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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