Nursing Care Plan for Premature Dilation of the Cervix (Incompetent/Dysfunctional Cervix)

Premature dilation of the cervix often occurs in the 4th or 5th mo and is associated with repeated second-trimester spontaneous abortions accounting for 15%–20% of second-trimester pregnancy losses.

NURSING PRIORITIES
1. Evaluate client/fetal status.
2. Assist with efforts to maintain the pregnancy, if possible.
3. Provide emotional support.
4. Provide appropriate instruction/information.

DISCHARGE GOALS
1. Client/fetal condition stable following procedure
2. Uterine contractions absent
3. Therapeutic needs and concerns understood

Nursing diagnosis of incompetent cervix: Anxiety may be related to situational crisis, threat of death/fetal loss possibly evidenced by increased tension, apprehension, feelings of inadequacy, sympathetic stimulation, and repetitive questioning.

Desired Outcomes
1. Verbalize fears and concerns.
2. Report anxiety is reduced to a manageable level. Use individually appropriate coping mechanisms to deal with the short- and long-term outcomes of the situation.

Nursing intervention with rationale:
1. Provide primary nurse, if possible.
Rationale: Facilitates continuity of care and increases client’s/couple’s confidence in care providers.

2. Review obstetric history.
Rationale: The degree of anxiety depends on the nature of the situation, the history of fetal loss, the client’s understanding of the events and proposed interventions, and the client’s coping behaviors, both past and present.

3. Identify client’s perception of the threat represented by this occurrence.
Rationale: The ambiguity of the outcome can aggravate anxiety.

4. Determine availability of support systems and psychological response to event.
Rationale: Establishes data base and plan of care. Degree of negative response and lack of/inadequate support contributes to heightened levels of anxiety, possibly to the point of affecting overall outcome.

5. Assess physiological indicators of anxiety: BP, pulse, respiratory rate, and diaphoresis.
Rationale: Physiological changes in vital signs may have psychological origin.

6. Remain with couple. Explain what is happening and what can be expected. Provide factual information about causes, implications, and proposed treatment.
Rationale: May reduce anxiety by increasing awareness of the circumstance.

7. Provide information on an ongoing basis.
Rationale: Can allay anxiety.

8. Refer to other sources for support or counseling if anxiety is excessive or support systems are inadequate.
Rationale: May aid in long-term adjustment to situation.

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Nursing Care Plan for Cesarean Delivery

Cesarean birth is an alternative to vaginal birth only when the safety of the mother and/or fetus is compromised.


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: Anxiety 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:
1. Verbalize fears for the safety of client and infant.
2. Discuss feelings about cesarean birth.
3. Appear appropriately relaxed.

Nursing interventions and rationale
1. Assess psychological response to event and availability of support system(s).
Rationale: The greater the client perceives the threat, the greater the level of her anxiety.

2. Note cultural influences/expectations.
Rationale: 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).

3. Ascertain whether procedure is planned or unplanned.
Rationale: With unplanned cesarean birth, the client/couple 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.

4. Stay with client, and remain calm. Speak slowly. Convey empathy.
Rationale: Helps to limit interpersonal transmission of anxiety, and demonstrates caring for the client/couple.

5. Reinforce positive aspects of maternal and fetal condition.
Rationale: Focuses on likelihood of successful outcome and helps to bring perceived/actual threat into perspective.

6. Encourage client/couple to verbalize and/or express feelings (cry).
Rationale: Helps to identify negative feelings/concerns and 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.

7. Support/redirect expressed coping mechanisms.
Rationale: 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.

8. Discuss past childbirth experience/expectations, as appropriate.
Rationale: Client may have distorted memories of past delivery or unrealistic perceptions of abnormality of cesarean birth that will increase anxiety.

9. Provide period of privacy, if possible. Reduce environmental stimuli, such as the number of people present, as indicated by client’s desires.
Rationale: Allows client/couple opportunity to internalize information, marshal resources, and cope effectively.

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Nursing Care Plan for Prenatal Hemorrhage

Prenatal Hemorrhage may occur early or late in pregnancy, owing to certain physiological problems, each with its own signs and symptoms, which help in establishing a differential diagnosis and in creating the plan of care. This general guide for care is meant to treat hemorrhage in the antepartal client. Where appropriate, interventions specific to each physiological problem are identified.

NURSING PRIORITIES
1. Determine client/fetal status.
2. Maintain circulating fluid volume.
3. Assist with efforts to sustain the pregnancy, if possible.
4. Prevent complications.
5. Provide emotional support to the client/couple.
6. Provide information about possible short- and long-term implications of the hemorrhage.

DISCHARGE GOALS
1. Homeostasis achieved
2. Pregnancy maintained
3. Free of complications
4. Client/couple dealing constructively with situation
5. Condition, prognosis, and treatment needs understood

Nursing diagnosis of Prenatal Hemorrhage: Fluid Volume deficit may be related to excessive vascular loss possibly evidenced by hypotension, increased pulse rate, decreased pulse pressure, decreased/concentrated urine, decreased venous filling, change in mentation.

Nursing intervention with rationale:
1. Evaluate, report, and record amount and nature of blood loss. Initiate pad count; weigh pads/underpad.
Rationale: Estimation of blood loss helps in differential diagnosis. Each gram of increased pad weight is equal to approximately 1 ml of blood loss.

2. Institute bedrest. Instruct client to avoid maneuver and intercourse or any sexual activity that could lead to orgasm.
Rationale: Valsalva’s Bleeding may stop with a reduction in activity.Increased abdominal pressure or orgasm (which increases uterine activity) may stimulate bleeding.

3. Position client appropriately, either supine with hips elevated or in semi-Fowler’s position for placenta previa. Avoid Trendelenburg position.
Rationale: Ensures adequate blood available to the brain.Elevating hips avoids compression of the vena cava, while semi-Fowler’s position allows the fetus to act as a tampon, controlling bleeding in placenta previa. Trendelenburg position may compromise maternal respiratory status.

4. Note vital signs, capillary refill of nailbeds, color of mucous membranes/skin, and temperature. Measure CVP, if available.
Rationale: Helps determine severity of blood loss, although cyanosis and changes in BP and pulse are late signs of circulatory loss and/or developing shock. Also monitors adequacy of fluid replacement.

5.Monitor uterine activity, fetal status, and any abdominal tenderness.
Rationale: Helps determine nature of the hemorrhage and possible outcome of hemorrhagic episode. Tenderness is usually present in ruptured ectopic pregnancy or abruptio placentae.

6. Ascertain religious practices and preferences.
Rationale: May prohibit use of blood products and establish need for alternative therapy.

7. Avoid rectal or vaginal examination.
Rationale: May increase hemorrhage, especially if marginal or total placenta previa is present.

8. Record intake/output. Obtain hourly urine samples; measure specific gravity.
Rationale: Determines extent of fluid losses and reflects adequacy of renal perfusion.

9. Obtain/review stat blood work: CBC, type and crossmatch, Rh titer, fibrinogen levels, platelet count, APTT, PT, and HCG levels.
Rationale: Determines amount of blood loss and may provide information regarding cause. Hct should be maintained above 30% to support oxygen and nutrient transport.

10. Prepare for cesarean delivery if any of the following are diagnosed: severe abruptio placentae, DIC; or placenta previa when fetus is mature, vaginal delivery is not feasible, and bleeding is excessive or unresolved by bedrest.
Rationale: Hemorrhage stops once the placenta is removed and venous sinuses are closed.

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Nursing Care Plan for Prenatal Substance Dependence/Abuse

Substance Dependence/Abuse is a continuum of phases incorporating a cluster of cognitive, behavioral, and physiological symptoms that include loss of control over use of the substance and continued use of the substance, despite adverse maternal/fetal consequences (e.g., poor nutrition/weight gain, anemia, predisposition to infection, PIH, fetal defects/IUGR, fetal alcohol syndrome [FAS]). The drugs most often abused are alcohol, cocaine (crack), heroin, methamphetamine, barbiturates, marijuana, and phencyclidine (PCP). Care depends on the degree of abuse and whether the client is intoxicated or is in the withdrawal phase. The client who is addicted may not seek care during the prenatal period, compounding any existing or developing problems. In addition, negative attitudes on the part of society and often from caregivers affect the pregnant woman and her care.

A return to health consists of gaining a mastery and control over self and environment, and pleasure seeking that does not require the use of drugs.


NURSING PRIORITIES
1. Promote physiological stability and well-being of client and fetus.
2. Support client’s acceptance of reality of situation.
3. Facilitate learning of new ways to reduce anxiety; strengthen individual coping skills.
4. Incorporate client into supportive community environment.
5. Promote family involvement in treatment process.
6. Provide information about condition, prognosis, and treatment needs.


DISCHARGE GOALS
1. Free of injury/complications to self and fetus/newborn.
2. Engaged in treatment modalities by identifying and using support systems.
3. Responsibility for own life and behavior assumed.
4. Abstinence from drug(s) maintained on a day-to-day basis.
5. Dependence condition and its impact on pregnancy, prognosis, and therapeutic regimen verbalized.
6. Participation in follow-up care by making and keeping all appointments, managing therapeutic regimen.

Nursing diagnosis of Prenatal Substance Dependence/Abuse: Nutrition: altered, less than body requirements may be related to insufficient dietary intake to meet metabolic needs for psychological, physiological, or economic reasons possibly evidenced by low-weight gain, prepregnant weight below norm for height/body build, decreased subcutaneous fat/muscle mass, poor muscle tone, reported altered taste sensation, lack of interest in food; sore, inflamed buccal cavity; laboratory evidence of protein/vitamin deficiencies.

Desired Outcomes:
1. Verbalize understanding of effects of substance abuse and reduced dietary intake on nutritional status and pregnancy.
2. Demonstrate behaviors and lifestyle changes to regain/maintain appropriate weight for pregnancy.

Nursing intervention with rationale:
1. Determine age, height/weight, body build, strength, and activity/rest pattern. Note condition of oral cavity.
Rationale: Provides information on which to base caloric needs/dietary plan. Type of diet/foods may be affected by condition of mucous membranes and teeth.

2. Obtain anthropometric measurements, e.g., triceps skinfold.
Rationale: Calculates subcutaneous fat and muscle mass to aid in determining dietary needs.

3. Note total daily calorie intake. Encourage client to maintain a diary of intake, times, and patterns of eating.
Rationale: Information about patient’s dietary pattern will identify nutritional strengths, needs, and deficiencies.

4. Discuss prenatal nutritional needs and develop dietary plan. Assist with developing a grocery budget and provide opportunity to choose foods or snacks to meet dietary plan.
Rationale: Enhances participation/sense of control and may promote resolution of nutritional deficiencies.

5. Evaluate energy expenditure (e.g., pregnancy needs, pacing or sedentary activities), and establish an individualized exercise program.
Rationale: Pregnant state and activity level affect nutritional needs. Exercise enhances muscle tone, may stimulate appetite, and promotes sense of well-being.

6. Weigh client weekly and record.
Rationale: Provides information regarding current status/effectiveness of dietary plan.

7. Consult with dietitian.
Rationale: Useful in establishing individual dietary needs/plan. Provides additional resource for learning about the importance of nutrition in nonpregnant and pregnant states.

8. Review laboratory work as indicated; e.g., glucose, serum albumin, and electrolytes.
Rationale: Identifies anemias, electrolyte imbalances, and other abnormalities that may be present, requiring specific therapy. Note: Toxic vapor abuse of toluenebased solvents (such as spray paint or glue) may cause a distal renal tubular acidosis with resultant hypokalemia, hypophosphatemia, hypomagnesemia, and hypocalcemia as well as rhabdomyolysis.

9. Refer for dental consultation as necessary.
Rationale: Teeth are essential to good nutritional intake, and dental hygiene/care is often neglected in this population.

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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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Nursing Care Plan for Adjustment Disorders

The essential feature of adjustment disorders is a maladaptive reaction to an identifiable psychosocial stressor that occurs within 3 months of the onset of the stressor. (The reaction to the death of a loved one is not included here, as it is generally diagnosed as bereavement.) The stressor also does not meet the criteria for any specific Axis I disorder or represent an exacerbation of a preexisting Axis I or Axis II disorder. The response is considered maladaptive because social or occupational functioning is impaired or because the behaviors are exaggerated beyond the usual expected response to such a stressor. Duration of the symptoms for more than 6 months indicates a chronic state. By definition, an adjustment disorder must resolve within 6 months of the termination of the stressor or its consequences. If the stressor/consequences persist (e.g., a chronic disabling medical condition, emotional difficulties following a divorce, financial reversals resulting from termination of employment, or a developmental event such as leaving one’s parental home, retirement), the adjustment disorder may also persist.


DSM-IV ADJUSTMENT DISORDERS (SPECIFY IF ACUTE/CHRONIC)
309.24 With anxiety
309.0 With depressed mood
309.3 With disturbance of conduct
309.4 With mixed disturbance of emotions and conduct
309.28 With mixed anxiety and depressed mood

ETIOLOGICAL THEORIES
Psychodynamics
Factors implicated in the predisposition to this disorder include unmet dependency needs, fixation in an earlier level of development, and underdeveloped ego.

The client with predisposition to adjustment disorder is seen as having an inability to complete the grieving process in response to a painful life change. The presumed cause of this inability to adapt is believed to be psychic overload—a level of intrapsychic strain exceeding the individual’s ability to cope. Normal functioning is disrupted, and psychological or somatic symptoms occur.

Biological
The presence of chronic disorders is thought to limit an individual’s general adaptive capacity. The normal process of adaptation to stressful life experiences is impaired, causing increased vulnerability to adjustment disorders. A high family incidence suggests a possible hereditary influence.

The autonomic nervous system discharge that occurs in response to a frightening impulse and/or emotion is mediated by the limbic system, resulting in the peripheral effects of the autonomic nervous system seen in the presence of anxiety.

Some medical conditions have been associated with anxiety and panic disorders, such as abnormalities in the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-thyroid axes; acute myocardial infarction; pheochromocytomas; substance intoxication and withdrawal; hypoglycemia; caffeine intoxication; mitral valve prolapse; and complex partial seizures.

Family Dynamics
The individual’s ability to respond to stress is influenced by the role of the primary caregiver (her or his ability to adapt to the infant’s needs) and the child-rearing environment (allowing the child gradually to gain independence and control over own life). Difficulty allowing the child to become independent leads to the child having adjustment problems in later life.

Individuals with adjustment difficulties have experienced negative learning through inadequate role-modeling in dysfunctional family systems. These dysfunctional patterns impede the development of self-esteem and adequate coping skills, which also contribute to maladaptive adjustment
responses.

NURSING PRIORITIES
1. Provide safe environment/protect client from self-harm.
2. Assist client to identify precipitating stressor.
3. Promote development of effective problem-solving techniques.
4. Provide information and support for necessary lifestyle changes.
5. Promote involvement of client/family in therapy process/planning for the future.

DISCHARGE GOALS
1. Relief from feelings of depression and/or anxiety noted, with suicidal ideation reduced.
2. Anger expressed in an appropriate manner.
3. Maladaptive behaviors recognized and rechanneled into socially accepted actions.
4. Client involved in social situations/interacting with others.
5. Ability and willingness to manage life situations displayed.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for Adjustment Disorder: Anxiety may be related to situational/maturational crisis; threat to self-concept; threat (or perceived threat) to physical integrity; unmet needs; fear of failure; dysfunctional family system; unsatisfactory parent/child relationship resulting in feelings of insecurity; fixation in earlier level of development possibly evidenced by overexcitement/restlessness; increased tension; insomnia; feelings of inadequacy; fear of unspecified consequences; poor eye contact, focus on self; difficulty concentrating; continuous attention-seeking behaviors; selective inattention; sympathetic stimulation; numerous physical complaints.

Desired Outcomes:

1. Verbalize awareness of feelings of/indicators of increasing anxiety.
2. Demonstrate/use appropriate techniques to interrupt escalation of anxiety.
3. Appear relaxed and report anxiety is reduced to a manageable level.

Nursing intervention with rationale:
1. Establish a therapeutic nurse/client relationship. Be honest, consistent in responses, and available. Show genuine positive regard.
Rationale: Honesty, availability, and unconditional acceptance promote trust, which is necessary for the development of a therapeutic relationship.

2. Provide activities geared toward reduction of tension and decreasing anxiety (e.g., walking or jogging, musical exercises, housekeeping chores, group games/activities).
Rationale: Tension and anxiety can be released safely, and physical activity may provide emotional benefit to the client through release in the brain of morphine like substances (endorphins) that promote sense of well-being.

3. Encourage client to identify true feelings and to acknowledge ownership of those feelings.
Rationale: Anxious clients often deny a relationship between emotional problems and their anxiety. Use of the defense mechanisms of projection and displacement are exaggerated.

4. Maintain a calm atmosphere and approach to client.
Rationale: Can help to limit transmission of anxiety to/from client.

5. Assist client to recognize specific events that precede onset of elevation in anxiety. Provide information about signs and symptoms of increasing anxiety and ways to intervene before behaviors become disabling.
Rationale: Recognition of precipitating stressors and a plan of action to follow should they recur provides client with feelings of security and control over similar situations in the future. This in itself may help to control anxiety response.

6. Offer support during times of elevated anxiety. Provide physical and psychological safety.
Presence of a trusted individual may provide needed security/client safety.

7. Administer medications as necessary, e.g., benzodiazepines: alprazolam (Xanax).
Rationale: Antianxiety medications induce a calming effect and work to maintain anxiety at a manageable level while providing the opportunity for client to develop other ways to manage stress.

Other NANDA diagnosis of Adjustment Disorder: VIOLENCE, risk for, directed at self/others; COPING, INDIVIDUAL, ineffective; ADJUSTMENT, impaired [when stressor is a change in health status]; GRIEVING, dysfunctional; HOPELESSNESS; SELF ESTEEM disturbance; SOCIAL INTERACTION, impaired; FAMILY PROCESSES, altered

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