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Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf | |
MATERNAL-INFANT NURSING CARE PLANS Karla L. Luxner RNC, MSN I- THOMSON LEARNING Africa Australia Canada Denmark Japan Mexico New Zealand Philippines Puerto Rico Singapore Spain United Kingdom United States | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NOTICE TO THE READER Publisher does not warrant or guarantee any of the products described herein or perform any independent analysis in connection with any of the product information contained herein. Publisher does not assume, and expressly disclaims, any obligation to obtain and include information other than that p... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
Pregnancy, childbirth, the puerperium, and the newborn transition to extrauterine life are natural physiologic processes. The healthy mother and her infant usually require little in the way of medical intervention during these life events; they may however, benefit greatly from comprehensive nursing care. Maternal-Infa... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
NURSING CARE PLANS Consultants Yondell Masten, RNC, Ph D, WHNP, CNS Professor Texas Tech University Health Sciences Center School of Nursing Lubbock, Texas Dori Bronstein Krolick, RNC, BSN, MS Candidate Operations Manager, Maternal-Child Services Benedictine Hospital Kingston, New York | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
Usinm the Maternal-Infant Nursing Care Plans These plans have been developed to reflect com- prehensive perinatal nursing care for mothers and their infants. The book is divided into four units: Pregnancy, Intrapartum, Postpartum, and Newborn. Each unit begins with an overview of the general physiologic and psychologic... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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TABLE OF CONTENTS | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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... Unl I :~na ncy.................................................................................................................................................. 1 Basic Care Plan: Prenatal Home Visit........................................................................................................................ | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
iv Unit IU: Newborn.............................................................................................................................................. 227 Healthy Newborn.............................................................................................................................................. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
UNIT I: PREGNANCY Healthy Pregnancy Basic Care Plan: Prenatal Home Visit Adolescent Pregnancy Multiple Gestation Hyperemesis Gravidarum Threatened Abortion Infection Substance Abuse Gestational Diabetes Heart Disease Pregnancy Induced Hypertension (PIH) Placenta Previa Preterm Labor Preterm Rupture of Membranes At-Risk... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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Healthy Pregnancy Pregnancy is a normal physiologic process. The goal of health care during pregnancy is to promote and maintain the health of the mother and fetus. Risk assessment, problem identification and incer- vention, and health teaching are important aspects of prenatal care. Physical Changes The placental horm... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
4 MATERNALINFANT NURSING CARE PLANS h CG (produced by the trophoblast) maintains 1 Corpus luteum (prevents menses) I Placenta Estrogen Progesterone I I J. peripheral vascular resistance Relaxin 4 Collagen changes +joint I mobility I cervical softening \ Fetal growth +protein synthesis Milk p I;pduction I I + maternal i... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 5 Prenatal Care Path Week Interview I l St visit Chief c/o Med/OB hx Psychosocial Religious Cultural Concerns h resources Risk assessment v Client concerns L I. c 20 Quickening? 24 28 32 34 Client concerns 86 discomforts. I Physical Exam Ht., Wt., B/P, TPR, reflexes Physical exam Fundal ht. &, FHT if indicate... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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PREGNANCY 7 Basic Care Plan: Healthy The nursing care plan is based on a thorough nursing history, assessment, and review of medical and laboratory findings. Specific client-related data should be inserted wherever possible and within parentheses. Nursing Care Plans Health Seeking Behaviors: Prenatal Care Related to: C... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
8 MATERNALINFANT NURSING CARE PLANS (Revisions to care plan? D/C care plan? Continue care plan?) Nutrition, Altered: Less Than Body Requirements Related to: Increased demands of pregnancy, inability to obtainhgesdutilize adequate nutri- ents. Defining Characteristics: Specify: (Client's report- ed daily intake v. requi... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 9 INTERVENTIONS RATIONALES Reinforce positive nutri-Reinforcement motintes tion habits at each prenatal visit. healthy diet during preg-the client to maintain a nancy. Referral provides addition- al information and support for clients with special dietary needs. Refer to dietitian, as need- ed (e. g., diabete... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
10 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES (rubella); prolonged expo- sure to heat (hot tubs, saunas); alcohol. Teach good body mechan- ics and appropriate exer- cise: not to lie flat on back; wear sensible shoes; keep back straight and feet apart when bendingllifting; usual... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 11 INTERVENTIONS RATIONALES Assess client for discomfort at each prenatal visit. Observe for nonverbal signs such as grimacing, guarding, etc. Ask client if she has any discomfort. Ask client to rate the dis- comfort on a scale of 1 to 10 with 1 being the least and 10 the most. Assess what the client usu- all... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
12 MATERNAL-INFANT NURSING CARE PLANS ~~~ INTERVENTIONS RATIONALES ally painless, don't I' in intensity over time, may decrease if activity changes (walking or resting). Suggest client practice breathing techniques with B-H contractions. Hicks contractions. Notify caregiver for unusual symptoms or severe discomfort. pl... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 13 Basic Care Plan: Prenatal Home Visit Prenatal home visits provide information about the client's home environment and family support system. Additional benefits are client convenience and comfort, which facilitate learning. Nursing Care Plans Basic Care Plan: Healthy Pregnancy (7) Additional Diagnoses and ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
14 MATERNALINFANT NURSING CARE PLANS Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Has client identified hygienic needs? Specify. ) (Has client obtained financial assistance? Specify. ) (Has client developed a plan to improve support systems? Specify. ) (Revisions to care pl... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 15 Defining Characteristics: Client expresses a lack of knowledge about preparing for labor and birth of newborn (specify). Client expresses erroneous ideas about labor and birth of newborn (specify). Goal: Client will obtain knowledge about prepara- tion for labor and birth of newborn (date/time to evaluate)... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
16 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES Assist client and significant other to make a birth plan based on the information provided. Instruct the client to share the plan with her provider and the hospital staff on admission (send plan to L&D prior to admission if very differ- ent from routine car... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 17 Adolescent Pregnancy The pregnant teenager is at risk for physical, psy- chological, and socioeconomic complications. Early prenatal care that is sensitive to the needs of adolescents can decrease these risks and help the adolescent gain control of her future. Physiologic Risks Poor dietary habits, anemia,... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
18 MATERNAL-INFANT NURSING CARE PLANS INTER~NTIONS RATIONALES Assess client's usual method of making deci- sions (e. g., alone, with help from friends andlor parents, etc. ). Ask client to describe deci- sions she has made in the past that she feels good about. Assess the reason the client is having difficulty making a... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 19 to see a doctor, I feel fine”). Goal: Client will change behaviors to maintain health by (date/time to evaluate). Outcome Criteria Client will identify unhealthy behaviors. Client will verbalize plan to engage in healthy behaviors (specify: stop smoking, avoid alcohol and other drugs, eat a balanced diet f... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
20 MATERNALINFANT NURSING CARE PLANS while accomplishing the developmental tasks of pregnancy. Outcome Criteria Client will gain appropriate weight for pregnancy and normal physical growth. Client will make plans to complete at least a high school education. Client reports satisfactory relationship with par- ent(s), si... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 21 Multiple Gestation The incidence of multi-fetal pregnancies is increasing due to use of drugs that induce ovula- tion and other infertility technologies such as in vitro fertilization (IVF). The fetuses may either be monozygotic (identical) resulting from one ovum that divides, or dizygotic (fraternal) whe... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
22 MATERNALINFANT NURSING CARE PLANS Additional Dlagnoses and Care Anxiety Related to: Fears for well-being of mother and fetus secondary to complicated pregnancy. Defining Characteristics: Client verbalizes anxiety about pregnancy outcome (specify: feels physically threatened, afraid babies will die, can't sleep, etc.... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 23 Evaluation (Datehime of evaluation of goal) (Has goal been met? not met? partially met?) (How does client rate her anxiety as now? Does client appear calm? Specify: not crying, smiling, pulse 72, etc. ) (Revisions. to care plan? D/C care plan? Continue care plan?) Activity Intolerance Related to: Prescribe... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
24 MATERNAL-INFANT NURSING CARE PLANS Evaluation (Date/time of evaluation of goal) (Has goal been met? not met? partially met?) (Does client exercise as prescribed? Describe rou- tine, times, etc. ) (Which 3 activities has client identified to combat the boredom and depression of bedrest?) (Revisions to care plan? D/C ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 25 mpes of Wins Dizygotic 2 ova / OVm ATION 1 Monozygotic 1 ovum 00 FERTILIZATION 0 0 DMSION TIMING Within 72 hours of fertilization diamnionic, dichorionic 2 placentas (may be fused) -- &tween 4 and 8 days after fertilization diamnionic, monochorionic oneplacenta 0 8 days after fertilization monoamnionic, mo... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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PREGNANCY 27 Hyperemesis gravidarum is a rare condition (1% of pregnancies) of severe nausea and vomiting which starts in the first 20 weeks of gestation. The vomiting results in weight loss, dehydration, aci- dosis from starvation, alkalosis from loss of hydrochloric acid, and electrolyte imbalances. The fetus is at r... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
28 MATERNAL-INFANT NURSING CARE PLANS Outcome Criteria Client will have intake equal to output. Client's mucous membranes will be moist, skin turgor will be elastic. INTERVENTIONS RATIONALES Assess intake 8r output: measure all fluid intake (P. o., IV, NG, TPN, etc. ) and compare to all output (emesis, urine, NG aspi- ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~~ PREGNANCY 29 Defining Characteristics: Client reports anorexia and vomiting and is unable to eat (specify amount of food client has been able to keep downhime). Client is not gaining appropriate weight or is los- ing weight (specify). Goal: Client will absorb sufficient nutrients for maternal needs and fetal growth ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
30 MATERNAL-INFANT NURSING CARE PLANS Hyneremesis Grauidarum Theoretical Causes + h CG + estrogen psychiatric gastric dysrhythm Excessive Nausea & Vomiting Fluid 86 Electrolyte Dehydration Imb mce J 1 Acid-Base Hypovolemia Imbalance 1 T J, renal function V dysrhythmias J/ placental perfusion J. protein / Starvation J, ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 31 Threatened Abortion Vaginal bleeding during the first half of pregnancy is considered a sign of a threatened spontaneous abortion. About 20-25% of women will experi- ence some bleeding in early pregnancy. About half of these will eventually abort in a matter of days or even weeks. Uterine cramping andor lo... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
32 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES hands before and after using the bathroom, changing peri pads, and before eating, etc. Monitor lab values as obtained: CBC, cultures, etc. Notify caregiver of any abnormal values. Wear clean gloves when changing peri pads for client. Teach client to change ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 33 INTERVENTIONS RATIONALES Teach client and signifi- cant other about the nor- mal grief process & stages and what they may experi- ence. Provide written materials if literate. Support client and signifi- cant other in the stage they are in and assist with reali- ty-orientation (specify: “I can see that you ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
34 MATERNAL-INFANT NURSING CARE PLANS Missed Abortion death of the conceptous \ without expulsion Complete Abortion expulsion of the complete products of conception; Causes 1st trimester: abnormal development (50%) 2nd trimester: maternal infection, chronic diseases, endocrine defects, autoimmune (antiphospholipid anti... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 35 Infect ion Pregnant women are at increased risk of infection due to the hormonal and immune changes that support pregnancy. Infection may affect the fetus by crossing the placenta or ascending the vagina. During the first trimester, infections may result in spontaneous abortion or fetal developmental defec... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
36 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Assess for fever, malaise, anorexia, weakness, fatigue, night sweats, respi- ratory congestion, diar- rhea, urinary burning, skin lesions, joint pain, and swollen lymph nodes. Assess client for risk behaviors: IV drug abuse, recurre... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 37 Outcome Criteria Client's temperature will be c 102" F. ~~ ~ INTERVENTIONS RATIONALES Assess temperature (specify route), B/P, pulse, and res- piration every (specify time frame: e. g., q 2-4 hours). Assess client for dehydra- tion: dry skin and mucous membranes, poor turgor, sunken eyes, output z intake, ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
38 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Establish a supportive rela- tionship with client. Ensure privacy. Take time, use good eye contact and therapeutic communica- tion techniques. Teach client accurate infor- mation about the disease: agent, mode of transmis- sion, and... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 39 Infection Maternal Infection 4 Fetal-Neonatal Exposure Across Placenta Viruses Rubella CMV Herpes HIV Protozoa Toxoplasmosis Spirochete Syphilis 1 Ascending Chorioamnionitis Vaginal Bacteria Group B p-hemolytic streptococcus Bacterial vaghosis Bacteria Group B p-hemolytic streptococcus Gonorrhea Chlamydia ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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PREGNANCY 41 ~ Substance Abuse The use of alcohol, tobacco, and illegal “street drugs” such as marijuana, cocaine (crack), heroin, PCP, and LSD can lead to an increase in perinatal mortality and morbidity. Miscarriage, malnutri- tion, infection, IUGR, placental abruption, still- birth, preterm birth, congenital malform... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
42 MATERNAL-INFANT NURSING CARE PLANS Additional Diagnoses and Care Plans Growth and Development, Risk for Altered: Fetal Related to: Maternal substance abuse (specify) and J( nutrition. Defining Characteristics: Inadequate maternal weight gain (specify). Evidence of SGA fetus or fetal IUGR (specify fetal sizdgestation... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
____~_____ PREGNANCY 43 Coping, Inefective hdividkd Related to: Substance abuse behavior in response to stress. Defining Characteristics: Client reports substance abuse (specify: alcohol, tobacco, cocaine, amounts, years of use, etc. ). Client states she uses substance to cope with stress (speci+, use quotes). Goal: Cl... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
44 MATERNAL-INFANT NURSING CARE PLANS Associated Factors social attitudes/envirnt stress, occupation (access) low self-esteem, poor coping skills, lack of knowledge familial substance abuse frequently uses combination of substances, amounts used signs/sympto?ns delay in seeking cm hx of spontaneous abortion stillbirth,... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
-PREGNANCY 45 Gestational Diabetes Diabetes mellitus is a metabolic disorder caused by inadequate insulin production. Insulin is a hor- mone that moves glucose from the blood into the cells for energy use or storage. Diabetes mellitus is broadly classified as Type I (insulin dependent, IDDM) or Type I1 (non-insulin dep... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
46 MATERNALINFANT NURSING CARE PLANS Defining Characteristics: Client expresses appre- hension about self and fetal well-being (specify). Client exhibits physical tension ( heart rate, B/P, etc. ). Gas Exchange, Impaired Risk for: Feta J Related to: Placental vascular changes secondary to poor glycemic control. (84 Add... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~~~ PREGNANCY 47 Perform weekly NST's as ordered from 28-32 weeks (or more frequently-speci- fy), CST or OCT as ordered. Measure fundal height at each visit, compare to pre- vious value, and correlate to estimated gestational age. Coordinate referrals as ordered (specify: perinatol- ogist, endocrinologist, dia- betic n... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
48 MATERNAL-INFANT NURSING CARE PLANS- INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES plan prescribed (specify: e. g., 2400 cal ADA, divid- ed into 3 meals and 3 snacks, etc. ). Instruct client and signifi- cant other in proper use of blood glucose monitoring equipment. Demonstrate and have client perform a return d... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 49 (Did client and significant other demonstrate blood glucose monitoring, urine dipsticks, SC insulin administration, etc?) (Revisions to care plan? D/C care plan? Continue care plan?) | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
50 MATERNAL-INFANT NURSING CARE PLANS polyuria polyphagia & amino acids polydipsia 9 ketones PLACENTA Maternal v + fattyhs & amino acids + need for insulin (glucose storage 8a fetal use) (h PL + insulin resistance) insufficient production of insulin in beta cells of pancreas + 4 J/ insulin 1 Inability of glum& to enter... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
Heart Disease Medlical Care Heart disease is the number four cause of mater- nal mortality after hypertension, hemorrhage, and infection. Rheumatic fever is declining as a cause of heart disease but advances in treatment of con- genital defects means that more of these women are now likely to become pregnant. Pregnancy... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
52 MATERNAL-INFANT NURSING CARE PLANS Defining Characteristics: (Specify: client reports weakness and fatigue. Client exhibits shortness of breath, dyspnea, tachypnea with activity [specify level]. Specify changes in pulse and B/P with activity. ) Additlonal Diagnoses and Care Plans Decreased Cardiac Output Related to:... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTERVENTIONS RATIONALES Assess social support and include family andlor sig- nificant other in teaching about condition and care. Teach client med. adminis- tration (specify: e. g., for digitalis need to teach to take apical pulse) and adverse effects to report (signs of digitalis toxicity). Teach client to rest in be... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
54 MATERNAL-INFANT NURSING CARE PLANS INTERVENTIONS RATIONALES lying), fingers (check rings), facial, and perior- bital. Rate extent (+I, +2, etc. ). Compare to previous findings. Assess skin turgor and stri- ae gravidarum (stretch marks) development (at each visit). Assess for other signs of PIH (at each visit): B/P, ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 55 monary and placental tissue perfusion by (datehime to evaluate). Outcome Criteria Client's B/P will be > (specify: e. g., 100/60 mm Hg). Sa O, will be > 95%. Fetal growth will be appropriate for gestational age. FHR will be 110-160 with average variability and no late decel- erations. INTERVENTIONS RATIONA... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
56 MATERNALINFANT NURSING CARE PLANS + C. O. (30-50%) J/ pulmonary 86 peripheral vascular resistance JC B/P, + P, + stroke volume Heart Disease obstruction abnormal openings \L C. O. J. perfusion sympathetic coronary stimulation arteries . t peripheral 4 J/ 02 vasoconst,tiction r 1 tachycardia (@or 1 + need for 02 (tac... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
~ PREGNANCY 57 Pregnancy Induced Pregnancy induced hypertension (PIH) is defined as persistent B/P readings of 140/90 mm Hg or higher (or an elevation of more than 30 mm Hg systolic or more than 90 mm Hg diastolic over baseline B/P) which develops during pregnancy. Pre-eclampsia is diagnosed when the hypertension is co... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
58 MATERNAL-INFANT NURSING CARE PLANS pitocin induction, possibly betamethasone IM (induce fetal lung maturity) Laboratory tests: H&H, platelets, serum creati- nine, BUN, liver enzymes, coagulation studies, 24 hour urine for protein and creatinine clear- ance Fetal testing: u/s, fetal size, NST, OCT, BPR AFV, amniocent... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 59 ~~ INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES with % solution). Report respiration < 12 and d/c Mg S04-support respira- tion. Inform client of expected side effects of N adminis- tration: feeling of warmth. Maintain strict bedrest. Keep side rails up (X4) and padded (with bath blankets), keep oral a... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
GO,MATERNAL-INFANT~ NURSING-RE PLANS Goal: Client will maintain intravascular fluid vol- ume by (datehime to evaluate). Outcome Criteria Client will exhibit decreased edema (specif): e. g., 2+ or less), increased urine output (specify hourly amount), hematocrit will return to normal for pregnancy (specify: e. g., < 40%... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 61 Outcome Criteria Client will deny any headache, visual distur- bances, or epigastric pain. Client will have platelet count > 100,000/mm3, liver enzymes (AST & ALT), WNL (specify for lab), fetal heart rate will remain between 11 0-160 without late decelera- tions. INTERVENTIONS RATIONALES Assess temp (q 2 h... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
62 MATERNAL-INFANT NURSING CARE PLANS bances, or epigastric pain? What is the platelet count? Are liver enzymes (AST and ALT) WNL (speci Q for lab)? What is FHR? Are there any late decelerations?) (Revisions to care plan? D/C care plan? Continue care plan?) Diversionary Activity Deficit Related to: Isolation and inabil... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 63 ~~ (Has goal been met? not met? partially met?) (Has client planned and participated in diversionary activities? Specify,) (Revisions to care plan? D/C care plan? care plan?) at least 3 Continue | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
64 MATERNAL-INFANT NURSING CARE PLANS Premnancy Induced Hypertension (PIHI /I' blood pressure 3. circulating volume /I' extravascular fluid lacen P IUGR 3. fetal 02 a cerebral edema ischemia headache f abruptio-seizure coma fetal intracranial distress hemorrhage 3. organ perfusion vaylar damage I I retinal kidneys- ede... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 65 Placenta previa is an abnormally low implantation of the placenta in relation to the internal cervical 0s. As the cervix softens, late in the second trimester and then dilates, the placenta is pulled away, opening the blood-filled intervillous spaces and possibly rupturing placental vessels. The result is ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
66 MATERNAL-INFANT NURSING CARE PLANS Impaired Gas Exchange, Risk for: Fetal Related to: Disruption of placental implantation. (82) Diversionary Activity Deficit (62) Related to: Inability to engage in usual activities secondary to enforced bedrest and inactivity dur- ing pregnancy. Defining Characteristics: Specify: (... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 67 INTERVENTIONS RATIONALES Monitor lab work as obtained: H&H, Rh & type, cross-match for 2 units RBC's, urinalysis, etc. Arrange portable ultra- sound as ordered. Determine if client has any objections to blood trans- fusions-inform physician. Administer blood transfu- sions as ordered with client consent pe... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
68 MATERNALINFANT NURSING CARE I?-S INTERVENTIONS RATIONALES fears (e. g., preparation for getting to the hospital quickly should bleeding begin). Suggest and teach relax- ation techniques, creative visualization, etc. Assess degree of fearhlness after discussion. Validate client's feelings and plan for further discuss... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 69 Placenta Previa painless vaginal bleeding ultrasound J complete previa marginal previa partial previa low-lying placenta bleeding stops fetus stable 1 bedrest observe bleeding dbntinues bleeding restarts cesarean birth vaginal or cesarean birth | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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PREGNANCY 71 Preterm Labor A term pregnancy lasts from 38 to 42 weeks after the LNMP Preterm labor refers to progressive uterine contractions, after 20 weeks and before 38 weeks gestation, that result in cervical change (effacement and dilatation). Preterm is a descrip- tion of fetal age, not maturity or size. Preterm ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
72 MATERNAL-INFANT NURSING CARE PLANS Diversionary Activity Deficit (62) Related to: Inability to engage in usual activities secondary to attempts to avoid preterm labor and birth. Defining Characteristics: Specify: (e. g., client reports feelings of boredom or depression related to bedrest or lack of activity). and Ca... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTERVENTIONS RATIONALES ignated rate (specify load- ing dose and titration). Teach client about side effects of the drugs; (speci- fy: Mg SO, causes feelings of warmth, flushing; terbu- taline or ritodrine may cause J, BIP, tachycardia (mom and baby), feeling “jittery,” possible N&V). Monitor maternal vital signs, bre... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
74 MATERNALINFANT NURSING CARE PLANS Knowledge Dejcit: Preterm Labor Prevention Related to: Unfamiliarity with preterm labor (signs/symptoms, and prevention). Defining Characteristics: Client reports that she doesn't know the s/s of preterm labor (specify with quote). Client is at risk for preterm labor (specify: subst... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 75 INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES Instruct client to drink a glass of water or juice every hour, or 2-3 quadday and to void at least every 2h while awake. Teach client to avoid overexertion, heavy lifting, or staying in one position for long periods (sitting or standing). Have employer cont... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
76 MATERNAL-INFANT NURSING CARE PLANS Preterm labor SROM chorioamnionitis maternal svstemic overdistended uterus multiple gestation hydraminos incompetent cervix uterine anomalies complications of preg;nancv PIH previa abruption anomalies Unknown Causes | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 77 Preterm Rupture of Preterm rupture of the fetal membranes describes ruptured membranes before 38 weeks of gestation. The term refers to the gestational age of the fetus at the time of rupture. Premature rupture of membranes (PROM) describes membrane rupture before the onset of labor. 'PROM may occur with e... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
78 MATERNALINFANT NURSING CARE PLANS . If fetus is mature, may carefully induce labor after waiting 12 hours for labor to ensue natu- rally Nursing Care Plans Anxiety (22) Related to: Threat to maternal or fetal well-being secondary to risk for infection or preterm birth. Defining Characteristics: Specify: (Client repo... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 79 INTERVENTIONS RATIONALES (What is client's temperature? Is fluid clear with no foul odor?) (Revisions to care plan? D/C care plan? Continue Thick foul-smelling fluid may indicate chorioam-Monitor color, amount, and odor of vaginal dis- charge. Notify caregiver if increased amount, color changes, or foul od... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
80 MATERNALINFANT NURSING CARE PLANS Preterm Rupture of Membranes Membrane Rupture < 38 weeks . c + nitrazine test + ferning test Calculation of Gestational Age Monitor fo Infection J 5-\ c 34 weeks s/s of infection > 34 weeks No labor No s/s infection No labor No s/s infection I 1 1 1 Ekpec. tant Expectant management ... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY Most serious maternal illnesses or complications of pregnancy create risks for the fetus too. Teratogens may seriously disrupt development of the embryo. Maternal anemia or poor nutrition may result in inadequate oxygen and nutrients for the develop- ing fetus. Abnormal maternal blood components may also affe... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
82 MATERNAL-INFANT NURSING CARE PLANS Goal: Client and family will gain knowledge about the suggested fetal test(s) by (datehime to evaluate). Outcome Criteria Client and family will describe the testing proce- dure and risks and benefits of the proposed fetal testing. INTERVENTIONS RATIONALES Assess client and family'... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
PREGNANCY 83 ~ INTERVENTIONS RATIONALES INTERYENTIONS RATIONALES Assess fetal growth pattern compared to expected rate using serial hndal height or ultrasound reports. Monitor maternal lab work for anemia or Rh sensitiza- tion (antibody titers, indi- rect Coombs test) as obtained. ) Teach client to take iron supplement... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
84 MATERNAL-INFANT NURSING CARE PLANS a v + Placental Perfusion v At-Risk Fetus LGA I hemolysis anemia Maternal Factors anemia J, C. O. vascular 4-+ blood exposure to malnutrition hypovolemiia damage gluco Se teratogens smoking dehydration PIH I antibodies Fetal Factors t cord / 1 I lcts | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 85 UNIT II: INTRAPARTUM Labor and Birth Basic Care Plan: Labor and Vaginal Birth Basic Care Plan: Cesarean Birth Induction & Augmentation Regional Analgesia Failure to Progress Fetal Distress Abruptio Placentae Prolapsed Cord Postterm Birth Precipitous Labor and Birth HEL. LP/DIC Fetal Demise | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
This Page Intentio nally Left Bl ank | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 87 Vaginal birth is a normal physiologic process that begins with softening of the cervix (ripening) and increased uterine contractility. The contractions become stronger and more regular causing efface- ment (thinning) and dilatation of the cervix, and descent of the fetus. Once the cervix is completely di... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
88 MATERNAL-INFANT NURSING CARE PLANS Fetal Adaptation During the peak of a moderate contraction (@ 50 mm Hg pressure) placental blood flow stops and the fetus must rely on oxygen reserves. Uterine resting tone between contractions is required to replenish oxygen supplies. | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
INTRAPARTUM 89 Passageway, Passenger, and Powers Maternal Pelvis & Soft Tissues Pelvic Types gynecoid (50%) 0 android 0 anthropoid 0 platypelloid 0 Pelvic Planes Inlet: Diagonal Conjugate:-> 12. 5-13 cm Midpelvis: Interspinous Diameter: 1 10. 5 cm Outlet: Transverse Diameter: 2 10 cm ripe soft 86 elastic w/o scarring V... | Maternal Infant Nursing Care Plans by Karla Rnc Msn Luxner z-lib.org.pdf |
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