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Second Trimester

NURSING DIAGNOSIS: Body Image, risk for disturbance
Risk Factors May Include: Perception of biophysical changes, responses of others
Possibly Evidenced By: [Not applicable; presence of signs/symptoms establishes an actual
diagnosis]
DESIRED OUTCOMES/EVALUATION Verbalize gradual acceptance/adaptation to
CRITERIA—CLIENT WILL: changing self-concept/body image.
Demonstrate a positive self-image by maintaining an overall
satisfactory appearance; dress in appropriately fitting clothes and
low-heeled shoes.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Review/assess attitude toward pregnancy, In the second trimester,the changing body
changing body shape, and so forth. (Refer to CP: contours are readily visible. Negative responses to
First Trimester; ND: Body Image disturbance.) such changes may occur in the client/couple whose
fragile self-concept is based on physical appearance.
Other visible effects caused by prenatal hormones
such as chloasma, striae gravidarum, telangiectasia
(vascular spiders), palmar erythema, acne, and
hirsutism can contribute to the client’s emotional
changes. These feelings may affect how she deals
with the changes that are occurring.
Discuss physiological aspects of, and client’s Individuals react differently to the changes that
response to, changes. Provide information about occur, and information can help the client
normalcy of changes. understand/accept what is happening.
Suggest styles and available sources of maternity Individual circumstances dictate needs for
clothing. clothing that will enhance the client’s appearance for
work and leisure activities.
Discuss methods of skin care and makeup (to Learning about, and being involved in, ways to
minimize/hide darkened areas of the skin), the use look and feel better may be helpful for maintaining
of support hose, maintenance of posture. positive feelings about the self.

Collaborative
Refer to other resources, such as classes in childbirth May be helpful in providing additional support
education and parenting or counseling. during this period of change; identifies appropriate
role models.

respiratory function is modified as the diaphragm’s ability to descend on inspiration is reduced by the enlarging uterus. changes in respiratory depth DESIRED OUTCOMES/EVALUATION Report decrease in frequency/severity of CRITERIA—CLIENT WILL: complaints. NURSING DIAGNOSIS: Knowledge deficit [Learning Need]. ACTIONS/INTERVENTIONS RATIONALE Independent Assess respiratory status (e. Obtain history of and monitor preexisting/ Other problems may further alter breathing developing medical problems (e.g. ineffective May Be Related To: Impingement of the diaphragm by the enlarging uterus Possibly Evidenced By: Complaints of shortness of breath. patterns and may compromise maternal/fetal asthma. which on exertion.. such as walking. good posture. (Refer to CP: tissue oxygenation. Semiupright positioning may increase lung expansion as the gravid uterus descends. Even though vital capacity increases. Stress importance of daily Increased plasma levels at 24–32 weeks’ gestation prenatal vitamins/ferrous sulfate intake as further dilute Hb levels. regarding natural progression of pregnancy May Be Related To: Continued need for information as the changes of the second trimester are experienced Possibly Evidenced By: Request for information. avoiding smoking. Demonstrate behaviors that optimize respiratory function. using modified semi-Fowler’s for lung expansion. Provide information about rationale for respiratory Reduces the likelihood of respiratory symptoms difficulties and realistic activity/exercise program. sinus problems. tuberculosis). occurs in approximately 60% of prenatal clients.) Note Hb and Hct levels. Good posture and small meals help maximize e. Note: Iron may be contraindicated for client with sickle cell anemia. and decreased oxygen-carrying capacity. eating smaller. shortness of breath Determines existence/severity of problem. available for maternal-fetal exchange. ND: Injury.g.. providing extra time for certain activities. increasing space available more frequent meals. allergic rhinitis. and participation in mild exercise. caused by overexertion.g. The High-Risk Pregnancy. Smoking reduces oxygen position for sitting/sleeping if symptoms are severe. diaphragmatic descent. risk for fetal. Encourage frequent rest periods. statement of concerns or misconceptions . dyspnea. Review measures client can take to ease problems. fatigue). resulting in possible anemia appropriate.. NURSING DIAGNOSIS: Breathing Pattern.

(Refer to CP: High- anemia. Recognize and act to minimize and prevent risk factors. and close monitoring as indicated. heart disease. possible abruptio placentae. (Strenuous exercise may result in reduced uterine blood flow/fetal bradycardia. More frequent prenatal visits may be needed to screening. cultural. gestational diabetes mellitus [GDM]. many individuals do not seek care until the second or even third trimester. point. to shorten labor. Institute/continue a learning program as outlined Repetition reinforces learning. normal Hb levels.. Discuss any medications that may be needed to Helpful in choosing treatment options because control or treat medical problem. (Refer to CPs: Diabetes Mellitus: Prepregnancy/Gestational. STDs). which may need treatment with insulin and/or diet. second trimester. monitoring and/or intervention. 18.g. Provide information about need for ferrous sulfate Ferrous sulfate and folic acid help maintain and folic acid. PIH. Encourage involvement in a moderate exercise A nonendurance perinatal exercise regimen tends program. and decrease the need for oxytocin augmentation. hypoxia related to asthma about potential high-risk situation requiring closer or tuberculosis. promote maternal well-being. as appropriate). information is useful at this [Learning Need]. and fetal malformation. DESIRED OUTCOMES/EVALUATION Verbalize/demonstrate self-care behaviors that CRITERIA—CLIENT WILL: promote wellness. Provides a helpful reminder/information for client spontaneous abortion.) Note: Exercise may be viewed as inappropriate in some cultures (e. Folic acid deficiency contributes to megaloblastic anemia. abortion. Identify danger signs/seek medical care appropriately. Note: For various reasons (e. and if client has not in CP: First Trimester. increase the likelihood of a spontaneous vaginal delivery.. regardless of whether changes are expected or unexpected.g. Monitoring Hb and Hct using electrophoresis detects specific anemias and is helpful in determining cause. kidney disorders. Review danger signs and appropriate actions. Discuss need for specific laboratory studies. need must be weighed against possible harmful effects on the fetus. the High-Risk Pregnancy. Screening for GDM at 24–26 weeks’ gestation or at 12. Note: Clients with sickle cell anemia require increased folic acid during and following crisis episode. Puerto Rican). Identify possible individual health risks (e. financial. Assume responsibility for her own healthcare..) . denial of condition).g. and 32 weeks’ gestation in high-risk client can detect developing hyperglycemia. Risk Pregnancy. ACTIONS/INTERVENTIONS RATIONALE Independent Review changes to be expected during the Questions continue to arise as new changes occur. ND: Knowledge deficit been seen previously.

may detect problems related to polyhydramnios or oligohydramnios. Certain genetic problems such as neural tube defects (NTDs) may be detected at this stage. especially ND: Injury. Provide information about diagnostic tests or Having information helps client/couple to deal procedure(s). risk for fetal Risk Factors May Include: M aternal health problems. Screens for multiple gestation. to confirm gestational age and rule out intrauterine growth retardation/restriction. exposure to teratogens/infectious agents Possibly Evidenced By: [Not applicable. Note quickening (maternal perception of fetal Perceivable fetal movements first occur between 16 movements) and fetal heart tones (FHT). Review maternal health status. e. STDs or other exposure to viruses/other STDs. These factors can have great impact on developing substance use/abuse. (Refer to CP: Prenatal Infection. risk for fetal.g.. healthcare provider if problem is detected. environmental viruses may be only mildly problematic for the factors). (Refer to CP: First Trimester.) for clients whose initial prenatal visit occurs at this time. with situation and make informed decisions. ACTIONS/INTERVENTIONS RATIONALE Independent Determine understanding of information Identifies individual needs/concerns and provides previously provided. .) client. normal or abnormal fetal growth. Refer to and 20 weeks’ gestation as fetal size increases. Assess uterine growth and fundal height at each visit. Review risks and potential side effects. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Verbalize awareness of individual risk factors. Collaborative Assist with ultrasonographic procedure. fetal tissues and organs. ways to minimize/prevent injury. and Detects presence of fetus as early as 5–6 weeks’ explain its purpose. NURSING DIAGNOSIS: Injury. malnutrition. less than body requirements. Also determines placental size and location and may detect some fetal abnormalities such as fetal heart defects when done between 18 and 20 weeks’ gestation.g. lack of movement may indicate an existing problem. and early identification ND: Nutrition: altered. Failure to detect FHT may indicate fetal demise or absence of fetus/presence of hydatidiform mole (gestational trophoblastic disease [GTD]).) and intervention may prevent untoward results. gestation and provides information about fetal growth.. but often have a great negative impact on fetal well-being. Assess for other factors existing in the individual Identification enables client and nurse to discuss situation that may be harmful to the fetus (e. (Refer to CP: First Trimester. CRITERIA—CLIENT WILL: Avoid factors and/or refrain from behaviors that may contribute to fetal injury. opportunity to clarify misconceptions.

as indicated.Obtain maternal serum sample for AFP level With an open NTD (most commonly.g. Assist with amniocentesis when AFP level is Analysis of amniotic fluid detects abnormal. Follow with genetic counseling as appropriate.) informed decisions about course of action in this pregnancy as well as future pregnancies. (Refer to CP: Diabetes Mellitus. a protein produced by the yolk sac and fetal liver. signs. CRITERIA—CLIENT WILL: Be free of pathological edema and signs of PIH.) NURSING DIAGNOSIS: Cardiac Output. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Remain normotensive during the prenatal course. is present in maternal serum at a level 8 times higher than normal at 15 weeks’ gestation. when cardiac output peaks.) output. . especially in high-risk population (e. risk for [decompensation] Risk Factors May Include: Increased circulatory demand. and anencephaly). Screen client for GDM with glucose tolerance GDM is associated with macrosomia and problems test (GTT) at 24–26 weeks’ gestation. however. it decreases until term. and/or preexisting cardiac problems.. spina bifida between 14 and 16 wk. Client/couple will need information to make (Refer to CP: Genetic Counseling. ventricular hypertrophy Possibly Evidenced By: [Not applicable. Note history of preexisting or potential cardiac/ These clients face the greatest risk for cardiac kidney/diabetic problems. genetic/chromosomal disorders and NTD. Prepregnancy/ Gestational. ACTIONS/INTERVENTIONS RATIONALE Independent Review physiological process and normal and During the second trimester. changes in preload (decreased venous return) and afterload (increased peripheral vascular resistance). Normally. Thereafter. hypertrophy of the abnormal changes. of dystocia. can compromise the system. (Refer to cardiac ventricles ensures increased cardiac CP: Cardiac Conditions. which reduces resistance to cardiac output. involvement during the second trimester. stress. Increases in fluid. which peaks at 25–27 weeks’ gestation to meet maternal/fetal oxygen and nutrient needs. if client has not already had CVS. and symptoms. AFP. the cardiovascular system compensates for increased cardiac output with dilation of blood vessels. older gravidas over age 35 yr). clients with possible genetic disorders/previous child having a chromosomal abnormality. Identify ways to control and reduce cardiovascular problems. This lowers the systolic pressure readings approximately 8 mm Hg while the diastolic pressure decrease averages 12 mm Hg.

(Refer to CP: Pregnancy-Induced progesterone activity. nonconstricting clothing. especially in increase greater than 30 mm Hg and diastolic clients with preexisting cardiac or kidney disease. elevate legs when sitting. hips. note presence of murmurs. and turn feet upward in dorsiflexion if sitting or standing for long periods. as blood pools in lower extremities. Dorsiflex foot to test for Homans’ sign. NURSING DIAGNOSIS: Fluid Volume risk for excess Risk Factors May Include: Changes in regulatory mechanisms. or venous before arising in the morning. Encourage client to avoid Sudden position changes may result in dizziness changing position rapidly. sodium/water retention Possibly Evidenced By: [Not applicable. A positive Homans’ sign may indicate refer to healthcare provider. Systolic murmurs are often benign and may be created by increased volume. Assess for faintness. and uterine pressure on pelvic blood [isotonic]. If present. and vulva vertical to the wall three times a day for 20 min. a murmur may indicate developing failure. diabetes. Distinguish (physiologic edema) often occurs because of between physiological and potentially harmful venous stasis caused by vasodilation from edema. heredity. thrombophlebitis.) vessels. displacement of the heart. decreased blood viscosity. excessive fluid retention. vulva. thrombosis. Assess for presence of ankle edema and Dependent edema of the lower extremities varicosities of legs. excess fluid Hypertension. Encourage client to avoid crossing legs and sitting/ Promotes venous return and reduces the risk of standing for long periods. Be free of hypertension. to put on support hose developing edema. or torsion of great vessels. ND: Fluid Volume deficit retention. CRITERIA—CLIENT WILL: Identify signs/symptoms requiring medical evaluation/intervention. albuminuria. Edema of facies and/or upper extremities may indicate PIH. or in the presence of multiple pregnancies or hydatidiform mole.Obtain BP and pulse measurement. . and rectum. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION List ways to minimize problem. to wear loose. increase greater than 15 mm Hg above baseline. Report systolic An increase in BP may indicate PIH. However. elevate legs. Auscultate heart sounds. varicosities. reducing circulating volume. and edema of facies. This increases the risk of venous thrombus formation.

occurring at the end of the day is normal. or presence of develop earlier. renal disease. Although up to 5 lb of fluid can be retained with no visible edema. no added table salt. Collaborative Schedule more frequent prenatal visits and Treatment helps promote positive maternal/fetal institute treatment if PIH exists.) NURSING DIAGNOSIS: [Discomfort] May Be Related To: Changes in body mechanics.ACTIONS/INTERVENTIONS RATIONALE Independent Monitor weight regularly. Have client record Detects excessive weight gain and invisible fluid weight between visits. Note reports of visual disturbances. Provide information about diet (e. total body water (plasma and red blood cells) increases by 1000 ml. especially in the client with hyperreflexia and clonus.) Recommend elevating extremities periodically Physiological edema of the lower extremities during the day. noting blood pressure. Detects vascular involvement associated with glomerular spasms of the kidney. (Refer to CP: outcomes. retention. During the second trimester. (for people of African heritage) indicate intravascular fluid shifts resulting in tissue edema. electrolyte imbalances . Test urine for albumin. which may be potentially pathological. West Indian) believe the more weight gained by the pregnant woman. which reduce resorption of albumin. owing in part to estrogen levels stimulating the adrenal gland to secrete aldosterone. such as diabetes.g. and fluid intake and caused by excessive fluid retention is not usually output. Although PIH location/extent of edema. If it does not resolve.. Pregnancy-Induced Hypertension. Note effects of variables. multiple gestation. contribute to water retention (too little sodium may result in dehydration. Note: Some cultures (e. increased Adequate nutrition. Indicators of pathological edema. but it should resolve with simple corrective measures. epigastric pain.g. especially increased protein. avoidance of foods reduces likelihood of PIH. this increase can contribute to cardiac decompensation. effects of hormones. predisposing factors. seen until the last 10 wk of pregnancy. Review Hct levels. protein. Assess for signs of PIH. or in presence of hydatidiform mole. hypertension. thereby retaining sodium and water. the healthier the mother and infant will be. such as In general. malnutrition (overweight or underweight). Excess sodium may and beverages high in sodium).. it may headache. Hct levels of 41% (for whites) or 38% altitude and race. the healthcare provider should be notified.

if leg cramps are severe or persist. Note presence of backache and lower back Relieves strain on lower back caused by increased pressure. citrus. Discuss dietary intake. exercise. Review proper dress (e. heartburn DESIRED OUTCOMES/EVALUATION Identify and demonstrate appropriate self-care CRITERIA—CLIENT WILL: measures. pelvic tilt. small meals per day. spices. Semi-Fowler’s position. curvature of the lumbosacral vertebrae and lying flat on back and pressing back to floor). strengthens back muscles. Recommend raising head of mattress or sleeping Elevating the upper body during sleep helps to on a wedge pillow.g. and avoidance of cold chocolate. offsetting calcium-phosphorus imbalances. the client usually experiences a sense appropriate nursing diagnoses. Demonstrate exercises (e. 1 quart of milk daily and taking aluminum Aluminum hydroxide traps dietary phosphorus in hydroxide. eat six reflux. leg cramps. and use of stool Aids in the prevention/management of softener as presented in CP: First Trimester. meals neutralize acidity. risk for. Constipation. potentiate leg cramps. teach client to extend leg Pressure on nerves in the pelvis.. Reassess for leg cramps. tissue calcium levels. loose. comfortable clothing). Explain physiology of problem. Reassess for changes in bowel elimination and Reduced gastrointestinal motility. refrain food/eating near bedtime help to prevent gastric from eating immediately before bedtime. frequent dietary history.g. low-heeled shoes. Recommend reducing intake of milk products Continued intake of calcium-containing and taking aluminum lactate.. ND: constipation. ACTIONS/INTERVENTIONS RATIONALE Independent Note presence of problems related to cardiac Although these conditions are often sources of output or breathing difficulties and refer to discomfort. Note presence of heartburn (pyrosis). reduce incidence of gastric reflux. Suggest that client avoid fried/fatty foods. or continuing with foods/products elevates ionized plasma levels. small. decreased fluid intake. Extension of the leg and dorsiflexion of the foot increase perfusion/oxygenation of tissue and help relieve pressure on nerves of lower extremities. supplements. intestinal tract. and increasing pressure/displacement from enlarging uterus interfere with normal functioning. review Fatty foods increase gastric acidity. Report discomfort is prevented or minimized. as well as low and dorsiflex foot. assume semi-Fowler’s position after meals. the effect of iron hemorrhoids. Possibly Evidenced By: Reports of back strain. of physical well-being free of the typical discomforts of the first trimester. and decrease fluid intake with meals. or very cold food. .

risk for ineffective Risk Factors May Include: Situational/maturational crisis. as appropriate. Recommend use of side-lying lowering blood pressure. personal vulnerability. Women may fear the death of their spouses. and the male partners may fantasize about themselves being pregnant (couvade syndrome. presence of signs/symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION Express feelings freely. Neutralizes gastric acidity. Evaluate degree of dysfunction client/partner is Clients experiencing difficulty adjusting to the experiencing in relation to changes that are overwhelming tasks associated with pregnancy/ occurring and those that are anticipated. arise at this time. Avoid use of bicarbonate as a substances such as sodium. CRITERIA—CLIENT WILL: Identify individual strengths. parenting may manifest inappropriate follow- through with prenatal healthcare or greater than normal states of emotional lability. that may be neutralizer or calcium products. NURSING DIAGNOSIS: Coping.) Reinforce the normalcy of these fears and fantasies. Collaborative Administer low-sodium antacid. May result in difficulties for the individual who does not see the normalcy of this experience. Can reduce phosphorus levels. . Display effective problem-solving and coping skills.Provide information about appropriate choices May be constipating and/or may contain of OTC antacids. Give calcium supplements and aluminum gel Substitutes for milk products in presence of as appropriate. dietary intolerance. Review rest/ blood vessels interfering with circulation/ sleeping position. Individual. unrealistic perceptions Possibly Evidenced By: [Not applicable. decreases phosphorus levels. Frequent use of calcium- containing antacids in addition to intake of high- calcium foods may contribute to calcium-phosphorus imbalance and development of muscle cramps. lack of interest in the pregnancy. contraindicated in certain situations owing to its water-retaining properties. The male partner may demonstrate negative coping in preoccupation with work or a new hobby. or involvement in sexual relations outside the relationship (raising concerns of STDs [including HIV]). ACTIONS/INTERVENTIONS RATIONALE Independent Identify fears/fantasies client/partner may have. position. Common female/male fears and fantasies may Discuss meaning of these thoughts. Investigate reports of dizziness/lightheadedness Supine position places weight of uterus on major or diaphoresis when lying down.

g. allay anxiety.) pelvic/perineal vasocongestion increasing orgasmic pleasure. CRITERIA—CLIENT/COUPLE WILL: Verbalize understanding of possible reasons for changes noted. Be alert to indications of possible sexual There appears to be a higher rate of deviations difficulties or inappropriate behaviors by the man. risk for altered. . (such as rape.Encourage client/partner to express feelings about Acknowledging and expressing feelings can help pregnancy and parenting. altered.) NURSING DIAGNOSIS: Sexuality Patterns. Identify acceptable alternatives to meet individual needs. (Refer to May need additional help to solve underlying CP: First Trimester. vaginal especially in the third trimester.. Review normalcy of feelings and discuss possible Fear of injuring the fetus during intercourse is choice of increasing physical contact through another common concern. often occurs in the second trimester as a result of ND: Sexuality Patterns. Verbalize mutual satisfaction or seek counseling. ACTIONS/INTERVENTIONS RATIONALE Independent Discuss impact of pregnancy on normal patterns Optimal sexual satisfaction for the prenatal client of sexual intercourse. limitations or changes in sexual behaviors/activities DESIRED OUTCOMES/EVALUATION Discuss sexual concerns.. and extramarital affairs). violent crimes. Puerto Rican) support abstinence for the pregnant woman. when mate is pregnant. issues. rear entry. female superior. Collaborative Refer to classes and counseling. The man may experience mixed feelings in response to his partner’s increased arousal and be confused by his own reduced or increased sexual desire in response to his partner’s changing body. altered May Be Related To: Conflict regarding changes in sexual desire and expectations. e. fear of physical injury to woman and/or fetus Possibly Evidenced By: Reported difficulties. if appropriate.g. Note: Some cultures (e. the individual begin to identify concerns and begin the problem-solving process. Review possible alterations in position for coitus. Reinforcement of the hugging and fondling rather than actually normalcy of these feelings and concerns can help engaging in intercourse. as needed. side-by-side. Assists couple in considering alternatives/making which may be useful as the pregnancy progresses. choices. ND: Role Performance. incest. (Refer to CP: First Trimester. Other choices are perfectly acceptable if both parties are satisfied.

Collaborative Refer to clinical nurse specialist/counseling May need additional help to solve underlying as indicated. or may be preexisting. problems which may develop as pregnancy progresses. .