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First Trimester NURSING PRIORITIES Encourage client to adopt health-promoting behaviors. Detect actual or potential risk factors.

Prevent/treat complications. Foster clients/couples positive adaptation to pregnancy. NURSING DIAGNOSIS: Nutrition: altered, risk for less than body requirements Risk Factors May Include: Changes in appetite, presence of nausea/vomiting, insufficient finances, unfamiliarity with increasing metabolic/nutritional needs Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Explain the components of a well-balanced CRITERIACLIENT WILL: prenatal diet, giving food sources of vitamins, minerals, protein, and iron. Follow recommended diet. Take iron/vitamin supplement as prescribed.Demonstrate individually appropriate weight gain (usually a minimum of 3 lb by the end of the first trimester). ACTIONS/INTERVENTIONS RATIONALE - Independent Determine adequacy of past/present nutritional Fetal/maternal well-being depends on maternalhabits using 24-hr recall. Note condition of hair, nutrition during pregnancy as well as during the 2nails, and skin.yr preceding pregnancy.Obtain health history; note age (especially less Adolescents may be prone to malnutrition, eatingthan 17 yr, more than 35 yr).disorders, anemia; and older clients may be prone toobesity/gestational diabetes. (Refer to CPs: ThePregnant Adolescent; Diabetes Mellitus:Prepregnancy/Gestational.)

Ascertain knowledge level of dietary needs.Determines specific learning needs. In the prenatalperiod, the basal metabolic rate (BMR) increases by20%25% (especially in late pregnancy), owing toincreased thyroid activity associated with thegrowth of fetal and maternal tissues, creating apotential risk for the client with poor nutrition.An additional 800 mg of iron is necessary duringpregnancy for developing maternal/fetal tissueand fetal storage. During the first trimester, thedemand for iron is minimal, and a balanced dietmeeting increased caloric needs is usuallyadequate. (Note: Iron preparations are not commonlyprescribed in the first trimester because they maypotentiate nausea.) Folic acid is crucial to fetaldevelopment requiring daily supplement of 0.4 mg of folate to prevent maternal

deficiencies.Provide appropriate oral/written information Reference material can be reviewed at home,about prenatal diet, food choices, and daily increasing the likelihood that the client will select avitamin/iron supplements.well-balanced diet.Review food preparation techniques to preserve Cooking vegetables in large volume of water maynutrients and reduce risk of exposure to cause vitamins to be lost. Microwaving foodcontaminants.destroys more folic acid than conventional cooking.Inadequate cooking of meats/eggs increases risk of bacterial/parasitic infection.Evaluate motivation/attitude by listening to clients If client is not motivated to improve diet, furthercomments and asking for feedback about evaluation or other interventions may beinformation given.indicated.Elicit beliefs regarding culturally proscribed diet May affect motivation to follow recommendationsand taboos during pregnancy. Provide alternativeof healthcare provider. For example, some cultureschoices to meet dietary needs.refuse iron, believing that it hardens maternal bonesand makes delivery difficult.Note presence of pica (craving for nonfood The ingestion of nonfood substances in pregnancysubstances). Assess choices of substances and may be based on a psychological need, culturaldegree of motivation for eating them.phenomenon, response to hunger, and/or a bodilyresponse to the need for nutrients (e.g., chewing onice may indicate anemia). Note: Ingestion of laundrystarch may potentiate iron deficiency anemia, andingestion of clay may lead to fecal impaction.Weigh client; ascertain usual pregravid weight. Inadequate prenatal weight gain and/or belowProvide information about optimal prenatal gain.normal prepregnancy weight increases the risk of intrauterine growth retardation (IUGR)/restriction inthe fetus and delivery of low-birth-weight (LBW)infant. Research studies have found a positivecorrelation between pregravid maternal obesityand increased perinatal morbidity rates (e.g.,hypertension and gestational diabetes) associatedwith preterm births and macrosomia.Review frequency and severity of nausea/vomiting. First-trimester nausea/vomiting can have aRule out pernicious vomiting (hyperemesis negative impact on prenatal nutritional status,gravidarum). (Refer to CP: The High-Risk Pregnancy;especially at critical periods in fetal development.ND: Nutrition: altered, risk for less than bodyrequirements.) Test urine for acetone, albumin, and glucose.Establishes baseline, is performed routinely to detectpotential high-risk situations such as inadequatecarbohydrate ingestion, diabetic ketoacidosis, andpregnancy-induced hypertension (PIH).Measure uterine growth.Maternal malnutrition may negatively affect fetalgrowth and contribute to reduced complement of brain cells in the fetus, which results indevelopmental lags in infancy and possibly beyond. Collaborative Obtain baseline Hb/Hct levels.Identifies presence of anemia and potential forreduced maternal oxygencarrying capacity. Clientswith Hb levels less than 12 g/dL or Hct levels lessthan or equal to 37% are considered anemic in thefirst trimester.Make necessary referrals as indicated (e.g., May need additional assistance with nutritionaldietitian, social services). choices; may have budget/financial constraints.Refer to Women, Infants, Children (WIC) food Supplemental federally funded food program helpsprogram as appropriate.promote optimal maternal/fetal nutrition. NURSING DIAGNOSIS:[Discomfort]May Be Related To: Physical changes and hormonal influences Possibly Evidenced By: Verbalizations, restlessness, alteration in muscletone DESIRED OUTCOMES/EVALUATION Identify measures that provide relief. CRITERIACLIENT WILL: Assume responsibility for alleviation of discomfort.Report absence/successful management of discomfort. ACTIONS/INTERVENTIONSRATIONALEIndependent

Note presence/degree of minor discomfort.Provides information for selection of interventions; isclue to clients response to discomfort and pain.

Evaluate degree of discomfort during internal Discomfort during internal examination mayexamination. Use extreme gentleness and pictures or occur, especially in the foreign client who has hadmodels, especially for the client with infibulation, a female circumcision or infibulation (whereby,female circumcision, or adolescents, those withafter removal of the clitoris, labia minora, andhistory of sexual abuse.medial aspect of the labia majora, the raw areasare drawn over the vagina to heal closed). Althoughmany foreign women are intimidated by theAmerican healthcare system and male physicians, itis important to anticipate the discomfort experiencedby these clients because they may not ask questionsor express discomfort/pain, especially when thehusband is present at the procedure. Adolescentsmay be self-conscious during an examination, whichmay further increase discomfort. In addition, womenwith a history of childhood or adult sexual abusemay experience a variety of physical and emotionaldiscomforts with vaginal examination.Recommend wearing of supportive bra. Review Provides proper support for enlarging breastnipple care (e.g., expose to air for 20 min daily; tissues; toughens areolar tissue.avoid soaps).Stress importance of avoiding excessive nipple Stimulation may contribute to preterm labormanipulation.through the release of oxytocin.Recommend wearing of hard plastic cup (e.g., WoolrichUse of specially designed breast shields helps tobreast shields) in bra for flat/inverted nipples.break adhesions and cause flat/inverted nipple toevert and to become more erect.Assess for hemorrhoids: note reports of itching, Reduced gastrointestinal (GI) motility andswelling, bleeding.displacement of bowel and pressure on vasculatureby enlarging uterus can predispose client to thedevelopment of hemorrhoids.Instruct in use of ice packs, heat, or topical Reduces discomfort and swelling; promotes GIanesthetics; teach how to reinsert hemorrhoid motility.with lubricated finger; encourage diet high in fiber,fruits/vegetables, noncaffeinated fluids; suggestperiodically elevating buttocks on pillow. (Referto ND: Constipation.)Instruct client to dorsiflex foot with leg extended Increases blood supply to the leg. Excess intake of and to reduce amount of cheese, yogurt, and milk dairy products results in greater levels of ingested if leg cramps develop.phosphorus than calcium, creating an imbalance thatmay result in muscle cramping.Encourage frequent bathing and perineal care, use Promotes hygiene by removing/absorbing excessof cotton underwear, and a dusting of cornstarch to vaginal secretions. Application of talcum powderabsorb discharge (leukorrhea). Tell client to avoid in the genital area is believed to contribute tothe use of talcum powder.development of cervical cancers.Recommend increasing carbohydrate intake on Reduces likelihood of gastric disturbances thatarising (e.g., eating dry toast), eating small and may be caused by the effects of hydrochloric acidfrequent meals, and avoiding strong odors if on the empty stomach or by increasednausea/vomiting is a recurrent problem. (Refer to sensitivity/aversion to odors, spices, or certainND: Fluid Volume, risk for deficit.)foods.Suggest humidification of air and avoidance of Increased estrogen levels contribute to nasalnasal sprays and decongestants to treat nasal congestion. Although humidification of air may becongestion.of limited benefit, sprays/decongestants absorbedsystemically can be harmful to the fetus. Review physiological changes resulting in urinary Although normal, urinary frequency caused byfrequency. Recommend avoidance of caffeinated pressure of the enlarging uterus on the bladder a cause of irritation. Caffeine has diuretic propertiesthat can further aggravate the problem of frequency.Assess fatigue level and nature of family/work Encourages client to set priorities and include timecommitments. (Refer to NDs: Fatigue and Family for rest.Coping: potential for growth.) Collaborative Substitute daily calcium supplements if intake of Assists in restoring calcium/phosphorus balancedairy products is reduced.and reducing muscle cramping. NURSING DIAGNOSIS:Fluid Volume risk for deficitRisk Factors May Include: Impaired intake and/or excessive losses (vomiting), increased fluidneeds Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Identify and practice measures to reduce CRITERIACLIENT WILL: frequency and severity of episodes of nausea/vomiting.Ingest individually appropriate amounts of fluid daily.Identify signs and symptoms of dehydration necessitating treatment. ACTIONS/INTERVENTIONSRATIONALEIndependent Auscultate FHT.Presence of a fetal heart tones confirms presence of afetus and rules out gestational trophoblastic disease(hydatidiform mole).Determine frequency/severity of nausea/vomiting.Provides data regarding extent of condition.Increased levels of HCG, changes in carbohydratemetabolism, and reduced gastric motility contributeto first-trimester nausea and vomiting.Review history for other possible medical Assists in ruling out other causes and inproblems (e.g., peptic ulcer, gastritis, cholecystitis).identifying interventions to address specificproblems.Recommend that client maintain diary of intake/Helpful in determining presence of perniciousoutput, urine testing, and weight loss. (Refer to vomiting (hyperemisis gravidarum). Initially,CP: The High-Risk Pregnancy; ND: Nutrition: vomiting may result in alkalosis, dehydration, andaltered, risk for less than body requirements.)electrolyte imbalance. Untreated or severe vomitingmay lead to acidosis, necessitating furtherintervention.Assess skin temperature and turgor, mucous Indicators assisting in evaluation of hydrationmembranes, blood pressure (BP), temperature, level/needs.intake/output, and urine specific gravity. Obtainclient weight and compare with pregravid weight.