied by increases in maternal heart rate and stroke volume necessitating a drop in systemic and pulmonary vascular resistance. The client with heart disease may not be able to readily accommodate the higher workload of pregnancy as a result of decreased cardiac reserves.

(This plan of care is to be used in conjunction with the Trimesters and The High-Risk Pregnancy.)

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Inability to carry on normal activities

Nocturnal/exertion-related dyspnea; orthopnea

Circulation

Tachycardia, palpitations; severe dysrhythmia.

History of congenital/organic heart disease, rheumatic fever.

Upward displacement of the diaphragm and heart proportionate to uterine size.

May have a continuous diastolic or presystolic murmur; cardiac enlargement; loud systolic murmur, associated with a thrill.

BP may be elevated or may be decreased with decreased vascular resistance.

Clubbing of toes and fingers may be present, with symmetric cyanosis in surgically untreated tetralogy of Fallot.

Elimination

Urine output may be decreased.

Nocturia.

Food/Fluid

Obesity (risk factor)

May have edema of the lower extremities

Pain/Discomfort

May report chest pain with/without activity

Respiration

Cough; may or may not be productive.

Hemoptysis.

Respiratory rate may be increased.

Dyspnea/shortness of breath, orthopnea may be reported.

Rales may be present.

Safety

Repeated streptococcal infections

Teaching/Learning

Possible history of valve replacement/prosthetic device, mitral valve prolapse, Marfan’s syndrome, surgically treated/untreated (rare) tetralogy of Fallot

Diagnostic Studies

White Blood Cell (WBC) Count: Leukocytosis indicative of generalized infection, primarily streptococcal.

Hemoglobin (Hg)/Hematocrit (Hct): Reveals actual versus physiological anemia; polycythemia.

Maternal Arterial Blood Gases: Provide secondary assessment of potential fetal compromise due to maternal respiratory involvement.

Sedimentation Rate: Elevated in the presence of cardiac inflammation.

Maternal Electrocardiogram (ECG): Demonstrates patterns associated with specific cardiac disorders, dysrhythmias.

Echocardiography: Diagnoses mitral valve prolapse or Marfan’s syndrome.

Radionuclide Cardiac Imaging: Evaluates suspected atrial or ventricular septal defects, patent ductus arteriosus, or intracardiac shunts.

Serial Ultrasonography: Detects gestational age of fetus and possible IUGR.

NURSING PRIORITIES

  1. Monitor degree/progression of symptoms.
  2. Promote client involvement in control of condition and self-care.
  3. Monitor fetal well-being.
  4. Support client/couple toward culmination of a safe delivery.
Discharge goals

Inpatient care not required unless complications develop.

NURSING DIAGNOSIS:                                                               Cardiac Output, risk for [decompensation]

Risk Factors May Include:                                                             Increased circulating volume, dysrhythmias, altered myocardial contractility, inotropic changes in the heart

Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION                                    Identify/adopt behaviors to minimize stressors and

CRITERIA—CLIENT WILL:                                                     maximize cardiac function.

Tolerate the stress of increasing blood volume as indicated by BP and pulse within individually appropriate limits.

Demonstrate adequate placental circulation, kidney function with FHR and fetal movement WNL, and individually appropriate urine output.

 

ACTIONS/INTERVENTIONS                                   RATIONALE

Independent

Determine/monitor client’s functional                             Useful for identifying client needs/limitations,
classification (as outlined by the New York                      effectiveness of therapies, and progression/
Heart Association):                                                                remission of condition.

Class I: No limitation of physical activity,
no discomfort during exertion

Class II: Ordinary activity may cause symptoms
of palpitation, dyspnea, and angina

Class III: Less than ordinary activity causes
cardiac symptoms, such as fatigue,
dyspnea, and angina

Class IV: Symptoms of cardiac insufficiency
occur in the absence of physical activity,
and mortality risk per Clark’s classification
system of risk status for pregnant women.

Provide information about the necessity of                                            Minimizes cardiac stress and conserves energy.
adequate rest (e.g., 8–10 hr at night and 1/2 hr                                         Class IV clients may require bedrest for the
after each meal).                                                                                     duration of the pregnancy. (Refer to ND: Activity
Intolerance, risk for.)

Discuss use of left or right lateral position.                                            The occurrence of supine hypotension possibly to the
point of loss of consciousness can be prevented if the
client avoids the supine position and adopts the
lateral recumbent resting position.

Monitor vital signs.                                                                                The beginning stage of decompensation caused by
intolerance of circulatory load, infection, or anxiety
may first be noted by an insidious change in the vital
sign pattern, associated with increased temperature,
pulse (110 bpm or greater), respiration (greater than
20–34/min), and BP.

Auscultate client’s breath sounds.                                                          Congestive heart failure (CHF) may develop,
especially in clients whose functional classification is
class III or IV. Conversely, clients with mitral valve
prolapse may be symptom-free during pregnancy,
owing to the increase in left ventricular volume, yet
are at high risk for involvement related to chest pain,
palpitations, and possibly death after delivery.

Evaluate FHR, daily fetal movement count, and                                    Fetal hypoxia caused by beginning stage of
NST results as indicated. (Refer to CP: The High-                                maternal cardiac decompensation may be noted in
Risk Pregnancy; ND: Injury, risk for fetal.)                                           the form of tachycardia, bradycardia, or reduction
in fetal activity.

Assess for evidence of venostasis with resulting                                   Prolonged positioning of legs and ankles below
dependent edema of extremities or generalized                                     the level of the heart further impairs venous return
edema. Instruct client to elevate legs when sitting                                 in an already stressed circulatory system and
down and periodically during the day.                                                   places the client at risk for PIH.

Instruct client to monitor fluid intake/output.                                         Although intake and output should be
(Refer to ND: Fluid Volume, risk for excess.)                                       approximately the same, cardiovascular involvement
may negatively affect kidney function, resulting in
oliguria/anuria.

Investigate reports of chest pain and palpitations.                                 Clients with mitral valve prolapse may develop
Recommend limiting caffeine as appropriate.                                        arrhythmias resulting in chest pain and palpitations.
Limiting caffeine may reduce frequency of episodes.

Review medication needs and reason for conversion                            Because of its large molecular size, heparin sodium
to heparin by warfarin (Coumadin) users.                                              does not cross the placenta, as does warfarin; also,
heparin may prevent clot formation in the client with
valve prosthesis/atrial fibrillation.

Instruct client in self-administration of medication                               Involves client in therapeutic process, and
such as heparin. Observe return demonstration of                                 promotes self-care.
procedure by client.

Assess for/review signs of ecchymosis, epistaxis,                                 Signs of bleeding may indicate a need to reduce
and so forth during anticoagulant therapy.                                             heparin dosage.

Collaborative

Participate in/coordinate multispecialty care                                         Provides opportunity to review management of
conference as appropriate.                                                                      both pregnancy and cardiac condition, and to plan
for special needs during intrapartum and postpartum
periods.

Administer medications such as digitalis glycosides                             Cardiac stress brought on by increased demand
(digoxin or digitoxin) or propranolol (Inderal) as                                  for output is greatest between 28 and 32
indicated. Monitor for early labor.                                                          weeks’ gestation, then levels off until delivery.
Digitalis glycosides maximize ventricular
contractions, but increased plasma volume
may lower circulating levels of the drug,
necessitating increased or more frequent
doses. Digitalis has a direct effect on the
myometrium, often causing early labor as
well as shortening the length of labor. Propranolol
may be used to control dysrhythmias associated
with mitral valve prolapse. Note: Although
these drugs cross the placenta and have no
reported teratogenic effects, studies have not
yet clearly established their safety in pregnancy.
In addition, ACE inhibitors are contraindicated
because of the risk of fetal death or intractable
neonatal renal failure.

Administer loading dose of heparin.                                                       Warfarin users should have their anticoagulant
converted to heparin. Initial dose may be
administered intravenously by healthcare
provider.

Treat underlying infections as necessary, e.g.,                                       Cardiac decompensation may develop/is
respiratory, and provide prophylaxis as necessary.                                worsened by superimposed upper respiratory
(Refer to ND: Infection, risk for maternal.)                                            infection, which is usually associated with
coughing and increased secretions, and which
may mask deterioration of cardiac function.
Prophylactic antibiotics help prevent
bacterial endocarditis in client with diseased
heart valves.

Using sequential serum/urine estriol levels and                                     Reduced cardiac function may negatively affect
CST/NST, assess placental functioning. (Refer to CP:                          placental functioning.
The High-Risk Pregnancy; ND: Injury, risk for
fetal.)

Obtain/review sequential ECGs.                                                            May demonstrate pathological pattern if
decompensation is present; may identify type of
dysrhythmia.

Monitor laboratory studies, such as clotting times                                 Prolonged clotting times may indicate need to
and electrolyte levels.                                                                             adjust heparin dosage. Hyponatremia/
hypokalemia may occur, owing to reduced sodium
intake or diuretic therapy with imbalances
potentiating-development/aggravation of
dysrhythmias.

Encourage use of antithrombotic stockings.                                           Promotes venous return; limits venous stasis.

Prepare client for hospitalization as warranted                                      Clients with a functional classification of class II
by her condition.                                                                                     through class IV are usually hospitalized 2 wk before
expected delivery, because likelihood of
decompensation is greatest during the latter part of
the third trimester. Clients with class IV function may
be hospitalized earlier in the pregnancy, depending
on fetal status/developing complications.

Monitor hemodynamic pressures using arterial                                     CVP lines measure venous return/circulating
and central venous pressure (CVP) lines or Swan-                                volume; the Swan-Ganz catheter may be required
Ganz catheter to monitor pulmonary artery wedge                                to monitor pulmonary pressures and, indirectly,
pressure as indicated.                                                                              left-sided heart function in client hospitalized for
progressive CHF.

NURSING DIAGNOSIS:                                                               Fluid Volume risk for excess

Risk Factors May Include:                                                             Increasing circulating volume, changes in renal function, dietary indiscretion

Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION                                    Demonstrate stable fluid balance with vital signs

CRITERIA—CLIENT WILL:                                                     WNL, appropriate weight gain, absence of edema.

Verbalize understanding of restrictions/therapy needs.

List signs that require notification of care provider.

ACTIONS/INTERVENTIONS                                   RATIONALE

Independent

Obtain baseline weight. Instruct client to monitor                                 Weight gain exceeding the normal 2–21/2 lb/wk
her weight at home periodically as indicated.                                         may indicate accumulating fluid and potential
CHF. If weight gain is sudden, rule out toxemia.

Review dietary intake, noting factors that may                                      Improper diet, specifically a deficiency of protein
contribute to excessive fluid retention; provide                                     and excess of sodium, contributes to fluid
information as needed.                                                                            retention.

Instruct client to monitor amount and color                                           Decreased output, dark amber urine; increasing
(concentration) of urine. Measure specific gravity as                            specific gravity may reflect impaired renal
appropriate during home/office visit.                                                     perfusion associated with developing CHF.

Assess for/review signs of CHF with client (e.g.,                                  Indicates developing failure and need for
dyspnea, distended neck veins, crackles, hemoptysis,                           immediate treatment. The normal increase of 1300
and so forth).                                                                                           ml in circulatory volume that occurs in pregnancy
can put stress on the cardiac system. Further increase
of fluid can be especially dangerous for the client
with existing cardiac problems.

Investigate unexplained cough.                                                              Cough unrelated to respiratory problems may
indicate developing CHF.

Collaborative

Restrict fluids and sodium in presence of CHF.                                    Minimizes risk of fluid retention/overload.

Administer diuretics, e.g., chlorothiazide (Diuril),                                Helps rid body of excess fluid resistant to
hydrochlorothiazide (HCTZ), furosemide (Lasix),                                conservative treatment of rest and decreased
as appropriate.                                                                                         sodium intake.

NURSING DIAGNOSIS:                                                               Tissue Perfusion, risk for altered: uteroplacental

Risk Factors May Include:                                                             Changes in circulating volume, right-to-left shunt

Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION                                    Display BP, pulse, ABGs, and WBC count WNL.

CRITERIA—CLIENT WILL:                                                     Demonstrate adequate placental perfusion as

indicated by reactive fetus with heart rate ranging from 120–160 bpm and size appropriate for gestational age.

ACTIONS/INTERVENTIONS                                   RATIONALE

Independent

Note individual risk factors and pregravid state.                                    Any preexisting cardiac problems complicated by
increased circulatory needs during pregnancy may
result in impaired tissue oxygenation. Note: Such
problems are greater in the older client with obesity
and long-standing cardiac involvement.

Assess BP and pulse. Note behavior changes,                                       Tachycardia (heart rate greater than 110 bpm) at rest,
cyanosis of mucous membranes and nail beds,                                      increasing BP, and behavior changes may indicate
activity intolerance, and signs of decompensation                                 early cardiac failure or hypoxia. A fall in peripheral
(i.e., excessive weight gain, unexplained cough,                                   vascular resistance may result in a worsening of right-
crackles/wheezes, hemoptysis, and increased                                        to-left shunting and cyanosis. Presence of cyanosis, a
pulse and respiratory rate).                                                                     late sign of hypoxia, reflects severe problems and
indicates severity of tissue damage and cardiac
compromise.

Provide information about use of modified upright                               Eases respiratory rate by reducing pressure of the
position for sleeping and resting.                                                            enlarging uterus on the diaphragm and helps
increase vertical diameter for lung expansion. Helps
prevent venous stasis in lower extremities.

Collaborative

Monitor laboratory studies as indicated:

Pulse oximetry/ABGs;                                                                        Reflects adequacy of ventilation and oxygenation.

Hb/Hct;                                                                                               Anemia further reduces oxygen-carrying capacity of
blood and may require treatment.

WBC count, culture of upper/lower respiratory                                 Any respiratory involvement reduces intake of oxygen.
secretions.                                                                                      Infection increases metabolic rates and oxygen needs
and may have a negative impact on tissue oxygenation.

Assess uterine/fetal blood flow using NST/CST;                                   Uterine/placental hypoxia reduces fetal activity
check estriol levels and FHR. (Refer to CP: The High-                         and FHR, and presents as late decelerations on
Risk Pregnancy; ND: Injury, risk for fetal.)                                           CST. Hypoxia may result in placental deterioration
and falling estriol levels.

NURSING DIAGNOSIS:                                                               Infection, risk for maternal

Risk Factors May Include:                                                             Inadequate primary/secondary defenses, chronic disease/condition, insufficient information to avoid exposure to pathogens

Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION                                    Identify/adopt behaviors to reduce individual risk.

CRITERIA—CLIENT WILL:

                                                                                                           Remain free of bacterial infection.

Demonstrate appropriate use of antimicrobial agents, as indicated.

ACTIONS/INTERVENTIONS                                   RATIONALE

Independent

Assess for individual risk factors and history of                                    There is increased risk of bacterial endocarditis in
rheumatic fever.                                                                                      the prenatal client with underlying heart disease,
such as valvular damage caused by rheumatic or
congenital processes, mitral valve prolapse,
ventricular septal defect, tetralogy of Fallot,
pulmonic stenosis, coarctation of the aorta, or
prosthetic valve.

Provide information about risk of bacterial                                            The client with a prosthetic valve is at high risk for
endocarditis during specific medical-surgical                                        bacterial endocarditis and emboli, even in an
procedures.                                                                                              uncomplicated vaginal delivery. Transient
bacteremia may occur following invasive
procedures, including dental work. (About 60%–
90% of clients develop bacteremia after dental
extraction).

Review signs/symptoms suggestive of infectious                                  Prompt recognition of problem facilitates timely
processes requiring notification of healthcare                                        intervention.
provider, e.g., fever, malaise, cough, cloudy/
odiferous urine.

Collaborative

Assess urine periodically, note pH, and presence                                  Bacturia may be asymptomatic and lead to
of bacteria.                                                                                               bacteremia if untreated.

Obtain cultures as indicated.                                                                   Useful in identifying infecting agent/appropriate
therapy.

Administer penicillin PO or IM, when indicated.                                   Prophylactic antibiotics may be recommended for
prevention of streptococal infection during
pregnancy, especially in the client with history of
rheumatic fever.

NURSING DIAGNOSIS:                                                               Activity Intolerance, risk for

Risk Factors May Include:                                                             Presence of circulatory problems, previous episodes of intolerance, deconditioned status

Possibly Evidenced By:                                                                   [Not applicable; presence of signs/symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION                                    Demonstrate self-responsibility for monitoring

CRITERIA—CLIENT WILL:                                                     activity tolerance/intolerance.

Adopt behaviors to maximize tolerance.

Take appropriate actions if cardiac/respiratory symptoms arise.

ACTIONS/INTERVENTIONS                                   RATIONALE

Independent

Assess for development of subjective/objective                                    Indicates a worsening of the cardiac condition,
symptoms (e.g., lessening of tolerance to ordinary                                evidenced by a decrease in the client’s functional
physical activity, fatigue, cyanosis, inability to carry                            capacity.
on normal daily activities, increasing dyspnea with
or without physical activity, nocturnal dyspnea,
change in pulse rate, development of respiratory
symptoms).

Review signs/symptoms with the client and                                          Promotes self-care and timely medical
significant other(s).                                                                                 interventions.

Assist client in setting priorities and restructuring                           Circulatory/respiratory impairment may interfere
daily routine to include needed rest/sleep periods.                           with ability to perform activities of daily living
Determine expectations of client and partner.                                   (ADLs) and may result in fatigue. Activity is
Explore conflicts/differences.                                                               limited in relation to the extent of cardiac
impairment. Clients with class I or II limitation may
only need to include midmorning and
midafternoon rest periods, whereas class III or
class IV clients may need bedrest for much or
all of the day.

Identify energy conserving methods to accomplish                               May enable client to manage activities more
necessary ADLs.                                                                                    effectively.

Ascertain effectiveness of household assistance and                             May be needed to maximize rest, limit fatigue, and
available resources.                                                                                 preserve cardiac function.

Collaborative

Refer to home care agency, community resources                                 Can provide additional assistance when necessary.
as indicated.

Refer to occupational therapist (OT), physical                                      May be helpful in identifying assistive
therapist (PT), as appropriate.                                                                 techniques/devices to conserve energy and
accomplish desired ADLs.

NURSING DIAGNOSIS:                                                               Knowledge deficit [Learning Need], regarding condition, prognosis, and treatment needs

May Be Related To:                                                                        Lack of exposure to and/or misinterpretation of information

Possibly Evidenced By:                                                                   Request for information, statement of misconception, inaccurate follow-through of instructions

DESIRED OUTCOMES/EVALUATION                                    Verbalize understanding of individual condition

CRITERIA—CLIENT WILL:                                                     and treatment needs.

Identify symptoms indicating deterioration of
cardiac functioning.

Intervene and/or notify healthcare provider appropriately.

ACTIONS/INTERVENTIONS                                   RATIONALE

Independent

Assess understanding of pathology/complications                                 Establishes data base for health teaching.
regarding cardiac condition and pregnancy.                                           Increasingly severe cardiac symptoms may
Review history, incidence of complications,                                          indicate client’s need for more information and/or
and so forth.                                                                                            assistance to manage necessary self-care.

Discuss necessity for frequent monitoring; i.e., every                           Provides for early detection of problems and
2 wk during first 20 wk, then every week                                              prompt intervention.
until delivery.

Provide information about symptoms indicative                                    Symptoms associated with decompensation
of cardiac involvement, such as shortness of breath,                              should be differentiated from symptoms
cough, palpitations, unusual or rapid weight gain                                  associated with PIH. (Refer to CP: Pregnancy-
(i.e., 2.2–4.4 lb or 1–2 kg in a 2-day period), edema,                             Induced Hypertension; ND: Fluid Volume deficit.)
or anorexia.

Provide information as appropriate regarding                                        Enhances informed decision making, helps reduce
diet, rest/sleep, exercise, and relaxation.                                                 likelihood of complications. The impact of pregnancy
superimposed on an existing cardiac problem may
necessitate changes in lifestyle. An understanding of
techniques designed to lessen cardiac stress may
require the acquisition of new knowledge.

Review need/techniques to avoid infection.                                           Resistance may be lowered because of general
condition.

Review side effects of both prescription and                                         Determines client’s level of knowledge and
OTC drugs.                                                                                             provides current information.

Discuss special considerations, such as need to                                     Such foods counteract/alter anticoagulant drug
avoid foods high in vitamin K (raw, deep-green                                    effect.
leafy vegetables) when on anticoagulants.

Include healthcare team in teaching/planning.                                        Provides continuity and completeness of care.

Provide appropriate information for protocol of                                    May foster self-responsibility and reduce anxiety.
care in home/community/hospital setting.

Identify support groups, community resources.                                     May serve as role model for necessary adaptations,
enhance coping ability, and provide encouragement
for a successful outcome.

Posted in Maternal and Newborn Nursing Care Plans | Tagged , , | Leave a comment

Nursing care plan DEMENTIA OF THE ALZHEIMER’S TYPE / VASCULAR DEMENTIA

DEMENTIA OF THE ALZHEIMER’S
TYPE/VASCULAR DEMENTIA

I. Pathophysiology
a. Cognitive disorder characterized by impaired memory,
language, thinking, and perception
b. Dementia of the Alzheimer’s type (DAT) (Hausman, 2006;
Nelson-Marsh, 2005)
i. Characterized by structural and chemical changes in the
brain, causing a steady and global decline in function
ii. Degenerative process occurring primarily in the cells
located at the base of the forebrain that sends information
to the cerebral cortex and hippocampus
iii. Decrease in acetylcholine production reduces the amount
of neurotransmitter released to cells in the cortex,
hippocampus, and nucleus basalis, resulting in a disruption
of memory processes.
iv. Enzyme required to produce acetylcholine is dramatically
reduced, especially in the area of the brain where neuritic
plaques and neurofibrillary tangles occur in the greatest
numbers.
v. Formation of plaques composed of beta-amyloid and tangles
appears to be related to the cholesterol-transporting
protein, apolipoprotein-E (ApoE).
c. Vascular dementia
i. Referred to as multi-infarct, post-stroke dementia, or vascular
cognitive impairment, resulting in decreased blood
flow to parts of the brain
ii. Multiple infarcts to various areas of the brain result in a
pattern of intermittent deterioration determined by the
area of the brain that is affected.
II. Classification
a. Alzheimer’s and vascular dementia are irreversible and
share common symptomology and therapeutic intervention.
i. Alzheimer’s disease accounts for 70% of dementia
diagnoses.
ii. Vascular dementia accounts for 17% of cases.
b. Criteria for dementia diagnosis (Alzheimer’s Association,
2008)
i. Decline in memory and at least one of the following
cognitive abilities
1. Coherent speech, understand spoken or written
language
2. Recognize or identify objects, assuming intact sensory
function
3. Execute motor activities, assuming intact motor
abilities, sensory function, and comprehension of the
required task
4. Abstract thinking, make sound judgments, plan, and
carry out complex tasks
ii. Decline in cognitive abilities must be severe enough to
interfere with daily life.

III. Etiology
a. DAT: Exact cause unknown; most likely due to multiple
factors rather than a single cause (Alzheimer’s Association,
2008).
i. Lifelong process—incidence increases with longevity,
and changes in the brain may develop decades before
the onset of dementia
ii. Genetics—familial pattern four times greater than
general population (Nelson-Marsh, 2005)
1. Familial or early-onset Alzheimer’s is linked to
defects on genes on chromosome 1, 14, or 21 with
some families exhibiting a pattern of inheritance
suggesting possible autosomal dominant gene
transmission (Kuljis, 2007).
2. Down syndrome: presents with an extra chromosome
21; may have a relationship to Alzheimer’s disease
a. At autopsy, both disorders have many of the same
pathophysiological changes.
b. High percentage of individuals with Down syndrome
who survive to adulthood develop
Alzheimer’s lesions by age 50 (Alvarez, 2008).
3. Studies suggest that autoantibodies are produced in
the brain, reflecting a possible alteration in the body’s
immune system.
iii. Proposed risk factors: Studies to date have not supported
causal relationship; however, various factors that have
been suggested include head trauma, low educational
level, cigarette smoking, cholesterol-reducing drugs
(statins), and ingestion of aluminum.
b. Vascular dementia
i. Predisposing factors: various diseases and conditions
that interfere with blood circulation, including cerebral
and systemic vascular disease, hypertension, cerebral
hypoxia, hypoglycemia, cerebral embolism, and severe
head injury
IV. Statistics (Alzheimer’s Association, 2008; Centers for
Disease Control and Prevention [CDC], 2008)
a. Morbidity: In 2008, an estimated 5.2 million people in the
United States were living with Alzheimer’s disease; it is
projected that 10 million baby boomers will develop
Alzheimer’s in their lifetime.
b. Mortality: DAT is the sixth-leading cause of death—72,914
Americans died in 2006.
c. Cost: In 2005, $112 billion was spent in direct medical
costs to Medicare and Medicaid for Alzheimer’s and other
dementias and $36.5 billion in indirect costs to businesses; it
is estimated that 9.8 million family, friends, and neighbors
provided 8.4 billion hours of unpaid care, a contribution
valued at $89 billion.

Care Setting
Client is cared for primarily in the home or assisted
living/extended care; however, inpatient care may be
required for treatment of other health problems.

Related Concerns
End-of-life/hospice care,
Extended care,
Pneumonia,
Psychosocial aspects of care,
Sepsis/septicemia,
Total nutritional support: parenteral/enteral feeding,

Nursing Priorities
1. Provide safe environment and prevent injury.
2. Promote socially acceptable responses and limit inappropriate
behavior.
3. Maintain reality orientation and prevent sensory deprivation
or overload.
4. Encourage participation in self-care within individual
abilities.
5. Promote coping mechanisms of client/SO(s).
6. Support client and family in grieving process.
7. Provide information about disease process, prognosis,
and resources available for assistance.

Discharge Goals
Not indicated in home or community setting. Following
inpatient care, based on underlying condition requiring
admission.

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Nursing care plan Psychosocial aspects of Care

PSYCHOSOCIAL ASPECTS OF CARE

I. Mind-Body-Spirit Connection
a. When a physiological response occurs, there is a corresponding
psychological response (Anandarajah & Hight,
2001).
i. Emotional instability associated with steroid therapy or
Cushing’s syndrome
ii. Irritability of hypoglycemia
iii. Anxiety associated with impaired oxygenation
b. Emotional response during illness is of extreme
importance.
i. The stress of illness is well recognized; however, the
effect on the individual is unpredictable.
ii. The client’s perception of, and response to, the event may
result in unmet psychological needs that drain energy
resources needed for healing.
iii. Values brought to the interactions between clients,
families, and healthcare providers affect the care that a
client expects and receives.

II. Psychoneuroimmunology (PNI) provides new information
about how interactions between the mind and the neuroendocrine
and immune systems influence health and healing.
a. Negative emotions or stressful experiences can intensify
health threats, contribute to prolonged infection, and
result in delayed healing (Kiecolt-Glaser et al, 1984;
Kiecolt-Glaser et al, 2002).
i. Chronic stress: decreased T and B cells, decreased natural
killer (NK) cells, increased blood levels of Epstein-Barr virus
ii. Depression: decreased T cells, decreased number and
function of lymphocytes, decreased NK cells
iii. Grieving: decreased lymphocyte proliferation
b. Positive emotions can enhance immune response, facilitate
healing, and slow disease progression.
i. Personal sharing of traumatic experience: increased
lymphocyte response
ii. Support group intervention: increased NK cells and
activity, increased lymphocyte count
iii. Humor and laughter: increased immunoglobulin A,
increased lymphocyte count and activity

Care Setting
Any setting in which nursing contact occurs and care is
provided.

Related Concerns
This is an aspect of all care and plans of care.

Nursing Priorities
1. Encourage effective coping skills of client and SO.
2. Reduce anxiety or fear.
3. Facilitate integration of self-concept and body-image
changes.
4. Support grieving process.
5. Promote safe environment and client well-being.

Discharge Goals
1. Client and family dealing realistically with current situation.
2. Anxiety or fear manageable.
3. Progressing through stages of grieving.
4. Safe environment maintained.
5. Plan in place to meet needs after discharge.

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Nursing care plan TRANSPLANTATION CONSIDERATIONS POSTOPERATIVE AND LIFELONG

I. Procedure
a. Transfer of whole or partial organs—including heart, lung,
kidney, liver, pancreas, and intestines—and tissues or cells
from one location to another
b. Long considered experimental, heart and other transplant
procedures are successfully moving to domain of conventional
therapy; however, others, such as hand and limb
transplants, are still at the experimental stage
c. Bone, bone marrow, heart valve, cartilage, vein, pancreatic
islet, cornea, and stem cell transplantations are also performed
on a daily basis (Sharma & Unruh, 2006).
i. Stem cell use is being investigated for treating a wide
range of diseases, tissue damage, or both.
ii. Two types of stem cells: human embryonic stem cells
(hES) and adult somatic stem cells (ASSC), which is
the source currently being used (Sullivan &
Schoonover-Shoffner, 2007)
d. Major concerns (Workman, 2006)
i. Immunological response of the client to donor tissues and
the ability of the immune system to distinguish self from
nonself leading to rejection of the transplant
ii. Special considerations necessitate meticulous measures
to prevent infection and identify early signs of rejection.

II. Types—characterized according to the genetic relationship
between the donor and recipient or the anatomical site of the
implantation
a. Genetic relationship characterized into four classes (Sharma
& Unruh, 2006)
i. Autograft
ii. Isograft or syngeneic graft
iii. Allograft or homograft
iv. Xenograft or heterograft
b. Site of implantation (Sharma & Unruh, 2006)
i. Orthotropic: tissue implanted in the anatomically correct
position
ii. Heterotopic: relocation of the implant at a site different
from the normal anatomy

III. Statistics (U.S. Organ and Procurement Network [OPTN],
2006)
a. Morbidity: In 2006, 28,291 transplants were performed
in all categories—heart, lung, kidney, pancreas, liver,
intestine, and multi-organ—in the United States; kidney
transplant is the most common (greater than16,000),
followed by liver (greater than 6,000) and heart
(greater than 2,100).
b. Mortality: Dependent on type of transplant, level of match
and human leukocyte antigen (HLA) status, recipient’s
age at transplant, preoperative condition, presence of
comorbidities (Parimon et al, 2005); in 2005, the 90-day
mortality for a live donor kidney was 0.7%; intestinal
transplant, 8.6% (U.S. Department of Health and Human
Services [USDHHS], 2007).
c. Cost: Varies according to procedure; estimated average
first-year medical charges per transplant episode for
kidney, $246,400; heart, $658,800; intestine, $908,600
(Hauboldt, 2007).

Care Setting
Post-intensive care unit (ICU) plan of care addresses early
recovery and long-term postdischarge community or clinic
follow-up phases.

Related Concerns
Refer to (1) specific surgical plans of care for general considerations
(e.g., cardiac surgery) and (2) organ-specific plans
(e.g., heart failure, renal failure, cirrhosis, hepatitis) relative to
issues of target organ problems following transplantation.
Peritonitis
Psychosocial aspects of care
Sepsis/septicemia
Surgical intervention
Thrombophlebitis: deep vein thrombosis

Nursing Priorities
1. Prevent infection.
2. Maximize organ function.
3. Promote independent functioning.
4. Support family involvement and coping.

Discharge Goals
1. Free of signs of infection.
2. Signs of rejection absent or controlled.
3. New organ function adequate.
4. Usual activities resumed.
5. Client and family education plan established.
6. Plan in place to meet individual needs following discharge.
Risk factors

Posted in Postoperative and Lifelong, Transplantation Considerations | Tagged , , , , | Leave a comment

Nursing care plan Rheumatoid Arthritis RA

I. Pathophysiology
a. Systemic inflammatory process originating in the synovium
or synovial fluid involving connective tissue and characterized
by destruction and proliferation of the synovial membrane
b. Phagocytosis produces enzymes within the joint, causing
inflammation
c. Collagen is destroyed over time and pannus formations
occur, narrowing the joint space
d. May result in joint destruction, ankylosis, and deformity,
with loss of articulation and joint motion
e. Inflammatory process can also affect the spine, blood vessels,
the pleural membrane of the lungs, or the pericardial
sac.
f. Condition may be short lived and limited or progressive and
severe.
g. Spontaneous remissions and unpredictable exacerbations can
occur.

II. Classification (New York Times, 2007)
a. Type 1: benign, less common, milder form lasting a few
months at most and leaving no permanent disability
b. Type 2: aggressive, more severe, progressive form lasting
for years, often for life

III. Etiology (King & Worthington, 2006)
a. Specific cause unknown
b. Associated factors: infectious triggers, genetic predisposition,
autoimmune response
c. Other possible factors: more common in females, with ratio
to males approximately 3:1; hormone interaction; psychological
stress; heavy, long-term smoking; history of blood
transfusions

IV. Statistics
a. Morbidity: Prevalence in United States is approximately
1% or 2.1 million adults (King & Worthington, 2006;
NIAMS, 2004); peak incidence occurs at ages 40 to
60 years (Gupta & Bhagia, 2006).
b. Mortality: Dependent on overall deterioration in health and
secondary organ dysfunction (King & Worthington, 2006);
shortens lifespan by 3 to 10 years.
c. Cost: Annual medical costs are approximately $14 billion
(Arthritis Foundation and National Pharmaceutical
Council, 2002).

Care Settings
Client is treated at community level unless surgical procedure
is required.

Related Concerns
Psychosocial aspects of care
Total joint replacement

Nursing Priorities
1. Alleviate pain.
2. Increase mobility.
3. Promote positive self-concept.
4. Support independence.
5. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals
1. Pain relieved or controlled.
2. Dealing realistically with current situation.
3. Managing activities of daily living (ADLs) by self or with
assistance, as appropriate.
4. Disease process, prognosis, and therapeutic regimen
understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan Acquired immunodeficiency syndrome aids

I. Pathophysiology
a. End result of infection with a retrovirus—the human
immunodeficiency virus (HIV)
b. Progression from HIV infection to AIDS is highly variable:
It may take weeks to years, with median rate of 9 to
11 years after infection in the absence of antiretroviral
therapy (United Nations Programme on HIV/AIDS
[UNAIDS] & World Health Organization [WHO], 2007).
c. Defined by the Centers for Disease Control and Prevention
(CDC) as presence of HIV infection with at least one other
criteria.
i. CD4 T-cell count below 200 cells/μl
ii. CD4 T-cell percentage of total lymphocytes at less than
14%
iii. Presence of opportunistic infection (OIs) or AIDSdefining
illness

II. Etiology
a. Primary HIV infection: unprotected sex, anal intercourse,
contaminated blood products, occupational exposure
b. OIs are major contributors to morbidity and mortality in the
HIV-infected client (Powderly, 1999)—undiagnosed HIV,
CD4 T-cell count below 200 cells/μl, not taking antiretrovirals,
drug resistance or failure of antiretroviral therapy
i. Infecting microbes: candidiasis, coccidioidomycosis,
cryptococcosis, cryptosporidiosis, cytomegalovirus (CMV),
herpes simplex, histoplasmosis, isosporiasis, mycobacterium,
Pneumocystis jiroveci (Pneumocystis carinii pneumonia
[PCP]), polyomavirus JC (causes progressive multifocal
leukoencephalopathy), salmonella, toxoplasmosis
ii. Other AIDS-defining illnesses: HIV-related encephalopathy,
Kaposi’s sarcoma (KS), invasive cervical cancer,
Burkitt’s lymphoma, wasting syndrome due to HIV

III. Statistics (CDC, 2007)
a. Morbidity: As of 2005, an estimated 984,155 individuals
had been diagnosed with AIDS, with 433,760 living with
AIDS in the United States.
b. Mortality: In 2005, 17,011 deaths resulted from AIDS in
the United States, and there have been more than 550,394
deaths since it was first diagnosed.
c. Cost: Yearly healthcare costs average $34,000 per individual
with an AIDS diagnosis, with approximately $24,000
going toward antiretroviral therapy (Saag, 2002).

Care Setting
The interventions listed here are appropriate for community
care as well as an inpatient or hospice setting. Most of the
signs and symptoms and psychosocial issues happen long
before inpatient care, which currently, is usually of very
short duration.

Related Factors
End-of-life care/hospice
Extended care
Fluid and electrolyte imbalances
The HIV-positive client
Psychosocial aspects of care
Sepsis/septicemia
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
Ventilatory assistance (mechanical)

Nursing Priorities
1. Prevent or minimize development of new infections.
2. Maintain homeostasis.
3. Promote comfort.
4. Support psychosocial adjustment.
5. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals/Goals
of Care
1 Infection prevented or resolved.
2. Complications prevented or minimized.
3. Pain and discomfort alleviated or controlled.
4. Dealing with current situation realistically.
5. Diagnosis, prognosis, and therapeutic regimen understood.
6. Plan in place to meet ongoing needs.

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Nursing care plan HIV positive client

I. Pathophysiology
a. Infection by a subgroup of retroviruses with a high affinity
for CD4 T-lymphocytes and monocytes, with viral DNA
incorporating itself into host DNA (Dubin, 2008)
b. Following successful transmission of HIV, the course of
subsequent infection is variable and dependent on a number
of factors.
c. Main consequence of infection is damage to the immune
system.

II. Stages: continuum with progression individually variable
(Health24, 2004; Highleyman, 2005)
a. Infection or initial incubation period lasts 2 to 4 weeks.
i. Individual asymptomatic
ii. HIV test negative but individual is infectious.
b. Primary infection or acute seroconversion stage usually
occurs 4 to 8 weeks after infection.
i. Individual may be asymptomatic or develop flu-like
symptoms—low-grade fever, sore throat, swollen lymph
nodes, rash, joint and muscle pain lasting 1 to 2 weeks
ii. HIV positive but immune system usually functional.
c. Latency or asymptomatic stage can last anywhere from
2 weeks to years.
i. Virus remains active.
ii. Individual may be unaware of HIV status.
d. Mild to moderate stage usually occurs between 5 to 7 years
after infection.
i. Immune system is compromised.
ii. Individual symptomatic—skin rashes; fatigue; night
sweats; weight loss; mouth ulcers; fungal skin and nail
infections, which progress to chronic oral or vaginal
thrush; recurrent herpes blisters on mouth or genitals;
ongoing fevers; persistent diarrhea
e. Severe or late stage HIV disease median occurrence is
11 years postinfection.
i. Viral load is very high; CD4 count is very low, thus
indicating full-blown AIDS.
ii. Severe immune system damage and development of
opportunistic infections (Refer to CP: AIDS for
information.)

III. Etiology
a. Infection results from one of two similar retroviruses—HIV-1
and HIV-2—that destroy CD4 lymphocytes and impair
cell-mediated immunity, thereby increasing the risk of certain
infections and cancers.
b. Mode of transmission
i. Sexual contact—deposition of HIV on mucosal surfaces,
especially the genital mucosa and intestinal epithelium
(most common mode)
ii. Direct inoculation into the blood through intravenous (IV)
needle sharing or use of contaminated blood products
(rare in United States)
iii. Mother-to-baby perinatal transmission
c. Worldwide, high-risk populations—sex workers, men who
have sex with men, injection drug users, and prisoners
(United Nations Programme on HIV/AIDS [UNAIDS] &
World Health Organization [WHO], 2006)
d. Risk and severity of opportunistic infections, AIDS,
and AIDS-related cancers are determined by the CD4
lymphocyte count and the client’s exposure to potentially
opportunistic pathogens.
e. Ability of virus to mutate has made disease management
challenging, which has hindered efforts at development of
a vaccine.

IV. Statistics
a. Morbidity: In 2005, there were an estimated 38.6 million
people worldwide with HIV (UNAIDS & WHO, 2006); in
2003, there were approximately 1 million with HIV/AIDS
in the United States (Glynn & Rhodes, 2005); annually,
40,000 Americans are newly infected (Armington, 2007);
new infections are still increasing in some age ranges
(e.g., 40–44), among males (white, black, and Hispanic),
and among female adolescent and adult injection drug
users (Centers for Disease Control and Prevention
[CDC], 2007).
b. Mortality: Associated with progression to AIDS; life
expectancy 2 to 3 years in untreated HIV progressing to
AIDS (Dubin, 2008); in 2002, AIDS-related deaths were
at a rate of 2.2%, with marked increase for non-HIV/
AIDS-related causes, such as diabetes, chronic hepatitis,
and cardiovascular disease (Highleyman, 2005).
c. Cost: In 2002, $36.4 billion estimated lifetime costs for
individuals newly diagnosed in the United States, with
$6.7 billion in direct medical costs and almost $30 billion
in productivity loss (Hutchinson et al, 2006).

Care Setting
Client is treated in a community setting, although development
of opportunistic infections may require occasional
inpatient acute medical care.

Related Factors
Acquired immunodeficiency syndrome (AIDS)
Extended care
Fluid and electrolyte imbalances
Pneumonia
Psychosocial aspects of care
Sepsis/septicemia

Nursing Priorities
1. Promote acceptance of reality of diagnosis and condition.
2. Support incorporation of behavioral and lifestyle changes
to enhance well-being.
3. Provide information about disease process, prognosis,
and treatment needs.
4. Assist in developing plan and strategies to meet long-term
medical, behavioral, and financial needs and enhancing
quality of life.

Goals of Care
1. Dealing with current situation realistically.
2. Participating in and appropriately managing therapeutic
regimen.
3. Diagnosis, prognosis, and therapeutic regimen understood.
4. Plan in place to meet medical, behavioral change, and
financial needs.

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Nursing care plan sepsis septicemia

I. Pathophysiology (Cunha, 2008; Kleinpell, 2006; Sharma &
Mink, 2007; Wood & Lavieri, 2007)
a. Presence of a systemic inflammatory response to documented
or presumed infection, which may progress along a continuum
i. Systemic inflammatory response syndrome (SIRS)
1. Infection with release of endo- or exotoxins activating
the inflammatory cascade—local release of cytokines
into the circulation in attempt to restore homeostasis
2. Failure of mechanism leads to destructive response
with loss of circulatory integrity
3. Criteria (two or more)—fever greater than
100.4ºF/38ºC or less than 96ºF/36ºC; heart rate greater
than 90 beats per minute; respiration greater than
20/min or PaCO2 less than 32 mm Hg; white blood
cell (WBC) count greater than 12,000/μL, less than
4,000/μL, or greater than than 10% of bands or
immature cells
ii. Severe sepsis—presence of known or suspected infection
and two or more SIRS criteria; associated with organ
dysfunction, hypoperfusion, hypotension with alteration
of mental status, hypoxemia, lactic acidosis, and/or
oliguria
iii. Septic shock—characterized by hemodynamic changes
and persistent hypotension, development of perfusion
abnormalities, and impaired cellular function that fails to
respond to adequate fluid resuscitation
iv. Multiple organ dysfunction syndrome (MODS)—organ
dysfunction leading to organ failure with inability to
maintain homeostasis

II. Etiology
a. Multiple microorganisms associated with sepsis
i. Bacteria, fungi, viruses, or rickettsiae
ii. Common pathogens: Streptococcus pneumoniae or
Staphyloccocus aureus, Candida, Salmonella,
Escherichia coli, Legionella, Klebsiella, Pseudomonas
b. Common origin of infections
i. Abdomen: appendicitis, bowel problems (perforated
diverticuli), infection of the abdominal cavity, and
gallbladder or liver infections
ii. Central nervous system: infections of the brain or the
spinal cord, such as encephalitis, meningitis
iii. Lungs: pneumonia
iv. Skin: wounds or cellulitis; punctures, such as from
intravenous (IV) lines, intravascular devices, or
catheters inserted into the body to administer or drain
fluids
v. Urinary tract: kidneys or bladder (glomerulonephritis,
pyelonephritis, cystitis), prostatic obstruction
c. Risk factors: unsanitary and/or crowded living conditions,
pollution, poor nutrition, immunosuppression, chronic
health conditions, improper use of antibiotics

III. Statistics (Angus et al, 2001)
a. Morbidity: A reported 751,000 cases of severe sepsis occur
annually in the United States.
b. Mortality: Dependent on progression of condition and
degree of organ failure, presence of comorbidities, and age;
in 2001, the rate was 28.6%.
c. Cost: Averages $22,100 per case, with approximately
$16.7 billion spent annually.

Care Setting
Although severely ill individuals will likely receive care in
the intensive care unit (ICU), this plan addresses care on an
inpatient acute medical-surgical unit.

Related Concerns
Acquired immunodeficiency syndrome (AIDS)
Chronic obstructive pulmonary disease (COPD) and asthma
Disaster considerations
Fluid and electrolyte imbalances
Metabolic acidosis—primary base bicarbonate deficiency
Peritonitis
Pneumonia
Psychosocial aspects of care
Pulmonary tuberculosis (TB)
Renal failure: acute
Surgical intervention
Total nutritional support: parenteral/enteral feeding
Ventilatory assistance (mechanical)

Nursing Priorities
1. Eliminate infection.
2. Support tissue perfusion or circulatory volume.
3. Prevent complications.
4. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals
1. Infection eliminated or controlled.
2. Homeostasis maintained.
3. Complications prevented or minimized.
4. Disease process, prognosis, and therapeutic regimen
understood.
5. Plan in place to meet needs after discharge.

Posted in Sepsis, Septicemia | Tagged , , | Leave a comment

Nursing care plan burns

I. Pathophysiology—Local and systemic response affecting
skin and/or other tissues depending on cause of burn injury
and physiological response (Hettiaratchy, 2004)
a. Local responses
i. Coagulation: Occurs at the point of maximum damage,
causing irreversible tissue loss due to coagulation of the
constituent proteins.
ii. Stasis: Area characterized by decreased tissue perfusion
that is potentially salvageable unless additional insults,
such as prolonged hypotension, infection, or edema,
occur, converting this zone into an area of complete
tissue loss.
iii. Hyperemia: Outermost area has increased tissue
perfusion, and tissue will recover unless severe sepsis
or prolonged hypoperfusion occurs.
b. Systemic response—Cytokines and other inflammatory
mediators are released at the site of burn injuries with total
body surface area (TBSA) of 30% or greater.
i. Cardiovascular: Increased capillary permeability leads
to shift of intravascular proteins and fluids into the
interstitial space, followed by vasoconstriction and
decreased myocardial contractility; combined with fluid
loss from the burn wound, systemic hypotension and
organ hypoperfusion occur.
ii. Respiratory: Bronchoconstriction occurs in response to
inflammatory mediators, which, in severe burns, can
cause acute respiratory distress syndrome (ARDS).
iii. Metabolic—Rate increases up to three times the baseline
rate, resulting in breakdown of muscle tissue.
iv. Immunological—Immune suppression response occurs.

II. Classification by burn wound and depth
a. Superficial partial-thickness (first-degree) burns: affect only
the epidermis, skin is often warm and dry, and wounds
appear bright pink to red with minimal edema and fine
blisters, if present
b. Moderate partial-thickness (second-degree) burns: include
the epidermis and dermis; wounds appear red to pink with
moderate edema and blisters that may be intact or draining
c. Deep partial-thickness (second-degree) burns: extend in
to the deep dermis; wounds are dryer than moderate
partial-thickness burns and appear pale-pink to pale-ivory,
with moderate edema and blisters
d. Full-thickness (third-degree) burns: include all layers of
skin and subcutaneous fat and may involve the muscle,
nerves, and blood supply; wounds have a dry, leathery
texture and appearance varies from white to cherry-red to
brown or black, with blistering uncommon; absence of pain
in the center, but the edges of the burn wound may have
heightened sensation
e. Full-thickness, subdermal (fourth-degree) burns: involve all
skin layers as well as muscle, organ tissue, and bone, with
charring

III. Etiology
a. Thermal burns: flame, hot fluids or gases, friction, or exposure
to extremely cold objects (e.g., snow, nitrogen, dry
ice); flame burns are often associated with smoke/inhalation
injury
b. Chemical burns: contact with a caustic substance (acid or
alkaline); degree of injury dependent on type and content as
well as concentration and temperature of injuring agent
c. Electral burns: current travels through the body along the
pathway of least resistance (i.e., nerves offer the least resistance
and bones the greatest resistance), generating heat in
proportion to resistance offered; degree of injury dependent
on type/voltage of current with underlying injury more
severe than visible injury
d. Radiation burns: exposure to ionizing radiation, most commonly
protracted and overexposure to ultraviolet rays—
UVA and UVG (e.g., the sun, sunlamps, tanning booths), or
high exposure to x-rays including radiotherapy (e.g., cancer
therapy)
e. Risk factors: substance abuse, careless smoking, cultural
practices, socioeconomic status (e.g., overcrowded living
conditions, insufficient parental supervision of children,
lack of safety precautions), and violence, including child
abuse and neglect, such as with those aged 4 years and
under or those aged 65 years and older
IV. Statistics (American Burn Association, 2007)
a. Morbidity: 500,000 burn injuries require medical attention
in the United States annually, with approximately 40,000
requiring hospitalization; approximately 25,000 are classified
as major burns, involving at least 30% of TBSA.
b. Mortality: There are approximately 4,000 deaths annually.
c. Cost: $7.5 billion is spent annually for fire and burn injuries
(Centers for Disease Control and Prevention [CDC], 2007).

Care Setting
The following adult clients are admitted for acute care and,
during the rehabilitation phase, may be cared for in a subacute
or rehabilitation unit: those with partial-thickness burns
more than 15% to 25% of TBSA or whose age is considered
high risk (older than 50 years and younger than 10 years);
full-thickness burns more than 2% to 10% of TBSA; and
those clients with second- and third-degree burns of face,
both hands, perineum, or both feet; or inhalation and all electrical
burns, including lightning injury (Edlich et al, 2006).

Related Concerns
Disaster considerations
Fluid and electrolyte imbalances
Metabolic acidosis—primary base bicarbonate deficiency
Psychosocial aspects of care
Respiratory acidosis (primary carbonic acid excess)
Sepsis/septicemia
Surgical intervention
Total nutritional support: parenteral and enteral feeding
Upper gastrointestinal/esophageal bleeding

Nursing Priorities
1. Maintain patent airway and respiratory function.
2. Restore hemodynamic stability and circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for client and significant other
(SO).
6. Provide information about condition, prognosis, and
treatment.

Discharge Goals
1. Homeostasis achieved.
2. Pain controlled or reduced.
3. Complications prevented or minimized.
4. Current situation dealt with realistically.
5. Condition, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

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Nursing care plan total joint replacement

I. Purpose
a. Definitive treatment for advanced, irreversibly damaged
joints with loss of function and unremitting pain
b. Commom conditions: degenerative and rheumatoid arthritis
(RA); selected fractures, such as with hip and femoral neck;
joint instability; congenital hip disorders; avascular necrosis

II. Procedures
a. Performed on any joint except the spine, with hip and knee
replacements the most common procedures
b. Prosthesis may be metallic, polyethylene, or ceramic, or a
combination
c. Implanted with methylmethacrylate cement or may be a
porous, coated implant that encourages bony ingrowth

III. Statistics
a. Morbidity: In 2004, there were more than 1 million primary
and revision procedures performed; females accounted
for 62% of all procedures, with a mean age (at time of
procedure) of 66 to 68 years (U.S. Bone and Joint
Decade, 2008).
b. Mortality: Rate is very low, 0.29% in 2004, related to
advanced age and comorbidities (Liu et al, 2008).
c. Cost: In 2004, annual hospital cost estimated at over
$44 billion (U.S. Bone and Joint Decade, 2008).

Care Setting
Client is treated in inpatient acute surgical unit and subacute
or rehabilitation unit.

Related Concerns
Fractures
Psychosocial aspects of care
Rheumatoid arthritis (RA)
Sepsis/septicemia
Surgical intervention
Thrombophlebitis: deep vein thrombosis

Nursing Priorities
1. Alleviate pain.
2. Prevent complications.
3. Promote optimal mobility.
4. Provide information about diagnosis, prognosis, and treatment
needs.

Discharge Goals
1. Mobility increased.
2. Complications prevented or minimized.
3. Pain relieved or controlled.
4. Diagnosis, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan amputation

I. Pathophysiology—Partial or complete detachment of body
part with residual extremity covered with well-vascularized
muscle and skin, although reattachment surgery may be
possible for fingers, hands, and arms
a. Primarily two types of amputations
i. Open or provisional: requires subsequent revisions
ii. Closed or flap: all surgical revision is performed and the
wound closed in one procedure
b. Five levels currently used in lower-extremity amputation:
foot and ankle, below knee (BKA), knee disarticulation and
above (thigh), knee-hip disarticulation, and hemipelvectomy
and translumbar amputation
c. Two basic types of prosthetic designs are used: exoskeletal
and endoskeletal

II. Etiology
a. Varied causes (Ellis, 2007)
i. Peripheral vascular disease, often associated with
diabetes, usually involves lower extremity; most common
in the United States, accounting for 65% of cases
ii. Trauma: battlefield wounds; upper extremity more
common
iii. Malignant bone tumors
iv. Infections: osteomyelitis, gangrene
v. Congenital disorders: approximately 5% of cases
b. Lower-extremity amputations are performed much more
frequently than upper-extremity amputations.
c. Upper-extremity amputations generally result from trauma
caused by industrial accidents.

III. Statistics
a. Morbidity: Approximately 70,000 new major amputations
performed annually in the United States (Ellis, 2007);
use and early implementation of prosthetic devices are
improving long-term outcomes.
b. Mortality: Dependent on underlying pathology; survival
rates decreased in presence of diabetes and end-stage renal
disease as well as with above-the-knee amputations
(Aulivola et al, 2004).

Care Setting
Client is treated in inpatient acute surgical unit and subacute
or rehabilitation unit.

Related Concerns
Cancer
Diabetes mellitus/diabetic ketoacidosis
Psychosocial aspects of care
Surgical intervention

Nursing Priorities
1. Support psychological and physiological adjustment.
2. Alleviate pain.
3. Prevent complications.
4. Promote mobility and functional abilities.
5. Provide information about surgical procedure, prognosis,
and treatment needs.

Discharge Goals
1. Dealing with current situation realistically.
2. Pain relieved or controlled.
3. Complications prevented or minimized.
4. Mobility and function regained or compensated for.
5. Surgical procedure, prognosis, and therapeutic regimen
understood.
6. Plan in place to meet needs after discharge.

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Nursing care plan fractures

I. Pathophysiology
a. Discontinuity or break in a bone
b. May be associated with serious injury to nerves, blood
vessels, muscles, and/or organs
c. More than 150 fracture classifications with five major
types: incomplete, complete, closed, open, and pathologic

II. Etiology
a. Common causes: trauma, including abuse; overuse injury;
osteoporosis; bone tumors; infections
b. Severity of fracture increases with age.

III. Statistics
a. Morbidity: Approximately 6.8 million Americans seek
treatment for fractures annually; in the United States,
osteoporosis accounts for 70% of fractures in people over
age 45; there were more than 2 million cases of fractures in
the United States in 2005 (National Osteoporosis
Foundation [NOF], n.d.).
b. Mortality: Dependent upon multiple factors including the
specific bone affected—humerous versus veterbra—and
severity of fracture, associated soft tissue and organ
involvement, age of individual, and presence of comorbidities;
of the 80,000 males who suffer a hip fracture annually,
one-third will die within 1 year (National Institute of
Arthritis and Musculoskeletal and Skin Diseases [NIAMS],
2007).
c. Cost: In 2005, osteoporosis-related fractures were responsible
for an estimated $19 billion in costs (NOF, n.d.).

Care Setting
Most fractures are managed at the community level.
Although many of the interventions listed here are appropriate
for this population, this plan of care addresses more
complicated injuries encountered on an inpatient acute
medical-surgical unit.

Related Concerns
Craniocerebral trauma—acute rehabilitative phase
Pneumonia
Psychosocial aspects of care
Renal failure: acute
Spinal cord injury (acute rehabilitative phase)
Surgical intervention
Thrombophlebitis: deep vein thrombosis

Nursing Priorities
1. Prevent further bone/tissue injury.
2. Alleviate pain.
3. Prevent complications.
4. Provide information about condition, prognosis, and treatment
needs.

Discharge Goals
1. Fracture stabilized.
2. Pain controlled.
3. Complications prevented or minimized.
4. Condition, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan mastectomy

I. Purpose
a. Removal of breast tissue due to presence of malignant or
cancerous tumor changes
b. Surgical procedures: dependent on tumor type, size, and
location as well as clinical characteristics or staging
i. Breast-conserving therapy
ii. Lumpectomy
iii. Partial or segmental mastectomy
iv. Lymph node surgery
v. Mastectomy (Mayo Clinic, 2007)
1. Simple or total
2. Modified radical
3. Radical
4. Skin-sparing mastectomy

II. Pathology—Tumor growth originates in cells of the breast
tissue occurring primarily in women, although men may also
be affected.
a. Types (National Comprehensive Cancer Network [NCCN],
2007)
i. Ductal
1. Occurs in the ducts that connect the lobes and the
nipple
2. Represents 80% of all breast cancers (invasive ductal
carcinoma)
ii. Lobular
1. Occurs in the lobes where milk is produced
2. Represents 10% to 15% of all cancers
b. Clinical staging (NCCN, 2007)
i. Classification: noninvasive, invasive, or infiltrating
ii. Size and spread of tumor: T stage
iii. Number of lymph nodes involved: N stage
iv. Metastasis: M stage
v. Grade measured from 0–IV, with zero resembling
normal breast tissue
vi. Some stages further divided by letters of the alphabet
(A, B, C, etc.)

III. Statistics (National Cancer Institute [NCI], 2008)
a. Morbidity: As of January 2005, approximately 2,477,847
American women had a history of breast cancer; in 2008,
an estimated 182,460 new cases of breast cancer were
diagnosed in women and 1,990 in men.
b. Mortality: In 2007, breast cancer was the second-leading
cause of death in women in the United States; an estimated
40,480 women and 450 men died of breast cancer in 2008.
c. Cost: Projected $8.1 billion spent in United States in 2004,
averaging $11,000 per Medicare client in first year following
diagnosis (Brown et al, 2002)

Care Setting
Client is treated at inpatient acute surgical unit.

Related Concerns
Cancer, (for additional nursing interventions
regarding cancer treatments, including chemotherapy and
radiation)
Psychosocial aspects of care
Surgical intervention

Nursing Priorities
1. Assist client and significant other (SO) in dealing with
stress of situation and prognosis.
2. Prevent complications.
3. Establish individualized rehabilitation program.
4. Provide information about disease process, procedure,
prognosis, and treatment needs.

Discharge Goals
1. Dealing realistically with situation.
2. Complications prevented or minimized.
3. Exercise regimen implemented.
4. Disease process, surgical procedure, prognosis, and therapeutic
regimen understood.
5. Plan in place to meet needs after discharge.

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