N107 – Essentials of Nursing Care: Reproductive Health

Needs of the Childbearing Family: Preconception

Chapter Objectives Know which topics to counsel and plan

with childbearing females/families Review health and lifestyle choices that

affect childbearing females/families Be able to perform a risk assessment Be able to create a care plan via the

nursing process regarding a patient with a preconception issue specifically

Counseling and Planning for Parenthood

Preconception care focuses on risk assessment and promoting healthy behaviors

Healthy well-informed women who plan pregnancy have better outcomes

Contraception is important aspect in planning process

Counseling and Planning for Parenthood Many women don’t realize they are

pregnant and don’t seek prenatal care until way into 1st trimester Half of all pregnancies in US are unintended The period of greatest danger for developing

fetus is 17 – 56 days after fertilization By end of first trimester, major structural

anomalies in the fetus are already present Fetus may be exposed to intrauterine

environmental hazards Radiation (x-rays, microwaves), carcinogens

(smoke, fumes)

Health and Lifestyle ChoicesPreconception Care Purposes:

Establish life-style behaviors to maintain optimum health

Diet, weight control, safe sex practices, rest & exercise, substance abuse

ID and treat “Risk Factors” before conception Medical conditions, substance abuse, test for immunity,

history of genetic defects, the need for genetic counseling To conceive absent of unnecessary Risk Factors

Monitor chronic illnesses (medications), environmental hazards (home, work)

ID carriers of inherited diseases African Americans/Southeast Asians (sickle cell disease),

Jewish Americans (Tay-Sachs disease) Prepare people psychologically for pregnancy and

responsibilities of parenthood

Health and Lifestyle ChoicesPreconception Care Why assess for and treat “Risk Factors”

Every woman of childbearing age is a potential mother

Nurses can make a difference through education and counseling; preconception education/counseling can decrease the incidence of birth defects

Type I diabetic with excellent glucose control reduces risk for congenital malformations in fetus

Adequate intake of folic acid (0.4 mg/day) decreases possibility for neural tube defects

Endocrine disorders interfere with female menstrual cycle and male libido

Renal and GU disorders affect sexual performance & reproductive capacity

Health and Lifestyle ChoicesPreconception Care Treating Risk Factors (Cont’d)

Hx of cholecystitis and hepatitis may be contraindications for oral contraceptives

Women under 15 and 0ver 40 at higher risk Cigarette smoking may delay conception Maternal smoking low birth weight

Increases risk for spontaneous abortion, fetal death, neonatal death & SIDS

Smoking increases morbidity in those using oral contraception,

and early menopause (Females) In males who also use drugs

Affects sperm count, causes impotence or decrease libido

Prenatal Care To promote positive outcomes for both mother

& child Should begin prior to conception First prenatal visit

Typically scheduled between weeks 8-12 of gestation Obtain health hx (first menarche, sexual & family

hx’s, Gravida/Para) Physical exam (vaginal exam, pap smear Confirm pregnancy Prenatal labs (blood type, Rh factor, rubella status,

Hep B status, STD, pap smear,

Prenatal Care Prenatal Visit (Cont’d)

Calculate EDC Nagel’s Rule

LMP – 3 months + 7 days Tables Wheels

Lines up LMP to indicate EDC & due date Auscultate fetal hear tones

May be difficult to hear prior to 12 weeks Only Positive signs of pregnancy

Presence of fetal heart tones Detection of fetus by US or X-ray

Testing (The Triple Screen)

Alpha-fetoprotein test Performed between week 16 – 18 Indicates neural tube defects and

chromosomal disorders High incidence of false positives If complication indicated

amniocentesis is recommended

The Triple Screen (Cont’d) Gestational Diabetes Screening

Performed at week 28 Fasting glucose test If failed, glucose tolerance test If positive, dietary consult and/or

diabetes educator consult Instruct on proper diet How to monitor blood glucose levels

(glucometer) If diet control unsuccessful, insulin injections

may be required

The Triple Screen (Cont’d) Group Beta Strep Bacteria detection

Not an uncommon finding Requires Abx upon rupture of membrane or

onset of active labor Recommended that one dose of Abx be

administered at least 4 hours prior to delivery to reduce risk of infant contracting group beta strep

Can cause serious illness in infant but harmless to mother

The Nursing Process Assessment

The Interview Process: Ask about current “lifestyle choices”

Nutrition, exercise, rest, substance abuse, alcohol & tobacco use, occupation, stressors, depression, support system domestic violence, and financial resources

Immunization status: Rubella, Hepatitis B Current medications to include OTC, non-

prescription and prescription meds

The Nursing Process Assessment (Cont’d)

Review of Systems Head to Toe assessment Discussion of any medical conditions

Reproductive System Review Previous pregnancies, miscarriages, living children’s

disorders Abnormal PAP smear results, mammogram results, STD

hx, sexual practices Obstetric History

Review of family planning and fertility counseling information

Previous abd/reproductive surgery, trauma’s or transfusions

The Nursing Process

Assessment (Cont’d) Environmental History

Home and/or work exposures Family History

Medical conditions Genetic conditions

Sickle cell, cystic fibrosis, bleeding disorders, hemophilia, PKU, birth defects

Should also include companions family history

The Nursing Process Assessment (Cont’d)

Risk Assessment Pediatric illnesses

Mumps in males sterility Rubella in childbearing females increases congenital

anomalies during 1st trimester Encourage immunization if not had or been

immunized Currently pregnant females should not receive

immunization Those planning pregnancy should wait 3 months

before becoming pregnant after receiving immunization

The Nursing Process Assessment (Cont’d)

Contraceptive and Obstetric History Psychosocial History

Family situation Ask directly “Have you been hit, slapped,

kicked or hurt with the past year?” “Are you afraid of your companion or anyone else?”

Readiness for pregnancy Age, life goals, stressors

Financial stability and resources

The Nursing Process Assessment (Cont’d)

Occupational History Physical activities

Standing all day? Heavy lifting? Exposures

Religious and Cultural Preferences Physical Examination

Emphasis placed on thyroid gland, breasts and pelvic structure

Lab studies CBC, UA, blood type and Rh, rubella immunity,

STDs, Hep B surface antigen, PAP smear, cervical culture.

OTHERS: PPD, HIV, toxicology screen, thalassemia

The Nursing Process Analysis

In collaboration with the patient/family and members of the healthcare team, synthesize data to identify the patient’s actual or potential health problems that can be managed by independent nursing actions

Identify a Nursing Diagnosis (NANDA) When choosing a nursing dx, look at all data and

their commonalities The common theme reveals the existence of a

problem and the need for nursing intervention The nurse may use physician (dependent) and

nursing (independent) interventions to minimize complications.

The Nursing Process Analysis (Cont’d)

Areas of concern for preconception care

Health-seeking behaviors, Optimum nutrition Health maintenance Deficient knowledge Fear Pain Risk for Infection

The Nursing Process Planning

Planning phase consist of determining the expected outcomes and formulating specific strategies to achieve the expected outcomes.

Assign priorities to the nursing diagnosis Maslow’s Hierarchy of Needs Most crucial to least crucial

Specify expected outcomes Outcomes must be realistic and measurable Expected outcomes are the basis for evaluating the

effectiveness of the nursing interventions and deciding whether the plan of care needs to be revised.

The Nursing Process Specify goals of nursing action ID specific nursing interventions appropriate for

attaining the outcomes Interventions should be listed in preferential order Interventions should be individualized as well as age,

gender, and culture-appropriate Can the implementation of the intervention be

rationalized? ID interdependent interventions

Will a physician order be required Document plan of care Communicate to appropriate personnel any need for

multidisciplanary approach to plan of care

The Nursing Process Patient Values

Always include patient and family in process What does patient consider to be a priority? Conflicts should be resolved in a way that is

mutually acceptable

Expected Outcomes (patient centered goals)

Pt will be able to recite Signs & Symptoms of…….. Pt will verbalize understanding of the importance

of adequate amount of folic acid in the diet.

The Nursing Process Nursing Interventions

Plan nursing interventions n the basis of established standards and priorities to move the patient/family toward the expected outcomes

ANA Standard of Practice, Nurse Practice Acts, taxonomy of nursing interventions (NIC)

Should be patient focused and outcome driven Assign patient care activities to be

implemented by other members of the heath care team as appropriate

The Nursing Process Implementation

Plan of care is put into use The nurse (RN) assumes responsibility for the

implementation and coordinate activities of all involved

FOCUS: Resolving pt’s nursing diagnosis, achieving expected outcomes while meeting pt’s health care needs.

Implement a teaching plan that promotes a positive woman’s health outcomes

Supervise patient care activities that were delegated to other members of health care team

When nursing interventions have been completed, the Implementation phase of the process has ended.

The Nursing Process Evaluation Phase

Assess the pt’s response to nursing interventions, including progress toward the patient-centered goals

Assess whether objectives were achieved Document the extent of the

achievements Plan of care may need to be revised Questions to ask during evaluation phase

(see page 54)

The Nursing Process