Nursing Care Plan for Puerperal Infection

Puerperal infection is an infection of the reproductive tract occurring within 28 days following childbirth or
abortion. It is one of the major causes of maternal death (ranking second behind postpartal hemorrhage) and includes localized infectious processes as well as more progressive processes that may result in endometritis/metritis (inflammation of endometrium), peritonitis, or parametritis/pelvic cellulitis (infection of connective tissue of broad ligament and possibly connective tissue of all pelvic structures).


NURSING PRIORITIES
1. Control spread of infection.
2. Promote healing.
3. Support ongoing process of family acquaintance.

DISCHARGE GOALS
1. Infection resolving
2. Involution progressing, sense of well-being expressed
3. Attachment/bonding demonstrated and care of infant resumed

Nursing diagnosis for Puerperal Infection: Infection may be related to presence of infection, broken skin and/or traumatized tissues, high vascularity of involved area, invasive procedures and/or increased environmental exposure, chronic disease (e.g., diabetes), anemia, malnutrition, immunosuppression and/or untoward effect of medication (e.g., opportunistic/secondary infections)

Desired Outcomes
1. Verbalize understanding of individual causative risk factors.
2. Initiate behaviors to limit spread of infection, as appropriate, and reduce risk of complications.
3. Achieve timely healing, free of additional complications.

Nursing intervention with rationale
1. Review prenatal, intrapartal, and postpartal record.
Rationale: Identifies factors that place client in high-risk category for development/spread of postpartal infection.

2. Demonstrate and maintain strict hand-washing policy for staff, client, and visitors.
Rationale: Helps prevent cross-contamination.

3. Provide for, and instruct client in, proper disposal of contaminated linens, dressings, chux, and peripads. Initiate/maintain isolation, if indicated.
Rationale: Prevents spread of infection.

4. Demonstrate/encourage correct perineal cleaning after voiding and defecation, and frequent changing of peripads.
Rationale: Cleaning removes urinary/fecal contaminants. Changing pad removes moist medium that favors bacterial growth.

5. Demonstrate proper fundal massage. Review importance and timing of procedure.
Rationale: Enhances uterine contractility; promotes involution and passage of any retained placental fragments.

6. Monitor temperature, pulse, and respirations. Note presence of chills or reports of anorexia or malaise.
Rationale: Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status. Note: Persistent fever unresponsive to antibiotic therapy may indicate pelvic thrombophlebitis.

7. Observe perineum/incision for other signs of infection (e.g., redness, edema, ecchymosis, discharge and approximation [REEDA scale]). Note subinvolution of uterus, extreme uterine tenderness.
Rationale: Allows early identification and treatment; promotes resolution of infection. Note: Although localized infections are usually not severe, occasional progression to necrotizing fasculitis can be life-threatening.

8. Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid per day. Note urine output, degree of hydration, and presence of nausea, vomiting, or diarrhea.
Rationale: Increased intake replaces losses and enhances circulating volume, preventing dehydration and aiding in fever reduction.

9. Encourage application of moist heat in the form of sitz baths and of dry heat in the form of perineal lights for 15 min 2–4 times daily.
Rationale: Water promotes cleansing. Heat dilates perineal blood vessels, increasing localized blood flow and promotes healing.

10. Arrange for transfer to intensive care setting as appropriate.
Rationale: May be necessary for client with severe infection (e.g., peritonitis, sepsis) or pulmonary emboli to provide appropriate care leading to optimal recovery.

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Nursing Care Plan for Child with Special Needs

The birth of a child with special needs, regardless of whether the condition is temporary or permanent, creates unique concerns for the family, who mourns the loss of a normal, healthy child. Conditions range from prematurity, growth deviations, and infections to gross anomalies. Although each case is individual and varies in degree of involvement, many similarities are observed in the parents’ responses to their child.

NURSING PRIORITIES
1. Facilitate grieving and positive coping.
2. Provide appropriate information related to short- and long-term implications of child’s illness or anomaly.
3. Facilitate learning of parenting role and participation in infant care tasks.

DISCHARGE CRITERIA
1. Demonstrate progress in dealing with grief at own pace.
2. Display appropriate attachment/bonding behaviors.
3. Participate in infant care; develop mastery of therapeutic regimen.
4. Have plan in place to meet needs after discharge.

Nursing diagnosis: Grieving may be related to perceived loss of the perfect child/ pregnancy/delivery, alterations of future expectations possibly evidenced by expression of distress at loss, sorrow, guilt, anger; choked feelings; reliving of pregnancy events; interference with life activities; crying.

Nursing intervention with rationale:
1. Promote trusting relationship with parents and significant other(s). Encourage verbalization of feelings through listening and an unhurried attitude.
Rationale: Facilitates sharing of feelings, fears, and concerns. Helps parents to focus on reality of the situation and examine their emotional responses. Grieving for the loss of the perfect child must be completed before parents can establish a positive relationship with their offspring. Staff needs to remain available, even if client seems self-sufficient or withdrawn.

2. Facilitate the grief process, even if the newborn’s independent of the severity/permanency of the infant’s problem.
Rationale: The amount of grief the parents experience is problem is temporary or surgically correctable.

3. Determine parents’ religious orientation, and contact appropriate support, if they desire it.
Rationale: Many couples lean heavily on their faith as a source of strength during crisis resolution. Note: Perception of situation/condition and individual’s response will also be affected by religious beliefs.

4. Assess for usual grieving responses (e.g., initial shock, disbelief, and denial, then anger, guilt, sadness, and negative self-evaluation/questioning, followed by acceptance) based on cultural/religious practices. Let parents know that these responses are normal.
Rationale: Grief is the anticipated, healthy emotional response to the profound experience of giving birth to a special needs child, and it involves mourning the loss of the idealized perfect newborn.

5. Note the stage of grief being expressed. Discuss the individual nature of movement through the stages of grief; let parents know that delays in the grief process or relapses of grief are normal.
Rationale: The process of grieving is not usually a fluid progression through the stages to resolution; more often the individual fluctuates between the stages, possibly skipping one or more. Understanding that grieving is individual helps the couple let each other grieve at her or his own pace.

6. Accept use of defense mechanisms (e.g., denial, anger, or silence). Encourage expression of angry feelings, setting limits on unacceptable acting-out behavior.
Rationale: Use of defense mechanisms at this time may be the best way for parents to deal productively with the situation. However, continued use of defense mechanisms may impair resolution of grief. In addition, preventing destructive behavior is important to the maintenance of the client’s selfesteem.

7. Provide information about extreme mood swings, which may be hormonally induced in the postpartal period.
Rationale: Usual hormonal adjustments of postpartal period can trigger labile responses and may require further evaluation/treatment.

8. Ask parents what helps them most in dealing with the affected child. Observe nonverbal signals, such as anguished tone of voice, looking down, or crying.
Rationale: Parents may have a hard time handling the crisis and may have difficulty identifying means of facilitating coping.

9. Evaluate parents for abnormal grief responses, such as inappropriate humor; lack of interest in infant; continued denial of, or failure to recognize, infant’s problem; poor eye contact; continual crying, excessive or vague complaints; inability to carry out self-care activities; or use of distancing in interactions with child (e.g., holding child at arm’s length instead of cuddling).
Rationale: Inappropriate initial responses may result in long term emotional dysfunction and lack of resolution
of grief. Thus, the grief process may be left open ended, and the parents’ unresolved feelings continually resurface. Early identification of problems and prompt intervention facilitates individual growth and coping abilities. Note: Parents may be afraid of becoming emotionally attached if they believe that the child might die.

10. Refer for appropriate individual or family counseling.
Rationale: Counseling may be necessary for resolution of grief and maintenance of family unity.

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Nursing Care Plan for Teen Pregnancy

Statistics for 1995 reveal that 56.9 babies were born for every 1000 females between the ages of 15 and 19. Although these rates appear to be dropping, pregnant adolescents are at risk physically, emotionally, and socially. The impact of adolescent pregnancy on the individual has far-reaching consequences, which may restrict or limit future opportunities for the adolescent and the child(ren). Educational goals may be altered or eliminated, thus limiting potential for a productive life. The client frequently may be of lower socioeconomic status, with the pregnancy perpetuating financial dependence and lowered self-esteem. Statistically, the obstetric hazards for adolescents and their infants include increased mortality and morbidity rates. Therefore, individualized prenatal nursing care for the adolescent client/family/partner that incorporates developmental needs and health education with prenatal needs has the potential to contribute positively to prenatal, intrapartal, and postpartal outcomes. In addition, neonatal outcomes associated with better Apgar scores, lower incidence of resuscitation, and fewer LBW infants can also be expected.


NURSING PRIORITIES
1. Promote optimal physical/emotional well-being of client.
2. Monitor fetal well-being.
3. Provide information and review the available options.
4. Facilitate positive adaptation to new and changing roles.
5. Encourage family/partner participation in problem-solving.

DISCHARGE GOALS
Inpatient care is not required unless complications develop necessitating hospitalization (refer to appropriate plans of care.)

Nursing diagnosis of teen pregnancy: Body Image disturbance/Role Performance, altered/Personal Identity disturbance/Self Esteem (specify) may be related to situational and maturational crises, fear of failure at life events, biophysical changes, absence of support systems possibly evidenced by self-negating verbalizations, expressions of shame/guilt, hypersensitivity to criticism, fear of rejection, lack of follow-through and/or nonparticipation in care.

Desired Outcomes:
1. Identify feelings and methods for coping with negative perception of self/abilities.
2. Verbalize increased sense of self-esteem in relation to current situation.
3. Demonstrate adaptation to changes/events as evidenced by setting of realistic goals and active participation in meeting own needs.

Nursing intervention with rationale:
1. Establish a therapeutic nurse-client relationship.
Rationale: Adolescent client needs a caring, nonjudgmental adult with whom to talk. Important to establish trust and cooperation so that the client is free to hear the information available.

2. Assess use of terms/language used by the client/significant other(s).
Rationale: Terminology may be specific to the adolescent culture, and words may have different meanings for client and nurse.

3. Determine developmental level and needs relative to age as early, middle, or late adolescence.
Rationale: Cognitive development during this period moves from concrete to abstract thinking (formal operations). The younger client may see control of the situation as external and beyond her grasp, and have little ability to understand the consequences of her behavior. With maturity, the abilities to understand possible consequences and to accept individual responsibility develop.

4. Identify client’s self-perception as positive or negative.
Rationale: Helps client become aware of how she views herself and to begin to increase her self-esteem. Until late adolescence, body image is still formative. The client is dealing with adolescent developmental tasks, establishing an adult identity. Low self-worth may lead to feelings of hopelessness about the future and inability to visualize a successful outcome.

5. Elicit the client’s feelings about sexual identity/roles.
Rationale: May have difficulty seeing herself as a mother. The adolescent must make a role transition from child/daughter to adult/mother, which can create conflicts for the client and significant other(s).

6. Discuss concerns and fears about body image and transitory changes associated with pregnancy; discuss personal value system.
Rationale: Establishes a basis for future learning. Conflicts may exist regarding how client has previously seen herself, what her expectations of pregnancy had been, and what the realities of pregnancy are. By midpregnancy, the enlarging abdomen and the increasing size of breasts and buttocks may prompt the teenager to try to control her appearance by dieting, with adverse consequences for fetal health and her own growth needs.

7. Discuss ways to promote positive self-image (e.g., clothing style, makeup) and recognition of positive aspects of the situation.
Rationale: Assists in coping with changes in appearance and presenting a positive image.

8. Discuss appropriate adaptation techniques and the communication skills to implement these techniques.
Rationale: Role playing and active listening can be used to learn skills of communication and adaptation. Helps client learn information necessary to development of improved self-esteem.

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Nursing Care Plan for Stage III of Labor Placental Expulsion

Stage III of labor begins with the birth of the baby and is completed with placental separation and expulsion. Lasting anywhere from 1–30 min, with an average length of 3–4 min in the nullipara, and 4–5 min in the multipara, this stage is the shortest. Careful management and monitoring are necessary, however, to prevent short- and long term negative outcomes.

NURSING PRIORITIES
1. Promote uterine contractility.
2. Maintain circulating fluid volume.
3. Promote maternal and newborn safety.
4. Support parental-infant interaction.

Nursing diagnosis of Placental Expulsion: Risk for Fluid Volume Deficit may be related to lack/restriction of oral intake, vomiting, diaphoresis, increased insensible water loss, uterine atony, lacerations of the birth canal, retained placental fragments

Desired Outcomes:
1. Display BP and heart rate WNL, palpable pulses.
2. Demonstrate adequate contraction of the uterus with blood loss WNL.

Nursing intervention with rationale:
1. Instruct the client to push with contractions; help direct her attention toward bearing down.
Rationale: Client attention is naturally on the newborn; in addition, fatigue may affect individual efforts, and she may need help in directing her efforts toward assisting with placental separation. Bearing down helps promote separation and expulsion, reduces blood loss, and enhances uterine contraction.

2. Assess vital signs before and after administering oxytocin.
Rationale: Hypertension is a frequent side effect of oxytocin.

3. Palpate uterus; note “ballooning.”
Rationale: Suggests uterine relaxation with bleeding into uterine cavity.

4. Monitor for signs and symptoms of excess fluid loss or shock (i.e., check BP, pulse, sensorium, skin color, and temperature). (Refer to CP: Postpartal Hemorrhage.)
Rationale: Hemorrhage associated with fluid loss greater than 500 ml may be manifested by increased pulse, decreased BP, cyanosis, disorientation, irritability,

5. Place infant at client’s breast if she plans to breastfeed.
Rationale: Suckling stimulates release of oxytocin from the posterior pituitary, promoting myometrial contraction and reducing blood loss.

6. Massage uterus gently after placental explusion.
Rationale: Myometrium contracts in response to gentle tactile stimulation, thereby reducing lochial flow and expressing blood clots.

7. Record time and mechanism of placental separation; i.e., Duncan’s mechanism (placenta separates from the inside to outer margins) versus Schulze’s mechanism (placenta separates from outer margins inward).
Rationale: Separation should occur within 5 min after birth. The Duncan’s mechanism of separation carries increased risk of retained fragments, necessitating close inspection of the placenta. Failure to separate may require manual removal. The more time it takes for the placenta to separate, and the more time in which the myometrium remains relaxed, the greater the blood loss.

8. Inspect maternal and fetal surfaces of placenta. Note size, cord insertion, intactness, vascular changes associated with aging, and calcification (which possibly contributes to abruption).
Rationale: Helps detect abnormalities that may have an impact on maternal or newborn status.

9. Administer oxytocin (Pitocin) through IM route, or dilute IV drip in electrolyte solution, as indicated. IM methylergonovine maleate (Methergine) or prostaglandins may be given at the same time.
Rationale: Promotes vasoconstrictive effect within the uterus to control postpartal bleeding after placental explusion. IV bolus may result in maternal hypertension. Water intoxication may occur if electrolyte-free solution is used. Note: Methergine is contraindicated in presence of hypertension/ hypotension.

10. Elevate fundus by dipping fingers down behind and moving uterine body up away from symphysis pubis.
Rationale: May be requested by practitioner to facilitate internal examination.

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Nursing Care Plan for Anorexia Nervosa

Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a
morbid fear of obesity. Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating, followed by self-induced vomiting. It may include abuse of laxatives and diuretics. Binge-eating is defined as recurrent episodes of overeating associated with subjective and behavioral indicators of impaired control over and significant distress about the eating behavior but without the use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise).

DSM-IV
307.1 Anoxexia nervosa
307.51 Bulimia nervosa
307.50 Eating disorders NOS
Binge-eating disorder (proposed, requiring further study)

ETIOLOGICAL THEORIES
Psychodynamics
The individual reflects a developmental arrest in the very early childhood years. The tasks of trust, autonomy, and separation-individuation are unfulfilled, and the individual remains in the dependent position. Ego development is retarded. Symptoms are often associated with a perceived loss of control in some aspect of life and may center on fears of sexual maturity/intimacy. Although these disorders affect women primarily, approximately 5% to 10% of those afflicted are men. Additionally, eating disorders are often associated with depression, anxiety, phobias, and cognitive problems.

Biological
These disorders may be caused by neuroendocrine abnormalities within the hypothalamus. Symptoms are linked to various chemical disturbances normally regulated by the hypothalamus. Furthermore, a physiological defect may make it difficult for the individual to interpret sensations of hunger and fullness.

Family Dynamics
Issues of control become the overriding factors in the family of the client with an eating disorder. These families often consist of a passive father, a domineering mother, and an overly dependent child. There is a high value placed on perfectionism in this family, and the child believes she or he must please others and satisfy these standards.

NURSING PRIORITIES
1. Reestablish adequate/appropriate nutritional intake.
2. Correct fluid and electrolyte imbalance.
3. Assist client to develop realistic body image/improve self-esteem.
4. Provide support/involve SO, if available, in treatment program to client/SO.
5. Coordinate total treatment program with other disciplines.
6. Provide information about disease, prognosis, and treatment.

DISCHARGE GOALS
1. Adequate nutrition and fluid intake maintained.
2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
4. Self-esteem increased.
5. Disease process, prognosis, and treatment regimen understood.
6. Plan in place to meet needs after discharge.

Nursing diagnosis of Anorexia Nervosa and Bulimia Nervosa: NUTRITION: altered, less than body requirements may be related to inadequate food intake; self-induced vomiting and chronic/excessive laxative use possibly evidenced by body weight 15% (or more) below expected (anorexia), or may be within normal range (bulimia, binge-eating), pale conjunctiva and mucous membranes; poor skin turgor/muscle tone, edema, excessive loss of hair; increased growth of body hair (lanugo), amenorrhea, hypothermia, bradycardia, cardiac irregularities, hypotension, electrolyte imbalances.

Desired Outcome:
1. Verbalize understanding of nutritional needs.
2. Establish a dietary pattern with caloric intake adequate to regain/maintain appropriate weight.
3. Demonstrate weight gain toward expected goal range.

Nursing intervention with rationale:
1. Establish a minimum weight goal and daily nutritional requirements.
Rationale: Malnutrition is a mood-altering condition leading to depression and agitation and affecting cognitive functioning/decision-making. Improved nutritional status enhances thinking ability, and psychological work can begin.

2. Involve client with team in setting up/carrying out program of behavior modification. Provide reward for weight gain as individually determined; ignore loss.
Rationale: Provides structured eating stimulation while allowing client some control in choices. Behavior modification may be effective only in mild cases or for short-term weight gain. Note: Combination of cognitive-behavioral approach is preferred for treating bulimia.

3. Use a consistent approach. Sit with client while eating; present and remove food without persuasion and/or comment. Promote pleasant environment and record intake.
Rationale: Client detects urgency and reacts to pressure. Any comment that might be seen as coercion provides focus on food. When staff member responds consistently, client can begin to trust her or his responses. The single area in which client has exercised power and control is food/eating, and she or he may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with client and avoid manipulative games.

4. Provide smaller meals and supplemental snacks, as appropriate.
Rationale: Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Note: Client may feel bloated for 3–6 weeks while body readjusts to food intake.

5. Make selective menu available and allow client to control choices, as much as possible.
Rationale: Client who gains self-confidence and feels in control of environment is more likely to eat preferred foods.

6. Be alert to choices of low-calorie foods/beverages; hoarding food; disposing of food in various places such as pockets or wastebaskets.
Rationale: Client will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.

7. Maintain a regular weighing schedule, such as Monday/Friday before breakfast in same attire, on same scale, and graph results.
Rationale: Provides accurate ongoing record of weight loss/gain. Also diminishes obsessing about changes in weight.

8. Weigh with back to scale (depending on program protocols).
Rationale: Although some programs prefer client to see the results of weighing, this approach can force the issue of trust in client who usually does not trust others.

9. Consult with dietitian/nutritional therapy team.
Rationale: Helpful in determining individual dietary needs and appropriate sources. Note: Insufficient calorie and protein intake can lower resistance to infection and cause constipation, hallucinations, and liver damage.

10. Transfer to acute medical setting for nutritional therapy, when condition is life-threatening.
Rationale: The underlying problem cannot be cured without improved nutritional status. Hospitalization provides a controlled environment in which food intake, vomiting/elimination, medications, and activities can be monitored. It also separates the client from SO(s) and provides exposure to others with the same problem, creating an atmosphere for sharing.

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