N107 – Essentials of Nursing Care: Reproductive Health

1. N107 – Essentials of Nursing Care: Reproductive Health Needs of the Childbearing Family: Preconception

2. Chapter Objectives • Know which topics to counsel and plan with childbearing females/families • Review health and lifestyle choices that affect childbearing females/families • Be able to perform a risk assessment • Be able to create a care plan via the nursing process regarding a patient with a preconception issue specifically

3. Counseling and Planning for Parenthood • Preconception care focuses on risk assessment and promoting healthy behaviors • Healthy well-informed women who plan pregnancy have better outcomes • Contraception is important aspect in planning process

4. Counseling and Planning for Parenthood • Many women don’t realize they are pregnant and don’t seek prenatal care until way into 1st trimester • Half of all pregnancies in US are unintended • The period of greatest danger for developing fetus is 17 – 56 days after fertilization • By end of first trimester, major structural anomalies in the fetus are already present • Fetus may be exposed to intrauterine environmental hazards • Radiation (x-rays, microwaves), carcinogens (smoke, fumes)

5. Health and Lifestyle ChoicesPreconception Care • Purposes: • Establish life-style behaviors to maintain optimum health • Diet, weight control, safe sex practices, rest & exercise, substance abuse • ID and treat “Risk Factors” before conception • Medical conditions, substance abuse, test for immunity, history of genetic defects, the need for genetic counseling • To conceive absent of unnecessary Risk Factors • Monitor chronic illnesses (medications), environmental hazards (home, work) • ID carriers of inherited diseases • African Americans/Southeast Asians (sickle cell disease), Jewish Americans (Tay-Sachs disease) • Prepare people psychologically for pregnancy and responsibilities of parenthood

6. Health and Lifestyle ChoicesPreconception Care • Why assess for and treat “Risk Factors” • Every woman of childbearing age is a potential mother • Nurses can make a difference through education and counseling; preconception education/counseling can decrease the incidence of birth defects • Type I diabetic with excellent glucose control reduces risk for congenital malformations in fetus • Adequate intake of folic acid (0.4 mg/day) decreases possibility for neural tube defects • Endocrine disorders interfere with female menstrual cycle and male libido • Renal and GU disorders affect sexual performance & reproductive capacity

7. Health and Lifestyle ChoicesPreconception Care • Treating Risk Factors (Cont’d) • Hx of cholecystitis and hepatitis may be contraindications for oral contraceptives • Women under 15 and 0ver 40 at higher risk • Cigarette smoking may delay conception • Maternal smoking  low birth weight • Increases risk for spontaneous abortion, fetal death, neonatal death & SIDS • Smoking • increases morbidity in those using oral contraception, and  early menopause (Females) • In males who also use drugs • Affects sperm count, causes impotence or decrease libido

8. Prenatal Care • To promote positive outcomes for both mother & child • Should begin prior to conception • First prenatal visit • Typically scheduled between weeks 8-12 of gestation • Obtain health hx (first menarche, sexual & family hx’s, Gravida/Para) • Physical exam (vaginal exam, pap smear • Confirm pregnancy • Prenatal labs (blood type, Rh factor, rubella status, Hep B status, STD, pap smear,

9. Prenatal Care • Prenatal Visit (Cont’d) • Calculate EDC • Nagel’s Rule • LMP – 3 months + 7 days • Tables • Wheels • Lines up LMP to indicate EDC & due date • Auscultate fetal hear tones • May be difficult to hear prior to 12 weeks • Only Positive signs of pregnancy • Presence of fetal heart tones • Detection of fetus by US or X-ray

10. Testing (The Triple Screen) • Alpha-fetoprotein test • Performed between week 16 – 18 • Indicates neural tube defects and chromosomal disorders • High incidence of false positives • If complication indicated amniocentesis is recommended

11. The Triple Screen (Cont’d) • Gestational Diabetes Screening • Performed at week 28 • Fasting glucose test • If failed, glucose tolerance test • If positive, dietary consult and/or diabetes educator consult • Instruct on proper diet • How to monitor blood glucose levels (glucometer) • If diet control unsuccessful, insulin injections may be required

12. The Triple Screen (Cont’d) • Group Beta Strep Bacteria detection • Not an uncommon finding • Requires Abx upon rupture of membrane or onset of active labor • Recommended that one dose of Abx be administered at least 4 hours prior to delivery to reduce risk of infant contracting group beta strep • Can cause serious illness in infant but harmless to mother

13. The Nursing Process • Assessment • The Interview Process: Ask about current “lifestyle choices” • Nutrition, exercise, rest, substance abuse, alcohol & tobacco use, occupation, stressors, depression, support system domestic violence, and financial resources • Immunization status: Rubella, Hepatitis B • Current medications to include OTC, non-prescription and prescription meds

14. The Nursing Process • Assessment (Cont’d) • Review of Systems • Head to Toe assessment • Discussion of any medical conditions • Reproductive System Review • Previous pregnancies, miscarriages, living children’s disorders • Abnormal PAP smear results, mammogram results, STD hx, sexual practices • Obstetric History • Review of family planning and fertility counseling information • Previous abd/reproductive surgery, trauma’s or transfusions

15. The Nursing Process • Assessment (Cont’d) • Environmental History • Home and/or work exposures • Family History • Medical conditions • Genetic conditions • Sickle cell, cystic fibrosis, bleeding disorders, hemophilia, PKU, birth defects • Should also include companions family history

16. The Nursing Process • Assessment (Cont’d) • Risk Assessment • Pediatric illnesses • Mumps in males  sterility • Rubella in childbearing females increases congenital anomalies during 1st trimester • Encourage immunization if not had or been immunized • Currently pregnant females should not receive immunization • Those planning pregnancy should wait 3 months before becoming pregnant after receiving immunization

17. The Nursing Process • Assessment (Cont’d) • Contraceptive and Obstetric History • Psychosocial History • Family situation • Ask directly “Have you been hit, slapped, kicked or hurt with the past year?” “Are you afraid of your companion or anyone else?” • Readiness for pregnancy • Age, life goals, stressors • Financial stability and resources

18. The Nursing Process • Assessment (Cont’d) • Occupational History • Physical activities • Standing all day? Heavy lifting? • Exposures • Religious and Cultural Preferences • Physical Examination • Emphasis placed on thyroid gland, breasts and pelvic structure • Lab studies • CBC, UA, blood type and Rh, rubella immunity, STDs, Hep B surface antigen, PAP smear, cervical culture. • OTHERS: PPD, HIV, toxicology screen, thalassemia

19. The Nursing Process • Analysis • In collaboration with the patient/family and members of the healthcare team, synthesize data to identify the patient’s actual or potential health problems that can be managed by independent nursing actions • Identify a Nursing Diagnosis (NANDA) • When choosing a nursing dx, look at all data and their commonalities • The common theme reveals the existence of a problem and the need for nursing intervention • The nurse may use physician (dependent) and nursing (independent) interventions to minimize complications.

20. The Nursing Process • Analysis (Cont’d) • Areas of concern for preconception care • Health-seeking behaviors, • Optimum nutrition • Health maintenance • Deficient knowledge • Fear • Pain • Risk for Infection

21. The Nursing Process • Planning • Planning phase consist of determining the expected outcomes and formulating specific strategies to achieve the expected outcomes. • Assign priorities to the nursing diagnosis • Maslow’s Hierarchy of Needs • Most crucial to least crucial • Specify expected outcomes • Outcomes must be realistic and measurable • Expected outcomes are the basis for evaluating the effectiveness of the nursing interventions and deciding whether the plan of care needs to be revised.

22. The Nursing Process • Specify goals of nursing action • ID specific nursing interventions appropriate for attaining the outcomes • Interventions should be listed in preferential order • Interventions should be individualized as well as age, gender, and culture-appropriate • Can the implementation of the intervention be rationalized? • ID interdependent interventions • Will a physician order be required • Document plan of care • Communicate to appropriate personnel any need for multidisciplanary approach to plan of care

23. The Nursing Process • Patient Values • Always include patient and family in process • What does patient consider to be a priority? • Conflicts should be resolved in a way that is mutually acceptable • Expected Outcomes (patient centered goals) • Pt will be able to recite Signs & Symptoms of…….. • Pt will verbalize understanding of the importance of adequate amount of folic acid in the diet.

24. The Nursing Process • Nursing Interventions • Plan nursing interventions n the basis of established standards and priorities to move the patient/family toward the expected outcomes • ANA Standard of Practice, Nurse Practice Acts, taxonomy of nursing interventions (NIC) • Should be patient focused and outcome driven • Assign patient care activities to be implemented by other members of the heath care team as appropriate

25. The Nursing Process • Implementation • Plan of care is put into use • The nurse (RN) assumes responsibility for the implementation and coordinate activities of all involved • FOCUS: Resolving pt’s nursing diagnosis, achieving expected outcomes while meeting pt’s health care needs. • Implement a teaching plan that promotes a positive woman’s health outcomes • Supervise patient care activities that were delegated to other members of health care team • When nursing interventions have been completed, the Implementation phase of the process has ended.

26. The Nursing Process • Evaluation Phase • Assess the pt’s response to nursing interventions, including progress toward the patient-centered goals • Assess whether objectives were achieved • Document the extent of the achievements • Plan of care may need to be revised • Questions to ask during evaluation phase (see page 54)

27. The Nursing Process