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NurseReview.Org - Third trimester

NurseReview.Org - Third trimester

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http://NurseReview.Org for more medical slides, audio lecture, video animation, test taking tips and lots more.
http://NurseReview.Org for more medical slides, audio lecture, video animation, test taking tips and lots more.

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Published by: nursereview on May 01, 2008
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05/09/2014

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NurseReview.org
Third Trimester
NURSING DIAGNOSIS:
[Discomfort]
May Be Related To:
Physical changes, hormonal influences
Possibly Evidenced By:
Reports of back strain/pain, leg cramps, paresthesia,
pruritus, uterine contractions
DESIRED OUTCOMES/EVALUATION
Use appropriate self-care activities to reduce
CRITERIA\u2014CLIENT WILL:

discomforts.
Report discomfort minimized/controlled.
Seek medical attention appropriately.

ACTIONS/INTERVENTIONS
RATIONALE
Independent
Continue ongoing assessment of client\u2019s
Updates data base for planning care and evaluates
discomforts and her methods of dealing with

appropriateness of interventions.
problems. (Refer to CP: Second Trimester;
ND: Discomfort.)

Assess client\u2019s respiratory status. (Refer to CP:
Reduced respiratory capacity as the uterus presses
Second Trimester; ND: Breathing Pattern,
on the diaphragm results in dyspnea, especially
ineffective.)
for the multigravida, who may not experience relief
with engagement (lightening) until the onset of labor.
Note reports of back strain and altered gait.
Lordosis and muscle strain are caused by the
Suggest use of low-heeled shoes, pelvic-rock
influence of hormones (relaxin, progesterone) on
exercise, maternity girdle, heat application, and
pelvic articulations and a shift in the center of
massage techniques to be used by partner.
gravity as the uterus enlarges. Multiple interventions
are usually more helpful to alleviate discomfort.
Determine presence of leg cramps. Encourage client
Reduces discomfort associated with altered
to extend leg and turn foot upward in dorsiflexion,
calcium levels/calcium-phosphorus imbalance, or
change position frequently; avoid prolonged
with pressure from enlarging uterus compressing
standing/sitting; and reduce milk intake
nerves supplying the lower extremities.
appropriately.
Assess for presence/frequency of Braxton Hicks
These contractions may create discomfort for the
contractions. Provide information regarding
multigravida in both second and third trimesters.
physiology of uterine activity.

The primigravida usually does not experience this
discomfort until the last trimester, when
progesterone\u2019s protective effect on uterine activity is
decreasing and oxytocin levels are increasing.

Note paresthesia of toes and fingers. Suggest
Reduces effects of extreme lordotic posture (which
client remove constrictive jewelry, maintain
strains brachial nerves and compresses nerve roots
adequate intake of prenatal vitamins (take
and femoral veins), edema, pressure on carpal
vitamin B6 supplement with orange juice or
tunnel nerves/ligaments, and vitamin B6
banana), use correct posture, exercise limbs
deficiency. Note: Some sources report controversy
regularly throughout the day, and avoid extremes
over the effectiveness of vitamin B6.
of temperatures.
Review reports of urinary frequency and
Third trimester uterine enlargement reduces
bladder pressure. (Refer to ND: Urinary
bladder capacity, resulting in urinary frequency.
Elimination, altered.)
Assess for constipation and hemorrhoids.
Increasing displacement of the bowel contributes to
problems of elimination.
Discuss dangers of using cathartics during the ninth
The use of cathartics may stimulate the onset of
month, and suggest other means of resolving
early labor. Some cultures, such as Hispanic,
constipation, such as a high-fiber diet. Note cultural
believe that use of cathartics ensures good delivery
practices that might influence behaviors. (Refer to

of a healthy boy.
CP: First Trimester; NDs: [Discomfort]; Constipation,
risk for.)

Assess for pyrosis (heartburn). Review dietary
Problem often occurs in second trimester and may
limitations.
continue as gastric emptying time is prolonged,
especially when diet is not modified.
Note presence of leukorrhea and pruritus.
As estrogen levels increase, secretions of the
Encourage client to bathe frequently, use cotton
cervical glands create an acid medium that
underwear, wear loose clothing, and to avoid
encourages proliferation of organisms.
long periods of sitting.
Assess for problems related to diaphoresis; suggest
Increased metabolism and body temperature
use of lightweight clothing, frequent bathing, and
caused by progesterone activity and excess weight
cool environment.
gain may create a constant feeling of being
overheated and may increase diaphoresis.
Collaborative
Give calcium supplements/calcium-rich antacid
Substitutes for milk products when intolerance is a
as appropriate. Recommend use of aluminum
problem. Gel can reduce phosphorus levels,
hydroxide gel as needed.
correcting calcium-phosphorus imbalance.
Refer for Therapeutic Touch or transcutaneous
May be indicated if other comfort measures are
electrical nerve stimulation (TENS), as appropriate.
insufficient to alleviate severe back pain.
NURSING DIAGNOSIS:
Knowledge deficit [Learning Need], regarding
preparation for labor/delivery; infant care
May Be Related To:
Lack of exposure/experience, misinterpretation of
information
Possibly Evidenced By:
Request for information, statement of concerns or
misconceptions
DESIRED OUTCOMES EVALUATION
Discuss physical/psychological changes associated
CRITERIA\u2014CLIENT/COUPLE WILL:
with labor/delivery.
Identify appropriate resources to obtain information
about infant care.
Verbalize preparedness for labor/delivery and infant.
ACTIONS/INTERVENTIONS
RATIONALE
Independent
Continue/institute learning program as outlined
Builds on previous learning and/or provides new
in CP: First Trimester.

information. Of greatest concern for the couple in this
trimester is how to prepare physiologically and
psychologically for the event of labor/delivery and
issues surrounding infant care. Note: For various
reasons (e.g., financial, cultural) clients may delay
seeking care until pregnancy is well advanced or
delivery is imminent, creating a challenge for
healthcare providers to provide meaningful
education in a timely fashion.

Provide information about normal physical/

Understanding the normalcy of such changes can
physiological changes associated with third trimester. reduce anxiety and foster adoption of self-care
(Refer to ND: Self Esteem, risk for situational low.)

activities.
Review oral/written information about signs of

Helps client to recognize onset of labor, to ensure
labor onset; distinguish between false and true labor. timely arrival, and to cope with labor/delivery
Discuss when to notify healthcare provider and when process.
to leave for hospital/birth center. Discuss stages of
labor/delivery.

Discuss birth plan written by client/partner and
Helps client to make informed choices that are
provide additional information as needed. Note
amenable to the specific care setting and reflect
cultural expectations/references.

individual needs. Note: Some cultures or personal values may limit male involvement in the delivery process, necessitating the identification of other support person(s).

Provide oral/written information about infant care,
Helps prepare for new caretaking role, acquiring
development, and feeding; offer appropriate
necessary items of furniture, clothing, and
references. Elicit cultural beliefs.

supplies; helps prepare for breastfeeding and/or
bottle feeding. Lack of preparation may be culturally
linked, indicating belief that preparation may be
associated with increased risk of infant\u2019s death
because they are \u201cdefying God\u2019s will.\u201d

Determine plan for discharge after delivery and
Early planning can facilitate discharge and help
home care support/needs.
ensure that client/infant needs will be met.
Encourage enrollment in childbirth classes (if not
Reduces anxiety associated with the unknown;
already attending) and tour hospital/birth center.
enhances coping mechanisms for labor/delivery.
NURSING DIAGNOSIS:
Sleep Pattern disturbance
May Be Related To:
Changes in level of activity, psychological stress,
inability to maintain comfort
Possibly Evidenced By:

Interrupted sleep, awakening earlier/later than desired, difficulty in falling asleep, not feeling well rested, dark circles under eyes

DESIRED OUTCOMES/EVALUATION
Report improvement in sleep/rest.
CRITERIA\u2014CLIENT WILL:

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