Nursing Care Plan for Genetic Counseling

Genetic counseling is a communication process that deals with human problems associated with the occurrence or risk of a genetic disorder in a family. Counseling involves genetic screening, whereby a high-risk or general population is analyzed to detect the presence of disease, and case finding for couples at potential risk based on medical/family histories. The process can be prospective (counseling delivered to a client/couple of reproductive age before conception or before the birth of an affected child), or it can be retrospective/postnatal (counseling delivered after the birth of an affected child). In many cases, however, the need for genetic counseling first becomes apparent during the first trimester.


NURSING PRIORITIES
1. Assist client/couple/family to recognize and understand specific situation.
2. Facilitate therapeutic use of informational resources.
3. Provide ongoing emotional support.

DISCHARGE GOALS
1. Copes effectively with situation
2. Completes counseling process
3. Understands information specific to individual situation

Nursing diagnosis: Anxiety related to presence of specific risk factors (e.g., history of genetic problem, exposure to teratogens), situational crisis, threat to self-concept (perceived/actual), conscious or unconscious conflict about essential values (beliefs) and goals of life possibly evidenced by increased tension, apprehension, uncertainty, feelings of inadequacy, or expressed concern regarding changes in life events, insomnia.

Desired Outcomes:
1. Acknowledge awareness of feelings of anxiety.
2. Verbalize realistic concerns related to process of genetic counseling/prenatal diagnosis.
3. Appear relaxed and report that anxiety is reduced to a manageable level.
4. Identify and use resources/support systems effectively.

Nursing care plan intervention and rationale:
1. Assess nature, source, and manifestations of anxiety.
Rationale: Identifies specific areas of concern and determines direction for and possible options/interventions.

2. Provide information about specific genetic disorder, risks involved in reproduction, and available prenatal diagnostic measures/options.
Rationale: May relieve anxiety associated with the unknown and assist family to cope with stress, make decisions, and adapt positively to choices. Note: A nursing diagnosis [ND]: Knowledge deficit large number of clients at risk of producing a child [Learning Need].) with a genetic abnormality do not receive prospective counseling/diagnostic services before conception because of ineffective case finding/lack of awareness and often enter counseling, during the first trimester or, retrospectively, after the birth of an affected child. New genetic research at the gene level will have future implications for diagnosis, carrier status, or prenatal detection of genetic disease. Some of the techniques used include restriction endonuclease, DNA probes, polymerase chain reaction (PCR), Southern blot, restriction fragment length polymorphisms (RFLPs)

3. Promote ongoing sharing of concerns/feelings.
Rationale: Opportunity for client/couple to begin resolution of situation. Note: Level of anxiety is usually higher in the couple who have already given birth to a child with a chromosomal disorder.

4. Review procedure and what to expect in terms discomfort if fetus is affected and couple elects
to terminate pregnancy and so on.
Rationale: Client/couple may be extremely anxious, guilt of ridden during uncomfortable procedure; information can enhance coping, reduce anxiety.

5. Visit couple after procedure. Provide anticipatory guidance in terms of physical/psychological changes.
Rationale: After abortion for genetic indications, follow-up visit by the primary nurse may help to reduce couple’s anxiety/depression.

6. Provide opportunity for discussion of test results on fetus and assist with interpretation of information, especially following abortion.
Rationale: Helps to confirm the diagnosis; reduces anxiety assoc iated with uncertainty of whether fetus was really affected and whether couple made the “right” choice.

7. Listen to expressions of concern/feelings about situation.
Rationale: When concerns and feelings are expressed/listened to, client needs can be identified more readily.

8. Refer for further counseling (e.g., psychiatric, group).
Rationale: Anxiety may not be resolved sufficiently, necessitating additional professional assistance.

9. Assist couple in identifying community agencies to aid in care of their newborn in the event that they elect to continue the pregnancy after fetus is found to be affected, or when diagnosis is made after delivery.
Rationale: Helps to reduce anxieties regarding how the couple will meet their baby’s special needs.

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Nursing Care Plan for Elective Termination

Therapeutic abortion may be done to safeguard the woman’s health, or a voluntary abortion may be a woman’s reproductive decision.

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: Risk for Decisional Conflict may be related to 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.

Desired Outcomes
1. Acknowledge feelings of anxiety/distress related to making difficult decision.
2. Verbalize confidence in the decision to terminate the pregnancy.
3. Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.
4. Display relaxed manner and/or calm demeanor, free of physical signs of distress.

Nursing care plan intervention with rationale:
1. Ascertain circumstances of conception and response of family/significant other. Encourage client to talk about the issues and process used to problem-solve and make decision regarding termination.
Rationale: Allows the nurse to determine whether the client/couple has explored alternatives. The decision to terminate a pregnancy may have been based on an inability to problem-solve or a lack of support and resources.

2. Note expressions of indecision and dependence on others.
Rationale: May indicate ambivalence about decision and need for further information and discussion.

3. Assist client to look at alternatives and use problem-solving process to validate decision. Involve significant others as appropriate.
Rationale: Helps client to reinforce reasons for decision and to be comfortable that this is the course she wants to pursue.

4. Provide explanations about the procedure desired by the client, pre-procedural and post-procedural tests, examinations, and follow-up.
Rationale: Lack of knowledge about the procedures, reproduction, or self-care may contribute to the 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.

5. Evaluate the influence of family and significant other(s) on the client.
Rationale: Conflict can arise within the client herself as well as within the family. Allows the nurse to encourage positive forces or provide support where it is lacking.

6. Remain with the client during examinations and the procedure. Provide both physical and emotional support.
Rationale: Physical presence of nurse can help client feel accepted and reduce stress.

7. Act as a liaison and lend support to significant other(s).
Rationale: Helps reduce stress and encourages significant other(s) to be supportive of the client.

8. Review safe options available based on gestation.
Rationale: Assists client in making informed decision.

9. Obtain/review informed consent.
Rationale: Depends on agency guidelines. No procedure should be performed unless the client freely consents to it.

10. Refer for additional counseling or resources, if needed.
Some clients may be more affected by the decision and may require additional support and/or education or genetic counseling.

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Nursing Care Plan for Postpartum Hemorrhage

Postpartal hemorrhage is usually defined as the loss of more than 500 ml of blood during or after delivery. It is one of the leading causes of maternal mortality. Hemorrhage may occur early, within the first 24 hr after delivery, or late, up to 28 days postpartum (the end of the puerperium).

NURSING PRIORITIES
1. Maintain or restore circulating volume/tissue perfusion.
2. Prevent complications.
3. Provide information and appropriate support for client/couple.
4. Have plan in place to meet needs after discharge.

DISCHARGE GOALS
1. Tissue perfusion/organ function WNL
2. Complications prevented/resolving
3. Clinical situation and treatment needs understood

Nursing diagnosis for postpartal hemorrhage: Fluid volume deficit may be related to excessive vascular loss possibly evidenced by hypotension, tachycardia, changes in mentation, decreased/concentrated urine, dry skin/mucous membranes, delayed capillary refill.

Desired Outcome: Demonstrate stabilization/improvement in fluid balance as evidenced by stable vital signs, prompt capillary refill, appropriate sensorium, and individually adequate urine output and specific gravity.

Nursing intervention and rationale
1. Review records of pregnancy and labor/delivery, noting causative factors or those contributing to hemorrhagic situation (e.g., lacerations, retained placental fragments, sepsis, abruptio placentae, amniotic fluid emboli, or retention of dead fetus for more than 5 wk).
Rationale: Aids in establishing appropriate plan of care and provides opportunity to prevent or limit developing complications. Note: Approximately20% of early postpartal hemorrhage is related to lacerations of the perineum, vagina, or cervix. Late postpartal hemorrhage is usually caused by abnormal involution of the uterus or retained placental fragments.

2. Assess and record amount, type, and site of bleeding; weigh and count pads; save clots and tissue for evaluation by physician.
Rationale: Estimate of blood loss, venous versus arterial, and presence of clots helps to make a differential diagnosis and determines replacement needs. Note: One gram of increased pad weight is equal to approximately 1 ml of blood loss. Blood losses of more than 1000 ml lead to shock state and increase risk of other complications, e.g., infection, extensive pelvic thrombophlebitis.

3.Assess location of uterus and degree of uterine contractility. Massage boggy uterus with one hand while placing second hand just above the symphysis pubis.
Rationale: Degree of uterine contractility aids in differential diagnosis. Increasing myometrial contractility may decrease blood loss. Placing one hand above symphysis pubis prevents possible uterine inversion
during massage.

4. Note presence of vulvar hematoma; apply ice pack as indicated and observe periodically.
Rationale: Small hematomas may be controlled by ice and rest.

5.Monitor BP, pulse; observe capillary refill, nail beds, and mucous membranes.
Rationale: Hypotension, tachycardia, delayed capillary refill; cyanosis of nail beds, mucous membranes, and lips reflects severe hypovolemia and developing shock. Changes in BP are not detectable until fluid volume has decreased by 30%–50%. Cyanosis is a late sign of
hypoxia. Note: Reports of fatigue, headache, thirst, presence of pallor, orthostatic hypotension may be signs of slow moderate blood loss that may be reported during follow-up visit.

6. Measure hemodynamic parameters, such as central venous pressure (CVP) or pulmonary artery wedge pressure (PAWP), if available.
Rationale: Provides more direct measurement of circulating volume, replacement needs, and response to therapy in severe/life-threatening situations.

7.Institute bedrest with legs elevated 20–30 degrees and trunk horizontal.
Rationale: Bleeding may decrease or cease with reduction in activity. Proper positioning increases venous return, ensuring greater availability of blood to brain and other vital organs.

8. Maintain nothing-by-mouth (NPO) regimen while determining client status/needs.
Rationale: Prevents aspiration of gastric contents in the event that sensorium is altered and/or surgical intervention is required.

9.Measure intake and output, and urine specific gravity, as indicated. Investigate reports of difficulty voiding/emptying bladder.
Rationale: Useful in estimating extent/significance of fluid loss. Adequate perfusion/circulating volume is reflected by output 30–50 ml/hr or greater. Note: Difficulty voiding may occur with hematomas in the upper portion of the vagina causing pressure on the urethra or meatus.

10. Monitor clients with placenta accreta (slight penetration of myometrium by placental tissue), PIH, or abruptio placentae for signs of DIC.
Rationale: Thromboplastin released during attempts at manual removal of the placenta may result in coagulopathy as manifested by continued vaginal bleeding; expistaxis; oozing from incisions, mucous membranes, gums, IV site.

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Nursing Care Plan for Postpartum Thrombophlebitis

Superficial thrombophlebitis is seen more often during the postpartal period than during pregnancy and is more common in women with preexisting varices. Postpartal deep vein thrombosis (DVT) and superficial thrombophlebitis have been attributed to trauma to pelvic veins from pressure of the presenting fetal part, sluggish circulation caused by mechanical edema, and alterations in coagulation related to the large amounts of estrogens produced during pregnancy. Thrombosis that involves only the superficial veins of the leg or thigh is unlikely to generate pulmonary emboli (PE). While approximately 50% of clients with DVT are asymptomatic, DVT is more serious in terms of potential complications, including PE, postphlebotic syndrome, chronic venous insufficiency, and vein valve destruction.

NURSING PRIORITIES
1. Maintain/enhance tissue perfusion, facilitate resolution of thrombus.
2. Promote optimal comfort.
3. Prevent complications.
4. Provide information and emotional support.

DISCHARGE GOALS
1. Tissue perfusion improved in affected limb/area
2. Pain/discomfort relieved
3. Complications prevented/resolved
4. Disease process/prognosis and therapeutic needs understood
5. Plan in place to meet needs after discharge

Nursing diagnosis for postpartum thrombophlebitis: altered peripheral tissue perfusion may be related to interruption of venous flow possibly evidenced by edema of affected extremity; erythema (superficial thrombophlebitis) or pallor and coolness (DVT), diminished peripheral pulses, pain.

Desired Outcomes:
1. Demonstrate improved circulation of involved extremity with palpable peripheral pulses of good quality, timely capillary refill, and decreased edema and erythema.
2. Engage in behaviors/activities to enhance tissue perfusion.
3. Display increasing tolerance to activity.

Nursing intervention with rationale:
1. Encourage bedrest with elevation of feet and lower legs 6 in above heart level during acute phase.
Rationale: Minimizes the possibility of dislodging thrombus and creating emboli. Rapidly empties superficial and tibial veins and keeps veins collapsed, thereby increasing venous return. Note: Caution is required in presence of leg ischemia.

2. Evaluate neurological function of extremity (both sensory and motor). Observe extremity for color; inspect from groin to foot for edema. Note asymmetry; measure and record calf/thigh circumference of both legs as appropriate. Report proximal progression of inflammation, traveling pain.
Rationale: Symptoms help distinguish between superficial thrombophlebitis and DVT. Redness, heat,tenderness, and localized edema are characteristic of superficial involvement. Pallor and coolness of extremity are more characteristic of DVT. Calf vein involvement of DVT is usually associated with absence of edema; mild to moderate edema suggests femoral vein involvement, and severe edema is characteristic of ileofemoral vein thrombosis.

3.Assess capillary refill, and check for Homans’ sign.
Rationale: Diminished capillary refill usually present in DVT. Positive Homans’ sign (deep calf pain in affected leg upon dorsiflexion of foot) is not as consistent a clinical manifestation as once thought and may or may not be present.

4. Instruct client to elevate legs when in bed or chair, as indicated. Periodically elevate feet and legs above heart level.
Rationale: Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing overdistension and, thereby, increasing venous return. Note: Some physicians believe that elevation may potentiate release of thrombus, thus increasing risk of embolization and decreasing circulation to the most distal portion of the extremity.

5. Caution client not to cross legs or wear constrictive clothing.
Rationale: Physical restriction of circulation impairs blood flow, thus increasing venous stasis, pain, and trauma.

6. Instruct client to avoid rubbing and massaging the affected extremity.
Rationale: Prevents fragmentation/dislodging thrombus, which could lead to embolism.

7.Initiate active or passive exercises while in bed (e.g., flex/extend/rotate foot periodically). Assist with gradual resumption of ambulation (e.g., walking 10 min/h) as soon as client is permitted out of bed.
Rationale: These measures are designed to increase venous return from lower extremities and reduce venous stasis, as well as improve general muscletone/strength. They also promote normal organ function and enhance general well-being.

8. Encourage deep-breathing exercises.
Rationale: Produces increased negative pressure in thorax, which assists in emptying large veins.

9. Observe respiratory ease and auscultate lung sounds, noting crackles or friction rub. Investigate reports of chest pain or feelings of anxiety.
Rationale: Pulmonary congestion, sharp substernal chest pain, sudden apprehension, dyspnea, tachypnea, and hemoptysis are indicative of pulmonary emboli, especially in DVT. Note: Client may remain symptom-free and undiagnosed until emboli develop.

10. Recommend increased fluid intake to 2000+ ml/day.
Rationale: Dehydration increases blood viscosity and venous stasis, predisposing to thrombus formation.

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Nursing Care Plan for Precipitous Labor

Rapid progression of labor, lasting less than 3 hr from onset to delivery, and out-of-hospital delivery are
emergency situations that place the client/fetus at increased risk for complications and/or untoward outcomes. The attending nurse may have primary responsibility for the safety of the mother and fetus.

NURSING PRIORITIES
1. Promote maternal and fetal/newborn well-being.
2. Provide a physiologically and psychologically safe experience for client and newborn.
3. Prevent complications.

Nursing diagnosis of precipitous labor: Anxiety may be related to situational crisis, threat to self/fetus, interpersonal transmission possibly evidenced by increased tension; scared, fearful, restless/jittery; sympathetic stimulation.

Desired Outcomes
1. Use breathing and relaxation techniques effectively.
2. Cooperate with necessary preparations for a rapid delivery.
3. Follow directions and/or actively participate in delivery process.

Nursing intervention with rationale
1. Maintain calm, deliberate manner. Offer clear, concise instructions and explanations.
Rationale: An emergency or extremely rapid delivery occurring out of the hospital or in a hospital setting without the presence of a clinician (physician or nurse midwife) can be extremely anxiety-provoking for the client/couple, who had anticipated an orderly progression through labor and delivery. When the actual birth event is not in keeping with their expectations, reactions may include hostility, fear, and disappointment. Composure of nurse reassures client and prevents transmission of undue concern and anxiety.

2. Provide a quiet environment and privacy within parameters of the situation. Position client for optimal comfort.
Rationale: Reduces distractions/discomfort, allowing client to focus attention. May reduce “contagious” anxiety of onlookers in out-of-hospital delivery and support modesty.

3. Encourage partner/support person to remain with client, provide support, and assist as needed.
Rationale: Allowing full participation by a support person enhances self-esteem, furthers cohesion of family unit, reduces anxiety, and provides assistance for the professional.

4. Remain with client. Provide ongoing information regarding labor progress and anticipated delivery.
Rationale: Reduces anxiety, fosters positive coping and cooperation, and reduces fear associated with the unknown.

5. Support appropriate coping/relaxation techniques.
Rationale: Enhances sense of control; optimizes participation in the birth process.

6. Arrange for services of medical/nursing staff as soon as possible. Inform client that help has been requested.
Rationale: The arrival of assistance helps the client/couple to feel less anxious and more secure.

7. Conduct delivery in a calm manner; provide ongoing explanations.
Rationale: Helps client/couple remain calm and cooperate with instructions.

8. Place newborn on maternal abdomen once newborn respirations are established. Allow partner to hold infant.
Rationale: Helps promote bonding and establishes a positive feeling about the experience.

9. Administer sedation as appropriate.
Rationale: May help slow labor progress and allow client to regain control.

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