(see also STIs, Lifestyle Choices and Influences That Impact Health in Pregnancy, Intrapartum, Postpartum, and Newborn, Health Promotion and Maintenance, and substance abuse, Health Promotion and Maintenance)

1. OTHER HIGH-RISK WOMEN
1. An adolescent who is pregnant
1. General aspects:
1. Pregnancy in women between 12 and 17 years old.
2. Incidence has started to ↓ ; approximately one third of all births are to adolescents.
3. Predisposing factors: early menarche, early experimentation with sex, poor family relationships, poverty, late or no prenatal care, cultural influence.
4. Associated health problems: preeclampsia, preterm labor, SGA infants, anemia, bleeding disorders, infections, CPD.
5. Social problems: mothers who are poorly educated, child abuse, single-parent families, mothers who are unemployed or working at minimum wage or who lack support system.
2. Assessment:
1. Present physical/health status.
2. Feelings toward pregnancy.
3. Plans for the future.
4. Factors influencing decisions related to self, pregnancy, baby.
5. Signs and symptoms of complications of pregnancy (see A. 1. d.Associated health problems ).
6. Need/desire for health maintenance information (family planning).
3. Analysis/nursing diagnosis:
1. Ineffective coping, individual/family, related to need to alter lifestyle, plans, expectations.
2. Altered family processes related to unexpected/unwanted pregnancy.
3. Altered parenting related to intrafamily stress secondary to unexpected pregnancy, developmental tasks.
4. Self-esteem disturbance related to altered self-concept, body image, role performance, personal identity.
5. Knowledge deficit related to family planning, health maintenance, risk factors, pregnancy options.
6. Altered nutrition related to lifestyle.
4. Nursing care plan/implementation:
1. Goal: emotional support.
1. Ensure confidentiality.
2. Establish acceptant, supportive environment.
3. Encourage verbalization of feelings, concerns, fears, desires, etc.
4. Maintain continuity of care—consistency of nursing approach, to establish trust, confidentiality.
2. Goal: facilitate informed decision making.

Discuss available options; aid in exploring implications of possible decisions.

3. Goal: nutritional counseling (anemia).
1. Needs for own growth and that of fetus.
2. High-quality diet—value for character of skin, return to prepregnant figure.
3. Include pizza, hamburgers, milkshakes as acceptable—to minimize anger at being "different."
4. Goal: health teaching.
1. Rest, exercise, hygiene—as for other women.
2. Prevention of infection—STI, UTI, etc.
3. Breast self-examination; Pap smear.
4. Future family planning options (see Table 4-1. Contraception ).
5. Goal: assist in achievement of normal developmental tasks. Encourage exploration of new role and responsibilities.
6. Goal: referral to appropriate resources.
1. Abortion; adoption resources.
2. Preparation for childbirth and parenting classes.
3. Family counseling.
4. Social services.
7. Goal: assist in facilitating/continuing/completing basic education.
1. Communicate with school nurse.
2. Explore other options available in community.
5. Evaluation/outcome criteria:
1. Makes informed decisions appropriate to individual and family needs, desires.
2. Actively participates in own health maintenance.
1. Complies with medical/nursing recommendations.
2. Minimizes potential for complications of pregnancy.
3. Copes effectively with normal physiological and psychosocial alterations of pregnancy.
4. Both woman and baby's father express satisfaction with decision and management of this pregnancy. If parenthood is chosen and pregnancy is successful, accepts parenting role.
2. Older mother: primigravida over age 35
1. General aspects—higher incidence of congenital anomalies (e.g., Down syndrome), increased possibility of complications of pregnancy. However, generally it is a conscious decision to have postponed childbearing. Individuals are usually used to making own decisions regarding career and health care.
2. Assessment:
1. Same as for other women who are pregnant.
2. Reaction to reality of pregnancy.
3. Family response to pregnancy.
3. Analysis/nursing diagnosis:
1. Fear related to threat to pregnancy.
2. Knowledge deficit related to aspects of pregnancy care.
4. Nursing care plan/implementation:
1. Goal: anticipatory guidance. Preparation for parenthood, altered lifestyle, potential change of career. Assist with realistic expectations. Refer to "over 30" parents' support group.
2. Goal: health teaching. Explain, discuss special diagnostic procedures (Figure 4-5. Amniocentesis) (Amniocentesis).
3. Other—same as for other women who are pregnant.
5. Evaluation/outcome criteria:
1. Experiences normal, uncomplicated pregnancy, labor, and birth of a newborn who is normal and healthy.
2. Expresses satisfaction with decision and outcome of this pregnancy.
3. Older mother: multipara over age 40
1. General aspects
1. Increased incidence of preexisting and coexisting medical disorders (hypertension, diabetes, arthritis).
2. Increased incidence of complications of pregnancy (preeclampsia/eclampsia, hemorrhage).
3. Smoking is major risk factor.
2. Assessment:
1. Same as for other women who are pregnant.
2. Reaction to pregnancy (varies from pleasure at still being "young enough," to despair, if facing decision to abort).
3. History, signs and symptoms of coexisting disorders.
4. Indications of reduced physical ability to cope with normal physiological alterations of pregnancy.
5. Family constellation: stage of family developmental cycle, responses to this pregnancy (especially adolescents' reaction to parents' pregnancy).
3. Analysis/nursing diagnosis: same as for over-35 age group.
4. Nursing care plan/implementation:
1. Goal: emotional support. Encourage verbalization of feelings, fears, concerns.
2. Goal: referral to appropriate resource.
1. Genetic counseling.
2. Abortion/support groups.
3. Preparation for childbirth and parenthood classes.
3. Goal: facilitate/support effective family process. Involve family in preparation for birth and integration of newborn into family unit.
4. Other—same as for other women who are pregnant.
5. Evaluation/outcome criteria:
1. Makes informed decisions related to pregnancy.
2. Expresses satisfaction with decision and outcome of this pregnancy.
3. Experiences uncomplicated pregnancy, labor, and birth of a newborn who is normal and healthy.
4. AIDS
1. General aspects—AIDS is a serious condition affecting the immune system. Heterosexual women are considered at risk if they or their sexual partners:
1. Are HIV positive.
2. Use IV drugs (50%).
3. Received blood between 1977 and 1985 (9%).
4. Are homosexual or bisexual men (39%).
5. Have hemophilia.
2. Assessment—general symptoms:
1. Malaise.
2. Chronic cough; possible tuberculosis.
3. Chronic diarrhea.
4. HIV positive.
5. Weight loss: 10 lb in 2 months.
6. Night sweats; lymphadenopathy.
7. Skin lesions; thrush.
8. Pelvic inflammatory disease (PID); STIs; vulvovaginitis (usually, yeast [Candidiasis]), often refractory and severe.
9. Cervical cytologic abnormalities; often infected with human papillomavirus (HPV).
3. Analysis/nursing diagnosis:
1. Altered nutrition, less than body requirements, related to general malaise.
2. Fatigue, related to altered health status, weight loss.
3. Fear related to progressively debilitating disease.
4. Knowledge deficit related to disease progression, treatment, life expectancy.
5. Ineffective individual coping related to disease progression.
4. Nursing care plan/implementation:
1. Identify women at risk.
2. Protect confidentiality.
3. Implement standard precautions.
4. Use proper gloves, gown, hand washing.
5. Use protective eyewear and mask during labor, birth.
5. Evaluation/outcome criteria:
1. No further transmission of virus.
2. Woman's confidentiality maintained.
3. Standard precautions implemented.
4. Emotional support implemented.
5. Supportive groups contacted.
6. Women who are HIV positive—pregnancy management:
1. Antepartum
1. Increased incidence of other STIs (gonorrhea, syphilis, herpes, HPV).
2. Increased incidence of cytomegalovirus (CMV).
3. Differential diagnosis for all pregnancy-induced complaints.
4. Counsel regarding nutrition.
5. Advise about risk to infant.
6. Counsel regarding safer sex.
2. Intrapartum
1. Focus on prevention of transmission.
2. Mode of birth not based on disease.
3. External electronic fetal monitoring (EFM) preferred.
4. Avoid use of fetal scalp electrodes or fetal scalp sampling.
3. Postpartum
1. No remarkable alteration in disease progression.
2. Breastfeeding contraindicated.
3. Implement standard precautions for mother and infant.
4. Refer to specialists in AIDS care and treatment.
7. Newborn or neonate:
1. General aspects: Neonatal AIDS—transmission may be transplacental, contact with maternal blood at birth, or postnatal exposure to parent who is infected (i.e., breastfeeding). Classic signs evident in adult often not present. Common signs: lymphadenopathy, hepatosplenomegaly, oral candidiasis, bacterial infections, failure to thrive.
2. Implement standard precautions for all invasive procedures. Bathe infant immediately after birth to decrease contact with mother's blood. Wear gloves for all contact before first bath.
3. Provide supportive nursing care (thermoregulation, respiratory).
4. Encourage parent-infant contact.
5. Provide opportunities for sensory stimuli and touch.
6. Monitor intake and weight gain.
7. Observe for signs of infection.
8. Initiate social service consultation.
9. Counsel family about vaccinations (should receive all except oral polio).
10. Administer medications as ordered (zidovudine [AZT]).