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Nursing Process Overview For Healthy Adaptation to Pregnancy Assessment Ideally, begins before the pregnancy. During a preconception assessment Evaluate Woman's health status Nutritional intake Lifestyle Identify any potential problems Identify the woman's understanding and expectations of conception, pr egnancy, and parenthood.

Establish a trusting relationship

Assess the woman's health and nutritional

status, as well as the well-being of the fetus, throughout pregnancy. Document the woman's physiologic adaptations and the family's psychological adaptations to pregnancy Physical findings are gained through the health history, physical assessment, and laboratory tests. Assessment in psychological areas interviewing

Nursing Diagnosis Examples of nursing diagnoses Anxiety related to unexpected pregnancy Altered breathing pattern related to r espiratory system changes of pregnancy Disturbed body image related to weight gain with pregnancy Deficient knowledge related to normal changes of pregnancy Imbalanced nutrition, less than body requirements, related to morning sicknes s

Outcome Identification and Planning Plan to review concerns of the woman as w ell as a plan to ask about the individual responses she is experiencing.

Implementation Help women at prenatal visits to voice their concerns about either physiologic or psychological changes of pregnancy, May ne ed suggestions on exercise and nutrition to prepare for pregnancy and to follow during pregnancy. Nursing interventions can be instrumental in not only guiding a woman safely through a pregnancy but also connecting her back with ongoing he alth care.

Outcome Evaluation Client states she is able to continue her usual lifestyle t hroughout pregnancy. Family members describe ways they have adjusted their life styles to accommodate the mother's fatigue. Couple states they accept the physi ologic changes of pregnancy as normal.

Psychological Changes of Pregnancy Woman's attitude toward a pregnancy depends a great deal on psychological aspects the environment the messages about pregnancy her family communicated to her as a child the society and culture in which she lives as an adult whether the pregnancy has come at a good time in her life.

Social Influences cultural background their personal experiences the experie nces of friends and relatives current public philosophy of childbirth. People' s opinions about adolescent pregnancies, “late in life” pregnancies, or lesbian pregnancies have changed markedly.

Cultural Influences may strongly influence how active a role she wants to take in her pregnancy certain beliefs and taboos may place restrictions on her beha vior and activities To learn about the beliefs of a particular woman and her pa rtner, ask at prenatal visits if there is anything they believe should or should not be done to make the pregnancy successful and keep the baby healthy. Suppor ting these beliefs shows respect for the individuality of the woman and her know ledge

Family Influences Loving family: more likely to have a positive attitude toward her pregnancy “People love as they have been loved” W oman who views mothering as a positive activity is more likely to be pleased whe n she becomes pregnant than one who devalues mothering

Individual Influences Woman's ability to cope with or adapt to stress Securit y in her relationship with the people around her, especially the father of her c hild, is usually also important to her acceptance of a pregnancy. A woman who t hinks of brides as young but mothers as old may believe pregnancy will rob her o f her youth.

The Psychological Tasks of Pregnancy First Trimester: Accepting the Pregnancy Accept the reality of the pregnancy. A diagnosis of pregnancy is a similar rite of passage. In reality, as many as 50% of pregnancies are still unintended, unwanted, or mistimed Often women imme diately experience something less than pleasure and closer to disappointment or anxiety at the news that they are pregnant.

The Partner Partner may go through some of the same psychological changes. Ac cepting the woman in her changed state. A partner should try to give the woman emotional support while she is learning to accept the reality of pregnancy Ofte n partners are proud and happy about the pregnancy, facilitating acceptance of i t. An unwed father may have a great deal of difficulty accepting a pregnancy un less he is actively involved in prenatal care.

Second Trimester: Accepting the Baby The Woman Accept that she is having a baby, a separate step from accepting the pregnancy. Second turning point in pregnancy : quickeni ng, or the first moment a woman feels fetal movement. She begins to imagine her self as a mother Realize that not only is she pregnant but also there is a chil d inside her.

Second Trimester: Accepting the Baby The Partner Feeling of being left out Some men may have difficulty enjoying t he pregnancy if they have been misinformed about sexuality, pregnancy, and women 's health. Many men comment that the information they receive about childbirth and pregnancy is too concerned with their partner or the child and not enough wi th how they feel to be relevant to them.

Third Trimester: Preparing for Parenthood “nest-building” activities” It is helpful for couples to attend childbirth education classes or classes on preparing for parenthood.

Emotional Responses to Pregnancy Ambivalence may want to be pregnant, and yet she may not be enjoying it. This leads to some degree of ambivalence. refers to the interwo ven feelings of wanting and not wanting that can exist at high levels. It is im portant to emphasize that this ambivalence is normal. Partners also experience ambivalence, sometimes more so than pregnant women. To help partners resolve so me ambivalence, provide an outlet for them to discuss concerns,

Grief Before a woman can take on a mothering role, she has to give up or alter her present roles. She must incorpo rate her new role as a mother into her other roles as a daughter, wife, or frien d. Her partner must incorporate a new role as a father into his other roles of son, husband, or friend.

Narcissism Self-centeredness (narcissism) is generally an early reaction to pregnancy. Dressing becomes a time-consuming, mirrorstudying procedure. She makes a ceremony out of fixing her meals. May lose interest in her job or community events Men may demonstrate the same behavior by reducing r isky activities Need to protect her body has implications for nursing care.

Introversion Versus Extroversion Introversion, or turning inward to concentrate on oneself and one's body, is a common finding during pregnancy. Th ey become more active, appear healthier than ever before, and are more outgoing.

Stress Time of extreme stress for a woma

May cause people who were dependent on

the woman before pregnancy to feel neglected To help families keep their perspe ctive, remind them that a decrease in the responsibilities that a pregnant woman takes on is a reaction to the stress of pregnancy, not the pregnancy itself. A woman with few support people around her almost automatically has more difficul ty

Couvade Syndrome Men experience physical symptoms such as nausea, vomiting, and backache to the same degree or even more intensely than th eir partners do during a pregnancy. These symptoms apparently result from stres s, anxiety, and empathy for the pregnant woman. The more the partner is involve d in or attuned to the changes of the pregnancy, the more symptoms he may experi ence. For the most part, these are healthy

Changes in Sexual Desire 1st Trimester: decrease in libido nausea, fatigue, and breast tenderness that accompany early pregnancy. 2nd trimester: libido and sexual enjoyment rise markedly. blood flow to the pelvic area increases to supply the placenta 3rd trimester: sexual desire may remain high, or it may decrease because of difficulty finding a comfortable position and increasing abdominal size.

Reproductive System Uterus (UterineMeasurements) Uterine Wt. Thickness Length Depth Width Capacity Pregnancy 50 gm. 2 cm 6.5 cm 2 .5 cm 4 cm 10 ml Term Pregnancy 1100 gm. 0.5 cm 32 cm 20 cm 24 cm 5000 ml

Reproductive System Blood Flow : Uterine blood flow increases from 20 ml before pregnancy to 700 to 900 ml at the end of pregnancy. ¾ of the b lood supply goes to the placenta. Shape : From pear shape before pregnancy to spherical and later on to ovoid shape in the last months of pregnan cy Position : After 12 weeks gestation, the uterus loses its anteflexed position.

Reproductive System Location of the Fundus : 12 weeks - at the level of the symphisis 16 weeks – halfway between symphisis and umbilicus 20 weeks – level of the umbilicus 24 weeks – 2 fingers above the umb ilicus 30 weeks – midway between umbilicus and xiphoid process 36 weeks – leve l of the xiphoid process 40 weeks – 2 fingers below the umbilicus, drops at 34 weeks level because of lightening

Reproductive System Contractility : uterus is a highly contractile organ.

Beginning on the first trimester,

the uterus undergoes irregular contractions. Late in pregnancy, these contracti ons, known as BraxtonHicks, becomes more intense and frequent causing some disco mfort

Reproductive System Cervix Color : Change from pink to purplish due to increase blood supply Leukorrhea : Estrogen stimulation results in increase mucus production that leads to the formation of operculum, the mucus pl ug of the cervix that protects against bacteria and infection. Consistency: Sof tening of the cervix, known as Goodel’s sign, is observable by 6 to 8 weeks gest ation.

Reproductive System Isthmus During pregnancy, the isthmus softens and elongates up to 25 mm. It will later form the lower uterine segment, together with the cervix. Hegar’s sign – softening of the lower uterine segmen t begins as early as 5 week gestation

Reproductive System Vagina Increase blood supply results in: Chadwick sign – change color from pinkish to purplish or dark-blue Increase sen sitivity and heightened sexual responsiveness Vaginal ph 3.5 to 6, acidic

Reproductive System Ovaries No Graafian follicle develop and no ovulation occurs during pregnancy Corpus luteum is the chief source of hormone progesterone during the first 12 weeks gestation, it also produces estrogen, rel axin, inhibins and sometimes oxytocin.

Reproductive System Breast Increase breast size due to alveolar tissue growth, fat deposition and increase vascularity. associated with pregnancy incl udes feeling of fullness and tingling sensation darkening of the skin around the areola. Montgomery’s gland becomes prominent and nipples stand out. A c lear fluid called colustrum, can be expressed from it as early as the 4th month.

Cardiovascular System Blood Volume Total volume increases by 45 to 50% for which 75% is plasma and 25% is RBC. Increase volume leads to increase in ca rdiac output by 25 to 50% Increase in blood volume reaches its peak at about 24 weeks, cardiac workload also reaches its peak during the 2nd trimester.

Cardiovascular System Blood Constituents Increase production of RBC by the bone marrow Hemodilution occurs causing pseu doanemia Increase protein requirement of the fetus and hemodilution contribute to the reduction of maternal plasma protein level. Reduc tion of protein level lowers osmotic pressure within intravascular spaces which causes fluid shift from intravascular to interstitial space. This contributes to the normal ankle and foot edema of pregnancy. Blood lipid and cholosterol leve l increases to provide an available supply of energy for the fetus Increase lev el of clotting factor making woman prone to thrombus formation. Instruct to avoi d massage

Cardiovascular System Heart The heart is displaced to the left and upward of the diaphragm Slight cardiac enlargement nancy. In the 1st trimester is due to parasympathetic stimulation ged uterus. Palpitation during preg

In the latter part of pregnancy, it is due to enlar

Cardiovascular System Blood Pressure Blood pressure remains the same as pre-pregnancy level. It may drop slightly on the 2nd trimester but returns to no rmal levels on the 3rd trimester. Arterial blood pressure is highest in sitting position, intermediate in supine and lowest in left lateral position.

Respiratory system Increase oxygen requirement Effects of estrogen and progesterone Mechanical e ffect of the enlarge uterus Hyperventilation – in an effort to blow off the extra CO2 from the fetus. Displacement of the diaphragm – because of the en larged uterus Chest crowding – compensate by expanding the lung horizontally Decrease residual volume – less air is left in the lung after expiration Short ness of breath

Respiratory system Total body comsumption of O2 increase by 15 – 20% Nasal congestion occurs due to estrogen stimulation.

Urinary System Urinary frequency during pregnancy is due to: 1st trimester – uterus exerts pressure on the bladder as it rises out of the pelvic cavity 2nd trimester – pressure of the pr esenting part on the bladder after lightening Increase blood flow to the kidney which increases glomerular filtration rate and consequently, urinary output.

Lactosuria presence of lactose in the urine is considered normal. Lactose is secreted by the mammary glands but since it is not yet used during pregnancy, it normally spills in the urine. Nocturia – increase urination at night

System Nausea and vomiting on the 1st trimester is attributed to: increase HCG level Increase estrogen level decrease maternal glucose level is being utilized for fetal brain development

Gastrointestinal System Effects of Progesterone Decrease GIT motility – constipation Pyrosis / Heartburn – relaxation of cardiac sphincter Slowed bile movement from gall bladder result in reabsorption of bilirubin in the maternal blood stream – pruritus

Gastrointestinal System Effects of Estrogen Ptyalism – increase salivation welling of the gums.

Epulis – hypertrphy or s

Intergumentary System Melasma – facial discoloration to the symphisis Darker areola Increase melanin production Striae gravidarum nd oil glands

Linea Negra – dark line from the umbilicus

Palmar erythema

Vascular Spider nevi Activation of sweat a

Endocrine System Thyroid glands – slightly enlarge due to increase metabolic rate Pancreas – elevated glucocorticoid level increase insul in production Parathyroid gland – increase needs for calcium Adrenal gland – i ncreased corticosteroid production and aldosterone promote sodium reabsorption a nd water retention.Posterior pituitary secretes increase amount of oxytocin and prolactin as pregnancy nears.

Skeletal System Softening of joints and ligaments, especially symphisis and sacroiliac joint is caused by relaxin and estrogen Leg cramps is caused by pressure of gravid uterus on nerves and imbalance of calcium in the body.

SIGNS AND SYMPTOMS OF PREGNANCY Pressumptive Amenorrhea Breast change Urinary frequency Quickening Easy fatigability Leukorrh ea Nausea and vomiting Chadwick sign Striae Linea negra Melasma Probable Hegar’s sign Uterine growth Ballotement Uterine Shuffle Goodel’s sign Braxton-Hi cks Contraction Fetal outline Positive Pregnancy test Positive Positive FHT Funic Shuffle Fetal movement X-ray visualization Positive Ultrasoun d