Emilio Aguinaldo Colleges

School of Nursing
Care of Mother and Child at Risk or with Problems
(Acute and Chronic)-LECTURE
PRELIM PERIOD
WEEK 4
III. Care given to a mother with special needs utilizing the nursing care plan.

A.1.Assessment:
 Assess the strengths and weaknesses of individual women (client)- to establish accurate nursing
diagnoses
 Establish a complete database early in pregnancy- to predict the risks a woman may be exposed to
when pregnancy is affected by age extremes physical or cognitive challenges
 If there is physical disability, establish the impact of this disability on a woman’s lifestyle before
beginning to offer guidance for care

2.Nursing Diagnoses
 Differ in degree but not in substance for all pregnant women
Examples:
 Risk for imbalanced nutrition related to combined needs of adolescent and pregnancy
 Risk for fetal injury related to drug and alcohol use
 Impaired physical mobility related to physical disability
 Risk for injury related to unstable balance
 Risk of injury related to potential for unintentional injuries
 Impaired verbal communication related to spastic muscle functioning
 Impaired home maintenance related to a sensory challenge
 Risk for social isolation related to bed rest at home
 Risk for disruption of social interactions related to unclear speech
 Disruption in family dynamics related to serious illness of family’s main provider
 Readiness for enhanced family coping related to commitment to have a child in the
face of a disabling condition

3.Outcome Identification and Planning

 Planning for a pregnant woman with special needs involves identifying support people
to help with this added stress; can come from family, friends, a professional
organization, or healthcare providers
 Woman should agree with the plan
 Plans should also include ways to strengthen confidence and self esteem
 Remember to include safe care of the newborn
4. Implementation: focus on the following
 Promoting a healthy pregnancy and preventing pregnancy complications
 Teaching and encouraging the client to determine how best to manage her
pregnancy according to her particular situation
 Consider a non judgmental attitude that focuses on the pregnancy and the baby,
while avoiding recriminations about a woman’s youth or circumstances.-to
encourage the young woman to prenatal care and keeping her coming for regular
visits
5. Outcome Evaluation
Examples:
 Patient states that she will use walker to maintain balance during pregnancy
 Adolescents list a weekly intake of adequate calories even with frequent meals at
fast food restaurants.
 Family members state they have been able to adjust to changing demands of
pregnancy in a who is physically challenged
 Patient reports to methadone maintenance clinic daily and reports no other
substance use
 Patient states that she is able to manage a daily rest period even in light of a
busy work and travel schedule
 Patient states she is able to carry out usual lifestyle activities in spite of cast
on injured arm.

The Pregnant Adolescent:

a. Developmental Tasks
a.1. to establish a sense of self-worth or a value system
a.2.to emancipate from parents
a.3.to adjust to a new body image
a.4. to choose a vocation
 Helping adolescents to make their own healthcare decisions at healthcare
visits helps to establish a sense of independence
 Weighing herself, viewing herself in front of the mirror
 Being interviewed apart from her parents
 Remind parents that a pregnant adolescent is considered as emancipated
minor or a mature minor – a person capable of making healthcare decisions
 In some countries, emancipated minors can qualify and are eligible for special
health insurance coverage
 Should avoid: issues with privacy, parental permission, and parental notification
b. Prenatal Assessment
 Adolescents are at high risk of:
 Iron-deficiency anemia
 Premature labor
 Low birth weight infants
 Disproportion between fetal and pelvic size
 High rate of intimate partner violence
 Adolescents do not seek prenatal care – it’s their way of protecting the
pregnancy (if they don’t tell anyone
Other factors:
 Denial that she is pregnant
 Lack of knowledge of the importance of prenatal care
 Dependence on others for transportation
Ask:
 About home life-could reveal dysfunctional family
 If the girl is planning to continue with school
e. Physical Examination
Examples:
 Starting to have colostrum
 Using a Doppler technique to obtain fetal heart tones
f. Pregnancy Education
 May respond positively to health teachings that is directed to their own
health more than to that of a fetus.
 Give instructions about possible discomforts and changes associated
with pregnancy
1.Nutrition
a. Maybe a problems as teenagers enter pregnancy
Reason: poor nutritional stores from years of eating a less-than-optimal diet
>can result to preterm births and low birth weight
To prevent: girls should have an intake that both allows for growth the fetus
and also provides for the needs of her own growing body
b. Obesity and overweight during pregnancy- due to over eating and lack of exercise
 Can lead to macrosomia or overgrowth in a fetus that can lead to increase in the
number of C/S
 Management: should not restrict nutrition during pregnancy to prevent protein and
vitamin deficiencies
c. Many girls do not eat well during pregnancy because they do not know what
constitutes good nutrients
Management:
 talk to the person who does the cooking at home
 Encourage adolescent to abandon food fad
 Get the adolescent’s approval to switch to noncaffeinated soft drinks
 Encourage “brown bag” or buy a nutritious cafeteria lunch if she is attending school
 Frequently remind adolescents to take their vitamins or iron supplement
2. Activity and Rest
 Adolescents vary in their levels of activity
 Assess and know the kind of sports they are engaged in
 If pregnant, may need to be discontinued
 To prevent her from being “shut out”, suggest alternative activities
3.Physiologic Changes
 All adolescent girls need substantial education on the physiologic changes that will
occur during pregnancy
 Provide specific instructions and information about labor and delivery
4.Childbirth Preparation
 When adolescent girls become pregnant, they may find themselves cut off from peer
or fellow classmates
 This can make them more inclined to join a class of other adolescnets in preparation
for childbirth.
5.Birth Decisions
 Pelvic measurements should be taken early and carefully in
adolescent girls-possibility of CPD (Cephalo Pelvic
Disproportion) because of the girl’s incomplete pelvic growth
 Remember that labor does not differ from labor in the older
woman
6.Plans for the Baby
> Adolescent girls might still be scared on how they will act as new
mother and find it comfortable if they talk to a good listener about
their concerns.
IF: Complications of Labor, Birth and The Postpartum Period
Occur
1.CPD- is present due to lack of engagement at the beginning of
labor, a prolonged first stage of labor and poor fetal descent
 Graphing labor progress- effective way to detect labor that is
becoming abnormal or prolonged.
 Presence of support person is important
2.Postpartum Hemorrhage
 Young adolescents are more prone to postpartum hemorrhage than the average
woman because if a girl’s uterus is not yet fully developed, it becomes
overdistended by pregnancy
 An overly distended uterus is more likely not to contract as a normally distended
uterus in the postpartum period that leads to bleeding after delivery.
 Adolescents have more frequent or deeper perineal lacerations because of the size
of the infant in relations to their body.
 But adolescents have the tendency to heal early because of the presence of healthy
and supple tissue
3.Inability to Adapt Postpartally
 Chances may occur for the adolescent girl to “block out” the hours of labor as if they
did not happen
 Giving birth is such a stress and a major crisis that almost all women have difficulty
integrating it into their life.
Management:
 Encourage her to talk about labor and birth to make the happening real to her-to
prevent as much as possible post partum depression
4.Lack of knowledge about infant care
 Although they may have some knowledge or experience in caring for baby once they
look after a neighbor’s child, but still, they can be overwhelmed in the postpartum
period when realizing the baby is their own and child care is not as simple as it
seemed.
Management:
 Spend time with the adolescent mother and observe how she handles her infant
 Demonstrating on how to care for a child-Role modelling on feeding the newborn,
changing the diaper, bathing an infant, performing cord care and proper handling
the infant are some of the ways on how to handle the situation.
4.Iron-Deficiency Anemia
> Many adolescent girls are deficient in iron because their low intake cannot balance
the amount of iron lost with menstrual flows.
Signs and Symptoms:
 Chronic fatigue
 Pale mucous membranes
 Hemoglobin level- < 11g/dL
 Could be associated with BUI during pregnancy
 Pregnancy compounds iron-deficiency anemia – since a girl should supply enough iron
from fetal growth and her increasing blood volume
Management:
 All pregnant women should take iron and folic acid supplement
*Folic acid- for RBC growth and prevention of neural tube defects
 Neural tube defects are birth defects of the brain, spine,
or spinal cord. They happen in the first month of pregnancy,
often before a woman even knows that she is pregnant.
The two most common neural tube defects are spina bifida and anencephaly. In spina
bifida, the fetal spinal column doesn't close completely.
 Help the adolescent girl to prepare a schedule in taking her iron and folic acid and
other vitamins
 Prepare a diet rich in iron content
 Iron supplement is not strong unless there is a strong dietary intake of iron rich
foods.
 Effects of the supplement: the client’s body recognizes It has additional iron, she will
begin rapidly forming immature red blood cells.
Assessment if the girl is taking the supplement or not:
1. Scheduling of reticulocyte analysis after 2 weeks-if not elevated, secondary
problem exists or the girl is not taking the supplement
2. Black tarry stool-the girl is taking the supplement
Other Health Teachings:
 Advice the girl to take the supplement after meal or with a full stomach to prevent
gastric irritation
 Advice the girl to eat high fiber diet and increase fluid intake to prevent constipation
C. The Pregnant Woman Over Age 40 Years
> Advanced maternal age is the label for pregnant women 35 years and older at
delivery.
 In the past, if the age is over 40 years old, the woman is considered at high risk for
many complications
 Today, there is little evidence of serious complications in women older than 40 years
1.Developmental Tasks and Pregnancy
 To develop Generativity- a sense of moving away from themselves and becoming
involved with the world or community
 Some people are thinking the way they are, the way they will be.
 Signs of developing this task: joining groups, civic organizations, community out
reach activities and the like
 A feeling of ambivalent during pregnancy may occur-feeling of she want to continue
with community activity yet want to continue to concentrate with her pregnancy
Management: encouraging her to discuss how this conflict fells can help her balance
her life and manage two life phases this way.
Other important worries:
 Sandwich generations: being pressured by responsibilities by both older and
younger family members
 Having enough energy
 Arranging for child care
 Financial and space strains
2.Prenatal Assessment
a. Health History: focus on:
 Signs and symptoms of pregnancy
 How the woman feel about the pregnancy, how it fits into her lifestyle
 Ask if medication is taken to relieve symptoms
b. Family Profile
 Ask about the decision is made to get married or pregnant
 Source of income
 How many persons are dependent on her-many people can complicate the
pregnancy
c. Day History
 woman’s type of work or home responsibilities
 Distance of home from workplace
 Diet
 Exercise
 If belongs to a health club-saunas and hot tubs must not be longer than 10 minutes
at a time if pregnant-contraindicated during pregnancy because of possible
hyperthermia and teratogenic effects of extreme heat
 Personal habits-cigarette smoking and alcohol consumption- could be detrimental to
a fetus
d. Physical Examination-to establish a general health and to identify any problems
 Check for the breasts- for any abnormalities
 Check for fundal height
>check for circulatory disturbances: presence of varicosities
 urinalysis- specific gravity, glucose and protein
Chromosomal Assessment:
 Down Syndrome is higher in older women
 Genetic screening is offered to detect if an open spinal cord or chromosomal defect
could be present in the fetus
 Procedure:
a. ultrasound-to examine for nuchal translucency (seen in chromosomal
abnormalities)
Nuchal translucency is the normal fluid-filled subcutaneous space identified at the
back of the fetal neck during the late first trimester and early second trimester (11
weeks 3 days to 13 weeks 6 days)
b. Analysis maternal serum levels of Alpha Feto Protein (AFP) and free beta
human chorionic gonadotropin (hCG)-to evaluate for chromosomal disorders in the
fetus
>done at 11 to 13 weeks
>between 15 and 20 weeks gestation, the MSAFP test is repeated to identify if the
fetus is at risk for open neural tube defects
c. Circulating free DNA (cfDNA)-to screen fro chromosomal abnormalities
>done as early as 10 weeks
>Accurate noninvasive blood test
d. Chorionic villi sampling (CVS) and amniocentesis – to diagnose chromosomal
genetic disorders
>considered and diagnostic tests rather than screening tests
> They asses the actual karyotype of the fetus to give a definite answers about the
presence and absence of chromosomal disorders
Nursing Consideration:
 Make sure is prepared for these studies
 Offer support during this time
 Alert her that false-positive results can occur
3.Pregnancy Education:
a. Nutrition
 assess for the number of meals and she eats outside her home each week,
including those she packs for lunch or eats in restaurants.
 If she enjoys these, give her tips on how to pack her meals
 Substitute a caffeine free soft drinks in place of an alcoholic beverages
 Milk or juice decaffeinated coffee for regular coffee
 For calcium- puddings or yogurt or ask her doctor for calcium supplement
b. Prenatal Class-urge her to join a childbirth preparation or prenatal exercises
Complications of Labor, Birth and the Postpartum Period
1.Failure to Progress in Labor
 May be prolonged due to cervical dilatation does not seem to occur as
spontaneously as it does in younger women.
 Graphing labor progress is a good method- to determine when labor is becoming
prolonged.
 Many women at this age need cesarean birth if labor becomes so overly prolonged
2.Postpartum Hemorrhage
>uterus may not contract as readily in the postpartum period
>may be prone to perineal- anal tears because her perineum is less supple
D. The Pregnant Woman Who is Physically or Cognitively Challenged
 In the past, women with conditions such as vision, hearing, cognitive, neurologic or
orthopedic challenges where sheltered by their families that prohibit them from
having sexual or marriage partners
 Today, with varying degrees of disability attend public schools, work in offices, join
community organizations, establish sexual relationships and plan pregnancies just
like anyone else.
1.Rights of the Physically or Cognitively Challenged Person
 People should be made feel psychologically welcome as well as physically able to
access the inside of the building
 Hospital cannot deny care to a person with a disability even though a disabling
condition complicates treatment
 A woman with disability has the full right to her child, so the baby cannot be taken
from her at birth without her full consent.
a. Safety measures to explore:
 Assess if the woman has an emergency contact persons, suppliers of transportation
and individual considerations such as mobility, elimination and possible autonomic
responses
 Be certain the woman reviews any medicine she is taking for her primary condition
with her pregnancy care provider to be certain this will continue to be safe during
pregnancy.
b. Pregnancy Education
> If couple are both visually challenged for example, refer them local branch of the
national nonprofit organization
c. Modifications for Labor and Birth
 A woman with spinal cord injury need to palpate her abdomen periodically for
tightening or the presence of contractions so she is aware for beginning of labor
 Women with muscle spasticity or spinal cord injury may not be able to push
effectively for the second stage of labor and so she may need a cesarean birth
>Birth from a a Sim or dorsal recumbent position is usually best as this avoid a lithotomy (true
for all women)
>Braille watches used by persons who are visually challenged may not have second hands. This
means they may need to time the length of contractions by counting their length rather than
timing them by a watch.
>During labor, the woman who is hearing challenged cannot hear information on how she is
progressing if you are not directly facing her. If she needs to communicate with her support
person in sign language, act as an advocate to keep her hands free by equipment such as
intravenous line. Hand the infant to her as soon as possible after birth so she can see and feel
the baby is crying and breathing well.
>Be certain to identify the usual sounds of birthing rooms for the visually challenged woman as
hearing sounds and not being able to identify them can be frightening.
d. Modifications for Post Partum Care
Assess if woman needs:
 Additional support to be successful at breastfeeding
 A return appointment for both herself and her infant for follow up care
 Or desires contraceptive information and what would be best for her individual circumstances
E. A Woman Who is Substance Dependent
 Substance abuse is defined as the inability to meet major role obligations, an
increase in legal problems or risk-taking behavior, or exposure to hazardous
situations because of an addicting substance
 A substance dependent- when he or she has withdrawal symptoms following
discontinuation of the substance, combined with abandonment of important
activities, spending increased time in activities related to the substance use, using
substances for a longer time than planned or continued use despite worsening
problems because of substance abuse.
1.Cocaine
 Derived from Erythroxylum coca, a plant grown almost exclusively in South America
 When sniffed into the nose or smoke in pipe, it is absorbed across the mucous
membranes and affects the CNS-vasoconstriction-increased V/S rapidly
 Alkaloidal cocaine- a concentrated mixture produces a more rapid and intense high
when inhaled-can lead to immediate death due to cardiac failure
Effects on Pregnancy:
 Harmful because the extreme vasoconstriction can severely compromise placental
circulation –premature separation of the placenta-preterm labor or fetal death
 Can be detected through urinalysis up to 1 week after use.
Management:
>counsel women to discontinue using it during pregnancy but usually disappointing
because the effects are so intense
2.Amphetamines
 Methamphetamine (i.e. speed) is a neuro stimulant and neurotoxin that has a
pharmacologic effect similar to cocaine
 It is easily and cheaply manufactured in home labs
 Ice, a rock type methamphetamine that is smoked can produce high concentrations of
the substance in the maternal circulation
 Women develop blackened and infected teeth
 Newborns show jitteriness and poor feeding at birth and maybe with growth restriction
3.Marijuana and Hashish
 They are obtained from the hemp plant, cannabis
 When smoked, they produce tachycardia and a sense of well being
 Effect on the fetus is not fully documented because they are frequently part of
polysubstance abuse or at the very least cigarette use
4. Phencyclidine
 Developed in the 1950’s as an intravenous anesthetics
 It is no longer used that way because although it creates a feeling euphoria, it
also causes irritation and possibly long term hallucinations
 It could injure the fetus because the substance tends to leave the maternal
circulation and concentrate in fetal cells
4.Narcoric Agonists
> Opiates – used for the relief of pain such as morphine, oxycodone, merperidine
(Demerol) and codeine are widely abused substances because they can be obtained
by prescription and they have dramatic euphoric effect
5. Inhalants
 Inhalants abuse refers to as “sniffing” or “huffing” of aerosol substances
 Usually abused by adolescents
 Include model airplane glue, cooking sprays and computer keyboard cleaner
 May seem innocent but they contain freon as a propellant – severe respiratory and
cardiac irregularities
Effects on Pregnancy:
 Not well documented but they have similar effects to alcohol dependency
 Respiratory depression can cause decreased fetal oxygen supply to a serious level.
6. Alcohol
 Can be legally purchased and served at social function it is just as detrimental to
fetal growth as illicit substance.
 Fetal alcohol spectrum disorder- a syndrome with recognizable facial features,
possible cognitive challenges, and memory deficits
 TRAUMA AND PREGNANCY
 Trauma means injury by force a phenomenon that seems remote from
pregnancy because pregnant people usually take extra care to protect their
body.
 Automobile accidents, homicide and suicide are common
 Orthopedic injuries is also mention and happened usually at the last trimester
of pregnancy due to enlarged belly

 PREVENTING UNINTENTIONAL INJURIES

 Frequently occur in people under stress
 Pregnancy is a life event that may cause stress in a family that’s why they
should take extra precaution for safety.
 Pregnancy counselling should include education about ways to avoid
unintentional injuries.
Physiologic changes in pregnancy that affect trauma care
 Primary rule to remember is that after a traumatic injury, a pregnant person’s
body will maintain its own homeostasis at the expense of the fetus.
 Maintain blood pressure in the face of hemorrhage
 Fluid replacement volume
 Monitoring the signs of shock
 Abdominal pain is difficult to localize during pregnancy because organs are
pushed aside by the growing uterus.
 Paracentesis- needle aspiration to assess abdominal cavity is bleeding
 Peritoneal lavage- process of inserting a peritoneal dialysis catheter into the
abdominal cavity checking for bleeding or bladder rupture
 PSYCHOSOCIAL CONSIDERATIONS
 Pregnant women are apt to be apprehensive and frightened if injury will
happened
 Sometimes the feeling of guilt about what they perceive to be their
carelessness can increase the level of stress
 Assessment of an injured pregnant person must be done quickly yet
thoroughly and should include both psychological and physical status.
 A patients needs support from people around them like family
 Taking pregnancy history before the a trauma history
 Physical examination to all body systems to ensure the safety of patients and
the fetus
 Therapeutic mngt:
 oxygenation and airway management
 CPR-check for responsiveness
 Call for help 911
 Continue chest compression
 Ask a person to place rolled towel or blanket under the patients right side to
relieve uterine pressure on the vena cava and help prevent supine hypotension
syndrome

OTHER UNINTENTIONAL INJURY

1) open wounds
2) Lacerations
3) Puncture wounds
4) Animal bites
5) Blunt abdominal trauma
 6. gunshot wounds
 7. poisoning
 8. choking
 9. orthopedic injuries
 10. burns

POST MORTEM CESAREAN BIRTH

 -a person does not survive serious trauma that possible for the child to be
born safely by post mortem CS
 Fetus is past 24weeks AOG and less than 20minutes has passed since the
mother died.
 No consent is necessary
 Classic cesarean incision is used
 Personnel should be available to resuscitate the newborn immediately.
 END OF WEEK 4 TOPICS

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