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Information

  1. INITIAL ASSESSMENT: Goal: establish baseline for health supervision, teaching, emotional support, or referral.
  2. OBJECTIVES:
    1. Determine woman's present health status and validate pregnancy.
    2. Identify factors affecting or affected by pregnancy.
    3. Determine current gravidity and parity.
    4. Identify present length of gestation.
    5. Establish an estimated date of delivery (EDD). Nägele's determination of EDD—subtract 3 months, add 7 days to last menstrual period (LMP).
    6. Determine relevant knowledge deficit.
  3. ASSESSMENT: history
    1. Family—inheritable diseases, reproductive problems.
    2. Personal—medical, surgical, gynecological, past obstetric, average nonpregnant weight.
      1. Gravida—a pregnant woman.
        1. Nulligravida—woman who has never been pregnant.
        2. Primigravida—woman with a first pregnancy.
        3. Multigravida—woman with a second or later pregnancy.
      2. Para—refers to past pregnancies (not number of babies) that reached viability (20–22 weeks whether or not born alive).
        1. Nullipara—woman who has not carried a pregnancy to viability (e.g., may have had one or more abortions).
        2. Primipara—woman who has carried one pregnancy to viability.
        3. Multipara—woman who had two or more pregnancies that reached viability.
        4. Grandmultipara—woman who has had six or more viable pregnancies.
      3. Examples of gravidity/parity. Several methods of describing gravidity and parity are in common use. One method (GTPAL) describes number of "Gravida" (pregnancies), Term (or full-term) infants, Preterm infants, Abortions, and number of Living children.
        1. A woman who is pregnant for the first time and is currently undelivered is designated as 1-0-0-0-0. After giving birth to a full-term living neonate, she becomes 1-1-0-0-1.
        2. If a woman's second pregnancy ends in abortion and she has a living child from a previous pregnancy, born at term, she is designated as 2-1-0-1-1.
        3. A woman who is pregnant for the fourth time and whose previous pregnancies yielded one full-term neonate, premature twins, and one abortion (spontaneous or induced), and who now has three living children, may be designated as 4-1-1-1-3.
        4. Others record as follows: number gravida/number para. Applying this system to the examples given above, those mothers would be designated as follows: a—G1P1; b—G2P1; c—G4P2.
        5. Others include recording of abortions:
          • G1P1 Ab0
          • G2P1 Ab1
          • G4P2 Ab1
  4. ASSESSMENT: initial physical aspects:
    1. Height and weight.
    2. Vital signs.
    3. Blood work—hematocrit and hemoglobin for anemia; type and Rh factor; tests for sickle cell trait, syphilis, rubella antibody titer, and hepatitis B screen.
    4. Urinalysis—glucose, protein, ketones, signs of infection, and pregnancy test (human chorionic gonadotropin [HCG]).
    5. Breast examination.
    6. Pelvic examination.
      1. Signs of pregnancy.
      2. Adequacy of pelvis and pelvic structures.
      3. Size and position of uterus.
      4. Papanicolau smear.
      5. Smears for monilial and trichomonal infections.
      6. Signs of pelvic inflammatory disease.
      7. Tests for STIs: Gonorrhea (gonococcus [GC]), chlamydia.
    7. Validation of pregnancy—physician or midwife makes differential diagnosis between presumptive/probable signs/symptoms of early pregnancy and other signs.
      1. Presumptive symptoms—subjective experiences.
        1. Amenorrhea—more than 10 days past missed menstrual period.
        2. Breast tenderness, enlargement.
        3. Nausea and vomiting.
        4. Quickening (weeks 16–18).
        5. Urinary frequency.
        6. Fatigue.
        7. Constipation (50% of women).
      2. Presumptive signs
        1. Striae gravidarum, linea nigra, chloasma (after week 16).
        2. Increased basal body temperature (BBT)
      3. Probable signs—examiner's objective findings.
        1. Positive pregnancy test.
        2. Enlargement of abdomen/uterus.
        3. Reproductive organ changes (after sixth week):
          1. Goodell's sign—cervical softening.
          2. Hegar's sign—softening of lower uterine segment.
          3. Vaginal changes (Chadwick's sign): purple hue in vulvar/vaginal area.
        4. Ballottement (after 16–20 weeks).
        5. Braxton Hicks contractions.
      4. Positive signs of pregnancy:
        1. Fetal heart tones.
          1. Doptone: weeks 10 to 12.
          2. Fetoscope: week 20.
        2. Examiner visualizes and feels fetal movements (usually after week 24).
        3. Sonographic examination (after week 14) when fetal head is sufficiently developed for accurate determination of gestational age. Pregnancy may be detected as early as fifth or sixth week after LMP.
  5. ASSESSMENT: nutritional status:
    1. Physical findings suggesting poor nutritional status:
      1. Skin: rough, dry, scaly.
      2. Lips: lesions in corners.
      3. Hair: dull, brittle.
      4. Mucous membranes: pale.
      5. Dental caries.
    2. Height, weight, age—average weight gain approximately 24 lb. Range 24 to 32 lb is best for mother and neonate.
    3. Laboratory values—Hemoglobin (Hgb): less than 10.5/100 mg; hematocrit (Hct): less than 32% indicates anemia.
    4. Nutrition history.
    5. Analysis/nursing diagnosis:
      1. Altered nutrition: less than body requirements related to anemia, vitamin/mineral deficit.
      2. Altered nutrition: more than body requirements related to obesity.
    6. Nursing care plan/implementation: Goal: health teaching.
      1. Nutritional counseling for diet in pregnancy and/or lactation.
    7. Evaluation/outcome criteria:
      1. If underweight at conception: should gain 28 to 42 lb (12.5–18 kg).
      2. If overweight at conception: 15 to 25 lb (7–11.5 kg).
      3. If obese at conception: 15 lb (7 kg) or more.
  6. ASSESSMENT: psychosocial aspects:
    1. Pregnancy: planned or not; desired or not.
    2. Present plans:
      1. Carry pregnancy, keep baby.
      2. Carry pregnancy, adoption.
      3. Abortion.
    3. Cultural, ethnic influences on decisions: will influence range of activities, types of safeguarding actions, diet, and health-promotion behaviors.
    4. Parenting potential: actively seeking medical care and information about pregnancy, childbirth, parenthood.
    5. Family readiness for childbearing and child rearing:
      1. Physical maintenance.
      2. Allocation of resources: identify support system.
      3. Division of labor.
      4. Socialization of family members.
      5. Reproduction, recruitment, launching of family members into society.
      6. Maintenance of order (relationships within family).
    6. Perceptions of present and projected family relationships.
    7. Review lifestyle for smoking, drugs, alcohol (ETOH), attitudes about pregnancy, health-care practices, and risks for hepatitis and human immunodeficiency virus (HIV).
  7. ANALYSIS/NURSING DIAGNOSIS:
    1. Altered role performance related to stress imposed by developmental tasks.
    2. Ineffective coping: individual, family related to stress caused by developmental tasks/crises.
    3. Altered family process related to developmental tasks. First baby may precipitate individual or family developmental crisis.
  8. NURSING CARE PLAN/IMPLEMENTATION:
    1. Goal: anticipatory guidance/support.
      1. Discuss mood swings, ambivalent feelings, negative feelings.
      2. Reinforce "normalcy" of such feelings.
    2. Goal: increase individual/family coping skills, reduce intrafamily stress.
      1. Reinforce family strengths (both partners), sense of family identity.
        1. Encourage open communication between partners; share feelings and concerns.
        2. Increase understanding of mutual needs, encourage mutuality of support.
        3. Increase tendency of mother to turn to partner as most significant person (as opposed to physician).
        4. Enhance bond, success of childbirth preparation classes.
      2. Promote understanding/acceptance of role change.
        1. Facilitate/support achievement of developmental tasks.
        2. Reduce probability of postpartum psychological problems.
        3. Promote family bonding.
    3. Goal: health teaching.
      1. Siblings:
        1. Alert parents to sibling needs for security, love.
        2. Include sibling in pregnancy experience.
        3. Provide clear, simple explanations of happenings.
        4. Continue demonstrations of love.
        5. Describe increased status ("big sister/brother").
        6. Discuss possible misbehavior to gain attention.
      2. Relatives: alert parents to possible negative feelings of in-laws.
      3. Referral to childbirth preparation/parenting classes.
      4. Appropriate community referrals for financial relief to decrease stress and provide aid.
  9. EVALUATION/OUTCOME CRITERIA:
    1. Actively participates in pregnancy-related decision making.
    2. Expresses satisfaction with decisions made.
    3. Demonstrates growth and development in parenting role.
    4. Prepared for the birth and for early parenthood.