1st Term 2020-2021

SEVILLA, Tania Cristhel B. September 2, 2020

rd
3 Year NUR181 Group 7 Ms. Marilen F. Pacis and Dr. Basilio Bermas, Jr.

NCM109- CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (RLE)

CASE MAPPING: Care of Mother with Sudden Pregnancy Complication

1. Study closely the concept map on sudden pregnancy complications.

Group 7 Assigned Topic: Psychiatric disorders during pregnancy

Focus: Depression, Anxiety, Eating Disorder, and Substance Abuse or Addiction
Content: Disease process and how it complicate pregnancy, care map: diagnosis, planning, nursing interventions,
alerts, and community resources
 Psychiatric Disorder #1: Anxiety

Case Scenario:

Debby Reyes, a 32-year old primigravid on her 28 th week of pregnancy, went to Sunshine OB Clinic for her
prenatal check-up. Nurse Cristel, a newly appointed nurse, was the one assigned to her. Before the
assessment, Nurse Cristel reviewed Mrs. Reyes’ health records from her previous prenatal visits. She found
out that the patient has a history of the following:

Health History: no alcohol consumption upon learning pregnancy, no use of illegal drugs, no medications
taken aside from vitamin supplements

Family History: Older sister has a history of first trimester miscarriage

Knowing Mrs. Reyes’ mental state, Nurse Cristel thought of asking the pregnant mother about her feelings
today. “To be honest, I feel worried about today’s check-up,” Mrs. Reyes stated with a quivering voice.
Observing the patient, she shows signs of sweating, face redness, hands tremors, and tenseness. The nurse
asked the mother, “Why do you feel worried about today’s check-up?” Mrs. Reyes replied nervously while
playing with her fingers, “I don’t know, maybe because this is my first pregnancy. Whenever I feel
contractions on my belly, I feel really nervous.”

Upon assessment, the nurse obtained the following vital signs:

Blood Pressure: 125/80 mmHg

Temperature: 37.4°C
Respiratory Rate: 21 bpm
Pulse Rate: 91 bpm
FHR: 143 bpm
Urinalysis: Negative for protein, bacteria, and glucose

From the data obtained from the nursing assessment, a safe and effective nursing care plan must be
tailored for the case of Mrs. Debby Reyes.
 Psychiatric Disorder: Anxiety during Pregnancy

y, a hormone called Coriticotopin-Releasing Hormone is released by the placenta to handle the higher stress, which results in an increase in stress hormone cortisol. As a
tics of excessive  and anxiety and linked behavioral disturbances

Types of Anxiety in Pregnancy Causes of Anxiety in Pregnancy The Disorder Process of Anxiety in Pregnancy
Manifestations of Anxiety in Pregnancy

Panic Disorder Genetic

Onset: susceptibility
Pregnant women report onset of anxiety symptoms as prominent during the 6thPhysical
to 28th Symptoms
week of gestation.
(Irritability, hand tremors, facial redness, dyspnea, rapid HR,
Obsessive-Compulsive DisorderHormonal changes (progesterone and estrogen increase)

Acute Stress Disorder

Cognitive Manifestations
Exacerbation: The symptoms of anxiety may be exacerbated by pregnancy.
Transition of Role
(inability to concentrate, frequent questions, confusion, rep

xiety disorder due to a general medical condition

Social expectations

Resurgence:
Substance Most
Abuse or pregnant
Addictionmothers experience resurgence of anxiety when new unfamiliar symptom appears.
Substance-induced anxiety disorder Behavioral Responses
(avoidance, nervous habits)

Anxiety as a Pregnancy Complication

Anxiety and Fetal Health Anxiety and Maternal Health

- Inability to concentrate
- Loss of fetus
- Confusion
- Premature baby
- Poor coping
- Decreased birth weight
- Poor nutritional health and immune changes
- Disturbance in cognitive development
-Isolation

Nursing Interventions
Nursing Care Plan based on Nursing Diagnosis
the Case Scenario 1. Assess level of anxiety.
Anxiety related to pregnancy outcomes as evidenced by increased
2. Monitor tension,
patient’s sweating,
vital signs. and tremors
3. Provide health teaching to the mother about the causes, disorder process, and manifestations o
4. Demonstrate and encourage deep breathing exercises.
Nursing Assessment 5. Acknowledge awareness of anxiety.
6. Establish rapport with the patient and allow to vent out feelings and emotions regarding her pre
Desired Outcomes 7. Demonstrate techniques in reducing anxiety for the patient such as recreational and diversional
“I feel worried about today’s check-up” 8. Educate mother about proper nutrition and medication.
9. Encourage support system such as husband and family members to communicate with the preg
emy first pregnancy.
patient will be able Whenever
to improveI concentration
feel contractions on my belly,the
by verbalizing I feel really
causes nervous.”
and manifestations of anxiety, show normal vital signs, and express decreased distress through f
9. Recommend patient to log her episodes of anxiety in a journal notebook.
erm: Older
After asister has history
continuous of miscarriage
nursing interventions and health teaching, the client will be able to verbalize less worries and doubts for her pregnancy outcome.

edness, hand tremors, tenseness, playing with fingers, BP: 125/80 mmHg, RR: 23 bpm, PR: 99 bpm

Community Resources Nursing Alerts

Refer pregnant mother to support groups,Watch

healthout for any signs
promotion of depression,
groups, isolation,
hospital, clinics, malnutrition,
emergency hotlinesan
 Psychiatric Disorder #2: Substance Abuse or Addiction

Case Scenario:

Miss Bohon Tis, a 25-year-old primigravid on her 24 th week of pregnancy went to Pagasa Clinic due to shortness of
breath. She indicates “pretty serious partying” with the likely father of her unborn baby. She has no record of
prenatal check-up since the first trimester of her pregnancy. Patient said, “I’m afraid to have prenatal check-up
because if they knew I took methamphetamine they will send me to rehabilitation center”. The nurse on duty made
her first assessment, she found out that the patient has a history of the following:

Health history: She found out she was pregnant at 16 th week of pregnancy by using pregnancy test kit. No
medications and vitamin supplements taken.

Family history: Her mother has a history of pre-eclampsia during her pregnancy.

Physical Assessment: Slight watery red eyes, pupils larger, puffy face, hands are shaking, frequent twisting of jaw
(back and forth), feeling nervous and difficulty in paying attention.

Miss Bohon Tis also mentioned she drinks alcohol every occasion before she found out she was pregnant, one to
three times per week, plus she uses methamphetamine influenced by her live-in partner. As she states, “I
intermittently use drugs to be relieved from pregnancy-related anxiety”.

Upon assessment, the nurse obtained the following vital signs:

Blood pressure: 140/90mmHg

Temperature: 38.5°C
Respiratory Rate: 30 bpm
Pulse Rate: 95 bpm

From the obtained from the assessment, a safe and effective nursing care plans must be tailored for the case of Miss
Bohon Tis.
 Physical Signs
Psychiatric Disorder: Substance Abuse during Pregnancy
• Inability to sleep,
awake at unusual
Pathophysiology: The primary factor in the development of addiction is neurophysiologic reinforcement.
One specific mesolimbic "reward pathway" has been identified in the brain, andtimes,
othersunusual
may exist. This
Refers to the harmful or hazardous use of pathway involves dopaminergic neurons that originate in the ventral tegmentallaziness
area (VTA) and project
psychoactive substances, including alcohol • Cold,are
into the forebrain, particularly the nucleus accumbens. The dopaminergic neurons sweaty palms;
probably under
and illicit drugs. continuous inhibition in the VTA, perhaps by gamma-aminobutyric acid (GABA). shaking
Releasehands
of dopamine
from these neurons onto the dopamine receptors in the nucleus accumbens produceseyes;
• Red, watery positive
reinforcement. Most stimulants exert their actions by elevating the synaptic levels of dopamine,
pupils larger or
norepinephrine, and serotonin. Consequently, it causes the blood vessels to contract and heart
smaller than usualrate
• Unusual smells on
breath
• Hyperactivity
4 General Categories of The Disorder Process of Manifestations of Substance
• Poor physical
substances abused Differential Diagnosis Substance abuse in Abuse in Pregnancy
coordination
during pregnancy Pregnancy • Nausea, vomiting or
excessive sweating
• Irregular heartbeat
CNS Depressants Depression Onset: Pregnant women • Hacking cough
report onset of substance • Puffy face, blushing,
abused when her partner or paleness
Stimulants Anxiety
use drugs. • Frequent rubbing of
nose
Personality disorders • Frequent twisting of
Opiates Exacerbation: Chaotic jaw
life, unwanted pregnancy, • Deterioration of
and financial crisis. hygiene
 Hallucinogens/ Posttraumatic stress
Psychotomimetic disorder
Resurgence: Postpartum
disorders, unhealthy
relationship, and poor
social support system with
Substance Abuse as a Pregnancy the child’s father
Complication

Substance abuse and Fetal Health Substance abuse and Maternal Health

respiratory infections
ns such as sudden infant death syndrome (SIDS), neonatal abstinence syndrome (NAS)complications
cardiovascular and (hypertension)
e and neurobehavioral changes neurologic complications (seizures)
renal and gastrointestinal complications
malnutrition and vitamin deficiencies.

Behavioral Signs
Nursing Care Plan based on Obstetric complications
the Case Scenario • Change in overall
Placenta previa
attitude
abruptio placentae
• Oversensitivity
premature rupture of membranes
• Chronic dishonesty
Nursing Assessment spontaneous abortion
• Forgetfulness
intrauterine growth retardation and
• Lack of motivation
premature delivery
• patient.
raid to have prenatal check-up because if they knew I took methamphetamine they will send me to rehabilitation center” as verbalizes by the Paranoia
Objective Data: • Silliness
Hands are shaking, • Moodiness,
Frequent twisting of jaw (back and forth), and irritability, or
Feeling nervous Nursing Diagnosis nervousness
Difficulty in paying attention • Excessive need for
tal signs: BP: 140/90 mmHg, RR: 30 bpm, PR: 95 bpm, and T: 38.5°C Deficient knowledge related to insufficient privacy
information about prenatal substance abuse as • Suspicious
evidenced by continued use despite
complications

Desired Outcomes

Nursing Interventions

s client’s knowledge of own condition.

s level of anxiety.
tor vital signs.
mine client’s method of accessing information.
de environment that is conducive for learning.
ss client’s perception of need.
urage drugs abstinence.
de health teaching on how to cope up with anxiety.
de health teaching on the importance of prenatal check-up.
Term: After 1-2 hours of nursing intervention, the client will be able to participate in learning process about dealing with anxiety, substance abuse complications and im
Long Term: After a continuous nursing interventions and health teaching, the client will be able to initiate necessary lifestyle changes and participate in treatm

Community Resources Nursing Alerts

Refer pregnant mother to support Watch out for obstetric and fetal complications.
groups, health promotion groups,
hospital, clinics, emergency hotlines
 Psychiatric Disorder #3: Depression

Case Scenario:

Mrs. Jennie Kim, a 24-year old primigravid on her 13 th week of pregnancy, went to Rainbow OB Clinic to see
her Physician.

Chief concern:
“My head is aching; I feel really exhausted and fatigued these past 2 weeks and find it difficult to sleep”

History of chief concern:

The patient entered pregnancy with excitement and enthusiasm. His husband, Mr. Jongin Kim, left her 3
weeks ago and work abroad to support her pregnancy. In the last 2 weeks, she does not have energy to do
the things she usually does and can’t even focus but feel tired all the time. She also said that she gained 2
kilos in the past 2 weeks. She cannot sleep when she’s thinking of what will happen to her baby, will she
and her baby be ok, and thinking that she’ll be lonely through-out her pregnancy it gives her a headache.

Health History: no alcohol consumption upon learning pregnancy, no use of illegal drugs, no medications
taken aside from vitamin supplements

Family History: Older sister has a history suicide attempt. Her mother has a history of Depression.

History of past illness: She was diagnosed of depression when she was only 18 years old but got treated by
medication and therapy.

Laboratory results:
Blood Pressure: 130/90 mmHg
Temperature: 37.4°C
Respiratory Rate: 20 bpm
Pulse Rate: 88 bpm
Urinalysis: Negative for protein and glucose

From the data obtained from the nursing assessment, a safe and effective nursing care plan must be
tailored for the case of Mrs. Jennie Kim.
 Psychiatric Disorder: Depression during Pregnancy

egnancy, hormonal changes like increase level of estrogen and progesterone are likely the cause of fatigue. And because there is a growing baby inside the patient might
eristics of excessive Fatigue and linked behavioral disturbances

Types of Depression in Pregnancy Causes of Depression in Pregnancy The Disorder Process of Depression in Pregnancy
Manifestations of Depression in Pregnancy

Perinatal Depression Genetic

Onset: Client reportsusceptibility
onset of Fatigue, exhaustion, headache, and difficulty in sleeping at 11thPhysical
week toSymptoms
13th weeks of gestati
(Fatigue or consistent lower energy level, back pain or aching mu
Seasonal depression Hormonal changes (progesterone and estrogen increase)

Situational depression
Exacerbation: The symptoms of Depression may be exacerbated by Cognitive Manifestations
pregnancy.
Transition of Role
(Fatigue, difficulty concentrating, negative thinking, distracti

Atypical depression
Fatigue

Resurgence:
Anxiety Most pregnant mothers experience the resurgence depression in third trimester
Major Depression Behavioral Responses
(Eating less, sleeping less, going to doctor with vague ac

Depression as a Pregnancy
Complication

Depression and Fetal Health

Depression and Maternal Health

- Loss of fetus (miscarriage)
- Premature baby - Inability to concentrate
- Decreased birth weight - Poor nutritional health
- Immune changes

Nursing Interventions
Nursing Diagnosis
Nursing Care Plan based on 1. Assess the patient’s description of fatigue: severity, changes
the Case Scenario Fatigue related to depression as In severity over time, aggregating or alleviating factors.
evidenced by headache, 2. Determining possible causes of fatigue: Pain, Emotional stress,
restlessness, and exhaustion Depression, Sleep disorders, Imbalance Nutritional intake,
Anemia.
Nursing Assessment 3. Implement the use of assistive device for ADLs
4. Aid the patient with developing a schedule for daily activity
Desired Outcomes
and rest
ally exhausted and fatigued these past 2 weeks and find it difficult to sleep” 5. Teach energy conservation method, collaborate with an
ng interventions, the patient will be able to improve sense of energy as evidence by verbalizing the 5 out ofoccupational
6 causes oftherapist
fatigue as
and participate in recommended treatmen
needed.
continuous nursing interventions and health teaching, the client will be able to perform activities of daily6.living and sufficient
Promote participate in desired
nutritional activities at level of ability.
intake
os in the past 2 weeks, Blood Pressure: 130/90 mmHg, Temperature: 37.4°C 7. Encourage verbalization of feeling about the impact of fatigue
8. Offer diversional activities that are soothing
9.support the patient in escalating levels of physical activities
ein and glucose and exercise.

Community Resources Nursing Alerts

Watch
Refer pregnant mother to support groups, out
health for any signs
promotion of depression,
groups, exhaustion,
hospital, clinics, malnutrition,
emergency hotlines a
 Psychiatric Disorder #4: Bulimia Nervosa

Case Scenario:

Mrs. Yoongi is a 25-year-old, G1P0, 20 weeks of gestation, visit the Fabella Medical Center for her daily
prenatal check - up. Nurse Jimin is appointed to get the following history of the client.

Chief Concern:
‘’My gums are swollen. I do not have any energy to do anything. I have been feeling lethargic for almost 2
weeks now. I have lost confidence ever since my pregnancy started. “

Nurse Jimin asked the client to recall the food she consumed during the last 24 hours day history:
Nutrition: 24-hour recall:
Breakfast: 3 cups of rice, 2 packs of noodles, 3 pcs of fried chicken and 2 cups of coffee.
Lunch: Fasting
Dinner: Fasting
Snacks: “I've eaten so much in the morning; I need to have my fasting for the rest of the day. “Mrs. Yoongi
stated
Sleep: Tries to sleep 8 hours a night but receives only 3 to 4 hours because of constant waking up.

Nurse Jimin is worried with the result of 24-hour food recall and asked the client to tell more about how she
feels.

“Being pregnant is so hard, I feel like I'm gaining weight every time I eat, People are always looking at me,
maybe because of my body. I always felt guilty whenever I eat a lot, that's why I decided to do fasting
afterward or I induced myself to vomit so that I won't feel any guilt whenever I eat. I hope my baby is not
affected by the decision I made.” Yoongi stated

Physical Examination:
General appearance: skinny, pale appearing pregnant woman.
Weight: 38 kgs
Height: 5”3’
BP: 90/60 mmHg
RR: 18 bpm
PR: 85 bpm
Temp: 36.8℃
Derm: Dry skin and brittle nails.
HEENT: puffy and swollen Checks.
Abdomen: Fundal height: 16 cm; linea nigra and striae present on abdomen; FHR: 158 beats/min
Pelvic: Deferred

Paula is diagnosed of bulimia nervosa during pregnancy.

A secure and efficient nursing care plan must be adapted to the case of Mrs. Yoongi based on the evidence 
collected from the nursing assessment.
 Psychiatric Disorder: Bulimia Nervosa during Pregnancy

a nervosa are unknown but client diagnosed with bulimia nervosa are afraid of gaining weight and having a distorted body image. Whereas pregnant woman needs to ga
ng and then purge to get rid of extra calories in an unhealthy way.

nappropriate Ways to Lose Weight in BN Complications of BN during Pregnancy Types & Causes of Bulimia N in Pregnancy Manifestations of BN in Pregnancy

Vomiting Digestive
Purging Type:Problems Physical
Regularly induced in vomiting or abuse laxatives, diuretics, or enemas after Symptoms
a period of bingeing.
(swollen glands, dizziness, fatigue, dry skin, brittle nails, dental pr
Excessive use of laxatives and diuretics which can lead to major problems such as kidney failure.
Dehydration,

Fasting
Non-Purging Type: excessive exercising and fasting are typical inBehavioral
Anxiety and Depression this form.Manifestations
(skipping meals, excessive exercising eating uncontrolla

Enemas and Use of Dietary Supplements

Heart Failure

Causes:Self
Causes are and
– Injury unknown butThoughts
Suicidal factors such as genetic, environmental, psychological, and cultural influences are the main c
Compulsive and Vigorous Exercise Cognitive Manifestations
(frequent questions, and inability to concent

BN as a Pregnancy Complication

BN and Fetal Health BN and Maternal Health

- Miscarriage
- Fetal Loss
- Preterm Birth
- Intrauterine Growth Restriction
- PIH
- Low Birth Weight
- Extreme underweight
- Small for Gestational Age - Postpartum Depression

Nursing Interventions
Nursing Care Plan based on Nursing Diagnosis
the Case Scenario 1. Monitor vital signs and weight.
Imbalanced Nutrition Less Than Body Requirement related to Psychological2.Disorder as evidenced
Take nutritional bywith
history Bodythe
Weight Below Ideal
participation Range, Weakness and Pale Mucous Membranes
of SO.
3. Ascertain etiological factors for decreased nutritional intake.
4. Review laboratory values.
Nursing Assessment 5. Note the patient's perspective and feeling toward eating and food.
6. Ascertain healthy body weight appropriate for age, weight and pregnancy needs. Refer to dietician for nutritional assessment
7. Provide pleasant environment.
8. Provide companion during mealtime.
er I eat a lot, that is why I decided to do fasting afterward or I induced myself to vomit so that I will not feel any guilt whenever I eat. I hope my baby is not affected by the decision
9.Desired
Consider Outcomes
six small nutrient dense meal.
10. Discourage caffeinated and carbonated beverages.
Long Term: After series (1
Objective month) nursing intervention, client11.
Data: will be able time
Determine to (a)
of demonstrate
the day when the progressive weight
patients' appetite is atgain appropriate
peak. Offer highestto pregnancy,
calorie meal at that time.
e, dry skin and brittle nails, puffy and swollen
(b) becheeks, signs of12.malnutrition
hypotension
free from Help patient and
andfamily to identify
display change
a stable vitalthat will make greatest contribution to improved nutrition. Discuss factors and in
sign,
(c) demonstrate behaviors, and lifestyle changes to maintain appropriate weight.
Short Term: After 1 hour of nursing interventions, patient will be able to verbalize understanding of causative factors and necessary intervention.

Community Resources Nursing Alerts

Refer pregnant mother to support groups, health promotion groups, hospital, clinics, emergency hotlines
Watch out for any signs of depression, isolation, malnutrition, self - injury
References:
 Barron, O. and Wiegartz, P. (2011). Issues in treating anxiety disorders in pregnancy. Psychiatric Times. Retrieved from
https://www.psychiatrictimes.com/view/issues-treating-anxiety-disorders-pregnancy
 Belleza, M. (2019). Anxiety disorders and panic disorders. Nurseslabs. Retrieved from https://nurseslabs.com/anxiety-disorders-and-panic-
disorders/
 Doenges, M., Moorhouse, M., and Murr, A. (2018). Nurse’s Pocket Guide: Diagnoses, prioritized interventions, and rationales. Bangkok: iGroup
Press Co., Ltd. 14th edition.
 Pearl La Marca-Ghaemmaghami, Sara M. Dainese, Günter Stalla, Marina Haller, Roland Zimmermann, Ulrike Ehlert. Second-trimester amniotic
fluid corticotropin-releasing hormone and urocortin in relation to maternal stress and fetal growth in human pregnancy. Stress, 2017; 1
DOI: 10.1080/10253890.2017.1312336
 Wayne, G. (2019). Anxiety. Nurseslabs. Retrieved from https://nurseslabs.com/anxiety/
 WHO (2020). Retrieved from https://www.who.int/topics/substance_abuse/en/
 NIDA. (2003, January 1). Diagnosis and Treatment of Drug Abuse in Family Practice - American Family Physician Monograph (2020).Retrieved
from https://archives.drugabuse.gov/publications/diagnosis-treatment-drug-abuse-in-family-practice-american-family-physician-monograph
 Phoenix House (2020). Retrieved from https://www.phoenixhouse.org/prevention/signs-and-symptoms-of-substance-abuse/
 Wilson, J, Thorp, Jr., J, Glob. libr. women's med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10115. Update due 2020. Retrieved from
https://www.glowm.com/section_view/heading/substance-abuse-in-pregnancy/item/115