Beruflich Dokumente
Kultur Dokumente
I-
THOMSON LEARNING
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 provided to it by the manufacturer.
The reader is expressly warned to consider and adopt all safety precautions that might be indicated by the activities
herein and to avoid all potential hazards. By following the instructions contained herein, the reader willingly assumes all risks
in connection with such instructions.
The Publisher makes no representation or warranties of any kind, including but not limited to, the warranties of fitness for
particular purpose or merchantability, nor are any such representations implied with respect to the material set forth herein,
and the publisher takes no responsibility with respect to such material. The publisher shall not be liable for any special,
consequential, or exemplary damages resulting, in whole or part, from the readers use of, or reliance upon, this material.
COPYRIGHT 0 1999 Delmar, a division of Thomson Learning, Inc. The Thomson Learningm is a trademark used herein
under license.
For more information, contact Delmar, 3 Columbia Circle, PO Box 15015, Albany, NY 12212-0515; or find us on the World
Wide Web at http://www.delmar.com
ALL RIGHTS RESERVED. No part of this work covered by the copyright hereon may be reproduced or used in any form
or by any means-graphic, electronic, or mechanical, including photocopying, recording, taping, Web distribution or
information storage and retrieval systems-without the written permission of the publisher.
ISBN: 1-56930-0992
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-Infant nurs-
ing is provided in diverse settings from homes and schools to Third-World clinics, hospitals, and OB
Intensive Care Units. Perinatal health promotion and wellness teaching form the foundation of this care and
lay the groundwork for healthy families of the future. For the families experiencing a complicated pregnancy
or birth, skilled nursing care based on sound scientific knowledge is provided-not instead of, but in addi-
tion to health promotion and wellness teaching. Knowledge and respect for cultural variations is essential to
modern nursing practice. Perhaps in no other specialty are there so many culturally defined prescriptions and
proscriptions as those accompanying pregnancy, birth, and infant care.
The nursing process serves as a learning tool for students and as a practice and documentation format for
clinicians. Based on a thorough assessment, the nurse formulates a specific plan of care for each individual
client. The care plans in this book are provided to facilitate that process, not supplant it. To that end, each
care plan solicits specific client data and prompts the nurse to individualize the interventions, consider cul-
tural relevance, and to evaluate the client's individual response. The book provides basic nursing care plans
for healthy clients during the prenatal, intraparturn, postpartum, and newborn periods. Common perinatal
and neonatal complications for each section are then presented with associated care plans. Home visit care
plans are included for the prenatal, postpartum, and newborn clients, reflecting current practice.
I am grateful to my family, students, nurse colleagues, and the many mothers, fathers, grandmas, and babies
who have enriched my understanding and shaped my practice. This book is dedicated to my own mother,
Elizabeth Hobart Romaine, who taught me that it could be done.
Karla L. Luxner
NURSING CARE PLANS
Consultants
Unl I : ~ nncy
a .................................................................................................................................................. 1
Healthy Pregnancy.,.................................................................................................................................. 3
Basic Care Plan: Prenatal Home Visit ...................................................................................................................................... 13
Adolescent Pregnancy .............................................................................................................................................................. 17
Multiple Gestation................................................................................................................................................................... 21
Hyperemesis Gravidarum ........................................................................................................................................................ 27
Threatened Abortion ............................................................................................................................................................... 31
Infection.................................................................................................................................................................................. 35
Substance Abuse ...................................................................................................................................................................... 41
Gestational Diabetes ................................................................................................................................................................ 45
Heart Disease .......................................................................................................................................................................... 51
Pregnancy Induced Hypertension (PIH) .................................................................................................................................. 57
Placenta Previa......................................................................................................................................................................... 65
Preterm Labor .......................................................................................................................................................................... 71
Preterm Rupture of Membranes .............................................................................................................................................. 77
At-Risk Fetus ........................................................................................................................................................................... 81
Psychological Changes
Developmental issues and possibly hormone levels
influence changes in maternal emotions and out-
look. Maternal psychological tasks of pregnancy
may include:
4 MATERNALINFANT NURSING CARE PLANS
hCG
(produced by the
trophoblast)
maintains
1
Corpus luteum
(prevents menses)
I Placenta
Estrogen Progesterone
I
\
Fetal growth Relaxation of
Relaxin +protein synthesis smooth muscle
4 I
Milk pI;pduction
uterus
arteries
Collagen I L GI/GU
changes + maternal insulin (syncope, GI
I
resistance Prostaglandin discomforts, risk
(risk for gestational for UTI)
+joint
diabetes)
1
Possible role Breast gland
mobility during labor development
I
cervical
softening + Body temp
J/ C02 tolerance
(physiologic
hyperventilation)
I
J. peripheral
+ Aldosterone
secretion
vascular I
resistance
(physiologic 4
edema)
PREGNANCY 5
LI
Exam
Chief c/o Ht., Wt., B/P, PNV, iron
lSt Med/OB hx TPR, reflexes Services,
Psychosocial Physical exam
visit Religious Fundal ht. &, FHT Antibody Substance
Cultural if indicated
Concerns h Pelvic exam,
resources adequacy,
Risk assessment sizeldates
L+
v Client concerns Wt.,vital signs,
FHT,fundal ht.
.
I .c I
20 Quickening?
24
Client concerns 86
discomforts
28
32
34
I contractions
This Page Intentionally Left Blank
PREGNANCY 7
Related to: Clients desire for a healthy pregnancy Provide emotional support Most women dislike pelvic
and newborn. during invasive or painhl exams. Nursing support
procedures. can decrease discomfort by
Defining Characteristics: Client makes and keeps promoting relaxation.
prenatal care appointment (date). Client states Modify plan of care based Individualizing the rou-
(specify: e.g.; I think that I am pregnant; I want on client requestdneeds tines of prenatal care
to have a healthy baby). List appropriate subjec- (e.g., female physician, shows respect for the
tive/objective data. teaching session rather clients unique needs and
than literature for illiterate concerns.
Outcome Criteria clients).
Client will keep all prenatal appointments. Provide the name and Often questions will arise
phone number (specify) outside of appointments.
Client will call the health care provider for any for client to call with any Client will feel comfort-
concerns related to pregnancy. questions. able with a person to con-
~ tact.
INTERVENTIONS RATIONALES
Provide written informa- Written information is
Establish rapport: ensure Client will feel comfort- tion about pregnancy. available to [he client in
privacy, listen attentively, able in the care setting and her home.
and allow adequate time to be willing to share con-
Refer client as needed Ensures client will obtain
address clients concerns. cerns.
(WIC, social services, etc.). needed assistance.
Assess reason for seeking Client concerns are the
care, remain nonjudgmen- basis of nursing care.
tal, use open-ended ques- Therapeutic techniques Evaluation
tions, and observe nonver- help the nurse obtain the
bal dues. most information. (Datehime of evaluation of goal)
Assess knowledge level of Assessment provides data (Has goal been met?not met? partially met?)
pregnancy and prenatal for development of an
care (previous OB hx). individualized teaching (Has client kept all prenatal appointments? Give
plan. data.)
(Has client called with concerns? Give data.)
8 MATERNALINFANT NURSING CARE PLANS
Client takes prenatal vitamins and iron as pre- Assist client to plan a Promotes compliance by
scribed. nutritious diet using the recognizing individual
Food Guide Pyramid mod- variations and includes
Client gains 25 to 35 pounds during pregnancy ified for pregnancy taking client in planning.
(2-5 pounds first 12 weeks, 1 pound/week there- into account personal and
after), (+ for multiple gestation). cultural preferences and
financial ability (specify:
diabetic, vegetarian,
kosher, etc.).
INTERVENTZONS RATIONALES Teach client to avoid high- Unprocessed, natural foods
ly processed foods or those contain the most nutrients.
Assess current food intake; Assessment provides base- with many artificial addi- Additives may adversely
24 hour diet recall; pica; line data. Pica is the inges- tives (clients with PKU affect the fetus (high
and appetite changes (at tion of non-food substances need to avoid phenylala- phenylalanine levels may
each prenatal visit). (dirt, starch, ice, etc). nine). cause mental retardation in
Assess for nausea and vom- Assessment provides infor- the fetus of PKU moms).
iting (amount, times). mation about the clients Reinforce need for prenatal Provides additional nutri-
ability to ingest and absorb vitamins and iron if pre- ents that may be dificult
nutrients. scribed. to obtain by diet alone.
PREGNANCY 9
(Does client take prenatal vitamins and iron as Assess fetal well-being at Complications of pregnan-
prescribed?) each visit. Ask about fetal cy may affect the fetus by
movement, listen to FHT interfering with placental
(What is client weight gain? ) for a full minute, measure function. The stressed
fundal height, and com- fetus may have 4 move-
(Revisions to care plan? D/C? Continue?) pare to EGA. ments or & fundal height.
Size-dates discrepancies
Injury, Risk for: MuternaUFetal may indicate IUGR.
Related to: Exposure to teratogens, complications Perform, or assist with, Testing provides informa-
of pregnancy. other fetal assessments as tion about fetus. The fetus
indicated or ordered (spec- may exhibit signs of dis-
Defining Characteristics: None, since this is a ify: CVS, amniocentesis, tress such as decreased
potential diagnosis. NST,ultrasound, CST, FHR variability or late
biophysical profile, etc.). decelerations.
Goal: Client and her fetus will not experience any
injury during pregnancy.
Teach client to avoid expo- Client may be unaware of
Outcome Criteria sure to terarogens during risks associated with com-
pregnancy: monplace exposures.
Client denies any exposure to teratogens. medicationddrugs not pre- Provides needed inforrna-
scribed by the physician, tion to help prevent harm
Client denies experiencing any danger signs of
including OTC meds; to the feerus.
pregnancy. radiation (including x-
Clients B/P remains c 140/90,reflexes same as rays); cat litter or raw
meat; viral infections
baseline (specify), urine negative for protein.
10 MATERNAL-INFANT NURSING CARE PLANS
(Urinary frequency: Teach May be caused by pressure (Braxton-Hicks contrac- The uterus contracts
client to void frequently, on the bladder from the tions: Teach client to dif- throughout pregnancy.
not to hold it. Teach enlarging uterus - more ferentiate from labor: usu- Labor contractions usually
Kegel exercises and common during first and
12 MATERNAL-INFANT NURSING CARE PLANS
~~~
INTERVENTIONS RATIONALES
ally painless, don't I' in I' over time, becoming
intensity over time, may more uncomfortable no
decrease if activity changes matter what the client
(walking or resting). does. Client may feel reas-
Suggest client practice sured about labor if she
breathing techniques with practices with Braxton-
B-H contractions. Hicks contractions.
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(What does client report the intensity of discom-
fort to be on a scale of 1 to lo?)
(Describe objective signs of discomfort or change
in them [e.g., client is smiling and no longer gri-
macing?])
(Revisions to care plan? D / C care plan? Continue
care plan?)
PREGNANCY 13
(Has client obtained financial assistance? Specify.) Provide information about Information provides
changes the family may anticipatory guidance to
(Has client developed a plan to improve support experience due to the preg- help the family adjust to
systems? Specify.) nancy and birth (specify changes they will experi-
for each family member). ence.
(Revisions to care plan? D/Ccare plan? Continue
Provide age-appropriate Enhances the childs self-
care plan?) (specify) information to esteem to be included in
Family Coping: Potential for Growth siblings of new baby: pic- the home visit with age-
ture~,books, stories, etc. appropriate methods.
Related to: Family adaptation and preparation for
Identify and praise effec- Identification and praise
birth of new member of family. tive coping mechanisms provides positive reinforce-
Defining Characteristics: Family members used by the family (speci- ment to the family and
fy) * helps identify skills they
describe impact of pregnancy in enhancing growth already possess.
(speciG: e.g., sibling states Im going to be a big
brother and help take care of the baby! etc.). Refer family members to Childbirth education pro-
appropriate childbirth edu- vides additional informa-
Family members are involved in prenatal visits and
cation classes (specify: sib- tion about the childbear-
preparations for baby (specify: e.g., husband ling, grandparent, and ing process for different
attends childbirth classes, Grandma plans to baby- VBAC classes, etc.). age groups.
sit, etc.).
Goal: Family will continue to cope effectively dur-
Evaluation
ing pregnancy by (date/time to evaluate).
(Datehime of evaluation of goal)
Outcome Criteria (Hasgoal been met? not met? partially met?)
Family will express positive feelings about the
pregnancy. (Does family express positive feelings about the
pregnancy?)
Family will be involved in prenatal care and prepa-
rations for the new baby (other specifics as appro- (Is family involved in prenatal care and prepara-
priate). tions for the new baby?)
(Revisions to care plan? D/C care plan? Continue
INTERVENTXONS RATIONALES care plan?)
Assess family structure and Client may be part of a Knowledge D.f;cit: Preparation for Labor
encourage participation in nontraditional family.
home visit as appropriate Participation during the
and Birth of Newborn
(specify according to ages prenatal period helps the Related to: (Specify: first pregnancy, first VBAC,
of children). family to bond with the
etc.)
new baby.
PREGNANCY 15
INTERVENTIONS RATIONALES
Evaluation
Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Does client describe what occurs during normal
labor and delivery?)
(Has client made a birth plan?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
PREGNANCY 17
Assess the reason the client Client may feel confused Encourage client to make a Encouragement reinforces
is having difficulty making and afraid. Identifying the decision regarding preg- the clients right to make
a decision: fear of parent main concerns helps the nancy as soon as possible. her own decisions.
or boyfriends response, client begin to begin the
value conflict, lack of decision-making process.
information about options. Evaluation
Encourage client to involve Social support can posi- (Date/time of evaluation of goal)
her significant others spec- tively affect the outcome
ify: parents, boyfriend, of adolescent pregnancy. (Has goal been met? not met? partially met?)
etc.) in helping her to (Has client listed her options? Has client described
explore options.
advantages and disadvantages of each option? Has
Assist client to explore her Individual, social, and cul- client related her fears and anxieties? Has client
values about pregnancy tural values and mores are made a decision and is she following through?)
and to identie those that important to the adoles-
are most important to her; cents growing sense of her (Revisions to care plan? D / C care plan? Continue
remain nonjudgmental. own identity. care plan?)
Assist client to list the pos- Listing options is the first Health Maintenance, Altered
sible choices she thinks she step in logical decision
has (specie: keeping the making. Only the client Related to: Substance abuse (specify: tobacco,
baby, marriage, living at can decide which options alcohol, marijuana, etc.); poor dietary habits
home, adoption, termina- are possible for her.
(specify: high fat diet, inadequate nutrients, etc.);
tion of pregnancy, etc.).
lack of understanding (specify: sexuality/reproduc-
For each option, ask client Fears and anxieties may tive health care needs).
to explore her fears and negatively affect the clients
anxieties as well as the ability to think clearly. Defining Characteristics: Client reports smoking
risks of not making a deci- Denial is a common cop- cigarettes (specify packdday), drinking, or using
sion. ing mechanism. other drugs (specify substance and amount).
Assist client to list advan- Exploring advantages and Client reports poor dietary habits (specify f fat
tages and disadvantages of disadvantages based on diet, skips meals, drinks soda instead of milk, etc).
each option. Provide accu- accurate information helps Client states inaccurate information about sexuali-
rate information as needed the client to see which ty/reproductive needs (specify: e.g., I dont need
PREGNANCY 19
* Increased iron (60-100 mg) and folic acid (1 monozygotic multiple pregnancy, cord entangle-
mg) is usually prescribed. ment, placental insufficiency, twin-to-twin trans-
fusion, etc.).
Maternal hemoglobin may be checked each
trimester.
Tests for fetal well-being beginning at 30 weeks
22 MATERNALINFANT 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 care plan? Continue
care plan?)
PREGNANCY 25
mpes of Wins
/
Monozygotic
OVmATION 1 Dizygotic
1 ovum 2 ova
0 0 0
FERTILIZATION
DMSION TIMING
0
--
Within 72 hours of
fertilization
diamnionic, dichorionic
2 placentas (may be fused)
@/
fertilization (may be fused together
diamnionic, monochorionic to look like one)
oneplacenta
w
0
-
8 days after fertilization
monoamnionic, monochorionic
one placenta
@
Conjoined twins
-
(Siamese twins)
monochorionic, monoamnionic
one placenta amnion (inner membrane)
placenta+ -<
This Page Intentionally Left Blank
PREGNANCY 27
PREGNANCY 29
Client will ingest and absorb (specify caloric Initiate feedings of pre- Infusion rates should be
requirements for this client) kcallday. scribed product (specify) at adjusted according to the
50 cclhour and increase as client's feelings of fullness.
Client will gain appropriate weight (specify gain client tolerates to 75 cclhr After client is comfortable,
and time frame: e.g., 2-4 pounds in first (specify amount to be rate may be ' Ito' provide
trimester). givenlday as ordered). specified amounts.
Teach client to maintain Client may need feeding
INTERVENTIONS RATIONALES infusion if at home, teach tube for days or weeks
to assess tube placement, until nausea has stopped.
Assess weight and weight Provides information may also teach to reinsert Allows client to participate
gain at each visit. about nutritional status. tube with assistance of sig- in her care.
Assess for physiologic signs Deficiencies of vitamins C nificant others.
of starvation: jaundice, and B-complex, Maintain strict I&O while Provides information to
bleeding from mucous hypothrombinemia, and on TPN or NG feedings. avoid overload.
membranes, or ketonuria ketosis may result from
at each visit. insufficient nutrition. Refer client to Registered Support groups may offer
Dietitian and/or support additional ideas, dietitian
Once acute nausea has Many women report that groups as needed (specify). can help the client plan an
passed, begin oral intake as they can't tolerate water, optimum diet.
tolerated: clear liquids desire salty foods (chips
(broth, juices), potato have f' potassium, folic Evaluation
chips, small meals of any acid, and vitamin C than
(Datehime of evaluation of goal)
-
desired foods q 2 3 saltines), feel better if liq-
hours. uids aren't taken with (Hasgoal been met? not met? partially met?)
meals.
(List kcal/day that client is receiving. Compare
Suggest herbal teas such as Ginger offers relief for
ginger, mint, or some women; herbal teas with those needed for this client.)
chamomile. may be soothing. (What is client's weight gain/loss? Is this appro-
If client is to receive TPN, TPN can be formulated to priate for goal?)
initiate and titrate accord- provide glucose, lipids,
ing to physician's orders amino acids, electrolytes, (Revisions to care plan? D/C care plan? Continue
and nursing protocols minerals, and trace ele- care plan?)
(specify). ments.
Hyneremesis Grauidarum
Theoretical Causes
+ hCG
+ estrogen
gastric dysrhythm
psychiatric
J
Imb mce
1
Acid-Base Hypovolemia
/\
1
Imbalance
J. protein J, vitamins
V
T
J, renal function
dysrhythmias
1
jaundice
bleeding
Fetus
IUGR
CNS malformation
death
PREGNANCY 31
abortion, followed by examination of the tissue Assess for signs of infec- Provides information
tion (specify how often: about the signs of inflam-
for abnormalities
e.g., q 4 hrs): temperature matory response and
Rh negative mothers who are not sensitized are (route), pulse, B/P, odor of infectious processes.
given RhoGam after an abortion vaginal discharge, abdomi-
nal tenderness.
Wash hands thoroughly Effective handwashing
with warm water, soap, removes pathogenic organ-
and friction before and isms from the hands.
after providing client care. Prevents transmission of
Teach client to wash her microorganisms.
32 MATERNAL-INFANT NURSING CARE PLANS
INTERVENTIONS RATIONALES
Teach client and signifi- Knowing that depression,
cant other about the nor- insomnia, crying, and
mal grief process & stages anger are normal reactions
and what they may experi- will help the family to
ence. Provide written cope with these feelings.
materials if literate.
Support client and signifi- Assists the client and sig-
cant other in the stage they nificant other to work
are in and assist with reali- through the process with-
ty-orientation (specify: I out feeling disapproval.
can see that you are angry, Presents reality. Anger may
this is a normal way to be turned on staff who
feel, or I can see that you need to recognize that this
are still hoping things will is normal.
turn out OK, I am hoping
so too).
Allow visitors as client Client advocacy: may wish
wishes. no visitors or a large sup-
port group.
Evaluation
(Datehime of evaluation of goal)
(Hasgoal been met? not met? partially met?)
(What do client and significant other describe as
the meaning of the possible loss? Use quotes.
Describe grief reactions the client and significant
other express: crying, anger, being stoic, etc.
Relate to culture as indicated.)
(Revisions to care plan? D/C care plan? Continue
care plan?)
34 MATERNAL-INFANT NURSING CARE PLANS
Causes
1st trimester: abnormal development (50%)
2ndtrimester: maternal infection, chronic diseases, endocrine
defects, autoimmune (antiphospholipid antibodies, HLA)
incompetent cervix, uterine defects,
environmental toxins
Threatened Abortion
\ Complete
Abortion
Missed Abortion
death ofthe
conceptous
without expulsion
expulsion of the
complete products
of conception;
PREGNANCY 35
Additional Diagnoses
and Care Plans
Rubella vaccination prior to pregnancy
Infection, Risk for
Screening for TORCH infections, Group B
Related to: Specify conditions that cause risk (e.g.,
streptococcus, and possibly hepatitis and HIV
heart disease, HIV positive, IV drug abuser, histo-
Medications: prophylactic antibiotics, antiviral: ry of recurrent STDs, etc.).
zidovudine (AZT),antiinfectives, immune
Defining Characteristics: None, since this is a
globulins, etc.
potential diagnosis.
Fetal screening/ultrasounds to determine effects
Goal: Client will not experience infectious
of infections
processes by (specify date/time to evaluate).
Assess client for risk Identifies clients at risk for Monitor for side effects of Provides information
medications (specify for about client tolerance of
behaviors: IV drug abuse, infection.
recurrent STDs. each). the medication.
Wash hands before and Friction and hot water Provide emotional support Provides information and
after caring for client. remove many microorgan- and accurate information support to help the client
Teach client to wash fre- isms from the hands and about the prognosis for the cope with a diagnosis that
quently: before eating, prevent their transmission. pregnancy (specify for each may endanger the fetus or
before and after using the infectious agent the client herself.
bathroom, etc. has).
Teach client to avoid con- Protects client from infec- Refer client and family as Referrals provide addition-
tact with people with tions spread by respiratory indicated (specify: drug al information and assis-
infections (large crowds, droplets. treatment programs, psy- tance to client and family.
enclosed areas). chological counseling, and
support groups, etc.).
Use and teach clients fam- Follows C D C guidelines to
ily to use clean gloves if prevent transmission of Evaluation
handling body fluids; use blood-borne pathogens to
masks, eye shields, etc. as caregiver or others in the ( D a d t i m e of evaluation of goal)
indicated. Do not recap family of client.
needles; clean spills with
(Has goal been met? not met? partially met?)
bleach solution in the (Does client deny s/s of infection? List s/s. Does
home. client identify how to avoid infection? Use quotes)
Monitor lab values as Provides information (Revisions to care plan? D/C care plan? Continue
obtained for signs of infec- about the microorganism care plan?)
tion risk (specify: cultures, causing the infectious
CBC, ELISA, Western process. Hypertbemia
Blot, PCR, HIV culture,
CD4, ecc.). Related to: Physiologic response to infectious
process.
Use protective isolation Interventions protect
techniques (gloves, mask, immune-compromised Defining Characteristics: Increased body temper-
gowns for staff or visitors, client from contact with ature (specifjr), warm, flushed skin, tachycardia.
etc.) for clients at high risk infection.
due to immune suppres- Goal: Client will have a return to normal body
sion. temperature by (specify date/time).
PREGNANCY 37
Infection
Maternal Infection
4
Fetal-Neonatal Exposure
1
Ascending
Across Placenta Chorioamnionitis Vaginal
Viruses Bacteria Bacteria
Rubella Group B p-hemolytic Group B p-hemolytic
CMV streptococcus streptococcus
Herpes Bacterial vaghosis Gonorrhea
HIV Chlamydia
Trichamoniasis
Protozoa
Toxoplasmosis Viruses
Herpes
Spirochete Hepatitis B
Syphilis HIV
Neonatal Sepsis
This Page Intentionally Left Blank
PREGNANCY 41 ~
PREGNANCY 43
Establish rapport by con- Clients who are substance Praise client for attempts Provides positive reinforce-
veying a nonjudgmental abusers may have learned to stop substance abuse ment. Clients may have
and caring attitude while to be manipulative to and encourage continued many relapses before final-
presenting reality. avoid negative conse- attempts if she has a ly being able to stop sub-
quences. relapse. stance abuse.
Assist client to identify all Client may attempt to Refer to appropriate pro- The client may need more
substances she abuses, and avoid admitting to all sub- fessional support (specify: assistance than the nurse is
approximate amounts used stances which are used or Alcoholics Anonymous, prepared to offer. Support
-allow time, suggest others the amounts used. Narc0 tics Anonymous, groups such as AA are
if client hesitates. psychiatric nurse coun- often successfd in helping
selors, or others as ordered: clients to quit substance
Teach client about the Provides information e.g., psychiatrist, in-patient abuse.
effects of the substances about the negative conse- psychia.tric unit, etc.).
she uses on herself and her quences of each substance.
fetus. Describe how each Evaluation
affects fetus and mother.
(Datehime of evaluation of goal)
Offer to assist client to Reassures client she is not
develop more effective alone and is worthy of the (Has goal been met? not met? partially met?)
coping mechanisms. attention of the nurse.
(List stresses client has identified)
Assist client to explore Provides information
original reasons for sub- about history and stimuli
(List ways client has decided to avoid specific
stance abuse and any for substance abuse. stresses.)
relapses if she has tried to
(Describe coping strategies client has decided to
stop.
use to cope with unavoidable stresses.)
(Revisionsto care plan? D/C care plan?
Continue care plan?)
44 MATERNAL-INFANT NURSING CARE PLANS
Associated Factors
social a t t i t u d e s / e n v i r n t
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 c m
hx of spontaneous abortion
stillbirth, LBW infants
malnutrition, dental decay
sinusitis, chronic URIs
cellulitis (track marks)
infections, poor personal hygiene
Growth
LBW
IUGR
FlT
-
PREGNANCY 45
Macrosomic infant
Anxiev (22)
Polyhydraminos Related to: Threat to biologic integrity secondary
to complicated pregnancy. Threat to well-being of
fetus secondary to maternal illness.
46 MATERNALINFANT NURSING CARE PLANS
Assess clients blood glu- Provides information Monitor fetal testing as Provides information
cose and HbA,-, as about glycemic control ordered (specify: BPP, about fetal growth, com-
ordered (specify method during pregnancy: blood ultrasound, fetal echocar- plications, and lung matu-
and timing: e.g. FSBG, glucose > 105 mg/dL fast- diogram amniocentesis). rity.
GTT, post-prandial, q.i.d., ing or 120 mg/dL 2 hour Assess client for signs of Client with diabetes is at
q.d., weekly, etc.). post-prandial may require PIH at each prenatal visit higher risk for PIH.
Review clients home test- insulin administration. If (B/P, wt gain, proteinuria,
ing records at each visit. HbA1-, is > 8.5, fetus is at edema, and reflexes).
f risk for congenital
anomalies.
~~~
PREGNANCY 47
INTERWNTIONS RATIONALES
Provide a comfortable Facilitates learning of corn-
environment for learning, plex content; significant
invite client to include sig- others may provide sup-
nificant others, allow ade- port and reinforce learning
Evaluation quate time for questions. at home.
(Dateltime of evaluation of goal)
Assess client and signifi- Provides baseline data for
(Has goal been met? not met? partially met?) cant others knowledge of planning education about
diabetes mellitus and abili- diabetes and self-care-
(What is clients fasting blood glucose? What is ty to learn needed skills. individualizes content to
fetal growth pattern relative to gestational age? client learning level.
How often is fetal movement felt in 2 hours?) Describe maternal and Basic information the
fetal pathophysiology of client needs to understand
(Revisions to care plan? D/C care plan? Continue
GDM in simple terms: use the condition and assess
care plan?) visual aids and written her physiologic responses.
materials; verify under-
Knowledge Deficit standing.
Related to: Lack of information about diabetes Teach client and signifi- Understanding the physi-
mellitus during pregnancy. cant other about the physi- ology will enhance cornpli-
ologic rationale for the diet ance and allow the client
48 MATERNAL-INFANTNURSING CARE PLANS-
Teach client to perform Ensures client is capable of Instruct client to report Clients with GDM are at
urine testing for glucose testing urine and under- any signs of illness or greater risk of infection,
and ketones: observe stands how to read results. infection to caregiver as which may result in DKA.
clients ability to read diet or insulin needs may
results accurately. change quickly.
(If insulin is prescribed: Teaching promotes safe Instruct client to keep a Written record provides
Instruct client and signifi- and accurate insulin record of all BG and urine information about clients
cant other in insulin administration technique - testing, insulin administra- individual responses.
administration: include enhances self-esteem to tion, diet, and activity lev- Allows client to modify
storage, drawing up accu- master this skill. els. Review record with self-care as needed.
rate dosage, rolling vial to client at prenatal visits.
mix, draw up clear
Provide written reinforce- Provides alternative source
(Regular) insulin before
cloudy (NPH) if mixing ment of all teaching topics, of information, reinforces
types, SC technique, rota- reassure client that you content and ensures clients
tion of sites - allow client will return to review con- questions will be answered.
to demonstrate skill at next tent (specify when).
dosage.) Suggest writing down
questions.
Teach client to engage in Exercise promotes utiliza-
regular nonstrenuous exer- tion of dietary CHO and Refer client to other Resources provide addi-
resources as needed (speci- tional information and
cise such as walking or may 4 insulin need. May
swimming and to adjust need to f CHO intake fy: American Diabetic support.
diet according to activity before vigorous activity or Association, support
level. 4 insulin if ill. groups, etc.).
Maternal
+ need for insulin
(glucose storage 8a fetal use)
(hPL + insulin resistance)
+
insufficient production of insulin
in beta cells of pancreas
4
J/ insulin
1
Inability of glum& to enter cells for
energy metabolism or storage
/ I
polyuria
polyphagia & amino acids
polydipsia 9 ketones
PLACENTA
v +fattyhs
& amino acids
Heart Disease Medlical Care
Diagnostics: echocardiogram, chest x-ray, elec-
Heart disease is the number four cause of mater-
trocardiogram, auscultation for murmurs, pos-
nal mortality after hypertension, hemorrhage, and
sible cardiac catheterization
infection. Rheumatic fever is declining as a cause
of heart disease but advances in treatment of con- Medications: vitamins and iron, flu vaccine,
genital defects means that more of these women Heparin (coumadin is teratogenic), thiazide
are now likely to become pregnant. diuretics, furosemide, cardiac glycosides (digi-
talis:),prophylactic antibiotics for dental or sur-
Pregnancy increases the workload of the heart.
gical invasive procedures and for delivery
Cardiac output is increased from 15-25Yoby 8
weeks of gestation and peaks at 30-50% by mid- Close monitoring to avoid excessive weight gain
pregnancy. The left ventricle has an increased (24# goal), anemia, fluid retention, PIH, and
workload, pulse rates increase, and there is a infection
decrease in peripheral and pulmonary vascular
Plan for low forceps vaginal delivery with
resistance. The diseased heart has a decreased car-
epidural anesthesia
diac reserve and may have difficulty adapting to
these changes. Hospitalization for Class I11 or IV prior to
delivery with possible invasive hemodynamic
monitoring
Assess intake and output Oliguria indicates 4 renal (Describe edema, does urine output approximately
and urine specific gravity perfusion, which activates equal intake? What was clients wt gain?)
(specify time frame). Teach the renin-angiotensin-
client to assess intake and aldosterone system causing (Revisions to care plan? D/C care plan? Continue
output at home and to Na+, K+, and H 2 0 reten- care plan?)
report urine output c 30 tion and I sp. gr. of
cclhr. urine. Essue Pe+ion, Altered placental
cardiopulmonary
Administer diuretics as (Describe how specific
ordered early in the day drug works to cause diure- Related to: Changes in circulating blood volume,
(specify: drug, dose, route, sis.) Teaching client about secondary to heart disease.
times) and assess results medications enables her to
(teach client to self-admin- participate in her care and Defining Characteristics: Specify: (pallor,
ister diuretics if indicated). assess for therapeutic or cyanosis, 4 B/P [specify normal and present B/P] ,
adverse effects. I capillary refill time [specify how many seconds],
Monitor lab results as Monitoring labs provides 4 SaO, levels [specify], anemia [specify Hgb &
obtained. Note serum information on fluid and Hct), fetal IUGR, and/or late decelerations on
albumin, sodium and electrolyte balance. EFM).
potassium levels.
God: Client will experience adequate cardiopul-
PREGNANCY 55
Heart Disease
+ C.O.(30-50%)
J/ pulmonary 86 peripheral
vascular resistance
+ +
JC B/P, P, stroke volume
obstruction
abnormal openings
\L C.O. Cardiomyopathy
J. perfusion
coronary
sympathetic
stimulation
J. renal
perfusion
A
Right ventricle
weakness
Left ventricle
weakness
arteries
.t 4
peripheral
4
+ renin, 4
+ systemic + pre
pulmonary
J/ vasoconst,tiction angiotensin, venous sure
1
0 2
1
aldosterone, congestion
+
ADH
1
n
r
1
distension
hepatomegaly
P
' edema
+ need for 02 9 circulating sudden weight J/ 0 2
(tachypnea)
+
volume fatigue
\
\ + venous return
\ 1I tachypnea
cough
\
+venous rales
engorgement hemoptysis
PREGNANCY 57
Injury, Risk for: MaternaUFetal Initiate and monitor MgSO, is a CNS depres-
MgS04 administration IV sant that J, acerylcholine
Related to: Tonic-clonic convulsions. via pump or IM (Z-track) release at motor neurons
as ordered (specify dose) preventing convulsions.
PREGNANCY 59
~~
- ~~~ ~~
I I I
vdscular and
-
P lacen a
IUGR
3. fetal
cerebral
edema
ischemia
headache
retinal
edema
visual
listurbance
kidneys
1
oliguria
Na+ retention
liver
1
periportal
hemorrhagic
hematologic
Tern
microangiopathic
hemolysis
0 2 proteinuria necrosis platelet adherence
I fibrin deposition
letachment
f
abruptio -seizure 3. plasma
coma proteins
pulmonary
4
peripheral
edema - edema
CHF
I
I I
necrosis
fetal
death
cvA \
f--------------
r
maternal
death
*I
acute renal
liver
PREGNANCY 65
INTERVENTIONS RATIONALES
fears (e.g., preparation for lessness.
getting to the hospital
quickly should bleeding
begin).
Interventions promote
Suggest and teach relax- relaxation and a sense of
ation techniques, creative control.
visualization, etc.
Evaluates effectiveness of
Assess degree of fearhlness teaching and discussion.
after discussion. Validate Provides continual sup-
clients feelings and plan port.
for further discussion as
needed.
Arrange for other health Increased information may
providers to talk with help client and family to
client as appropriate (spec- feel calmer about possible
i+ e.g., pastoral care, outcomes.
NICU staff, etc.).
Evaluation
(Date/time of evaluation of goal)
(Has goal been met? not met? partially met?)
(List fears client verbalized. Does client report a
decrease in fearfulness?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
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
Preterm Labor
Frequent prenatal visits and assessments for
A term pregnancy lasts from 38 to 42 weeks after
clients at risk
the LNMP Preterm labor refers to progressive
uterine contractions, after 20 weeks and before 38 Horne uterine monitoring, decreased activity,
weeks gestation, that result in cervical change bedrest, P.o., tocolytics, subcutaneous terbu-
(effacement and dilatation). Preterm is a descrip- taline pump
tion of fetal age, not maturity or size.
Hospitalization, hydration, antibiotics as indi
Preterm birth is the number one cause of neonatal cated
morbidity and mortality. Preterm birth may result
Toccolytics: MgSO,, i3-adrenergic receptor ago
from preterm labor, spontaneous preterm rupture
nists (ritodrine, terbutaline), others:
of membranes, or the baby may be delivered early
pro,staglandin inhibitors, calcium channel
because of severe maternal or fetal illness. Infants
blockers
born between 24 and 34 weeks have the highest
incidence of complications. Complications may Testing: urinalysis, B-strep, fetal fibronectin,
result in permanent physical and mental disabili- amniocentesis: L/S ratio, phosphatidylglycera
ties. Advances in neonatal intensive care have
resulted in greatly improved outcomes for infants
Betamethasone to 'l' fetal lung maturity
born after 34 weeks of gestation. Cervical cerclage for incompetent cervix
The exact cause of preterm labor is unknown as is
the exact mechanism that begins term labor. All Nursing Care Plans
pregnant women should be assessed for risk fac-
tors and monitored carefully during pregnancy.
Anxiety (22)
Related to: Threat to fetal well-being secondary
Risk Factors preterm labor/SROM.
Defining Characteristics: Specify: (e.g., client i:
Previous preterm labor or birth
tremblling, eyes dilated, shaking, crying, etc.
Infection: maternal or fetal Client verbalizes anxiety about fetal well-being)
6 Chronic maternal illnesses: heart disease, kidney Activity Intolerance (23)
disease, diabetes mellitus
Related to: Prescribed bedrest or decreased acti7
Uterine or cervical anomalies or scarring, DES secondary to threat of preterm labor.
exposure, trauma, abdominal surgery
Defining Characteristics: Specify: (e.g., client
Pregnancy factors: multiple gestation, 'l' amni- reports feelings of weakness, fatigue, shortness c
otic fluid (hydramnios), PIH, placenta previa or breath, etc.).
abruption, SROM
Low socioeconomic status
72 MATERNAL-INFANT NURSING CARE PLANS
Related to: Inability to engage in usual activities significant other. Provide high anxiety and need
secondary to attempts to avoid preterm labor and accurate information while repeated explanations.
birth. providing emotional sup-
port.
Defining Characteristics: Specify: (e.g., client
Place external fetal moni- External tocodynamometer
reports feelings of boredom or depression related
tor on client; also assess does not provide informa-
to bedrest or lack of activity). uterine contractions by tion on contraction inten-
palpation to determine fre- sity, may not show preterm
quency, intensity, and labor contractions.
duration (specify frequen-
and Care Plans cy)*
Injury, Risk for: MatemaWFetaal Assess FHR for baseline Assessment provides infor-
rate, variability, accelera- mation about fetal well-
Related to: Risk for preterm birth. Adverse effects tions, or decelerations being.
of drugs used to prevent preterm birth. (specify frequency).
Perform sterile vaginal Vaginal exam provides
Defining Characteristics: None, since this is a
exam if indicated (as information about fetal
potential diagnosis. ordered) - limit exams. presentation and labor
Goal: Client and fetus will not experience progress - excessive exams
may introduce infection or
preterm birth or injury from drugs used to stop stimulate labor.
preterm labor by (date/time to evaluate).
Place client on cardiac Beta-adrenergic agonists
Outcome Criteria monitor if ordered. Obtain (ritodrine, terbutaline)
baseline vital signs. may cause hypotension
Contractions will stop. FHR will remain 1 10-160 Monitor for tachycardia or from relaxation of smooth
with accelerations. dysrhythmias. muscle resulting in tachy-
cardia and additional stress
Client's B/P will remain > 100/70 (or specify for on the heart.
client), pulse < 120 (or specify), respirations > 14,
DTR's 2+ (or specify for client). Start an IV with designat- Provides venous access,
ed fluids (specify) at hydration, and a port for
ordered rate (specify) via piggyback medications.
INTERVENTIONS RATIONALES IV pump. Provide bolus if
ordered then reduce rate as
Position client on left side Positioning hcilitates ordered (specify).
as much as tolerated. uteroplacental perhsion.
Change to right side if Supine position causes Prepare piggyback IV Careful preparation of
client becomes uncomfort- compression of the inferior tocolytic medication as tocolytic drugs ensures the
able - avoid supine posi- vena cava by the heavy ordered or per policy proper dose will be given.
tion. uterus, 4 blood flow to (specifjl: e.g., drug Piggyback allows the drug
the heart and 4 B/P and strength, dose, IV solu- to be discontinued while
placental perfusion. tion). Piggyback tocolytic maintaining venous access.
to mainline IV and begin Pump ensures the client
Explain all procedures and Client and significant i n h i o n via pump at des- receives the right dose.
equipment to client and other may be experiencing
INTERVENTIONS RATIONALES INTEKVENTIONS RATIONALES
Preterm labor
SROM
complications of preg;nancv
anomalies PIH
previa
abruption
Unknown Causes
PREGNANCY 77
Defining Characteristics: Specify: (Client reports Apply external fetal moni- Assessment provides infor-
tor; assess fetal well-being mation about fetal well-
feeling weak or tired; decreased muscle tone, con-
and palpate for uterine being and preterm labor.
stipation, etc.). contractions (specify fre-
Diversionary Activity Deficit (62) quency of monitoring).
Assist caregiver with sterile Interventions provide
Related to: Inability to engage in usual activity speculum exam, ferning information about mem-
due to enforced bedrest. test, and vaginal cultures - brane status and possible
monitor the lab results. infection.
Defining Characteristics: Client reports boredom,
depression (specify). Client exhibits withdrawal, Obtain specimens for Laboratory studies provide
sleeps more than usual, etc. (specify). CBC and urinalysis as information about possible
ordered (specify: e.g., daily inflammation and infec-
Injury, Risk for: MaternaUFetal(72) CBC) - monitor the lab tious processes.
results.
Related to: Tocolytic drugs used to delay birth for
administration of glucocorticoids. Administer antibiotics as (Specify action of individ-
ordered (specify drug, ual drug.)
dose, route, time).
Additional Diagnoses Provide accurate informa- Client and family may be
and Care Plans tion and emotional sup-
port to client and family.
anxious and confused
about prognosis for their
Infiction, Risk for: Maternal/Fetal Allow time for questions. baby.
Related to: Site for organism invasion secondary Assess client's temperature Assessment provides infor-
to preterm rupture of fetal membranes. q 2-4 hours (specify). mation about the develop-
Notify caregiver if ment of infection.
> 99.5" F.
PREGNANCY 79
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
80 MATERNALINFANTNURSING CARE PLANS
J
c 34 weeks
No labor
Monitor fo Infection
5
s/s of infection
-\
> 34 weeks
No labor
No s / s infection I No s/s infection
1
Ekpec.tant
management
1
Delivery
Expectant
1
management or
(steroids) Induction after
Fetal testing 12 hours
without labor
PG present
PREGNANCY
Preterm ruptured membranes or labor Defining Characteristics: Client and family ver-
balize unfamiliarity with the prescribed test or
IUGR, fetal anomalies misinformation about the tests (specify: use
Postterm pregnancy (42+ weeks) quotes).
82 MATERNAL-INFANT NURSING CARE PLANS
INTERVENTIONS RATIONALES
Assess client and familys Assessment provides base- Evaluation
previous understanding or line information to plan (Datehime of evaluation of goal)
perception of the proposed needed teaching content.
fetal testing (specify tests). (Has goal been met? not met? partially met?)
Reinforce caregiver expla- Provides information the (Do client and family describe the test procedure,
nations of the test includ- client and family need to
risks and benefits? Use quotes.)
ing preparation needed, make informed decisions
actual procedure, duration, about fetal testing. (Revisions to care plan? D/C care plan? Continue
information to be gained Primary caregiver is care plan?)
(benefits) and when the responsible for informing
results will be available. the client of riskdbenefits. Gas Exchange, Impaired Risk f i r : Fetal
Identify any risks to fetus Explanation helps the
or mother (specify for each client and family to evalu- Related to: Specify: insufficient placental func-
test). Use visual aids, ate the proposed testing. tion, altered cord blood flow, J( oxygen-carrying
videos, or written informa- Visual aids and written capacity of maternal blood [anemia, substance
tion as indicated. information enhances
abuse], fetal hemolysis, etc.
understanding.
Mow time for questions An unhurried approach Defining Characteristics: None, since this is a
about the testing or fetal promotes understanding potential diagnosis.
condition that indicates a and comfort. Clients from
need for testing. Ask client some cultures may need to
Goal: Fetus will demonstrate adequate gas
about cultural or religious be encouraged to ask ques- exchange for intrauterine environment by
concerns if indicated. tions, some religions disal- (date/time to evaluate).
low blood transfusions.
Outcome Criteria
Provide emotional support Honesty and support helps
without encouraging false client and significant other Fetal growth will be appropriate for gestational age
hopes. Encourage family to express and cope with (fundal height, ultrasound), FHR between 110-
and friends support of fears. 160 without late or severe variable decelerations.
client and significant
other.
Verify understanding of Ensures that client and
PREGNANCY 83
Teach client to take iron Teaching promotes com- Provide humidified oxygen Interventions provide 5"
supplements as ordered and pliance with medical regi- at 10-12 Wmin via face- oxygen for the fetus.
avoid substance abuse to men, helps client to partic- mask or n/c as needed
enhance the amount of ipate in caring for her (specify: e.g., Sickle Cell
oxygen available for the fetus. crisis, late decelerations).
fetus.
Administer medications as (Describe action of specific
Assess any vaginal dis- Assessment provides infor- ordered (specify drug, drug related to factors that
charge: fluid, bleeding, etc. mation about cause of dose, route, time e.g. Rh alter fetal gas exchange.)
(specify frequency if active hypovolemia, anemia, immune globulin
loss). potential for cord com- (RhoGAM), SC terbu-
pression. taline for a prolapsed cord
etc.).
Assess FHR for baseline Assessment provides infor-
rate, variability, accelera- mation about oxygenation, Arrange for tour of NICU Impaired gas exchange for
tions, and decelerations cord compression, placen- if indicated by fetal condi- the fetus may necessitate
(speci@ frequency). tal perfusion. tion or prognosis. If client NICU stay due to preterm
is unable to tour unit, have delivery or other perinatal
Perform NST, OCT, etc. as Testing provides informa- NICU nurse come talk to problems.
ordered. Assist with other tion about fetal reserve; her.
tests as appropriate (specify other tests may indicate
for each test ordered). cause of impaired gas Evaluation
Monitor results. exchange.
(Datel'time of evaluation of goal)
Explain all procedures and Decreases anxiety about
equipment to client and unfamiliar procedures and (Hasgoal been met? not met? partially met?)
significant other. Provide anxiety about the condi-
reassurance and emotional tion of the fetus. (What is fetal growth compared to expected size
support. for gestation?)
Position client on left side Facilitates placental perh- (What is FHR? Are there decelerations?)
or semi-fowlers with wedge sion by avoiding compres-
under right hip. sion of the vena cava. (Revisions to care plan? D/C care plan? Continue
care plan?)
Monitor intake and output, Monitoring provides infor-
assess hydration: skin tur- mation about maternal
gor, mucous membranes, fluid balance and placental
and urine sp. gravity perhsion.
(specify frequency).
84 MATERNAL-INFANT NURSING CARE PLANS
At-Risk Fetus
Maternal Factors
a v
+ Placental Perfusion
LGA
v I
1
hemolysis
anemia
t cord /
Fetal Factors
I
lcts
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
This Page Intentionally Left Blank
INTRAPARTUM 87
1st Stage: Begins with onset of regular uterine 2nd Stage: Works hard at pushing and sleeps or
contractions and ends with complete dilatation appe:ars exhausted between contractions
of the cervix (10 crns); divided into: Latent 3rd Stage: Client is usually elated with birth of
Phase: 0 to 4 crns dilatation, Active Phase: 4 to baby and pushes on request to deliver placenta
8 crns dilatation, andTransition Phase: 8 to 10
crns 4th Stage: Client is alert and ready to bond or
breast feed her baby; may be talkative and hun-
2nd Stage: From complete dilatation of the gry
cervix to birth of the baby
88 MATERNAL-INFANT NURSING CARE PLANS
Fetal Adaptation
During the peak of a moderate contraction (@ 50
mmHg pressure) placental blood flow stops and
the fetus must rely on oxygen reserves. Uterine
resting tone between contractions is required to
replenish oxygen supplies.
INTRAPARTUM 89
anthropoid 0 Attitude
flexed
beginning of one
contraction to the
beginning of the next
platypelloid 0 Presentation Duration
Position
Maternal positioning
may shorten labor
Psyche
Maternal anxiety and
tension may lengthen labor
90 MATERNAL-INFANT NURSING CARE PLANS
Temp q 4h until
ROM then q 2h
ransition I
Observe
show, signs
bloody
of 2 n d
stage: grunting,
Bedrest or
chair as
desired, hands
desired
Stage
Apgar @ 1&5min
Time, maternal
B/Pt P, R
----+--
if stable
9
Oxytocics
after
placenta
INTERVENTIONS RATIONALES
~~
God: Client and fetus will not experience infec- INTEKVENTIONS RATIONALES
tion from invasive procedures used during labor
and birth by (datehime to evaluate). 2h) to keep dient dry. moist dark environment
Keep epidural dressing dry. where bacteria may multi-
Provide perineal care as ply. Front-to-back cleans-
Outcome Criteria needed, cleaning from ing prevents fecal contami-
Client's temperature will remain c 100F; new- front to back. nation of vagina/urethra.
born's temp will be < 98.9"E
Maintain a clean environ- Cleaning prevents the
~- ~
ment: ensure that house- spread of nosocomial
INTERVENTIONS RATIONALES keeping has cleaned the infections within the hos-
room (OR), equipment, pital.
Assess maternal tempera- Assessment provides infor- and bathroom (whirlpool);
ture q 4h until membranes mation about inflammato- empty trash as needed.
rupture, then q 2h until ry processes.
Avoid sharing equipment Equipment should be des-
birth.
with other clients or other ignated for obstetrics only
Assess maternal pulse and Maternal and fetal tachy- units in the hospital. to prevent cross-contami-
FHR baseline according to cardia may indicate infec- nation.
protocol for stage of labor. tion.
Encourage client to void q Urinary stasis during preg-
Assess amniotic fluid for Foul-smelling or thick, 2h during labor. Provide nancy provides an opti-
color and odor during each cloudy amniotic fluid may privacy, run water, etc. to mum environment for
vaginal exam. Limit vagi- indicate chorioamnionitis. stimulate urination. Teach bacterial growth. Voiding
nal exams. Bacteria may be intro- s/s of UTI to report: fre- frequently avoids the need
duced during vaginal quency, urgency, burning. for catheterization.
exams. Teaching allows early iden-
tification of a UTI.
Assess any invasive devices Systematic assessment pro-
(e.g., catheter, IV, continu- vides information about Wash perineum prior to Cleaning the perineum J
ous epidural) for sls of inflammation and infec- vaginal birth per hospital the number of microor-
infection: redness, edema, tious processes allowing protocol using sterile tech- ganisms that may invade
discomfort, warmth, etc. q early treatment. nique. Wash from front to the vagina or lacerations
4h or as indicated. back using a new sponge during birth.
for each wipe - clean labia
Maintain medical asepsis Frequent hand washing first and wash over the
by frequent hand washing; prevents the spread of vagina last.
use clean gloves when in pathogens; clean gloves
contact with body fluids. protect the caregiver from For cesarean birth, per- Interventions J the num-
pathogens. form abdominal scrub and ber of microorganisms that
shave-prep per agency pro- may be introduced into
Use sterile technique per Sterile technique prevents tocol, remove scalp elec- the abdominal cavity and
agency protocol for inva- the introduction of trode, assist with mainte- uterus during surgery.
sive procedures: e.g., IV microorganisms into sterile nance o f sterile technique
therapy, vaginal exams, areas of the body. during the surgery.
placement of a spiral elec-
trode, AROM, catheteriza- After the placenta has Sterile peri pad prevents
tion, etc. delivered and any suturing the introduction of
is completed, apply a ster- microorganisms to the
Change under-buttocks Interventions promote ile perineal pad (ice pack if vagina, episiotomy, or lac-
pads frequently (at least q cleanliness and avoid a
96 MATERNAL-INFANT NURSING CARE PLANS
~~ ~
~ ~~
Initiate and maintain IV Provides replacement of Notify caregiver if bleeding Continued blood loss may
fluids and/or blood prod- fluid and/or blood losses. continues after nursing indicate retained placental
ucts as ordered (specify interventions. fragments or a cervical lac-
fluids and rate). eration.
Monitor lab results as Changes in Hgb and Hct
obtained (specify: e.g., indicate the extent of
Hgb, Hct, urine sp. gravi- blood loss. 9 sp. gravity
ty, clotting studies, etc.). may indicate fluid loss.
Clotting studies indicate
the client at T risk for Evaluation
hemorrhage. (Datehime of evaluation of goal)
Monitor vaginal losses: Monitoring provides infor-
bloody show and amniotic mation about abnormal
(Hasgoal been met? not met? partially met?)
fluid. Notify care giver of blood loss: possible placen- (What is clients urine output? Is it 30 cdhr or
excessive bloody show or if tal abruption, or need for greater? Are mucous membranes moist? What is
fetus develops severe vari- amnioinfusion to prevent
able decelerations. fetal cord compression. clients B/P? Is it 2 (specify for client)?)
Note any unusual bleeding Abnormal bleeding may (Revisions to care plan? D/C care plan? Continue
(e.g., from injection sites, indicate a clotting abnor- care plan?)
gums, epistaxis, petichiae) mality.
and inform caregiver.
After delivery of the pla- Assessments provide infor-
centa, assess uterine posi- mation about uterine dis-
tion, tone and color and placement and tone; vagi-
amount of lochia; observe nal blood loss, hidden
for hematomas and note bleeding, and wound
integrity of incisions (spec- dehiscence.
ify frequency).
Encourage frequent emp- Bladder distension may
tying of the bladder after inhibit uterine contraction
birch (catheterize as need- leading to excessive bleed-
ed). Massage the uterus if ing. Massage stimulates
boggy, guarding over the uterine tone (over-stimula-
Symphysis. Administer tion may cause relaxation),
This Page Intentionally Left Blank
INTRAPARTUM 99
Administer appropriate (Specify rationale for Noti6 caregiver if pain is Caregiver may order a dif-
pain medication as ordered choosing the drug: eg., is not controlled or if com- ferent analgesic or decide
(spec;@ drug, dose, route, drug contraindicated if plications are suspected. to re-evaluate the client.
times. Instruct pt in PCA breast feeding? Describe
pump use if indicated). action of specific drug.)
Evaluation
Assess client for pain relief Assessment provides infor- (Datehime of evaluation of goal)
(specify timing for particu- mation about client's
lar drug given). Observe response to medication. (Hasgoal been met? not met? partially met?)
for adverse effects (specify
for drug: e.g., itching, uri- (What degree of pain does client report? Is client
nary retention with calm? relaxed? not grimacing, etc? Describe client's
epidural morphine). activity.)
Keep narcotic ~ r a g o n i s t Ndoxone reverses the
(Revisions to care plan? D/C care plan? Continue
(naloxone) available if effects of narcotics in cases
client has received narcotic of overdose.
care plan?)
analgesia. Positioning Injury (Perioperative), Risk for
Assist client to change Position changes decrease
Related to: Positioning and loss of normal sensory
positions, encourage muscle tension, ambula-
ambulation as soon as pos- tion decreases flatus, com- protective responses secondary to anesthesia.
sible. Provide a comfort- fortable environment
Defming Characteristics: None, since this is a
able environment (temper- enhances relaxation.
ature, lighting, etc.).
potential diagnosis.
Teach client to ask for pain Pain medication is more Goal: Client will not experience any positioning
medication before pain effective and less is needed injury for duration of anesthesia.
becomes severe or before if given before pain is
planned activity. severe. Premedication Outcome Criteria
affords pain relief for activ-
Client's B/P remains 2 (specify for client). Client
ity.
denies any leg or back pain after anesthesia wears
Teach client nonpharma- (Specify rationale: e.g., Off.
cological interventions: splinting and rolling to the
(specify: e.g., splinting side prevents traction on
incision with pillow, the incision site.) I"T0NS RATIONALES
rolling to side before rising
from bed, etc.). Assess client for any previ- Assessment provides infor-
ous back or leg injuries or mation about pre-existing
Offer nonpharmaco~ogical N o n p ~ ~ m a c o l o ginter-
ic~ conditions that may be risk factors for periopera-
pain interventions if ventions may use distrac- affected by surgical posi- tive injury.
desired: e.g., therapeutic tion or the gate-control tion.
touch, back rub, music, theory to 4 pain percep-
etc. tion.
102 MATERNALINFANT NURSING CARE PLANS
INTEIWENTIONS RATIONALES
Assist with positioning for Proper positioning facili- up after surgery. Note any sue injury.
epidural anesthesia as tates introduction of the reddened or blanched
needed. epidural catheter and areas.
avoids client injury.
Assess return of motor and Assessment provides infor-
If client has epidural anes- Interventions protect the sensory hnction in legs as mation about when client
thesia, protect her legs clients legs from filling epidural wears off. may safely use her legs
from possible falls or tor- and hyperextending the Maintain safety precau- again.
sion injury- SR b ?, hip joint. tions (side rails up, etc.)
guard legs if knees are until client has full use of
raised to insert foley, etc. extremities.
Position client supine on Safety strap prevents client Notitjl caregiver and anes- Notification allows care-
the operating table with a falls. Alignment presents thesia provider of any giver to investigate possible
wedge under her right hip nerve injury. Tilting the unusual findings or com- injury.
and a pillow under her uterus to the left facilitates plaints.
head. Apply safety straps. maternal venous return
Align spine and neck at all and uteroplacental perh-
times. Tilt the table to the sion.
Evaluation
left as ordered. (Datehime of evaluation of goal)
Evaluate fetal heart rate Assessment provides infor- (Hasgoal been met? not met? partially met?)
prior to abdominal scrub mation about placental
and draping. perhsion. (Did clients B/P remain 2 (what was specified for
client)? Does client deny any leg or back pain
Ensure that clients legs are Natural positioning pre-
in a natural, aligned posi- vents torsion and pro- afier anesthesia has worn off?)
tion without crossed ankles longed mechanical pressure (Revisions to care plan? D/C care plan? Continue
before draping (inform on nerves and circulatory
client not to cross ankles if system during surgery. care plan?)
preparing for general anes- Partw-hfint Attachment, Risk for Altered
thesia). Assist anesthesia
provider with natural posi- Related to: Barriers to or interruption of attach-
tioning of clients arms at ment process secondary to surgical routine or ill-
side or on arm board
ness of motherhnfant.
Use padding for bony Padding decreases pressure
prominences (e.g., pad over bony areas, which can Defining Characteristics: None, since this is a
arm boards, heels, etc.). interfere with circulation. potential diagnosis.
After surgery is complited, Maintaining alignment Goal: Client will demonstrate appropriate attach-
move client to a stretcher prevents torsion or twist- ment behaviors by (date/time to evaluate).
using a roller and draw ing of the clients body.
sheet and enough staff to Providing adequate st& Outcome Criteria
maintain clients body prevents staff injuries.
alignment during move. Parents will hold infant following birth.
Assess clients skin condi- Assessment provides infor- Parents and infint will make eye contact. Parents
tion as she is being cleaned mation about possible tis- will verbalize positive feelings towards infant.
INTRAPARTUM 103
Assess maternal feelings Assessment provides infor- For vaginal births, keep Attachment requires prox-
towards the fetus prior to mation about prenatal the infant with the par- imity. Involvement in
birth: e.g., DOyou have a attachment to the fetus. ents. Teach parents about assessments and interven-
name chosen? Note non- assessments and interven- tions facilitates the begin-
verbal cues. tions as they are per- ning of parenting skills.
formed.
Inform parents of fetal Information helps the par-
responses as assessed by ents view fetus as a real Administer pain medica- Pain may distract the
FHR prior to birth. baby. tions to the mother as client from attachment
needed (specify). and bonding with her
Assess cultural expectations Assessment provides infor-
infant.
of the parents and their mation about cultural vari-
families related to mother- ations: e.g., in some cul- Encourage and facilitate Early breast-feeding pro-
baby care after birth. tures the mother is expect- breast-feeding immediately vides lactose for the infant
Solicit information about ed to rest while others care after birth if indicated. after the stress of labor;
dietary needs, and who is for the infant. Cold foods nipple stimulation causes a
expected to care for the may be prohibited during release of oxytocin for the
infant. Share information the puerperium. mother: f uterine con-
with all staff. traction and C vaginal
bleeding.
Provide parents with an Mothers and infants are
opportunity to see and ready to form attachment Encourage parents to hold Skin-to-skin positioning
touch the baby immediate- in the first few minutes their baby skin-to-skin provides warmth for the
ly after birth. If infant after birth. If the infant is (kangaroo care). infant and facilitates
needs resuscitation, allow ill, seeing and touching the attachment.
parents to see and touch baby reduces parental anxi-
ety and fosters attachment. Promote bonding by Intervention helps parents
infant prior to transfer to
pointing out attractive fea- adjust their idealized
nursery.
tures o f the infant and his thoughts about the baby
Delay eye prophylaxis and Eye prophylaxsis may response to the parents. with the real baby.
other unnecessary proce- interfere with the infants
ability to see his parents Praise parental care-giving Parenting is a learned
dures until parents have
skills as indicated. process. Praise promotes
had an opportunity to faces. The first period of
self-esteem.
hold infant for 30 minutes sensitivity lasts 30 - 90
to 2 hours per protocol. minutes. Assess attachment behav- Failure to make eye con-
Allowing father to be pre- iors of parents: eye con- tact, avoidance of touch,
For cesarean births with
tact, touch, and verbaliza- or negative expressions
general anesthesia, allow sent fosters parent-infant
tion about the baby, Share may indicate attachment
the father (or significant attachment even if mother
observations with caregiver problems, which need to
other) to be present after is asleep.
and postpartum staff. be evaluated further.
induction to bond with
the infant. If infant is ill and taken to Interventions foster attach-
nursery, take parents to see ment and reduce parental
For cesarean births, take Post-operative clients, who
infant as soon as client is anxiety. If infant is very ill,
infant to recovery room are not too sedated, are
stable. Encourage parents parents may be afraid to
with mother and encour- able to interact with their
to participate in caring for touch or care for their
age her to hold and breast baby just as vaginal birth
infant in the nursery as baby.
feed infant if desired. mothers do.
possible.
104 MATERNAL-INFANT NURSING CARE PLANS
INTERVENTIONS RATIONALES
If infant is transferred to Interventions promote
another facility, provide attachment and informa-
parents with photos and tion until the client is
mementos of the infant reunited with her infant.
before transport and the
phone number of the facil-
ity.
If mother is too ill to care Family-centered care pro-
for infant, or if cultural motes attachment with all
prescriptions interfere with family members.
infant care, encourage
father or other family
member to stay in room.
Refer parents as needed Intervention provides addi-
(specify: e.g., social ser- tional assistance for par-
vices, congenital anomaly ents having difficulty with
support groups, grief sup- attachment or supports
port, etc.). cultural beliefs.
Evaluation
(Date/time of evaluation of goal)
(Has goal been met? not met? partially met?)
(Did parents hold infant following birth? Did par-
ents and infant make eye contact? Did parents
verbalize positive feelings towards infant? Specify
using quotes.)
(Revisions to care plan? D/C care plan? Continue
care plan?)
Induction & Augmentation -
AROM (artificial rupture of membranes) may
stimulate contractions
Induction refers to artificial stimulation of labor C o n ~ ~ u oEFM;
u s ~ n t ~ v e n ooxytocin
us
before it has spontaneous~ystarted. ~ugmentation ( P ~ t o c ~pig~backed
n~ to a mainline IV via an
is artificial stimulation to enhance labor after it i n ~ s i o npump; dilution of pitocin is per order.
has begun naturally. Pitocin is titrared to labor pattern and fetal tol-
Reasons for induction include maternal and fetal erance
conditions that prohibit continuing the pregnan-
cy. These may include: severe PIH, fetal demise, Nursing Care Plans
IUGR, prolonged ruptured membranes,
chorioamnionitis, diabetes mellitus or other severe
maternal illnesses, and verified postterm pregnan-
cy. Induction may be accomplished by use of cer-
vical ripening agents if the cervix is unfavorable, Ildditional Diagnoses
followed by ~ n ~ ~ and t oxytocin
o m ~ infusion.
Augmentation usualIy consists of amniotomy
and Care Plans
andlor oxytocin infusion to increase the intensity ~~~~~,
~~~~r~ ~~~e~~~~~~
and frequency of hypotonic uterine contractions.
R e l a d to: Effects of drugs used to induce or aug-
Contraindications to induction or augmentation ment labor.
are contraindications to labor contractions and
Defining Characteristics: None, since this is a
vaginal birth. These include f e d distress, com-
potential diagnosis,
plete placenta previa, active genital herpes, CPD,
previous classical uterine incision, and fetal ma1 God: Client and fetus will not experience any
presentation. Care shodd be taken to verifj fetal injury related to the use of drugs used to induce
gestational age prior to inducing labor. or augment labor by (dateltime to evaluate}.
Outcome Criteria
Medical Care ~ o n ~ a c u frequency
on not less than q 2-3 min-
Fetal maturity assessment: LNMP, serial ultra- utes, not more than 60 second duration, and ade-
sound me~urements,and possibly amniocente- quate resting tone benveen contractions. FHR
sis for U S rario remains reassuring with no late decelerations.
Determination of fetal lie, presentation, and sta-
tion
Assessment of cervical readiness for labor:
e ~ c e m e n tdilatation,
, position, and consisten- Obtain baseline maternal Assessment provides base-
cy (Bishops scoring may be used) vls. Assess fetal presenta- line data prior to induc-
tion, position, Station, and tion or augmentation.
Cervical ripening agents (PGq gel, dynopras- cervical &cement and Position kcilitates placen-
tone, or misoprostof) may be used to soften the dilatation. Position client taI perfusion.
cervix prior to oxytocin induction on left side if tolerated.
106 MATERNAL-INFmTNURSING CARE PLANS
exams as needed to moni- information about effec- Monitor hourly intake and Urine output may 4 as
tor progress of labor. tiveness of induction or output while oxytocin is oxytocin causes the kid-
augmentation. inhsing. neys to reabsorb free water.
Keep cfienr and significant Informat~onpromotes Observe client for signs of Oxytocin dosage > 20
other informed of labor understanding and water intoxication includ- mUlmin is associated with
progress and any changes decreases anxiety, which ing subtle changes in men- 4 urine output. Excessive
in the plan of care. may slow labor progress, tal status, confusion, retention of free water
lethargy, nausea, andior causes a ~yponatremic,
convuIsions. Discontinue hypoosmotic state, result-
oxytocin and JI mainline ing in cerebral edema.
to W O ; notify physician.
Serum sodium < 120
Monitor lab values as mEqlL or plasma osmolal-
obtained. ity I240 mOsm/kg indi-
10s MATERNAL-INFANT NURSING CARE PLANS
~ ~ ~ T I O N RATIONALES
S
If RN is to perform Many boards of nursing do rule out prolapsed cord.
AROM, obtain order, not allow staff nurses to Notify caregiver of severe
ensure that presenting part perform AROM or may variable decelerations,
is cephalic and well- require extra competency interventions, and fetal
engaged against the cervix. instruction and certifica- response.
If not, notify caregiver of tion. The RN is responsi-
Provide for amnioinhsion ~ n i o i n f u ~ i omay
n be ini-
findings and do not per- ble for knowing what the
as ordered per agency pro- tiated to reduce pressure
form AROM. Perform state board defines as the
tocol (speci~). on the cord.
procedure according to scope of practice, and per-
agency protocol. Palpate forming the procedure Prepare client for emer- Obstruction of fetal gas
for a prolapsed cord after safely. gency cesarean if ordered exchange may require
fluid has escaped. for prolapsed cord or fetal emergency cesarean birth.
distress.
Assess FHR immediately Assessment provides infor-
after amniotomy and mation about fetal oxy-
through the next few con- genation. Prolapsed cord Evaluation
tractions. may be obvious or occult.
(Date/time of evaluation of goal)
Note date and time of Documentation provides
AROM on EFM strip and information about activi- (Has goal been met? not met? partially met?)
in chart. ties affecting fetal condi-
tion during labor.
(Is FHR reassuring? Describe FHT: baseline, vari-
ability, periodic, and nonperiodic changes. Does
Observe color, amount, Assessments provide infor- vaginal exam rule out prolapsed cord after
and odor of amniotic fluid mation about fetal well-
AROM?)
at time of AROM and being: rneconium indicates
during each subsequent stress unless fetus is (Revisions to care plan? D/C care plan? Continue
vaginal exam. breech, blood may indicate care plan?)
abruption, an unpleasant
odor may indicate infec-
tion.
Induction Augmentation
1
cenrical Po
J
readiness? start at
/l
No Yes AROM
0.5 mU/min
1
ce&cd
ripening agents
I
oxytocin f-------l
start at
1-2 mu/&
titrate o ~ o c i n 4
to labor pattern
and fetal
response
INTRAPARTUM 111
Goal: Client will experience a decrease in pain by Explain the medical pain Information empowers the
(date/time to evaluate). relief options available to client to decide between
the client (specify: IV nar- the available options to
Outcome Criteria cotics, epidural, inuathe- meet her individual needs.
cal, etc.). Briefly discuss
Client will report a decrease in pain (specify: e,g., advantages and disadvan-
< 5 on a scale of 1 to 10). Client will not be cry- tages of each option.
ing or grimacing (specify for individual response).
Administer systemic anal- (Specify action and side
gesia as ordered (specify: effects for each drug.)
drug, dose, route, & time).
INTERVENTIONS RAIITONALES
Notify anesthesia care Early notification pro-
Assess client for pain every Assessment provides infor-
provider if client is to have motes timely pain relief if
hour during labor. Note mation about etiology of
regional analgesia. anesthesia provider is not
verbal and nonverbal cues. pain (e.g., contractions,
readily available.
Assess location and charac- perineal stretching, or
ter. Ask client to rate pain uterine rupture.) Rating Monitor maternal and fetal (Specifj. for drugs given:
on a scale from 1 to 10 allows objective quantita- response to medication; e.g., IV narcotics may
with 1 being least, and 10 tive reassessment. observe for adverse effects cause 4 FHR variability.)
being the most pain. (specify for drug).
Accept the clients inter- Pain is a personal experi- Reevaluate clients percep- Timing of pain relief varies
pretation of pain and avoid ence. The expression of tion of pain afier drug has with different drugs and
cultural stereotyping. pain is influenced by cul- taken effect (specify time routes.
tural norms. frame for drug given)
using a scale of 1 to 10.
Explain the physiology of Explanations decrease fear
the discomfort the client is of the unknown and assist Notify caregiver or anes- Pain refief measures need
experiencing (e.g., back the client to cope with dis- thesia provider if measures to be individualized.
labor and OP position, comfort.
INTRAPARTUM 113
(What does client rate pain on a scale of 1 to 10, Raise side rails, place call Interventions promote
bell within reach and safety by preventing rnater-
Is client crying or grimacing? Describe activity.)
instruct client not to get nal falls while sedated.
(Revisions to care plan? D/C care plan? Continue out of bed after receiving
care plan?) narcotic or epidural anal-
gesia.
~ n Risk jfor: M
~ u ~~ e and
~ ~uF~e d~ Reassess clients BiP, P, and Assessment provides infor-
Related to: Effects of drugs used for pain relief R and fetal well-being at mation about clients phys-
expected peak of drug iologic response to drug
during labor and birth.
action (specify for drug). and fetal effects.
Defining Characteristics: None, since this is a Time systemic narcotics to Narcotics given to the
potential diagnosis. avoid respirato~depres- mother should wear off
sion in the newborn (spec- before or peak after birth
Goal: Client and fetus will not experience any ify for individual drug). to avoid respiratory depres-
injury from medications used during labor by sion in the newborn.
(date/time to evaluate).
If client is to receive an Epidural analgesia may J
Outcome Criteria epidural encourage the the sensation of a full blad-
client to void before the der and the ability to void
Clients B/P, P, R remain within normal limits procedure. easily.
(specify a range for client). FHT remain reassur-
Apply continuous EFM Continuous EFM provides
ing and newborn exhibits spontaneous respirations for clients receiving region- information about effects
at birth. al analgesia. Document of analgesia on the fetus.
assessments of fetal well-
INTER~~ONS RATIONALES being per agency protocol.
Assess clients baseline vital Assessment provides infor- Ensure that oxygen, suc- Systemic effects of regional
signs before analgesia mation about individual tion, and resuscitation analgesia may result in life-
administration. baseline to help identify drugs and equipment threatening complications
any adverse drug effects. including bag and mask (respiratory arrest, cardiac
are readily available. d y s r h y ~ m ietc.).
~,
Assess fetal well-being Assessment provides infor-
(FHR, variability, accelera- mation about baseline fetal
tions, or decelerations) status to help identify any Assist anesthesia care Assistance facilitates
before providing analgesia. adverse drug effects. provider to provide epidur- epidural placement.
al or intrathecal analgesia
114 ~ T E ~ ~ I NURSING
N F ~ CARE
T PLANS
Regional Analgesia
local narcotic
anesthetic agents
1
vaginal birth
1
vaginal or labor pain
1
labor pain
tissue repair cesarean vaginal or vaginal birth
birth cesarean birth
This Page Intentionally Left Blank
INTRAPARTUM 117
Nursing Care Plans Provide physical and emo- Client may expend more
tional support to client energy being distressed.
and significant others. Family may also be tired.
Related to:Cephalopelvic disproportion, dystocia, Inform client and signifi- Client and family may
prolonged labor, etc. cant others about expected have unrealistic expecta-
labor progress and realistic rions about labor progress.
Anxiety (97) evaluation of clients labor
pattern.
Related to:Perceived threat to self or fetus sec-
ondary to prolonged labor with lack of progress. Assess for the causes of Assessment provides infor-
failure to progress: powers, mation about possible
Defining Characteristics: Client expresses feelings passenger, passageway, causes and infers solutions
of helplessness and tension, expresses worry about position, and psyche. to the problem of failure
to progress.
fetal well-being (specify, using quotes). Client
exhibits signs of anxiety (specify: e.g., crying, Notify caregiver of lack of Information assists caregiv-
withdrawn, or angry and critical, etc.). progress, clients fatigue er in determining a plan of
and assessment findings. care for client.
118 MATERNALINFANT NURSING CARE PLANS
INTERVENTIONS RATIONALES
of clients request for the instruction and supervised
intervention. practice.
Provide privacy and avoid Therapeutic touch is a very
interruption of the process personal experience. The
(e.g., time labor assess- practitioner needs to focus
ments to promote uninter- on the clients energy field
rupted time for therapeutic in order to facilitate the
touch). flow of healing energy.
Encourage and facilitate Rest promotes harmony
rest after therapeutic touch and balance of energy flow.
is completed.
Evaluate clients verbal and Evaluation provides infor-
nonverbal response to mation about effectiveness
intervention. Monitor of intervention.
labor progress.
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Does client report feelings of relief? Specify using
quotes. Has labor progressed? Specify changes in
dilatation or descent.)
(Revisions to care plan? D/C care plan? Continue
care plan?)
120 MATERNAL-INFANT NURSING CARE PLANS
Failure to Progress
maternal positioning
1 psychological factors
fear, tension
a c k of progress --i
cervical dilatation
and/or
fetal descent
after active labor has begun
Maternal
/ Labor \Fetal
infection distress
exhaustion birth trauma
uterine rupture
post partum hemorrhage
INTRAPARTUM 121
Fetal Distress
Cord Compression Placental Insufficiency Anemia
prolapse +B/P maternal
oligohydraminos hemorrhage fetal isoimmunization
placental infarct
uterine hypertonus /
Fetal Hypoxemia
1
CompensatoryvMechanisms
possible
hypercapnia
tissue hypoxia
1
homeostasis
(+
1
I
0 2 )
anaerobic metabolism
(+lacti acid)
respiratory acidosis
5
metabolic acidosis
(+H+, + PHI (+H+, + PHI
4
Organ r
cell destruction
permanent disability
or death
INTRAPARTUM 125
Abruatio Placentae
Placental abruption is the separation of a normally
Fluid blume Deficit, Risk for (36)
implanted placenta before birth of the baby. The Related to: Excessive losses secondary to prema-
separation may be partial or complete. A marginal ture placental separation.
abruption describes detachment of the edges of
the placenta. Partial separation may also occur in
Impaired Gas Exchange: Fetal (121)
the center of the placenta. With a total placental Related to: Insufficient oxygen supply secondary
abruption the entire placenta detaches. to premature separation of the placenta.
Hemorrhage from the exposed surfaces may be
obvious or occult. The amount can vary from Defining Characteristics: Signs of fetal distress
mild with a marginal abruption to torrential with (specify: loss of variability, late decelerations,
a total separation. Classic symptoms of abruption tachycardia, or bradycardia, etc.) .
are abdominal tenderness and board-like abdomi- Fear (129)
nal rigidity with or without vaginal bleeding. Fetal
prognosis is poor if > 50% of the placenta detach- Related to: Perceived or actual grave threat to
es. Maternal complications include development body integrity secondary to excessive bleeding,
of DIC, hypovolemic shock, kidney or heart fail- and threat to fetal survival.
ure, and increased risk for post partum hemor-
Defining Characteristics: Client verbalizes fare
rhage. The cause is unknown but abruptio placen-
(specify using quotes). Client exhibits physiologic
tae may be associated with hyptertensive disorders, sympathetic responses (specify: e.g., dry mouth,
maternal cocaine use, abdominal trauma, and pallor, tachycardia, nausea, etc.) .
uterine overdistention.
Vaginal delivery may be preferred for a fetal Goal: Client will maintain adequate tissue perfu-
demise or if the fetus is tolerating a partial sion by (dateltime to evaluate).
abruption
Outcome Criteria
Close observation may be employed if the Client will maintain B/P and pulse (specify for
abruption is small, the fetus is immature, and client: e.g., > 100/60, pulse between 60-90), skin
appears stable
126 ~ T E ~ ~ - I NURSING
N F ~ TCARE PLANS
warm, pink, and dry. Urine output > 30 cdhr. INTERVENTIONS RATIONALES
Client will remain alert and oriented. FHR pat-
tern remains reassuring. shunting of blood away
from the peripheral circu-
lation to the brain and
vital organs.
Assess clients Sa02, B R P, Assessment provides infor- Initiate IV access with 18 Intervention provides
and R (specify frequency). mation about clients tissue gauge (or larger) catheter venous access to replace
perfusion. Hypovolemia and provide fluids, blood fluids. Size 18 gauge or
Causes 4 BJP with f P and products, or blood as larger is preferred to trans-
f R as compensatory ordered (specify fluids and fuse blood.
mechanisms for C perfu- rate).
sion and hypoxemia. Monitor laboratory values Laboratory studies provide
Monitor for restlessness, Intervention provides as obtained (e.g., Hgb, information about extent
anxiety, air hunger, and information of developing Hct, cloning studies). of blood foss and signs of
changes in level of con- indications of inadequate impending DIC.
sciousness. cerebral tissue perfusion. Observe client for signs of Observation provides
Monitor all intake and Monitoring provides infor- spontaneous bleeding (e.g., information about the
output (insert foley mation about renal perfu- bruising, epistaxis, seeping depletion of dotting fac-
catheter as ordered). sion and function and the from puncture sites, hema- tors and development of
Evaluate blood loss by extent of blood loss. Partial turia, etc.). DIC.
weighing peri pads or chux abruption may progress Keep client and significant Infor~ationpromotes
(1 gm = I cc). (Specift fre- rapidly to complete abrup- other informed of condi- unde~tandingand cooper-
quency of documentation.) tion. tion and pIan of care. ation.
Notify caregiver of f losses.
Notify caregivers and pre- Continued blood loss or
pare for immediate deliv- development of DIC may
Continuously monitor The fetus may initialfy ery and neonatal resuscita- lead to maternal or fetal
FHR pattern and compare respond to 9 placental tion if maternal or fetal injury or death.
to baseline data from pre- perfusion by raising the
natal record. Inform care- FHR above the normd
giver of nonreassuring baseline. Nonreassuring Evaluation
changes. FHR is an indication for (Datehime of evaluation of goal)
delivery.
(Has goal been met? not met? partially met?)
Assess for uterine irritabili- Assessment provides infor-
ty, abdominal pain, rigidi- mation about severity of (What is clients BIP and P? Is skin warm, pink,
ty, and increasing abdomi- placental abruption.
and dry? Is urine output > 30 cclhr? Is client alert
nal girth (measure Bleeding may be occult
abdomen at umbilicus). causing abdominal rigidity and oriented? Describe FHR pattern.)
{Specifyfrequency.) and pain. (Revisions to care plan? D/C care plan? Continue
Assess clients skin color, Assessment provides infor- care plan?)
temperature, moisture, tur- mation about peripheral
gor, and capillary refill tissue perfusion.
(specify frequency). Hypovolemia results in
INTRAPARTUM 127
Abruptio Placentae
Possible Causes
hypertension
cocaine abuse
trauma
sudden changes in
intrauterine pressure
Margnal central
(symptomsdepend on (symptomsdepend on
degree of separation) degree of separation)
1 4
T
mild to moderate mild to moderate abdominal/ back pain
vaginal bleeding concealed bleeding +abdominal girth
4
> 500/0separation
I
Inform client and signifi- Information promotes a (Hasgoal been met? not met? partially met?)
cant other of things they sense of control over
(Did client and significant other verbalize correct
can do to help (specify: frightening events by
e.g., position changes; allowing client and signifi-
understanding of the emergency? Was client able
keep oxygen mask on; sig- cant other to be involved to cooperate with instructions? Specify.)
nificant other can support in the solutions.
(Revisions to care plan? D/C care plan? Continue
client breathing and relax-
ation, etc.). care plan?)
Prolapsed Cord
Unengaged Presenting Part
SROM/AROM
I
cord precedes
presenting part
+ C02 buildup
respiratory
acidosis
- '
1 +
acute hypoxia
Medical Care
Careful determination of dates: LNMR fundal
A pregnancy that continues to 42 weeks or more
height, serial ultrasound measurements
after the LNMP with fertilization two weeks later,
is considered to be postterm. The postterm fetus is Daily fetal movement counts by client after 40
at higher
- than normal risk for hypoxia,
.~
birth weeks
injury, meconium aspiration, and hyperbilirubine-
Meekly cervical exam, NST and ultrasound for
mia in the neonatal period. The cause of pro-
amount of amniotic fluid; may be 2 times per
longed pregnancy is unknown though some con-
. . .. . . .. week
. . - _-__- - __ 42
after - - weeks
. . - .--_
-genital anomalies are associated with postterm
birth including anencephaly and congenital adren- Other fetal testing possible: BPP or OCT
al hypoplasia. (CST)
Sometimes the date of the LNMP is hard to deter- Induction at 42 weeks if dates are accurate and
mine, or the woman may have had a long men- cervix is favorable
strual cycle in which case the fetus really isnt post-
Uncertain dates: close surveillance with induc-
term even at 42+ weeks.
tion if J( fetal movement perceived by the
The truly postterm neonate has a characteristic mother or 6 amniotic fluid
appearance. The infant appears alert, is long and
Fetal monitoring during labor with scalp elec-
thin with abundant scalp hair and long finger-
trode and possibly IUPC; possible amnioinfu-
nails. The skin may be meconium stained, loose,
sion
dry and peeling, with little subcutaneous fat. No
vernix or lanugo are present. Cesarean birth for unsuccessful induction
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Did infant aspirate meconium?Was any meconi-
um suctioned from the p h a p or trachea? 1s air-
way clear?What is respiratory rate?)
(Revisions to care plan? D1C care plan? Continue
care plan?)
136 MATERNAL-INFANT NURSING CARE PLANS
Postterm Birth
I
t d t WGGJSS
I
macrosomia
4
placental aging
(> 4000 g)
I A
hypoglycemia
1
3
polycythemia chronic
hypoxia
fluid
cord
compression
1
acute
hypoxia
J. subcutaneous
tissues
1
birth
v
hyperbiliru binemia meconium
trauma staining
meconium aspiration
syndrome (MAS)
Precipitous labor Fear (123)
Related to: Perceived threat to self and fetus sec-
ondary to rapid labor progress, possibility of unat-
tended birth.
Precipitous labor is defined as a labor that lasts
three hours or less from start to finish. Precipitous Defining Characteristics: Client verbalizes fear
birth is any birth that happens much b t e r than is (specify using quotes), Client exhibits physi~logi-
normally anticipated. This may result in an unat- cal signs of sympathetic response (specify: e.g.,
tended birth. The fetus may suffer head trauma tachycardia, tachypnea, dry mouth, pallor,
from rapid descent through the birth canal. When tremors, etc.).
the contractions are very intense or tumultuous,
the mother is at risk for lacerations: cervical, vagi-
nal, perineal, periurethral, or even uterine rupture.
Additional Diagnoses and Plans
This w e of rapid intense labor may also be asso- Tissue Integrity, Risk for Impaired
ciated with amniotic fluid embolus or postpartum Related to: ~ e c ~ trauma
a n from
~ ~uterine
hemorrhage. hypertonus and rapid fetal descent.
Clients who are at risk for precipitous labor and Defining Characteristics: None, since this is a
birth are those who have had a previous precipi- potential diagnosis.
tous ~ a b o r / b i r clients
~; with a large pelvis or a
smaif fetus; and cfients with uterine hypertonus. Goal: Client will not experience tissue injury dur-
ing birth.
Outcome Criteria
Close observation of clients with risk factors; Perineum is intact after delivery.
client may be asked to stay close to the hospital
as she reaches term gestation
INTERVENTIONS RATIONALES
Client may be induced if she lives far from the
Palpate contractio~for Assessments provide infor-
hospital frequency, duration, inten- mation about hypertonic
sity, and resting tone (spec- uterine activity and fetal
Tocolytics may be used to decrease the intensity
ify frequency). Assess FHR well-being.
of contractions per agency protocol (speci-
+I-
H u ~ Care
~ nPlans
~ Notify caregiver if uterine Notification provides
resting tone lasts less than information about fetal
Pain (II2) 60 seconds between con- risk. The caregiver may
tractions. elect to use tocolytics to 9
Related to: Tumultuous labor contractions and
resting tone to improve
maternal tension. placental perfusion.
Defining Characteristics: CIient verbalizes acute Stay with the client experi- Staying with the client
pain (specify using quotes or a pain scale). Client encing tumultuous con- avoids an unattended
is (specie: crying, grimacing, etc.).
138 MATERNAL-INFANT NURSING CARE PLANS
Obtain precip equipment. Preparation allows a sterile Provide routine post-deliv- Post delivery care promotes
Notify caregiver of rapid controlled birth by caregiv- ery care to mother and attachment and helps pre-
progress. Wash hands, er. Sterile technique pre- infant per protocol until vent complications.
open precip pack; don vents the introduction of caregiver arrives.
sterile gloves if birth microorganisms during
appears imminent. birth. Evaluation
Encourage client to blow Intervention may help (Datehime of evaluation of goal)
or pant if the urge to push avoid cervical or vaginal
occurs before complete lacerations. (Has goal been met? not met? partially met?)
cervical dilatation.
(Were any lacerations noted after delivery?)
Support the clients per- Gentle counter pressure
ineum as the head crowns. and a slow delivery of the (Revisions to care plan? D/C care plan? Continue
Ask client to blow as the head help prevent rapid care plan?)
head delivers. Suction the expulsion and tearing of
infants nose then mouth. the perineum.
Check for a nuchal cord
and slip over the head or
double-clamp and cut the
cord.
Guide infants body down Guidance during birth
to slide the anterior shoul- helps prevent perineal or
der under the symphysis vaginal tears during deliv-
pubis, then up to deliver ery of the infants shoul-
the posterior shoulder. ders.
Labor e 3 hours
Rapid Birth
1
hypkia lacer&ions
head trauma amniotic fluid embolus
hemorrhage
This Page Intentionally Left Blank
INTRAPARTUM 141
Evaluation
(Date/time of evaluation of goal.)
(Has goal been met? not met? partially met?)
(Does client exhibit any bleeding? What are clot-
ting factor lab values?)
(Revisions to care plan? D / C care plan? Continue
care plan?)
144 MATERNAL-INFANT NURSING CARE PLANS
.
6
Release of Tissue Vascular Endothelial Damage
Thromboplastin sepsis I
1
Extrinsic Pathway
1
Intrinsic Pathway
INTRAVASCULAR
C ~ A ~ U ~ T I O ~
i
9 fibrinogen -+fibrin _I+ 3. fibrinogen levels
J, clotting factors
i fhrombocytopenia
microemboli
'E fibrinolysis
1
vascular occlusion
i
(+ fibrin degradation
ischemia products, FDP -
anticoagulant) Hemorrhage
1
renal necrosis
ARDS
Prostaglandin E, suppositories may be used
before 28 weeks to induce labor
Fetal death after 20 weeks gestation is often Analgesia and sedation is often ordered
referred to as an Intrauterine Fetal Demise
(IUFD) or stillbirth. Causes of fetal demise may
EFM may be applied with the toco only or an
be related to complications of pregnancy such as
IUPC inserted
PIH, diabetes, hemorrhage, a cord accident, or Autopsy to determine cause of death
fetal anomalies. No apparent cause is found in
approximately 25% of cases.
Nursing Care Plans
The mother may notice a lack of fetal movement
and decreased breast size. Fundal height may not
Any of the intrapartum care plans would be
appropriate without interventions designed to
correlate with expected gestational age. Frequently
ensure fetal well-being.
the first sign is an absence of FHT on ausculta-
tion. Fetal death is confirmed by real-time ultra-
sound. Ninety percent of women will sponta-
neously labor and deliver within three weeks of
fetal death. When the pregnancy continues
Injury, Risk f i r
beyond a month, the mother is at risk for devel- Related to: Effects of suppository medications
oping DIC due to the release of tissue thrombo- used to terminate pregnancy with IUFD before 28
plastin. weeks.
The attachment process begins early in pregnancy. Defining Characteristics: None, since this is a
Fetal demise represents an emotionally devastating potential diagnosis.
tragedy for the mother and family. Normal grief
Goal: Client will not experience any injury during
responses that may be noted during labor include
labor or birth.
denial, anger, bargaining, and depression. The
birth of a subsequent baby may be accompanied Outcome Criteria
by renewed grief for the lost child.
Clients vital signs remain stable (specify for client,
give ranges for temperature, B/P, P, and R. EBL <
500 cc after birth.
May wait 2 to 3 weeks if client desires, to see if
labor begins spontaneously INTERVENTIONS RATIONALES
Monitoring of blood clotting factors to avoid Assess TPR,B/P, and con- Assessment provides base-
DIC traction status prior to line information about
insertion of suppository. maternal homeostasis and
Induction with oxytocin if near term and cervix May place toco only of uterine activity.
is favorable fetal monitor or use palpa-
tion to assess contractions.
Use of cervical ripening agents followed by oxy- Explanations help the
Explain procedure and
tocin if cervix is unfavorable expected outcome to client client and significant other
146 MATERNAL-INFANT NURSING CARE PLANS
Ensure that all caregivers Intervention prevents Prepare a memory packet Memory items provide
and auxiliary staff are anguish from well-inten- for the parents. Include tangible evidence of the
aware of the clients loss tioned comments about pictures of the baby, foot- reality of the baby. Clients
(e.g., sign on door). the baby. prints, a lock of hair if may initially reject the
requested, etc. If client packet and then want it
Support cultural grief Grieving is an individual refuses packet, file it safely later (e.g., on the anniver-
behavior of client and fam- process influenced by cul- for future requests. sary of the birth).
ily (e.g., screaming, tearing tural norms that may be
clothes, etc). Provide for very different from the Assist parents to make The hospital may be pre-
privacy if needed and nurses. decisions regarding dispos- pared to dispose of
remain nonjudgmental. al of the remains, transfer remains if under 20 weeks.
to a postpartum or gyn Some funeral homes do
Provide clear explanations Client and significant
room, and early discharge not charge for the services
and instructions. May other may be distracted if possible. to young couples who have
need to repeat informa- and have trouble concen- a stillborn.
tion. trating on information.
Provide information about Information assists client
Encourage parents to talk Encouragement provides the normal grief process to understand feelings that
about the baby and their permission to grieve (written and verbal). may be overwhelming at
feelings about the loss. Use together openly. The use of times.
touch as culturally appro- touch has cultural implica-
priate. tions. Discuss gender differences Discussion facilitates open
in grieving: e.g., the moth- communication between
Allow visitors as client and Intervention promotes er has usually formed a parents to prevent anger or
significant other desire. family support for client
longer attachment to the guilty feelings about differ-
and significant other while fetus than the fither has. ences in grieving.
protecting them from
unwanted guests. Provide age-appropriate Understanding of death
information about helping varies with age. Ensures
Encourage parents to name Naming the baby validates siblings to cope with their that siblings are not for-
the baby if not already the existence and loss of grief. gotten.
done. Refer to the baby by the child.
name. Refer client and significant Support groups may help
other to a grief support client and significant other
Encourage client and sig- Seeing and holding the group (specify for area). to cope with loss.
nificant other to see and baby validates the birth of
hold the baby. Clean and a unique individual and
wrap infant in warm blan- the loss. The infant gener-
Evaluation
ket (may apply lotion or ally doesnt look as bad as
powder to infant). Prepare the parents might imagine (Datehime of evaluation of goal)
parents for how the baby it does. Bathing and dress-
will look and feel (e.g., ing the baby provides an (Has goal been met? not met? partially met?)
bruising, cold, etc.). Point opportunity to parent the (Give example of how client, significant other, and
out attractive characteris- infant before giving it up.
family expressed and shared their grief with each
tics of the baby. Allow par-
ents to bathe and dress other.)
baby if desired.
(Revisions to care plan? D/C care plan? Continue
care plan?)
148 MATERNAL-INFANT NURSING CARE PLANS
Related to: Perinatal loss. Contact the clients spiritu- A spiritual advisor may
al advisor or pastoral care offer support and comfort
Defining Characteristics: Client expresses feelings department if client to the client and family
of rejection, of disturbance in spiritual belief sys- desires.
tem (speci?: e.g,, How could God do this?).
Evaluation
Goal: Client will experience relief from spiritual
(Rateltime of evaluation of goal)
distress by (dateltime to evaluate).
(Hasgoal been met? not met? partially met?)
Outcome Criteria
(Is client able to express feelings about belief sys-
Client will be able to express feelings about belief
tem? Does clienr indicate that spiritual needs are
system and pregnancy loss.
being met? Specify: e,g., talked with pastor,
Client verbalizes that spiritual needs are being memorial service planned, etc.).
met.
(Revisions to care plan? DIC care plan? Continue
care plan?)
PGEz
ripening agents
oxytocin
Emotional Response
(Kubler-RossStages of Grieving)
Denial
Depression
Acceptance
This Page Intentionally Left Blank
POSTPARTUM 151
Cultural Diversity
All cultures have beliefs related to maternalhnfant care after childbirth. The nurse should ask the client about
her individual cultural beliefs to avoid stereotyping. Assessment of the following areas may reveal cultural
prescriptions and prohibitions.
ActivitylRest no activity restriction, rooming-in desirable, rest when the baby does,
father helps at home, PP exercises
avoid rooming-in, someone else cares for baby while mother rests and
regains her strength
bedrest under several blankets for 7 days to 3 months
female relatives or hired women help with baby
activity may be restricted up to 40 days
Nutrition increase calories and calcium for lactation; otherwise, lose weight gained
during pregnancy
eat and drink only foods/liquids considered hot and avoid those considered
cold (not necessarily related to temperature or spices)
special traditional foods may be indicated (e.g., seaweed soup, steak dinner)
Hygiene shower and hair washing as soon as possible
avoid cold air or water; no showers
avoid bathing until lochia stops
dont wash hair for one week; wear head covering for warmth
Safety infant car seat; infant sleeps in crib, not with mother
avoidance of evil influences: no praise of infant, dont touch infants head,
use of talismans/protective objects
infant sleeps with mother, carried close to body
Spirituality infant Baptism/Christening, Bris
naming ceremony (may be named after someone special)
rituals performed by father
.
burial/burning of placenta
Infant Care breast offered at birth, feed on demand, avoid formula supplements
Breast-Feeding colostrum discarded, infant fed sugar-water or honey and water until
milk comes in (3-5 days)
infant dressed in diaper and shirt, loose blanket
infant tightly wrapped, belly-binder applied
Other cigars, flowers, balloons, announcements
men are excluded from birth or contact with lochia
desired visitors include family, friends, neighbors
freely ask for pain medication and information
avoid complaining or showing pain, avoid eye contact
avoid asking questions and bothering the staff
156 ~ T E ~ ~ - I NURSING
N F ~ T CARE PLANS
H&H
bowel movement
I infant care: cord,
bathing, circ. care,
safety,
social services
WIC
Prn
immunizations
4 hours f
B/P,T,P, R,
dsg CDM
fundusJlochia
q4hX2
holding infant
bulb syringe
~ ~ d
pericare
w a ~
I
~ g
sips 8k chips
or DAT with
snacks
8 hours
infant security
I up with
B/P, T,p, R, breast-feeding: rooting, assistance
f~dus/lochi~ l&~~hjn removing,
~-~~,
dsg CD&I frequency, breast care
bowel sounds
Hornans sign, bottle feeding:
breast assessment positioning, burping,
and bonding breast care
9 8h
1860
1 I
2nd PP day i
bladder 4
after void X 2
or until WNL
assess or BM
infant care: cord care
bathing, circ care,
pa. pain meds
o n s prn
safety, ~ r n ~ ~ ~ ~ t i Rubella
lactation
specialist prn
and when to call the doc- activity that leads to an Client may need permis-
tor. Observe client as she increase in the flow of sion to rest.
cares for infant and rein- lochia is a sign that she
force positive attempts. needs to slow down.
Instruct client in breast Information helps the Demonstrate respect for Cultural respect avoids
care. For non-nursing client to avoid activities clients cultural prescrip- conflicts about care that
mothers teach to wear a that may stimulate the tions and prohibitions may make the client feel
snug bra, avoid stimula- breasts and cause increuse:d regarding postpartum care. guilty.
tion of the breasts and to discomfort from engorge-
Teach client about the Knowledge helps the client
use ice packs (frozen peas) ment.
return of menstruation and to understand how her
or mild analgesics as
ovulation. Inform about body works and to make
ordered for discomfort.
the possibility of becoming personal decisions about
Reassure client that dis-
pregnant and assist her to family planning.
comfort should subside in
make contraceptive choic-
a day or two.
es.
Teach breast-feeding Information helps the
Teach client about any Specify action, dose, route,
mothers to wash their client to avoid infection or
medications that are pre- and indications for any
hands before feeding, wash drying of the nipples.
scribed for her after dis- prescribed medications.
their breasts without soap,
charge. Instruct breast- Most drugs distributed by
wear a support bra, and
feeding moms to avoid the blood are also found in
inspect the nipples for pain
taking medications with- the breast milk.
or sores after each feeding.
out checking with the
Teach client to continue Information helps the babys caregiver first.
PW, drink 8-10 glasses of client to plan for adequate
nutrition for recovery from Provide information about Support groups may offer
watedday, and eat a nutri-
and phone numbers for increased information
tious diet. Use the food childbirth. Fresh fruits,
local support groups (spec- about topics of special
guide pyramid to plan a vegetables, and added fiber
help prevent constipation. ify: e.g., La Leche League, interest to the client.
culturally acceptable diet
Mothers of Twins, etc.).
including fresh fruits and Protein and vitamin C
vegetables, fiber, protein, enhance tissue healing. Teach client about use of Information promotes
and vitamin C. Provide Nursing mothers require infant car seat, need for infant safety.
information for breast- extra calories and fluids to follow-up PKU, and infant
feeding mothers about produce milk and meet immunizations.
extra fluids and dairy their own needs.
products needed (specify). Provide written and verbal Information assists the
information about danger client to seek immediate
Teach client to avoid stren- Strenuous exercise may signs to call the primary care for puerperal compli-
uous activity or exercise for cause postpartum hemor- caregiver: fever, chills, f cations.
six weeks. Provide infor- rhage before the placental bleeding, foul smelling
mation from caregiver site is healed. Exercise lochia, 9 incision, breast
about postpartum period helps the clients body or leg pain, wound dehis-
exercises. return to its pre-pregnancy cence, or burning on uri-
shape. nation.
Encourage client to obtain Client may try to do too Observe clients self-care Observation provides
adequate rest during the much, delaying healing and infant care ability dur- information about clients
puerperium. Teach her that and risking exhaustion.
POSTPARTUM 163
INTERVENTIONS RATIONALES
ing hospitalization. Refer ability to care for herself
client for additional assis- and her baby after dis-
tance as needed (specify: charge. Referral provides
e.g., home visit). additional education.
Discuss the need for Rh Rh-negative clients should
immune globulin understand the need for
(RhoGAM) with Rh nega- Rh immune globulin after
tive clients. Provide blood miscarriage or birth of an
type card. Rh-positive baby to pre-
vent isoimmunization of
future infants.
Review and reinforce all Intervention promotes
teaching at discharge. access to continued infor-
Provide client with a mation after client is dis-
phone number to call for charged.
questions after she gets
home.
Evaluation
(Date/time of evaluation of goal)
(Has goal been met? not met? partially met?)
(Does client verbalize understanding of self-care
and infint care information? Does client demon-
strate psychomotor skills needed for self- and
infant care? Specify.)
(Revisions to care plan? D/C care plan? Continue
care plan?)
This Page Intentionally Left Blank
POSTPARTUM 165
Related to: Excessive fluid losses secondary to Wash hands before and Interventions help prevent
&er caring for client; use the spread of pathogens
operative delivery. Inadequate intake for needs.
gloves when indicated; between staff and patients.
Spiritual Well-Being: don't share equipment
with other units.
Enhanced Potential for (I 60)
Assess client's temperature, Assessment provides infor-
Related to: Life-affirming experience of giving B/P, P, and R (specify fre- mation about developing
birth. quency). Notify caregiver infection: temperature may
if temp is 100.4" F after be slightly f early due to
Defining Characteristics: Describe client and sig-
the first 24 hours, or if dehydration from labor.
nificant other's response to birth (e.g., quotes pulse is consistently > l o o . Slight J, P is common
related to spiritual dimension of the experience). after birth and tachycardia
Specie nurturing and loving behaviors of client may indicate infection.
and significant other towards infmt. Teach surgical clients to Teaching helps gain client
Knowledge Deficit: TCDB and encourage compliance to prevent pul-
ambulation. Instruct in leg monary stasis that may
InfAlnt and Self-care (IGI) exercises while in bed. lead to infection.
Related to: Limited experience with infant and Assess dressings or inci- Assessment provides infor-
self-care (specify: e,g., first baby, first cesarean sions (specify frequency) mation about developing
birth, etc.). noting if dressing is clean, infection: Local inflamma-
dry, and intact, if incisions tory effects cause redness
Defining Characteristics: Client expresses lack of exhibit redness, edema, and edema. This may be
knowledge about self- and infant care after birth ecchymosis, drainage, and followed by purulent
(specify). Client verbalizes incorrect information approximation (REEDA). drainage and wound dehis-
about self- or infant care (speci?). cence.
Assess client for increased Assessment provides infor-
Additional Diaanoses and Plans abdominal tenderness dur-
ing fundal checks. Instruct
mation about inflamma-
tion of the endometrium.
Infection, Risk for client to report continuous
pelvic pain.
Related to: Site for microorganism invasion sec-
ondary to childbirth and/or surgical interventions.
166 MATERNAJ,.,-INFmTNURSING G4R.E PLANS
Note color, odor, and con- Foul smelling or purulent before each use or use individual tubs prevent
sistency of lochia. Instruct lochia signals infectious individual disposable tubs. cross-contamination.
client to report foul- processes. Lochia has a
smelling lochia. characteristic odor some-
Maintain a clean environ- A clean environment may
ment. Ensure that clients discourage the growth of
what like menstrual dis-
room and bathroom are microorganisms.
charge.
cleaned frequently and
Provide catheter care per Interventions keep the appropriately.
agency protocol. Keep opening to the urethra
catheter bag below the clean, prevent urine back-
level of the bladder and off flow and contamination of Evaluation
the floor. Use aseptic tech- catheter bag. (Datehime of evaluation of goal)
nique to obtain specimens.
Teach client to perform Teaching helps client keep
(Hasgoal been met? not met? partially met?)
peri care after elimination the perineum clean and (What is clients temperature? pulse?Are incisions
and to change peripads fre- dry. Warm, moist environ-
dry and intact, edges well-approximated, without
quently, applying snugly ment facilitates the growth
from front to back. of microorganisms.
redness or edema, no foul-smelling lochia or
pelvic pain?)
Encourage client to void Postpartum diuresis may
every 4 hours. Assess blad- cause over-distention or (Revisions to care plan? D/C care plan? Continue
der emptying (speciQ fre- incomplete emptying of care plan?)
quency). Catheterize only the bladder. Urinary stasis
as needed employing ster- provides a medium for Pain
ile technique. Instruct growth of microorganisms.
client to report any burn- Burning and pain are signs Related to: Tissue trauma secondary to surgery,
ing or pain with urination. of inflammation associated perineal trauma from vaginal birth, uterine invo-
with UTI. lution; engorged breasts,
Obtain specimens as Laboratory examination of Defining Characteristics: Client complains of
ordered (specify: e.g,. urine specimens is indicated to pain (specify using quotes). Client rates pain on a
specimens, wound cul- determine the causative
scale of 1 to 10 (specify). Client is grimacing,
tures). Monitor lab results. organisms and their sensi-
tivity to antibiotics. guarding painfiil area, etc. (specify).
Inspect IV sites per agency Inspection provides infor- Goal: Client will experience a decrease in pain by
protocol. Note redness, mation about the develop- (dateltime to evaluate).
warmth, pain, or edema. ment of inflammation and
Discontinue or change site infection at invasive sites. Outcome Criteria
as indicated.
Client rates pain as less than (specify) on a scale of
Administer antibiotics as Specify action of each drug 1 to 10 with 1 being least, 10 being most. Client
ordered (specify: drug, given. appears calm, no grimacing or guarding of area.
dose, route, times).
Administer appropriate Specify action of specific Teach client to perform Kegel exercises promote
pain medication as ordered drug and rationale for Kegel exercises (suggest perineal circulation and
(specify: drug, dose, route, choice. frequency). healing.
times). Teach client correct use of Specify action of medica-
Assess client for pain relief Assessment provides infor- products ordered for relief tions ordered.
within an appropriate time mation about clients of episiotomy or hemor-
afcer medication adminis- response to peak levels of rhoid pain (specify: e.g.,
tration (specify for drug). drug. anesthetic ointments,
sprays, or witch hazel
Observe client for adverse Observation allows early pads).
effects of drug (specify for detection and treatment of
drug given). adverse effects. Teach client to eat fresh Teaching provides infor-
fruits and vegetables, and mation the client needs to
Instruct clients receiving Pain medication is more whole grains daily and to make diet decisions that
regular pain medication to effective and lower doses drink 8-10 glasses ofwater. will help prevent constipa-
ask for the drug before are needed if given before Administer stool softeners tion. Stool softeners help
pain becomes unbearable. pain becomes severe. as ordered (specify). decrease pain from bowel
movements when client
Teach client about the Knowledge may +b the
has a 4th laceration or
physiology of her discom- anxiety associated with
episiotomy.
fort (specify for client: e.g., unfamiliar pain.
afier-pains when breast- Encourage ambulation as Ambulation decreases
feeding are caused by stim- soon as possible after birth. venous stasis. Venous stasis
ulation of oxytocin release Evaluate client for develop and I platelets at birth
and uterine contraction). ment of pain in the lower lead to potential develop-
extremities (Homans sign). ment of thrombophlebitis.
168 MATERNAL-INFANT NURSING CARE PLANS
INTERVFiNTIONS RATIONALES
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(What does client rate pain on a scale of 1 to lo?
Does client appear calm? Is client grimacing or
guarding body areas?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
POSTPARTUM 169
INTERVENTIONS RATIONALES
Client identifies priority activities that she will Discuss situational factors Discussion helps client and
focus on during the postpartum period. Client that increase fatigue (e.g., family identify factors that
small children to care for, increase fatigue.
and family identify tasks that family members will
lack of social support sys-
be responsible for. tem, beliefs about house-
keeping, difficult-to-con-
sole infant, etc.)
INTERVENTIONS RATIONALES
Assist client and family to The family may have
Assess clients current rest Assessment provides infor- identify strengths they can unexpected resources and
and activity patterns. mation about adequacy of use to cope with current strengths. Reassurance
clients rest and activity increased demands. helps decrease anxiety and
pattern. Reassure family that associated fatigue.
expressed feelings are com-
Assist client to identifjr pri- Client may be too tired to mon and that most fami-
mary cause of fatigue (e.g., identifjr primary problem lies adjust by 6 weeks post-
worry, lack of sleep at without some assistance. partum.
night, etc.).
Assist client and family to Identification of priorities
Discuss physiologic factors Understanding the physio- identify priority activities helps the family to deter-
that increase fatigue during logic basis of fatigue helps (e.g., mother and infant mine essential and non-
the puerperium: long the client plan self-care care, eating, sleeping) and essential tasks.
labor, cesarean birth, epi- activities to J, fatigue. those which may be
siotomy pain, and anemia. delayed (e.g., cleaning,
Assess client for postpar- Excessive bleeding may social responsibilities).
tum complications; exces- cause anemia and fatigue Assist client and family to Delegation allows the
sive bleeding or signs of related to insufficient identifjr tasks that each client to focus only on
infection: fever, malaise, hemoglobin. Signs of member can be responsible essential activities.
redness, edema, purulent infection also include for (specify for ages of
drainage from incisions, fatigue. children).
pelvic pain or foul-
smelling lochia. Notifj. Encourage the client to Encouragement gives the
caregiver. rest or sleep when the client permission to nap
infant is sleeping. frequently.
Help client express frustra- Facilitating expression of
tion related to infant care feelings validates the Teach relaxation tech- Anxiety produces increased
and fatigue. Provide emo- clients experience. niques, mental imagery, or psychological demands and
tional support and reassur- meditation to help cope reduces energy.
ance. with tension.
Assess client for signs of A short-lived period of Assess current diet and Poor nutrition and dehy-
postpartum blues or depression accompanied by encourage client to ingest dration add to feelings of
POSTPARTUM 171
INTERVENTIONS RATIONALES ty. Client and partner will identify ways to meet
-~
sexual needs during the puerperium.
~
Outcome Criteria Reinforce the understand- Client may believe that she
ing that subsequent preg- cant get pregnant if shes
Client and partner will verbalize understanding of nancy is possible even breast-feeding or until
postpartum physiologic changes affecting sexuali-
POSTPARTUM 173
INTERYENTIONS RATIONALES
before the first postpartum menstruation returns.
menses begin.
Provide contraceptive Clienr may need informa-
counseling as indicated. tion about contraceptive
options.
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Did client and partner verbalize understanding of
postpartum physiologic changes affecting sexudi-
ty? Have client and partner identified ways to
meet sexual needs during the puerperium?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
This Page Intentionally Left Blank
POSTPARTUM 175
Breast-Feeding Contraindications
Maternal cytomegalovirus, chronic hepatitis B,
Lactation is a normal physiologic process that pro-
or HIV infection
vides optimum nutrition for the infant. The hor-
mones of pregnancy prepare the breasts for lacta- Maternal need for medications that may
tion. The process is completed when the placenta adversely affect the infant (the mother may
separates and there is an abrupt drop in estrogen pump her breasts for the duration of drug ther-
and progesterone. This allows the unobstructed apy and resume breast-feeding later)
influence of prolactin to stimulate milk produc-
tion. Oxytocin is released by the posterior pitu-
itary gland in response to suckling. This hormone
Advantages
causes contraction of the uterus (enhances involu- human milk is 95% esciently used by the
tion) and the myoepithelial cells in the breast alve- human infant: breast-fed infants experience less
oli. Milk is then released into the ducts and sinus- constipation and gas than bottle-fed infants
es and ejected from the nipples. This is known as
nursing accelerates uterine involution and loss
the let-down reflex. The infants cry or even just
of weight gained during pregnancy
thinking about the infant may stimulate the reflex.
If the mother is very tense and anxious, the let- children who were breast-fed have higher I Q
down reflex may be inhibited causing frustration scores
for both infant and mother.
breast-fed infants have fewer allergies
Colostrum is a clear yellow secretion produced by
breast milk is free, warm, sterile, and always
the breasts for the first four or five days after
available
birth. It is gradually replaced by production of
mature breast milk. Colostrum contains antibod-
ies that may protect the infant from parhogens. In Disadvantages
some cultures colostrum is thought to be
the mother may feel tied to the infant in the
unhealthy for the newborn and is discarded.
early puerperium while supply is being estab-
O n the 3rd or 4th day after birth the mother may lished
notice breast discomfort associated with venous
leaking breasts
and lymphatic engorgement accompanying the
start of lactation. This usually subsides within 24- need to plan ahead to pump breasts when the
48 hours. Frequency of nursing has a direct effect mother will not be available for feedings
on the level of prolactin released and therefore on
the amount of milk produced. Most women will
be discharged from the hospital before milk pro-
Nursing Care Plans
duction begins. Anticipatory guidance and follow- iritwl Wefl-Being, Enhanced Potential
up may be needed to ensure success. g r (160)
Related to: Life-affirming experience of success-
fully breast-feeding a newborn infant.
176 MATERNALINFANT NURSING CARE PLANS
INTERVENTIONS RATIONALES
Evaluation
Assess clients weight, Assessment provides infor-
weight gain during preg- mation about clients (Date/time of evaluation of goal)
nancy, and ideal weight. weight and individual
(Has goal been met? not met? partially met?)
Calculate caloric require- caloric needs (2500 to
ments for lactation (usual- 3000 calories for lacta- (Did client verbalize the caloric and food guide
ly 500 kcal over regular tion). pyramid requirements for good nutrition while
dietary needs).
breast-feeding her baby? Did client plan to eat
Assess clients usual intake Assessment provides infor- appropriate nutrients? Specify)
using 24-hour diet recall. mation about current
intake, (Revisions to care plan? D/C care plan? Continue
care plan?)
Provide client with written Written instruction allows
and verbal information client to review material Breast-Feeding, Inefectiue
about daily nutrient and once she is discharged. For
caloric needs during lacta- illiterate clients, materials Related to: Specify (e.g., maternal anxiety/insecu-
tion: PNV, 4 servings pro- may be in picture format. rity/ambivalence, or discomfort, ineffective infant
tein, 5 servings dairy (I Individual instruction pro- sucking/swallowing secondary to prematurity, cleft
quart milk), 2-3 servings motes compliance.
lip/palate, etc.).
fruit (2 vitamin C-rich), 2-
3 servings vegetables ( 1+
green leafy), 2-3 quarts flu-
ids.
178 MATERNAL-INFANT NURSING CARE PLANS
God: Client and infant will demonstrate effective Describe the feedback loop Understanding the rela-
breast-feeding by (date/time to evaluate). of milk production and tionship between milk
suckling. Inform client supply and infants suck-
Outcome Criteria that infant will need to ling empowers the client to
nurse often (q 1 to 3 hr) at evaluate frequency of
Client will identify actions to promote effective first in order to build up breast-feeding.
breast-feeding. Infant will latch-on correctly and milk supply. The infant Anticipatory guidance
nurse for 10 minutes. may need to nurse more related to growth spurts
frequently later during helps the client feel secure
growth spurts at 2 and 6 about her milk supply.
INTERVENTIONS RATIONALES weeks, then again at 3 , 4 ,
and 6 months of age.
Offer to assist client with Offering assistance obtains
breast-feeding. permission to assist client. Teach client that the infant Understanding the physi-
will empty a breast within ology of breast-feeding
Assess clients beliefs, pre- Assessment provides infor- 10-15 minutes. The client promotes self-confidence
vious experience, knowl- mation to help plan assis- may chose to alternate and decision making about
edge, and role models for tance. Lack of knowledge breasts once or more often method for breast-feeding.
breast-feeding. or support for breast-feed- during each feeding. The
ing may interfere with hind milk or last milk in
clients ability to succeed. the breast contains ? fat
content to promote
Provide for privacy and a Anxiety and embarrass-
growth.
calm, relaxed atmosphere. ment interfere with learn-
Reassure client that breast- ing. Reassurance helps Describe and demonstrate Demonstration increases
feeding is a natural activity client to believe in the wis- her infants reflexes that clients understanding of
in which her body is pre- dom of her body. facilitate breast-feeding infant reflexes that pro-
pared to engage. (rooting, latching-on). mote effective nursing.
Teach client that relaxation Teaching helps client Assist client to get herself Client may benefit from
is necessary for effective understand that infants and infant into a comfort- suggestions about infant
breast-feeding. Describe respond to their mothers able position for nursing and self-positioning to
how the infants behavior emotional state and ten- with infants body flat avoid fatigue and promote
and the let-down reflex sion level. Maternal ten- against hers: tummy-to- correct latching-on.
are affected by her emo- sion and emotional upset tummy.
tions. inhibit the let-down
reflex causing frustration Teach client that the infant Teaching provides infor-
for the infant. needs to have most of the mation about breast-feed-
areola in his mouth in ing technique to avoid
Instruct client about com- Comfort promotes relax- order to empty the milk complications.
fortable positions for ation. Nursing stimulates sinuses and avoid nipple
breast-feeding. Suggest she thirst and the client soreness.
keep a glass of water close shouldnt interrupt feeding
POSTPARTUM 179
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Did client identifjl actions to promote effective
breast-feeding? Speci9. Did infant latch-on cor-
rectly and nurse for 10 minutes?)
(Revisions to care plan? DIC care plan? Continue
care plan?)
POSTPMTUM 181
Breast-Feeding
birth and
placental separation
t prolactin release
milk production
I
4
infant suckling
.t
t involution 1
infant satiety
1
4-sucking
1
L mi& production
This Page Intentionally Left Blank
POSTPARTUM 183
Defining Characteristics: Client or significant Observe client and signifi- The fight or flight sym-
cant other for signs of dis- pathetic response may
other state (specify: e.g., Im scared; Whats tress: pallor, trembling, indicate f fear. Emotional
wrong with my baby? etc.). Client and signifi- crying, etc. Provide emo- support helps the client
cant other demonstrate physical signs of fear tional support. and significant other to
(specify: e.g., sympathetic response: pale, f P, cope.
f R, dry mouth, nausea, etc.). Encourage significant Significant other provides
other to remain with support during a stressful
Goal: Client and significant other will cope with
client. period. Allows understand-
fear while emergency interventions are being ing of events.
employed.
Allow expression of feel- Intervention shows respect
Outcome Criteria ings (helplessness, anger). for clients experience and
Support cultural variation cultural expression of emo-
Client and significant other can identify the in emotional expression. tion.
threat. Client is able to cooperate with instruc-
Inform client and signifi- Information allows client
tions from caregivers.
cant other when crisis has and significant other to
INTERVENTIONS RATIONALES passed. Provide informa- reevaluate their feelings
tion about what will hap- and consider what to
Inform client and signifi- Calm information 4 fears. pen next. expect next.
cant other of a problem as It is more frightening to
sense that something is Praise client and signifi- Praise enhances self-
soon as its identified.
wrong than to know what cant other for their coop- esteem. Intervention shows
Speak slowly and calmly.
eration and coping during that the clients abilities are
it is.
a stresshl event. valued.
Describe the problem in Simple explanations are
less frightening than com- Visit client after birth Visiting the client after the
simple terms and what
plicated physiology or (specify when: e.g., 1st or crisis has passed provides
interventions might be
medical terminology the 2nd PP day) to discuss an opportunity to relive
expected (specify: e.g., for
client may not understand. events surrounding birth. the experience and fill in
hemorrhage the nurse will
Clarify any misconceptions any gaps in understanding
start another W, massage
about the emergency or before discharge.
the hndus; the neonatolo-
complication.
gist is resuscitating the
baby, etc.).
Explain all equipment and Explanation promotes
procedures as theyre being understanding of unfamil-
done (specify: e.g., foley iar interventions.
catheter, W,ambu bag and
mask, etc.).
186 MATERNALINFANT NURSING CARE PLANS
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Did client and significant other verbalize correct
understanding of the emergency? W as client able
to cooperate with instructions? Specify)
(Revisions to care plan? D/C care plan? Continue
care plan?)
POSTPmTUM 187
Postpartum Hemorrhage
Risk Factors
Birth Trauma
+
uterine atony
retained placental
or membrane
vaginal
cervical
+
coagulation defects
I 1
lacerations
- fraTts
large hematomas
fluid replacement
transfusion
blood and
blood products
This Page Intentionally Left Blank
POSTPARTUM 189
common procedure in the United Stares. Related to: Tissue m u m a secondary to (specify:
Mediolateral episiotomy is an incision from the e.g., operative obstetrics, vaginal birth).
midline of the posterior vagina and extends at a
45" angle to either left or right. ~ediolateralepi- Defining Characterisiks: Client reports pain
siotomies provide more room without danger of (specifj, toation and severity based on a scale of I
extension into the rectum. They bleed more and to 10). Client exhibits grimacing, crying, reluc-
cause greater discomfort postpartum than midiine tance to move affected area, etc. (specify).
episiotomies. Infiction, ~ i s (165'
k ~ ~
Lacerations of the perineum or vagina may occur Related to: Site for organism invasion secondary
during birth. This is more common in nulliparas to (specify: e.g., episiotomy, lacerations, etc.).
and young clients, when an episiotomy has been
done (extension), or the client has a vacume
extractor or forceps-assisted birth, Additional Dia~n~ses
a ~ Plans
d
~~~~~~ i in^^^^ ~~~~~~ Ahmd
Related to: Diminished bladder tone and sensa-
1st degree: laceration through the skin and tion secondary to (spec+: e.g., childbirth trauma;
mucous membrane only anesthesia; periurethral edema).
Assess for bladder disten- Assessment provides infor- Inform client about post- Information empowers the
tion whenever h n d d mation about bladder dis- partum diuresis and client to care for self with
height is checked after tention. diaphoresis. Reassure client an understan~ngof puer-
childbirth. that Ip urine output is peral physiology. Frequent
expected and that she voiding prevents urinary
Encourage client to void A distended bladder inter- shouldnt delay voiding. stasis, which provides a
every 2 to 3 hours after feres with uterine contrac- medium for infection.
birth. Provide for privacy, tion and may cause hern-
assist client to bathroom if orrhage (atony). Teach client the signs and Teaching ensures that the
possible, or to sit on bed- Interventions may stimu- symptoms of urinary tract client will recognize signs
pan, run water, pour watm late micturation. Client infection to report to care- of developing infection
water over perineum, etc. should void at least 100 cc giver: frequency, urgency, and seek appropriate med-
Measure amount voided each time. burning or pain with uri- icd care.
until normal pattern is nation.
established.
Monitor intake and output Monitoring intake and Evaluation
(specilFy frequency). output provides inforrna-
tion about expected diure- (Datehime of evaluation of goal)
sis and bladder emptying. (Has goal been met? not met? partialIy met?)
Assess for bladder disten- Assessment provides infor-
tion after each voiding mation about bladder
(Does client demonstrate ability to empty bfadder
until the client demon- emptying. Bladder tone every 2 to 4 hours? Does client verbalize signs and
strates ability to empty and sensation may return symptoms of UTI to report?)
bladder completely. slowly after childbirth.
(Revisions to care plan? D/C care plan? Continue
Catheterize, using sterile Catheterization relieves care plan?)
technique, clients who bladder distention when
have a distended bladder client is unable to void. ~ o ~ s Ris~k f i ~r ~ ~ o ~ ,
and are unable to void, or Sterile technique avoids
have not voided within 4 introduction of microor- Related to: Decreased muscle tone and GI motili-
hours &er birth. ganisms into the bladder. ty after childbirth, dehydration, fear of discomfort
secondary to episiotomy, lacerations, or hemor-
Reassess client in 2 hours Retention catheter pre-
and if still unable to void, vents bladder distention in rhoids.
insert a retention (foley) clients who have not
God: Client will obtain relief from constipation
catheter as ordered. regained bladder sensation
and tone. by (datehime to evaluate).
Administer antibiotics as Caregiver may order Outcome Criteria
ordered by caregiver (speci- antibiotics to avoid urinary
fy: drug, dose, route, and tract infection. {Specify
Client has an adequate bowel movement. Client
times). action of drug.} verbalizes u n d e r s r ~ d i n gof need for fiber and flu-
ids in her diet.
Teach client to wash hands Teaching provides infor-
before and after using the mation the client needs to
bathroom and to wipe and avoid the introduction of
apply peripads front to pathogens into the urinary
back. tract.
~U~~~~~~ 131
Evduatian
(Dadtime of evduarion of goal)
(Has god been met? not met? parrialfy mer?)
192 MATERNALINFANT NURSING CARE PLANS
~FetlHead\isio
perineal stretching
lubrication and
unassisted
spontaneous midline or mediolate ral
SUPPOfi
+
delivery of head
between contractions
4
lacerations
possible
I
I I
lacerations extension
?
? bleeding
t pain
3rddegree
4
4* degree
P~STP~TU~ 193
Promote sleep and rest by Rest is necessary ro pro- Make referrals as needed Client may need addition-
scheduling nursing care to mote healing, Much nurs- (specify: e.g,, social ser- al help to parent effective-
avoid interruptions (sped- ing care can be resched- vices, counsding, parent- IF
uled. ing groups),
$)*
Provide opportunities far The mother and baby need
the client to see and hold opportunities to engage in Evaluation
her baby. Provide photos the attachment process. (Datehime of evaluation of goal)
and encourage phone calls
if i n h t is restricted to (Has goal been met? not met? partially met?)
nursery
(Does client make eye contact with infant? Does
Role model infant care and Client may nor have expe- she touch and talk to her baby?Does diem report
appropriate parenting rienced appropriate moth-
behaviors when i n h t is in ering behaviors. Noting
the desire to care for her infmt?)
room. Point out positive infants features and {Revisions to care plan? D/C care plan? Continue
features and infant responses facilitates attach-
care plan?)
responses to sensory stimu- ment.
lation.
POS~~TUM 195
Puerperal Infection
Normal Vaginal Bacteria
Bacteria deposited by
vaginal exams
internal monitoring
1
ruptured membranes
1
bacterial &oliferation
and colonization
tissue invasion
metritis
myorietritis
1
parasketritis
(pelviccellulitis)
septic peivic ~ r o m ~ p ~ e b i t i s
-i
pelitonitiS
This Page Intentionally Left Blank
POSTPARTUM 197-
Venous Thrombosis -
SVT DVT
more common more common with
The formation of blood clots in either superficial with history of history of thrombosis
(SVT) or deep veins (DVT) is a potential compli- varicosities femoral vein, pelvic
cation of childbirth. The term thrombophlebitis saphenous vein most veins symptoms
refers to thrombus (clot) formation due to inflam- common begin around 10 days
mation of the veins, as in septic pelvic throm- postpartum
symptoms begin
bophlebitis. Emboli are clots that have detached fever, chills, pale,
3-4 days postpartum
from the vein wall and travel through the blood- cool, edematous leg:
stream. Pulmonary embolism describes the situa- local heat, and
redness along milk leg
tion when a clot lodges in the pulmonary artery.
Complete occlusion of the artery results in severe vein positive Homans
respiratory distress and death. tenderness, firmness sign pain: foot,
or bumps along vein leg, inguinal, pelvic
Puerperal p h y s i o l o ~that predisposes to thrombus
formation includes increased clotting factors and
platelets, decreased fibrinolysis, and release of Medical Care
thromboplastin from the placenta, membranes,
Pulmonary Embolism
and decidua.
Respiratory support: oxygen
Medications: IV heparin, streptokinase, and
others
venous stasis: immobility
surgical embolectomy
history of thrombus formation
varicose veins, heart disease, hemorrhage,
SVT DVT
anemia bedrest with elevation strict bedrest with
of leg above heart elevation of legs above
traumatic birth
support hose heart
puerperal infection heat application application of moist
maternal obesity, advanced age, grand analgesics prn heat
muitiparity Medications: IV
heparin gradually
converted to warfarin,
Signs and Symptoms analgesics, antibiotics
Pulmonary Embolism if pyrexic
Serial clotting studies:
sudden onset respiratory distress: dyspnea, PT, PTT
tachypnea, cough, rales, hemoptysis, chest pain, gradual return to
tachycardia, diaphoresis, pallor, cyanosis, feel- ambulation with sup-
ings of impending doom port hose
Discharged on war-
farin ( ~ o u m a ~ i n }
198 MATERNAL-INFANT NURSING CAW- PLANS
N ~ ~ i fCare
l g Plans
k s s clients vls and Assessment provides infor-
lower extremities for color, mation about the develop-
Related to: InGammation and ischemia secondary temperature, edema, and ment of superficial or deep
tenderness (Womans sign) vein thrombosis.
to phlebitis.
q 8h.
Defining Characteristics: Client reports pain in Instruct client to maintain Elevation of legs facilitates
affected extremity {specify using quotes and a pain bedrest with legs elevated venous return. Rest and
scale). Positive Homans sign (specify extremity). as ordered {specify). Avoid avoiding massage 1 activi-
massaging aected feg. ties rhat might lead to
~ ~ ~ 0 ~ ~ s
Related to: Perceived threat to biologic integrity Maintain warm, moist Heat catfses vasodilatation
secondary to risk for pulmonary embolism. heat to affected leg as and f circulation to area
ordered. to resolve thrombus faster.
Defining Characteristics: Client expresses feelings
of appreh~nsion(specify). Client is (specify: e.g., Observe client for signs of Observation helps identify
pulmonary embolism. pulmonary embolism early.
restless, tense, crying, etc.). Notify physician and pro- Respiratory support may
Purmgkgi Risk for Al..med (19.3) vide respiratory support, help if the embolus is not
occluding the pulmonary
Related to: Interruption of bonding process sec- artery.
ondary to maternal illness. Administer anticoagulant Specie action of individ-
medications as ordered ual drug. ~ t i c o a ~ u I a n ~ ~
Additional Diagnoses and Plans (specify: e.g., drug, dose,
route, and times).
prevent further thrombus
formation while the body
Injary, Risk for naturally dissolves the clot.
Related to: Venous obstruction, anticoagulant Monitor lab values. Inform Usual range for APPT dur-
physician before giving ing heparin therapy is 1.5
medications, risks for embolism. heparin if APPT is outside to 2.5 times normal.
Defining Characteristics: None, since this is a of range (specify}. Longer times may indicate
risk of hemorrhage.
potential diagnosis.
Keep antidotes to antico- Antidotes reverse the
Goal: Client wiIl not experience any injury by agulant drugs available: effects of anticoagulant
(dateitime to evaluate). protamine sulfate for medications and decrease
heparin, vitamin K for the risk of hemorrhage.
Outcome Criteria war &in,
Clients leg doesnt exhibit pain, pallor, redness, or Closely monitor client for Abnormal bleeding may
edema. Bilateral pedal pulses are equal. No signs signs of abnormal bleed- indicate excessive anticoag-
of respiratory distress: dyspnea, tachypnea. Client ing: bleeding gums, easy ulant therapy.
doesnt experience abnormal bleeding: bleeding bruising, epistaxis, or
hematuria. Assess stools for
gums, bruising, petechiae, or hematuria.
occult blood as indicated.
POSTPARTUM 199
Management of Therapeutic Regimen, Teach client about her Anticoagulant drugs may
Inefective medications: (specify: e.g., have serious adverse effects
warfarin, heparin, antibi- if taken improperly. Client
Related to: Insuficient understanding of condi- otics), dose, route, time, should not take other
tion and therapeutic regimen. drug interactions, need for drugs including OTC
follow-up lab tests, excre- without checking with
Defining Characteristics: Client verbalizes desire tion in breast milk, etc. caregiver.
to learn about condition and manage own care Inform client about risks Early identification of
(specify). of bleeding with anticoag- abnormal bleeding allows
ulants and signs and symp- prompt administration of
Goal: Client will manage therapeutic regimen
toms to report immediate- the antidote.
effectively by (date/time for evaluation).
ly.
Outcome Criteria If client is taking warfarin, Ingestion of large amounts
teach about dietary sources of vitamin K may 4 the
Client describes factors contributing to and of vitamin K (green, leafy effectiveness of warfarin.
actions she can take to avoid venous thrombosis.
200 MATERNAL-INFANT NURSING CARE PLANS
INTERVENTIONS RATIONALES
vegetables) and possible
effects on drug therapy.
Evaluation
(Date/time of evaluation of goal)
(Has goal been met? not met? partially met?)
(Does client describe factors contributing to and
actions she can take to avoid venous thrombosis?
Does client relate intent to comply with therapeu-
tic regimen?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
POSTPARTUM 20 1
Venous Thrombosis
Risk Factors
vessel trau
superficial
saphenous vein
deep
femoral vein
1
pelvic veins
1
high risk
PUbnarY
embolism
This Page Intentionally Left Blank
Hematomas Administration of blood and clotting factors if
indicated
A hematoma forms when injury to a blood vessel Laparotomy with ligation of hypogastric artery
allows bleeding into adjacent tissues. Hematomas or possible hysterectomy for severe hemorrhage
sustained as a result of birth trauma are usually
small but they may be large enough to result in
life-threatening hemorrhage. Puerperal hematomas
Nursing tare Plans
commonly develop in the vulvar, vulvovaginal, Fluid Volume Deficit, Riskfor (159)
vaginal (at the level of the ischial spines), or
Related to: Excessive losses secondary to disrupted
retroperitoneal areas.
vasculature.
The primary symptom of a hematoma is constant
pain that may be severe. Other symptoms include
Pain (I66)
rectal pressure or difficulty voiding. Abdominal Related to: Ischemia and edema secondary to
pain with increasing girth and unexplained signs blood vessel trauma.
of shock may result from a large retroperitoneal
Defining Characteristics: Client reports discom-
hematoma.
fort (specify location, type, and severity using a
pain scale). Client exhibits (specify: e.g., guarding,
Risk Factors grimacing, moaning, etc.).
obstetrical interventions: episiotomy, puden-
dal block, forceps delivery Aclditional Diagnoses and Plans
genital varicose veins Anxiev
precipitous birth Related to: Perceived threat to self or infant sec-
ondary to (specify: e.g., postpartum or neonatal
prolonged second stage
complication).
macrosomic infant
Defining Characteristics: Client verbalizes anxiety
primipara (specifjr: e.g., feels physically threatened, afraid
baby will die, cant sleep, etc.). Client rates anxiety
PIH, clotting abnormalities
as a (specify) on a scale of 1 to 5 with 1 being no
anxiety and 5 being the most.
Medical Care God:Client will demonstrate decreased anxiety
Application of ice packs to perineum after deliv- by (date and time to evaluate).
ery and observation
Outcome Criteria
Incision, evacuation, and ligation of bleeding
Client will rate anxiety as a (specify) or less on a
vessels if indicated
scale of 1 to 5 with 1 being least, 5 the most anxi-
Vaginal packing ety. Client will appear calm (specify not crying, no
tremors, HR < 100, etc.).
Administration of broad spectrum antibiotics
204 MATERNAL-INFANT NURSING CARE PLANS
INTERVENTIONS RATIONALES
Assess for physical signs of Anxiety may cause the ing to self, etc. (suggest
anxiety: tremors, palpita- fight or flight syrnpathet- others).
tions, tachycardia, dry ic response. Some-cultures
Arrange a tour ofthe Familiarity and knowledge
mouth, nausea, or prohibit verbal expression
NICU if appropriate, or decrease fear of the
diaphoresis. of anxiety.
ask for a consult with unknown.
Assess for mental and Anxiety may interfere with appropriate caregivers
emotional signs of anxiety: normal mental and emo- (specify).
nervousness, crying, diffi- tional funaioning.
Provide information about Severe anxiety may require
culty with concentration
counseling or support individual counseling.
or memory, etc.
groups as appropriate Support groups provide
Ask client to rate her feel- Rating allows measure- (specify: groups for parents reassurance and coping
ings of anxiety on a scale ment of changes in anxiety of multiple gestation, con- strategies.
of 1 to 5. level. genital anomalies, etct).
Hematomas
Vessel Trauma
bleeding
into tissues
hematoma formation
/ ------A
Vaginal
Vulvar
vu1vovaginal Retroperitoneal
1
visible bluiih-red bulge
pain, pressu
1
3
Reabsorption
application of ice
Rupture Extension
symptomatic katment
resolution
+
Hemorrhage
surgical evacuation
ligation of bleeding vessel
vaginal packing
blood transfusion
This Page Intentionally Left Blank
POSTPARTUM 207
Outcome Criteria
Nursing Care Plans Client will verbalize acceptance of body changes
Purenting, Altered (193) associated with pregnancy and birth. Client plans
health-promoting postpartum diet and exercise
Related to: Conflict between meeting own needs program.
and those of infant secondary to maternal imma-
turity.
INTERVENTIONS RATIONALES
Defining Characteristics: Specify client behaviors:
Establish a trusting rela- Discussion of body image
e.g., inappropriate or non-nurturing behavior tionship with client. requires a trusting safe
towards infant, lack of attachment behaviors (give Provide for privacy and relationship. Sitting down
examples). Client verbalizes dissatisfaction with time for discussion. Sit shows the client that the
inhnt or own parenting skills. down. nurse is available and will-
ing to talk.
Encourage client to express Client may need encour-
her feelings about body agement to express nega-
208 MATERNAL-INFANT NURSING CARE PLANS
POSTPARTUM 21 1
(Does client identi+ unhealthy behaviors? Did Reinforce nutrition teach- Reinforcement promotes
client make plans to engage in healthy behaviors? ing relating it to the compliance. Young adoles-
clients growth needs as cents may need more
Specify.) well as recovery and lacta- nutrients and calories than
(Revisions to care plan? D/C care plan? Continue tion if indicated. adult mothers do.
care plan?) Assess the impact of moth- Teen parenting may
erhood on clients educa- adversely affect education
Growth and Developmmt, Altered tion and future plans for a and skill attainment and
vocation or career. the development of a
Related to: Physical changes of pregnancy and
mature identity.
birth. Interruption of the normal psychosocial
development of adolescence. Discuss body image issues The adolescent may fear
and correct misconcep- mutilation or permanent
Defining Characteristics: Specify clients age and tions (e.g., Ill never wear disfigurement from birth.
maturity level. Client is underweight/overweight a bikini again).
(specify ht, wt, and percentile). Client reports dif- Encourage client to finish Encouragement assists the
ficulty with peers, or parent(s) related to the preg- basic schooling and make client to plan for her
nancy and baby. Client verbalizes confusion about realistic plans for the future. Inadequate educa-
plans for the future (specify). future including childcare. tion and low income
212 MATERNAL-INFANT NURSING CARE PLANS
INTERYENTIONS RATIONALES
become a vicious circle for
many teen mothers.
Assist client to assess rela- Motherhood may affect
tionships with parent(s), relationships. Teens need
significant other, and peers social interaction in order
(plan ways to improve to develop identity and
these if needed). independence.
Teach client about the Teaching may decrease
developmental tasks of some confusion from con-
adolescence (Erikson) and flicting feelings and
stages of maternal role desires.
attainment.
Refer client as needed Referrals may assist the
(specify: e.g., special client to plan a future for
schoolinglvocational pro- herself and the infant.
grams, etc.).
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Does client choose appropriate nutrition? Does
client have plans to finish high school? Does client
report satisfaction with relationships?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
POSTPARTUM 213
Postpafluin Depression
Psychiatric disorders that manifest themselves dur- Blues Depression
ing the puerperium are often called postpartum Early onset: first few Late onset: 4th week
blues, postpartum depression, or puerperal days up to 1 year
psychosis, although these terms are not recog- Short-lived: 2-3 days Continue for more
nized in the Diagnostic and Statistical Manual of than 2 weeks
Mild depression
Mental Disorders, 3rd Edition revised (DSM-
Anxiety, irritability, Hopelessness, help-
IIIR). Major depression and psychosis during the crying episodes lessness
puerperium are most likely to affect women with
Appropriate fatigue , Agitation Or exagger-
a history of psychiatric illness (20%-25% recur-
ated slowness of
rence rate postpartum). The experience of post-
movement
partum blues, however, is much more common
(50%-80% of all new mothers) and may be relat- Insomnia or excessive
ed to hormonal changes and adjustment to new sleeping
motherhood. 4 interest
4 energy
Restlessness, agitation, labile mood swings (elation Unable to concen-
to despondency), abnormal sleep patterns, irra- trate
tionality, hallucinations, and delirium may be
Appetite changes
used to identify psychosis. The client may have a
history of bipolar illness, schizophrenia, or previ- Feelings of guilt or
ous puerperal psychosis. The client may experi- worthlessness
ence suicidal ideation, which needs immediate Thoughts of death or
psychiatric intervention. suicide
Medical Care
Blues: anticipation, recognition, reassurance
history of psychiatric illness or postpartum Major depression or psychosis: psychotropic
depression medications including antidepressants, antipsy-
chotics, lithium, tranquilizers. Psychotherapy,
unwanted pregnancy
counseling or day-treatment programs. Possible
lack of stable relationships hospitalization and/or electroconvulsive therapy
(ECT).
lack of financial and emotional support
multiple babies Nursing Care Plans
low self-esteem, dissatisfaction with self Anxiety (203)
The client who exhibits signs of depression, and Related to: Actual or perceived threat to self-con-
her family, need information and assessment to cept secondary to difficulty adapting to birth and
differentiate the blues from major depression. parenting.
214 MATERNAL-INFANT NURSING CARE PLANS
Assist client to identify, Identification and ranking Teach client and signifi- Information provides
and rank in intensity, all of stressors helps the client cant other the signs and anticipatory guidance for
current stressors in her life. organize her thinking. symptoms of postpartum recognition of emotional
baby blues: transient fragility that occurs in the
Observe clients nonverbal Observation provides addi-
feelings of sadness, crying, first few weeks after birth.
behaviors as she describes tional information about
common emotional labili-
feelings and stressors. the client and what she is
ty, and feelings of mild
saying.
depression in the first few
Ask client how she usually Asking the client to identi- days after childbirth.
copes with similar stressors fy and evaluate usual cop- Encourage significant Encouragement of support
in her life and if this is an ing mechanisms increases
other to be supportive to promotes effective family
effective method. clients self-awareness.
client during this time and coping.
Explore alternative coping Exploration assists the reassure them that this
mechanisms with client. client to identify the only lasts 2 or 3 days.
Help client identify ways potential to alter a stressor Provide information about Information allows client
to avoid the stressor, and alternatives to usual signs and symptoms of and significant other to
change the situation, or coping methods. developing major depres- differentiate between the
cope with what cant be sion to report to clients blues and major depres-
changed. caregiver: severe depression sion after childbirth.
Help client identify per- Identification of strengths with late onset, lasts more
sonal strengths that have promotes self-esteem and than 2 weeks, and inter-
helped her in the past. decreases feelings of help- feres with normal activities
Explore how these can lessness. of daily living.
help in the present. Encourage client and sig- Planning helps family cope
Provide positive reinforce- Positive reinforcement nificant other to plan ways with stresses related to car-
ment for description of enhances clients self- to cope with stress of hav- ing for a newborn.
positive coping mecha- esteem and encourages ing a new baby when they
nisms. effective coping. go home.
216 MATERNAL-INFANT NURSING CARE PLANS
INTERVENTIONS RATIONALES
Provide information about Information helps client
community support ser- and family to obtain addi-
vices (specify: e.g., support tional help after discharge.
groups, mental health
agencies, etc.).
Provide for follow-up Follow-up helps reinforce
phone call or arrange a effective coping and iden-
home visit with client at 2 ti+ additional problems
to 3 weeks postpartum. that may develop after dis-
charge.
Evaluation
(Dateltime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Did client identify current stresses leading to
ineffective coping? Did client explore personal
strengths and plan new ways to cope with stress-
es?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
POSTPARTUM 217
Postpartum Depression
Postpartum Stresses
+
Risk Factors
+ +
history of history of discomfort
bipolar illness major depression fatigue
schizophrenia previous postpartum anxiety over
previous puerperal depression parenting skill
psychosis low self-esteem emotional let-down
8ocioeconomic stress unwanted pregnancy difficult infant
Arrange for the parents to Early visitation encourages Provide parents with the Intervention promotes
visit their baby in the attachment. There may be phone number of the unit, trust and a sense of securi-
NICU as soon as possible a sensitive period for the name of their babys ty for parents to know how
after birth. optimal parental attach- nurses and instruct them to get information about
ment. to call or visit when they their baby.
want to.
Provide parents with antic- Anticipatory guidance
ipatory guidance before decreases the anxiety Assist parents to review Review helps parents
going to the NICU: what encountered in an unfa- their labor, birth, and any incorporate the events sur-
they will see and hear in miliar environment. The resuscitation events. rounding the birth into
the unit, what they may infant may have many Provide accurate informa- their present situation.
expect their baby to look monitors attached to him. tion and correct miscon-
like including equipment Pictures in books, or ceptions.
around him. Use written videos help the parents
materials or videos to rein- visualize what the NICU is Encourage parents to Encouragement promotes
force teaching. like. express their feelings about expression of normal feel-
their babys birth. Reassure ings that the parents may
Focus parents attention on Parents may be distracted them that many parents think are shameful.
their baby. Point out by the noise and machin- feel guilty, angry, helpless,
attractive features or indi- ery of the NICU, increas- or depressed.
vidual attributes. Address ing their feeling of separa-
variations from the way a Provide parents with infor- Resolution of grief is facili-
tion from the infant.
normal term newborn Drawing their attention to mation about parent- tated if the parents have
looks (e.g., preterm skin the baby helps them begin infant attachment. Note been able to form an
may be red, thin; imma- the identification process. rhe importance even if the attachment to their baby.
ture genitalia; baby may be Parents may be afraid to baby doesnt survive (if this Knowing that they cared
pale, retracting, etc.). ask questions about abnor- is indicated). for their baby in some way
Show pictures of babies mal-looking attributes. comforts them.
POSTPARTUM 221
~ ~~
Assess the parents beliefs Assessment provides infor- Encourage parents to ask Social support helps ease
about thc pcrccived loss. mation and clarification. for support from family the burden of grief and
and social support system. may help with future
Provide accurate informa- Parents may be overly anx-
needs.
tion about the babys Con- ious due to being unin-
dition and prognosis. formed about current con- Offer to contact the par- Religious support may be
Provide information dition. Provision of a con- ents clergy or thc hospital helpful to parents.
updates from a consistent sistent source helps prevent chaplain if desired.
source. conflicting information.
Encourage and assist par- Grief work is facilitated if Evaluation
ents to form an attach- the parents formed an (Datehime of evaluation of goal)
ment to their baby. (If the attachment to the baby
baby is nonviable, allow and provided some care (Has goal been met? not met? partially met?)
parents to hold the infant before death.
until he or she expires.) (What do client and significant other describe as
the meaning of the possible loss? Use quotes.
Assisc parents to describe Identifjring the meaning of
Describe grief reactions the client and significant
what the perceived loss this loss helps the parents
means to them. Dont know what they are griev- other express: crying, anger, being stoic, culturally
minimize the loss (e.g., ing for and begin the grief prescribed responses, etc.)
Well at least she isnt process.
brain-damaged) .
{Revisions to care plan? DIC care plan? Continue
care plan?)
Support the familys cul- Different cultures express
tural expressions of grief in different ways - Breast-Feeding Int e m p t e d
loss/grief in a respectful the nurse needs to allow
and nonjudgmental man- and facilitate grief work Related to: Specify (e.g., prematurity, NPO status
ner. without being judgmental. of high-risk neonate, congenital anomalies: cleft
lip/palate, etc.).
Teach parents about nor- Knowing that shock,
mal grieving and relate it anger, disbelief, guilt, and Defining Characteristics: Mother desires to
to their loss of a perfect depression, etc. are normal breast-feed her infant but is unable to do so
baby. Describe feelings reactions will help the par-
because of (specify: e.g., infant is on IV fluids
that they may experience. ents to cope with these
Provide written materials if feelings. only; preterm infant or infant with congenital
literate. anomaly is unable to sucWswallow effectively,
etc.).
Support parents in the Support assists the parents
stage they are in and assist to identi@ the stage they Goal: Client will maintain lactation and provide
with redicy-orientation are in and work through milk for infant until breast-feeding can be
(specifjr: e.g., I can see the process without feeling
that you are angry, this is a that the nurse is judging
resumed.
normal way to feel, or I them.
can see that you are hop-
Outcome Criteria
ing things will turn out Client will identify actions to promote lactation.
OK; I am hoping so too). Client will verbalize understanding of pumping,
POSTPARTUM 223
INTERVENTIONS RATIONALES
benefits of breast milk if tinue supplying breast
only for the first few weeks milk.
or months.
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Did client identify actions to promote lactation?
Does client verbalize understanding of pumping,
storing, and delivering breast milk for her baby?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
POSTPARTUM 225
*
Interruption of Parent-Infant
Attachment
Avoidance Acceptance
4
Neglect
Failure to Thrive
Abuse
1
Resume Attachment
This Page Intentionally Left Blank
NEWBORN ~~
227
UNIT Ill:NEWBORN
Healthy Newborn
Basic Care Plan: Term Newborn
Basic Care Plan: Newborn Home Visit
Circumcision
Preterm Infant
Small for Gestational Age (SGA, IUGR)
Large for Gestational Age (LGA, IDM)
Postterm Infant
Birth Injury
Hyperbilirubinemia
Neonatal Sepsis
HIV
Infant of Substance Abusing Mother
This Page Intentionally Left Blank
NEWBORN 229
Cardiopulmonary Transition
First breath Cord cutting
+
surfactant
-1 surface opening of
loss of
placental
vascular bed
loss of
umbilical
tension of
alveoli
7 ? PO2- Ductus
1
L PGEz T systemic
4 Arteriosus volume functional
I
constriction closure of
vasodilation 86 functional Ductus
opening of closure Venosus
Pulmonary
Circulation
Y
-1 pulmonary t systemic
vascular vascular
resistance resistance
1
t lymph circulation
0
Foramen Ovale
absorption
of excess
lung fluid
232 MATERNAL-INFANT NURSING CARE PLANS
gestational age
assessment
8 hours
HBsAg
return to warmer until
stable then open crib
cordcare -
formula q 3-4
breast q 2-4
assess feeding
lactation
1
specialist pm
1" day
Discharge
weight
(MDexam
w/in 24 hr)
assess voiding
aftercirc
weight
M D exam
metabolic screen
circumcision
~
circ care I
I photos
4 ID bands 8a remove
remove cord clamp
provide PKU info
appointment for 4 up
infant-care
information sheets
gift pack
car seat
NEWBORN 233
The care plan is based on a review of the prenatal Assess respiratory rate and Assessment provides infor-
effort, note nasal flaring, mation about effectiveness
record, labor and delivery summary, gestational
retractions, or grunting of suctioning and stimula-
age assessment and a thorough physical assess- (specify frequency of tion to clear the airway.
ment. Specific infant data should be inserted assessment). Tachypnea, flaring, grunt-
wherever possible. ing, and retracting are
signs of respiratory dis-
tress.
Nursing Care Plan Repeat suctioning with Excessive suctioning may
Airway Clearance, Ineflective bulb syringe or wall suc- stimulate a vagal response,
tion only as needed to causing bradycardia and
Related to: Excessive secretions (specify if cause is remove excessive secre- further compromise.
identified: e.g., secondary to cesarean birth). tions.
Defining Characteristics: Infant experiences chok- Auscultate bilateral breath Auscultation provides
ing or gagging on excessive secretions; tachypnea; sounds and apical pulse information about fluid in
(specify frequency). the lungs and heart rate,
abnormal breath sounds (specify).
rhythm, and regularity.
Goal: Infant will experience a clear airway by When stable, place infant Skin-to-skin promotes
(datehime to evaluate). skin-to-skin with mother warmth and attachment.
covered by a warm blanket Bulb syringe allows imme-
Outcome Criteria with bulb syringe readily diate clearance of secre-
Infants respiratory rate will be between 30-GO available. tions.
bpm. Bilateral breath sounds will be clear to aus- Monitor infant for Infant may experience
cultation. episodes of increased secre- additional secretions and
tions (choking and gag- need for suctioning during
ging) during periods of the first and second peri-
INTERVENTIONS RATIONALES reactivity. Clear airway ods of reactivity.
with bulb syringe as need-
Suction infants mouth, Suctioning before birth of
ed.
then nares with bulb the shoulders clears the
syringe after birth of the upper airway before the Teach mother to use bulb Teaching parents promotes
head. first breath. Neonates are syringe: Depress bulb first timely airway clearance.
obligate nose-breathers; then insert syringe into Depressing bulb first
suctioning the nares may side of infants mouth and avoids blowing secretions
cause gasping and aspira- release bulb compression. into infants lungs.
tion of mouth contents if Remove from mouth and Inserting syringe into side
mouth has not been depress bulb to discharge of mouth avoids vagal
cleared first. contents. Clear mouth stimulation from touching
before suctioning nose. back of pharynx.
Position infant with head Positioning facilitates
slightly down and on a drainage of fluid by gravi- Notify caregiver if secre- Copious secretions are a
side. Stimulate crying if ty. Crying opens the air- tions continue to be exces- sign of tracheoesophageal
needed. way and improves lymph sive. malformations.
234 MATERNAL-INFANT NURSING CARE PLANS
~~~~
Neonatal eye prophylaxis is Teach family to avoid Teaching helps the family
Wipe excess secretions
from infants eyes. a legal requirement to pre- exposing the infant to peo- to care for their baby and
Administer eye prophylaxis vent ophthalmia neonato- ple with infections. prevent infection.
as ordered (specify: e.g., rum caused by exposure to Instruct family to wash
erythromycin 0.5% oph- gonorrhea and/or chlamy- their hands before han-
thalmic ointment O.U.) dia in the vagina. Waiting dling the infant.
within 2 hours of birth. for a fewhours promotes Teach parents to use a Parents may not know
attachment during the first thermometer before dis- how to use and read a
period of reactivity. charge. Instruct them to thermometer. Guidelines
Provide mother with infor- Infants of mothers who are take the infants tempera- are provided to ensure
mation about hepatitis B positive for HBsAg should ture only if he appears ill prompt treatment if the
vaccination; obtain con- receive the vaccine at birth. (hot, lethargic, refusal to infant becomes ill.
sent. Administer 1st dose It is recommended for all eat, diarrhea, dehydrated,
of vaccine to infant per newborns to prevent etc.) and to call the doctor
protocol (specify drug, hepatitis B infection. for fever > 101F rectally
dose, and route). or 100.4Faxillary.
~~ ____
INTERVENTIONS RATIONALES
Teach family to never leave Teaching prevents falls.
infant alone on an unpro- Infant may roll or turn
tected surface. over before parents expect.
Provide information on Anticipatory guidance
normal infant behavior helps parents to provide
and care. Teach ways to safe care for their baby.
comfort a crying infant:
burping, feeding, chang-
ing, motion, use of a paci-
fier, etc.
Obtain specimens for Metabolic screening pro-
metabolic screening before vides information about
discharge. Inform parents conditions that can cause
of the need for repeat test- mental retardation or
ing (specify where and handicaps unless treated.
when).
Provide appointment for Newborn exams and
newborn check up. Inform immunizations help identi-
parents about the need for fy abnormalities and pre-
immunizations for their vent serious illness.
baby.
Reinforce teaching and Reinforcement helps par-
provide the nursery phone ents assimilate informa-
number and written infor- tion. Phone number pro-
mation on infant care at vides additional help after
discharge. Ensure that discharge. A properly used
infant is properly placed in car seat protects the infant
a car seat at discharge. riding in an automobile.
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partialy met?)
(Date, time, dose, route and site of vitamin K
injection?Was metabolic screening begun? Did
mother demonstrate safe care and handling of her
baby?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
NEWBORN 24 1
Outcome Criteria
Family participates actively in home visit by ask-
Newborn Home Visit ing questions about their baby. Family states
intentions to keep all well-baby appointments and
The newborn home visit allows assessment of the obtain immunizations on schedule.
home environment and family adaptation to hav-
ing a new baby. The family benefits from an
opportunity to have their questions answered in INTERVENTIONS RATIONALES
the comfort of their own home. Anticipatory Invite family to participate Participation enhances
guidance is provided to promote optimal growth in assessments of their familys knowledge about
and development of the infant. The care plan is baby. Provide continual their baby and promotes
based on a review of prenatal and hospital records information as obtained feeling comfortable when
and praise positive parent- asking questions.
and assessments made during the visit. ing evidence.
Note general appearance,
Nursing Care Plans hygiene, warmth, and
Assessment provides infor-
mation about familys need
color of infant. for more information relat-
Family Coping: Potentialfor Growth (169) ed to hygiene, appropriate
Related to: Effective family adaptation to birth coverings, or neonatal
jaundice.
and care of newborn.
Evaluate anterior fontanel, Provides information
Defining Characteristics: Family members are infants head and eye about hydration and
able to describe the impact of the new baby. movement. Evaluate babys neurosensory status.
Family members are moving in the direction of response to noise.
providing a healthy and growth-promoting envi- Auscultate i n h t s heart Cardiorespiratory assess-
ronment and lifestyle. rate and rhythm, and ment provides information
breath sounds. Note respi- about infants physiologic
ratory rate and effort. health.
Inspect umbilicus for red- Assessment provides infor-
Health Seeking Behaviors ness or drainage. Note mation about familys
whether cord has fallen off. understanding of bathing
Related to: Limited knowledge and experience Ask family about bathing and skin care for their
caring for a newborn. and skin care practices. baby. Powders may be
Teach not to use powders aspirated and cause irrita-
Defining Characteristics: Infants mother and on baby. tion.
family seek information to promote the infants
health (specify: e.g., When should I feed him Evaluate diaper area for Diaper rash is a common
rashes. Suggest frequent parental concern. Exposure
cereal? Does he need to eat more? etc.).
diaper changes, exposing to air facilitates healing;
Goal: Family will obtain information about pro- the area to air several times ointments protect the skin
moting infant health by (datehime to evaluate). a day and use of a barrier from urine and feces.
ointment (e.g.,A&D) for
diaper rash.
Ask family about infants Information about elimi-
elimination patterns: fre- nation indicates adequate
242 MTERNAL-INFANT NURSING CARE PLANS
Assess attachment and A lack of bonding behavior (Revisions to care plan? D/C care plan? Continue
bonding: Does family may indicate ineffective care plan?)
touch and comfort infant? parenting. Lack of infant
Do they talk to him mak- attachment behavior may Infant Behavior, Organized: Potentialf i r
ing eye contact? Do they indicate sensory deficits. Enhanced
say nice things about the
baby? Does baby respond? Related to: Normal infant behavior.
Assess siblings response to Focusing on siblings pro- Defining Characteristics: Infant is able to regulate
the new baby. Provide motes self-esteem. Sibling heart rate and respiration (specify rates). Infant
information about safety rivalry depends on the exhibits normal reflexes (specify). Infants move-
related to siblings. older childs age and ments are smooth without tremors. Infant exhibits
dependency needs.
appropriate state behaviors (specify: e.g., sleeps
Assess infants sleeping area Assessment provides infor- soundly, is alert upon waking, follows object with
for safety concerns: screens mation about familys eyes, responds to sound, etc.). Infant is consoled
on windows, firm crib knowledge, or need for
easily (describe).
mattress without pillows. information about safety.
Crib: not painted with Goal: Infant will continue appropriate growth and
lead-based paint; slats no > development.
2 318 inches apart; side
rails kept up and locked.
Provide information as
Outcome Criteria
needed. Parents verbalize understanding of normal infant
behavior. Parents verbalize intent to stimulate
NEWBORN 243
~
~~~
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(Is infant's weight gain appropriate?Specify. Is
infant being fed an appropriate diet? Specify.)
(Revisions to care plan? D/C care plan? Continue
care plan?)
This Page Intentionally Left Blank
NEWBORN 247
The infant should have received his vitamin K Assess infant for signs of Assessment provides infor-
pain during and after pro- mation about physiologic
injection at birth; the procedure is done several
cedure: grimacing, crying, responses to pain.
hours after a feeding to prevent vomiting and restlessness and interrup-
aspiration tion in normal sleep pat-
terns.
The infant is restrained on a circumcision board
with arms and legs secured to prevent move- Apply sterile 4x4 gauze Sterile lubricated gauze
ment pad with petroleum jelly prevents the wound stick-
or A&D ointment to cir- ing to the gauze and pro-
Anesthesia: none, or an anesthetic cream cumcised penis (except if tects the wound from
applied topically, or dorsal penile nerve block Plastibell was used). Cover pathogens. Loose diapers
with a loose diaper. decrease pressure on the
wound.
248 MATERNAL-INFANT NURSING CARE PLANS
Administer mild andgesics Specify action and side Assess surgical site for Pressure is used to obtain
if ordered (specify drug, effects of drug if ordered bleeding after procedure. hemostasis. The physician
dose, route, times). Apply gentle pressure to may order application of
the area with sterile gauze gel foam or need to ligate
Teach parents whose infant Parents need information and notify the physician. the blood vessel.
was circumcised with a to prevent complications
Plastibell that the rim after discharge. Teach parents not to wipe The exudate is granulation
should fall off within 8 off the yellow-white exu- tissue. Removal may cause
days and to notify caregiv- date that forms on the bleeding.
er if it doesnt. penis after circumcision.
NEWBORN 249
INTERVENTIONS RATIONALES
Assess infants heart rate Tachycardia and tachypnea
and respiration after proce- may be signs of excessive
dure. fluid loss.
Observe and instruct par- Frequent observation pre-
ents to check circumcision vents hemorrhage.
site for signs of bleeding
during each diaper change.
Weigh infant daily and Weight loss should not be
compare to previous more than I % to 2% per
weight. day. Excess may indicate
dehydration
Monitor all intake and Intake and output provides
output (specify: e.g., weigh information about fluid
or count diapers), check balance. Dry mucous
fontanels and skin turgor q membranes and poor skin
8 hours. turgor indicate tissue dehy-
dration.
If infant is receiving W IV fluids put the infant at
fluids, monitor hourly risk for FVD or FVE.
I&O, urine specific gravity Urine sp. gravity > 1.013
and glucose, and lab values indicates dehydration, gly-
for Hgb, Hct, and elec- cosuria may cause osmotic
trolytes as obtained. diuresis, lab values indicate
hydration and electrolyte
balance.
Maintain a neutral thermal Excessive heat from radiant
environment. Humidify warmers or phototherapy
any oxygen the infant f fluid losses. Humidified
receives. oxygen prevents drying of
mucous membranes.
Evaluation
(Datehime of evaluation of goal)
(Hasgoal been met? not met? partially met?)
(Did infant have any bleeding after circumcision?
What is infants I&O? Describe infants skin tur-
gor, mucous membranes, and fontanels.)
(Revisions to care plan? D/C care plan? Continue
care plan?)
250 MATERNAL-INFANT NURSING CARE PLANS
Newborn Circumcision
As a religious rite: Jewish males are circumcised on their 8th day as a symbol of a biblical covenant.
Islamic males are circumcised between 4 and 13 years of age.
As a rite of passage to manhood, circumcision is performed at puberty in some cultures.
In the United States, circumcision is often done to conform to the cultural norm: because the babys father
or brothers were circumcised
Medical opinions and research findings are inconclusive about the health benefits of neonatal circumcision.
NEWBORN
NEWBORN 253
~~ ~
the babys skin. Barriers Wash off afier application. be used, washing it off 4
provide protection to the the chance of injury.
skin.
Provide mouth care and The infants mouth may (Revisions to care plan? D/C care plan? Continue
apply lubricant if needed become dry and cracked. care plan?)
for dry lips.
Wash infant only as need- The infant doesnt require
ed with warm water. Use daily bathing other than
mild soap on diaper area eyes, mouth, and diaper
only if needed to remove area. Soap is irritating and
feces. drying to the skin.
Apply oil or lubricant as Preterm infants skin
ordered for dry skin after absorbs more substances
bathing. than term infants.
Safflower oil may provide
the infant with additional
fatty acids.
Cover central line sites Transparent dressings allow
with transparent dressing hourly assessment to pre-
and assess hourly. Change vent infection.
dressing per agency proto-
col.
Ensure that alarms are Warming devices can burn
turned on for warming the infants delicate skin.
devices.
Evaluate the need before The preterm infants skin
putting anything on the may absorb harmful sub-
infants skin (e.g.. alcohol, stances or suffer a chemical
tincture of benzoin, burn from substances that
provodone iodine, etc.). are not harmful to mature
skin. If the substance must
NEWBORN 257
pulmonary tP ~ O P S S ~ V ~
vascular resistance
atelectasis
4
+
persistent fetal
I
+
circulation
""T need
& ability to sustain
respiration
I
4 0 2
T
anaerobic
+
metabolism
? lactic acid
1
1
metdmlic respiratory
acidosis aci!osis
This Page Intentionally Left Blank
NEWBORN 259
_ _ ~ ~
Defining Characteristics: Infant exhibits (sped@: Provide IV fluids as Fluids may be ordered to
ordered (specify). decrease blood viscosity.
Hct > 65%, plethora, persistent peripheral
cyanosis, 4 peripheral pulses, respiratory distress, Assist with exchange trans- Partial plasma exchange
jitteriness, hypoglycemia, seizures, hyperbiliru- fusions as indicated. transfusion may be indi-
binemia). cated to lower blood vis-
cosity.
Goal: Infant will experience adequate tissue perfu-
Monitor bilirubin levels as Excessive RBCs become
sion by (datehime to evaluate). obtained. damaged in the capillaries
and break down releasing
Outcome Criteria bilirubin. The infant is at
Infants Hct will be < G5%. I n h n t will be pink high risk for hyperbiliru-
binemia.
without cyanosis.
Explain all procedures and Explanations help the par-
assessments to parents. ents to cope with unfamil-
iar procedures.
262 MATERNAL-INFANT NURSING CARE PLANS
Growth and Development, Altered Promote rest by clustering Promoting periods of rest
care, decreasing unneces- allows the infant to reorga-
Related to: Insufficient nutrients and oxygen for sary noise and stimulation, nize and decrease oxygen
optimal intrauterine growth and development; and covering the isolette and glucose use.
during sleep.
preterm birth.
Describe and promote Skin-to-skin contact
Defining Characteristics: Size/gestational age dis- kangaroo care with par- between parent and infant
crepancy (specify: e.g., SGA, IUGR, LGA). ents. promotes infant develop-
Preterm birth (specify gestational age). NICU ment and parental bond-
environment instead of with parents. ing.
Goal: Infant will experience improved growth and Suggest ways to stimulate Provision of infant stimu-
development by (date/time to evaluate). the infant (specify: e.g., lation to promote develop-
mobiles, photos, talking to ment is a parenting role.
the baby, tapes of music, Parents may benefit from
Outcome Criteria womb sounds, rocking, suggestions.
Infant gains 20-3Og. per day after stabilization. stroking, etc.).
Infant is able to maintain a quiet-alert state with
Assist parents to provide Short periods of stimula-
varying facial expressions indicating interest. short periods of infant tion help the parents assess
Infant exhibits hand-to-mouth movements and stimulation and note how their baby is respond-
sucking. infants responses. ing without offering too
much stimulation at once.
INTERVENTIONS RATIONALES
Encourage sibling visits Sibling visits promote fam-
Assess infants weight daily. Daily weights provide
with preparation for what ily bonding, stimulate the
information about contin-
they will see and hear in infant, and reassure the
uing patterns of loss or
the NICU environment. siblings that their baby is
gain.
real. Preparation decreases
Promote optimum nutri- Adequate nutrients are anxiety.
tion by assisting parents needed for growth.
Provide additional infor- Additional information
with feedings as needed
mation about infant devel- promotes engagement and
(specify: e.g., referral to a
opment and referrals to effective parenting. Books,
lactation consultant, offer-
support groups as indicat- videos, and other parents
ing formula q2h, etc.).
ed (specify). are potential resources.
Discuss infant develop- Parents need information
ment with parents and in order to promote opti-
solicit ideas for appropriate mal development of their
stimulation. baby.
NEWBORN 263-
Evaluation
(Datehime of evaluation of goal)
(Has goal been met? not met? partially met?)
(What is infant's weight gain pattern? Describe
infant's behaviors and responses to stimulation.)
(Revisions to care plan? D/C care plan? Continue
care plan?)
264 MATERNAL-INFANT NURSING CARE, PLANS
IUGR
Symmetric Asymmetric
$ maternal oxygen PIH
multiple gestation placental infarcts
drug & alcohol abuse severe IDDM
TORCH infections I
IUGR Infant
$. $.
7reserves $02 J glycogen reserves
.1enzymes for
1 gluconeogenesis
* fetal distress
I 1
polycythemia
I I 1 $ subcutaneous fat
&brownfat
*I I meconium aspiration
hyperbilirubinemia I
i
4
cold stress
4
& tissue perfusion t i respiratory distress
+
hypoglycemia
NEWBORN 265
Medical Care
The infant who is at or above the 30th percentile Prevention through maternal glycemic control
for weight compared to gestational age is designat- during pregnancy
ed as LGA or large for gestational age. Benign fac- Estimation of fetal size and pelvic adequacy -
tors associated with LGA infants include heredity possible planned cesarean birth
(large parents tend to have large infants) and sex,
with males being generally larger than females. Frequent blood glucose testing after birth
Pathologic factors may be erythroblastosis fetalis, IV therapy with 10%-15% glucose until stable
transposition of the great vessels, Beckwith-
Wiedemann syndrome, and the infant of a diabet- Assessment for injury: x-ray, CT scan
ic mother (IDM).
The diabetic mother with poor glycemic control Nursing Care Plans
and an uncompromised vascular system delivers Gas Exchange, Impaired (263)
large amounts of glucose to her fetus. The fetus
responds with increased insulin production by the Related to: Immature respiratory development
islet cells in the pancreas. Insulin facilitates uptake and insufficient surfactant production secondary
of glucose and glycogen synthesis, lipogenesis, and to maternal diabetes mellitus.
protein synthesis. This results in a macrosomic Defining Characteristics: Specify (e.g., signs of
infant with increased fat stores and organomegaly. respiratory distress at birth, central cyanosis,
Birth deprives the infant of the expected glucose blood gases, or oximetry readings).
supply placing the neonate at high risk for com-
plications of hypoglycemia. Insulin also acts as an Tissue Pe@sion, Altered (261)
antagonist to lecithin synthesis and inhibits pro- Related to: Obstruction secondary to blood vis-
duction of phosphatidylglycerol (PG), thereby cosity/polycythemia.
delaying pulmonary maturation.
Defining Characteristics: Specify (e.g., color, res-
Complications UDM) piratory effort, hematocrit, etc.).
CPD, birth trauma: shoulder dystocia, cephal- Growth and Development, Altered (262)
hematoma, fractures, Erb's palsy, facial paralysis Related to: Excessive glucose use secondary to
oxytocin use, forceps or cesarean delivery maternal diabetes mellitus.
INTERVENTIONS RATIONALES
decreased. Titration
ensures adequate blood
sugar levels during this
transition.
Evaluation
(Date/time of evaluation of goal)
(Has goal been met? not met? partially met?)
(Does infant have any birth injuries? What is
infant's blood glucose level?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
268 WTERNAGINFANT NURSING CARE PLANS
1
t fetal insulin production
fetal
1
macrosomia
NEWBORN 269
polycythemia
Eldditlonal Diannoses
- and Plans
hyperbilirubinemia
Gas Exchange, Impaired
neonatal seizures
Related to: Meconium obstruction of airway.
Pulmonary immaturity resulting in deficient sur-
factant production. Persistence of fetal circulation.
270 MATERNAL-INFANTNURSING CARE PLANS
Administer IV fluids via IV fluids are initiated to activity and stimulates res-
infusion pump as ordered maintain circulating vol- piration.
(specify fluid, site, rate). ume and replenish glucose.
Explain all equipment and Information reduces par-
Assess IV hourly. Hourly assessments pre-
procedures to infants par- ents anxiety about unfa-
vent fluid overload or
ents. miliar procedures and
injury from infiltration.
equipment.
Monitor hourly intake and Monitoring I&O provides
output. information about fluid
balance. Urine output
should be 1-3 cc/kg/hr.
Evaluation
Administer medications (Specify action of pre-
(Datehime of evaluation of goal)
(e.g., antibiotics, amino- scribed drugs in facilitating
phylline, calcium glu- gas exchange.) (Has goal been met? not met? partially met?)
conate, Priscoline,
dopamine) as ordered; (What are infants blood gases? Is the PaO, > 50-
(speciFy: drug dose, route, 80 torr? PaCO, between 45-55 torr ? pH 7.25 -
times). 7.45? SaO, > 94%?)
Monitor infant for thera- (Specify therapeutic effects
(Revisions to care plan? D/C care plan? Continue
peutic and adverse effects expected related to gas
of medications. exchange. Provide rationale care plan?)
for adverse effects.)
intrauterine hypoxia
1
meconium passage into
amniotic fluid
1
aspiration of rneconium
I
+
chemical
+
airway
+
& production of 5- 0 2 ,r CO2
pneumonia
pneumothorax
(Rto L shunt)
NEWBORN
. Neonatal resuscitation
potential diagnosis.
Goal: Infant will not experience further injury by
Diagnostic studies: x-ray, ultrasound, CT scan, (datehime to evaluate).
EEG
Outcome Criteria
Laboratory: Hgb, Hct, blood glucose, bilirubin,
Identified birth injuries are resolved without com-
electrolytes, spinal fluid
plication.
~-~ ~ ~
~~
(Datdtime of evaluation of goal) Assess respiratory effort, Timely and correct neona-
heart rate, and color at tal resuscitation promotes
(Has goal been met? not met? partially met?) birth. Provide vigorous cerebral oxygenation and
resuscitation to distressed prevents or corrects acido-
(Is infant able to move affected body part normal- newborn per Neonatal sis.
ly? Has infant experienced any complications from Resuscitation protocol.
impaired mobility? [Specify potential complica-
Document immediate Documentation assists in
tions for particular injury.])
assessments (including identifying infants who
(Revisions to care plan? D/C care plan? Continue Apgar and cord blood experienced intrauterine
care plan?) gases), interventions and hypoxia, provides informa-
infant response. tion about appropriate
Tissue Perfusion, Altered (Cerebral) resuscitation efforts and
infants response.
Related to: Decreased cerebral blood flow and
Provide warm humidified Interventions promote
oxygenation secondary to perinatal asphyxia
supplemental oxygen ther- cerebral oxygenation.
(hypoxia and ischemia). Increased ICP secondary apy as ordered (specify:
to birth trauma or intracranial bleeding. e.g., oxyhood, ventilator:
type, Fi02, rate, etc.).
NEWBORN 277
Breech Delivery
7 Prolonged 2nd stage
CPD
I
perinatal hy-poxia
abdominal
trauma I shoulder
dystocia
cephalic
(forceps)
I
I
bruising
hemorrhage
cervical or
spinal cord
seizures
hy-poxic-ischemic
encephalopathy
1 1
clavicle
fracture
I------
conjunctival
hemorrhage
7 forceps
marks
lupture: injury retinal bruises
liver peripheral hemorrhage petechiae
spleen nerve facial nerve abrasions
kidneys damage paralysis lacerations
bowel Erbs palsy
v cephalhematoma
cerebral palsy intracranial hemorrhage
mental retardation subgaleal hemorrhage
cranial fracture
370
NEWBORN
Jaundice occurs within the first 24 hours of life Lab work: Hgb, Hct, serum bilirubin, total pro-
tein, direct and indirect Coombs, reticulocyte
Bilirubin rises more than 5 mg/dL/day counts
Bilirubin levels exceed 12 mg/dL Transcutaneous bilirubin meter
Phototherapy
Physiologic Jaundice Exchange transfusion
Cause: normal RBC breakdown, liver immatu-
rity, and lack of intestinal bacteria
50% of term and 80% of preterm neonates
280 MATERNAL-INFANT NURSING CARE PLANS
Fluid Volume Deficit, Risk for Assess skin turgor, mucous Assessment provides infor-
membranes, and anterior mation about dehydration
Related to: Increased losses from evaporation, and fontanel q 2 hours. of tissues: skin turgor, dry
frequent loose bowel movements. Decreased mucous membranes, and
intake secondary to the effects of phototherapy. sunken anterior fontanel.
Notify caregiver of signs of Caregiver may initiate IV
Defining Characteristics: None, since this is a dehydration. fluids if p.0. intake is
potential diagnosis. insufficient to meet fluid
needs.
Goal: Infant will maintain adequate fluid balance
during phototherapy (specify datehime to evalu- Provide additional fluids Additional fluids are neces-
ate). during phototherapy (spec- s a r y to balance the losses
ify: e.g., 25% more formu- from therapy.
Outcome Criteria la with more frequent Phototherapy may result in
feedings; breast-feed q 2-3 increased fluid losses
Infant will have at least 6 wet diapers/day. Infant's hours; additional water as through the skin, urine,
skin turgor will be elastic, anterior fontanel soft ordered). and loose bowel move-
and flat, and mucous membranes moist. ments.
Show parents how to assess Explanations and teaching
skin turgor, mucous mem- assist parents to care for
INTERVENTIONS RATIONALES branes, and fontanel for their infant after discharge
signs of dehydration. and seek medical treat-
Monitor daily weight. Monitoring weight pro-
Teach them that the infant ment for dehydration.
vides information about
should have 6 to 8 wet
excessive fluid losses.
diapers daily.
Assess infant's hourly Assessment of intake and
Initiate and maintain IV IV fluids may be required
intake and output (weigh output provides informa-
fluids as ordered (specify: to maintain fluid balance
diapers, 1 gm = 1 cc). tion about fluid balance.
fluid, rate, site). or venous access if infant is
Infant should have output
to have an exchange trans-
of 1-2 cclkglhour.
fusion.
Monitor number, color, Phototherapy may result in
and consistency of bowel Assess N site hourly for Assessment provides infor-
fluid loss from frequent
movements. rate, color, temperature, mation about complica-
loose stools. Monitoring
and edema. tions of IV therapy: infil-
provides information
about losses. tration, infection, or incor-
rect rate.
Assess urine specific gravi- Specific gravity provides
ty (specify frequency). Monitor lab values as Lab values indicate fluid
information about fluid
obtained (specify :e.g., and electrolyte balance or
balance. High sp. gravity
Hct, electrolytes etc.). imbalance.
~~
NEWBORN 283
Evaluation
(Datehime of evaluation of god)
(Has goal been met? not met? partially met?)
(Specify feelings family verbalized. Describe how
family supports one another and decisions they
have made to maintain functionality as a family.)
(Revisions to care plan? D/C care plan? Continue
care plan?)
~
NEWBORN 285
Hyperbilirubinemia
Rh or ABO incompatibility
(other causes) -b f hemolysis of fetal RBCs
* +
f erythropoesis
unconjugated
+
globin 1
released into
bilirubin + iron -blood stream
for reuse
bound to
protein
Erythroblastosis Fetalis I hyperbilimbinemia
anemia jaundice
hypxia kernicterus
heart failure 1
bilirubin
1
Hydrops Fetalis
Liver (+ glucuronyl transferase)
*I
encephalopathy
I
$.
1
conjugated bilirubin seizures
anasarca
4
bile
mental
retardation
cerebral palsy
pulmonary effision
4
1
severe respiratory distress
cardiac failure
intestine (+ intestinal bacteria)
4
stercobilin
4
urobiligen reabsorption
feces urine
$.
excretion
This Page Intentionally Left Blank
NEWBORN 287
~~ ~~ ~
Defining Characteristics: None, since this is a Assess anterior fontanel Assessment provides infor-
(specify frequency) and mation about possible
potential diagnosis.
continually observe infant spread of infection to the
Goal: Infant will not experience spread of infec- for changes in activity or CNS: signs of meningitis.
tion by (datehime to evaluate). behaviors (e.g., feeding,
sleeping, jitteriness or
seizure activity, etc.).
Outcome Criteria
Infant's heart rate remains c 160 (specify range for Provide respiratory support Respiratory support may
as indicated (specify: e.g., be needed during the acute
infant). Respiratory rate c 60 (specify range).
oxyhood, ventilato,r etc.). phase of infection to pre-
Anterior fontanel is soft and flat. vent additional physiologic
~~ ~
stress.
INTERVENTIONS RATIONALES Feed infant as ordered Nutritional needs may
(specify: e.g., breast, for- increase during infection
Ensure that all people Hand washing prevents
mula, OG feedings, or while the infant may feed
coming in contact with the spread of pathogens
TPN). Provide for non- poorly. OG feedings or
infant wash their hands from person to person.
nutritive sucking if unable TPN ensure that nutrient
well before and after
to breast- or bottle feed. needs are met if the infant
touching the baby.
is too ill to suck effectively.
Ensure that all equipment Interventions prevent the
Administer IV fluids as IV fluids help maintain
used for infant is sterile, spread of pathogens to the
ordered via an infusion fluid balance. An infusion
scrupulously clean, or dis- infant from equipment.
pump (specify: fluids, rate, pump, hourly I&O, and
posable. Do not share
site). Assess rate and site q site assessment help pre-
equipment with other
hour. vent complications of ther-
infants.
apy: FVE, infiltration, and
Place infant in isolette/iso- Placing the infant in an infection.
lation room per hospital isolette allows close obser-
Administer antibiotics per (Specih action of each
policy (specify for agency). vation of the ill neonate
order (specify, drugs, drug. Specify adverse
and protects other infants
doses, routes and method effects.)
from infection.
[e.g., syringe pump], and
Maintain a neutral thermal A neutral thermal environ- times). Observe for adverse
environment. ment decreases the meta- effects (specify for each
bolic needs of the infant. drug).
Lab results provide infor-
The ill neonate has difi-
Monitor lab results as mation about the
culty maintaining a stable
obtained (culture reports, pathogen and infant's
temperature.
NEWBORN 289
INTERVENTIONS RATIONALES
CBC, differential, CRP, response to illness and
electrolytes, drug peak and treatment.
trough, etc.). Notify care-
giver of abnormal findings.
Interventions provide
Assess hourly intake and information about infant's
output and daily weight. fluid balance.
Assess urine specific gravi-
ty q 8 hours.
Assessments provide infor-
Monitor infant for hypo- mation about development
glycemia, jaundice, devel- of complications of infec-
opment of thrush, or signs tion: hypoglycemia, hyper-
of bleeding (petechiae, bilirubinemia, opportunis-
occult blood in stools). tic infections, and coagula-
tion deficits/DIC.
Evaluation
(Date/time of evaluation of goal)
(Has goal been met? not met? partially met?)
(What is infant's heart rate? respiratory rate? Is
anterior fontanel flat and soft?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
290 MATERNAL-INFANT NURSING CARE PLANS
Sepsis Neonatorum
Prenatal
+I
Intrapartum
*
I
Neonatal
congenital
malformations
PTL $.
pretem ROM 4- ascending
I 1-
I
nosocomial
pathogens
1
pathogens
chorioamnionitis
preterm birth invasive
L immunity blood borne procedures
t invasive pathogens
procedures
vaginal, GI
organisms
t nosdcomial
exposure
NEONATAL 4
SEPSIS
I \
antibiotics
meningitis
1
DIC
thrush
superinfection
resolution
NEWBORN 29 1
There are three perinatal modes of transmission Avoidance of an episiotomy or other actions
for HIV. The fetus may be infected across the pla- creating excess bleeding during birth, careful
centa during pregnancy, the neonate may acquire suctioning of infant at birth, bathing of infant
the virus during birth from exposure to maternal before any injections or invasive procedures,
blood and body fluids, or HIV virus in the breast formula feeding
milk may infect the infant. The infant infected in Laboratory testing: urine screening, baseline
utero has a poor prognosis. One goal of nursing immunological tests
care is to prevent the last two modes of transmis-
sion. Frequent pediatric follow-up visits; testing for
HIV infection
Newborns of HIV positive mothers will also test
positive at birth due to the HW antibodies Prophylactic drugs: infant is started on zidovu-
received passively from the mother during the last dine, trimethoprim-sulfamethoxazole (to pre-
few weeks of pregnancy. Approximately one third vent pneumocystis carinii pneumonia), and
of these infants will actually be infected with the monthly doses of gamma globulin IV while
virus. Additional testing is needed to determine diagnostic tests are being done
which infants have acquired the virus and which
have not. The polymerase chain reaction and HIV
culture tests may provide a diagnosis as early as 4
Nursing Care Plans
to 6 months of age while maternal antibodies are FZuid kZume Deficit, Risk for (282)
still present for 15 to 18 months (basis of ELISA Related to: Decreased intake secondary to poor
and Western Blot tests). Most infants will be feeding. Increased fluid loss secondary to loose
asymptomatic at birth. stools/diarrhea.
INTERVENTIONS RATIONALES
~
Evaluation
(Date/time of evaluation of goal)
(Has goal been met? not met? partially met?)
(Did parents discuss fears and risk of developing
parenting problems? Describe parents behaviors
toward infant (e.g., eye contact, holding, talking
to, and feeding the baby). Are they appropriate?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
NEWBORN 297
HIIVAIDS
perinatal exposure
maternal HIV/AIDS
$.
transplacental intrapartum breast milk
1
transmission of HIV retrovirus
to fetus/neonate
destruction of T lymphocyte -
replication of HIV
1
4helper T-lymphocytes
1
& monocyte-macrophage
response
immune suppression
opportunistic infections
Infant Feeding Pattern, Ineflective Supplement oral feeding The infant needs adequate
with gastric feeding to calories for growth and
Related to: Muscle weakness/hypotonia secondary ensure caloric intake as development of skills
to neurological impairment, maternal substance ordered (specify formula needed to obtain nutrients
use, congenital defects, or lack of maternal skill type, moundday: e.g., orally.
1501250 kcallkglday may
(specify). be ordered).
Defining Characteristics: Infant is unable to initi- Encourage mother to hold Kangaroo care during gas-
ate or sustain an effective suck; unable to coordi- and cuddle infant during tric feeding promotes
nate suck, swallow, and breathing. Infant vomits gastric feedings (e.g., kan- maternal-infant attach-
most of feedings (specify). Infant is unable to garoo care). ment and bonding and
obtain adequate calories (specify intake/calories calms infant to promote
digestion.
and calorie needs for this infant).
Provide for non-nutritive Non-nutritive sucking pro-
Goal: Infant will obtain needed nutrition by the sucking (pacifier, hands). vides exercise to muscles
needed for an effective
feeding pattern.
INTERVENTIONS RATIONALS
Consult with occupational Consult provides early
Assess the mothers skill in Assessment provides infor-
therapist as needed for interventions to promote
feeding infant and infants mation about the potential
interventions to improve optimum oral motor
feeding pattern: suck, swal- cause of ineffective feeding
oral muscle development development.
low, and coordination of patterns.
and coordination.
swallowing with breathing.
Assess caloric intake com- Assessment provides infor-
pared with needs (specify). mation about fluid balance
oral route by (datehime to evaluate).
Monitor intake and out- and infants additional
put. caloric needs. Outcome Criteria
Support mothers attempts Support and teaching assist
Infant ingests (specify ounces of formula/breast
to feed baby and provide the mother to feed her milk per feeding/day). Infant gains appropriate
teaching as needed: pro- baby and promote mater- weight (specify). Infant shows increasing skill in
mote a quiet, calm envi- nal role attainment. oral feedings (specify for baby: e.g., obtains / p of
ronment, upright position- calories orally, etc.).
ing of infant, use of root-
ing reflex, support of Evaluation
infants chin as needed.
(Datehime of evaluation of goal)
Offer praise for mothers The mother may be
attempts to feed her baby. unsure of her skills and (Hasgoal been met? not met? partially met?)
Explain motor develop- feel inadequate if the
ment delays and interven- infant is a poor feeder. (Specify infants intake. Specify infants weight and
tions to improve infants Support and explanation gain. Describe infants skill in oral feedings: e.g.,
feeding pattern. help the mother to under-
stand the infants needs.
NEWBORN 30 1
Wrap infant snugly and Wrapping, holding, and (Revisions to care plan? D/C care plan? Continue
provide repetitive motion: repetitive movements pro- care plan?)
rocking, walking, or pat- vide comfort, security, and
ting back. promote behavioral organi- Infant Behavior, Disorganized
zation. Related to: Altered CNS response secondary to
Play soft music or womb Soft sounds may be com- prenatal exposure to drugs/alcohol.
sounds and note infants forting to infant or may be
302 MATERNALINFANT NURSING CARE PLANS
Evaluation
(Datehime of evaluation of goal)
(Hasgoal been met? not met? partially met?)
(Does infant exhibit periods of quiet alert state?
Describe changes in motor excitability. How is
infant consoled? Has this improved?)
(Revisions to care plan? D/C care plan? Continue
care plan?)
304 MATERNALINFANTNURSING CARE PLANS
Maternal Prenatal
Substance Abuse
Congenital Defects
FAS
craniofacial malformations
congenital heart or brain
defects
1
Birth
Pregnancy
Complications
PIH
abruptio placentae
placenta previa
microencephaly
1
asphyxia
preterm
LBW
withdrawal
CNS GI Respiratory
Long-Term
Problems
mental retardation
behavior disorders
hyperactivity
? incidence of
neglect/abuse
? incidence of SIDS
REFERENCES 305
This Page Intentionally Left Blank
REFERENCES 307
References
Bobak, I. M., and Jensen, M. D. Maternity and Gynecologic Care: The Nurse and the Family, 5th Ed. St.
Louis, MO: Mosby-Year Book, 1993.
Carpenito, L. J. Nursing Diagnosis:Application to Clinical Practice, 7th Ed. Philadelphia, PA: J. B. Lippincott,
1997.
Cunningham, G.F., et al. Williams Obstetrics, 19th Ed. Norwalk, CT: Appleton & Lange, 1993.
Doenges, M. E., and Moorhouse, M. F. Maternal/Newborn Plans of Care: Gui&linesfor Planning und
Documenting Client Care, 2nd Ed. Philadelphia, PA F. A. Davis, 1994.
Fischbach, F. T. A Manual of Laboratory and Diagnostic Tests, 5th Ed. Philadelphia, PA J. B. Lippincott,
1995.
Jaffe, M. Pediatric Nursing Care Pkzns. Englewood, CO: Skidmore-Roth Publishing, 1998.
Masten, Y. The Skidmore-Roth Outline Series: Obstetric Nursing, 2nd Ed. Englewood, CO: Skidmore-Roth
Publishing, Inc., 1997.
McCance, K. L., et al. Patbopbysiology: The Biologic Barisfor Diseare in Adults and Cbikdren, St. Louis, MO,
Mosby -Yearbook, 1997.
Murray, M. L. Antepartal and Intrapartal Fetal Monitoring, 2nd Ed. Albuquerque, NM: Learning Resources
International, 1997.
Murray, M. Essentials of Electronic Fetal Monitoring: Antepartal and Intvapartul Fetal Monitoring, NAACOG
Educational Resource, 1989.
Nichols, F. H., and Zwelling E. Maternal-Newborn Nursing: Theory and Practice Philadelphia, PA: W.B.
Saunders. 1997.
Rudolph, A. M., et al., eds. Rudolphi Pediatrics, 20th Ed. Stamford, CT: Appleton & Lange, 1996.
Wilson, B. A., et al. Nurse: Drug &ide 1996,Stamford, CT: Appleton & Lange, 1996.
Wong, D. L. Wbulq, Q Wongi Nursing Care of Infnts and Childven, 5th Ed. St. Louis, MO: Mosby -
Yearbook, 1995.
Periodicals
Cosner, K. R., and deJong, E. Physiologic Second-Stage Labor. MCN 18 (Jan/Feb): 38-43, 1993.
Drake, l? Addressing Developmental Needs of Pregnant Adolescents. JOGNN 25(6): 518-524, 1996 .
308 MATERNAL-INFANT NURSING CARE PLANS
Findlay, R. D., et al. SurfactantTherapy for Meconium Aspiration Syndrome. Pediatrics 90( 1): 48-52,
1996.
Gebauer, C. L., and Lowe, N. K. The Biophysical Profile: Antepartal Assessment of Fetal Well-Being.
JOGNN 22(2): 115-124, 1993.
Giotta, M. I? Nutrition During Pregnancy: Reducing Obstetric Risk Journal of Perinatal and Neonatal
Nursing 6(4): 1-12, 1993.
Griffin, T., et al. Parental Evaluation of a Tour of the Neonatal Intensive Care Unit During a High-Risk
Pregnancy. JOG 26(1): 59-65, 1997.
Hutti, M. H. A Quick Reference Table of Interventions to Assist Families to Cope with Pregnancy Loss or
Neonatal Death Birth lS(1): 33-35, 1988.
Keleher, K. C. Occupational Health: How Work Environments Can Affect Reproductive Capacity and
Outcome. Nurse Practitioner. 16(1): 23-33, 1991.
Lewis, C. T., et al. Prenatal Care in the United States, 1980-94. Vital Health Stat 21(54), National Center
for Health Statistics, 1996.
Lowe, N. K., and Reiss, R. Parturition and Fetal Adaptation. JOG 25(4): 339-349, 1996.
Ludington-Hoe, S. M., and Swinth, J. Y. Developmental Aspects of Kangaroo Care. JOGNN 25(8): 691-
703, 1996.
Maloni, J. A., and Ponder, M. B. Fathers Experience of Their Partners Antepartum Bed Rest. I W G E
29(2): 183-188, 1997.
Maloni, J. A. Bed Rest During Pregnancy: Implications for Nursing. JOGNN 22(5): 422-426, 1992.
Miles, M. S. Maternal Concerns About Parenting Prematurely Born Children. MCN 23(2): 70-75, 1998.
Mitchell, A., et al. Group B Streptococcus and Pregnancy: Update and Recommendations. MCN 22
(Sept/Oct): 242-248, 1997.
Neonatal Circumcision.AWHONN Clinical Commentary, The Association of Womens Health,
Obstetric, and Neonatal Nurses, 1994.
Obstetric Epidural Analgesia and the Role of the Professional Registered Nurse. AWHONN Clinical
Commentary, The Association of Womens Health, Obstetric, and Neonatal Nurses, 1996.
Pain in Neonates. AWHONN Clinical Commentarv, The Association of Womens Health, Obstetric, and
Neonatal Nurses, 1995.
Penny-MacGillivray, T. A Newborns First Bath: When?JOGNN 25(6): 481-487, 1996.
Perinatal Group B Streptococcal Disease. AWHONN Clinical Commentarv, The Association of Womens
Health, Obstetric, and Neonatal Nurses, 1996.
REFERENCES 309
Four-Year CollegeKJniversity
For desk or review copies call: 1-800-423-0563or fax 1-606-647-5020
For orders call: 1-800-354-9706or fax 1-800-487-8488
Mail to: ITP Higher Education
Attn: Order Fulfillment
P.O. Box 6904
Florence, KY 41022
Retail
Mail to: International Thomson Publishing
Attn: Professionalnechnical Order Fulfillment
P.O. Box 6904
Florence, KY 41022
Phone: 1-800-842-3636or fax 1-606-647-5963
Canada
Mail to: Nelson ITP Canada
1120 Birchmount Road
Scarborough, Ontario M1K 5G4
Canada
Telephone Number: 1-416-752-9448or 1-800-268-2222
Fax Number: 1-416-752-8101or 1-800-430-4445
E-mail: inquire@nclson.com
International Ordering
Mail to: International Thomson Learning
P.O. Box 6904
Florence, KY 41022
Phone: 1-606-282-5786
Fax: 1-606-282-5700