1. Alterations affecting elimination
      1. Urinary system
        1. Physiological changes:
          1. Relaxation of smooth muscle results in conditions that can persist 4-6 weeks after birth:
            1. Dilatation of ureters.
            2. Decreased bladder tone.
            3. Increased potential for urinary stasis and infection (UTI).
          2. Increased glomerular filtration rate (50%) during last two trimesters.
          3. Increased renal plasma flow (25-50%) during first two trimesters; returns to near normal levels by end of last trimester.
          4. Increased renal-tubular reabsorption rate - compensates for increased glomerular activity.
          5. Glycosuria - reflects kidney’s inability to reabsorb all glucose filtered by glomeruli (may be normal or may indicate gestational diabetes; glycosuria always warrants further testing).
          6. Increased renal clearance of urea and creatinine (creatinine clearance used as test of renal function during pregnancy).
          7. Hormone - induced turgescence of bladder and pressure on bladder from gravid uterus.
        2. Assessment:
          1. Urinary frequency, first and third trimesters.
          2. Nocturia.
          3. Stress incontinence in third trimester.
        3. Nursing care plan/implementation:
          4. Goal: health teaching
          1. Void with urge, to prevent bladder distention.
          2. Learn signs and symptoms of UTI.
          3. Decrease fluid intake in late evening.
          4. Perform Kegel exercises to reduce incontinence.
      2. Gastrointestinal system
        1. Physiological changes:
          1. General decrease in smooth-muscle tone and motility due to actions of progesterone.
          2. Intestines: slowed peristalsis, increased water reabsorption in bowel.
          3. Stomach
            1. Gastric emptying time is delayed (e.g., 3 hr vs. 1 and ½ hr).
            2. Gastric secretion of HCI and pepsin decreases.
            3. Decreased motility delays emptying; increased acidity.

          4. Cardiac sphincter relaxes.
          5. Increasing size of uterus and displacement of intraabdominal organs.
          6. Gallbladder: decreased emptying.
        2. Assessment:
          1. Nausea and vomiting in first trimester.
          2. Constipation and flatulence.
          3. Hemorrhoids.
          4. Heartburn, reflux esophagitis, indigestion.
          5. Hiatal hernia.
          6. Epulis-edema and bleeding of gums.
          7. Ptyalism-excessive salivation.
          8. Jaundice.
          9. Gallstones.
          10. Pruritus due to increased retention of bile salts.
        3. Nursing care plan/implementation:
          4. Goal: health teaching
          1. Nausea and vomiting
            1. Avoid fatty food; increase carbohydrates.
            2. Eat small, frequent meals.
            3. Eat dry crackers in morning.
            4. Decrease liquids with meals.
            5. Avoid odors that predispose to nausea.
          2. Constipation and flatulence
            1. Increase fluids (6-8 glasses/day).
            2. Maintain exercise regimen.
            3. Add fiber to diet.
            4. Avoid mineral oil laxatives.
            5. Avoid gas-producing foods (e.g., beans, cabbage).
          3. Heartburn and indigestion
            1. Eliminate fatty or spicy foods.
            2. Eat small, frequent meals (6/day).
            3. Eat slowly.
            4. Avoid gastric irritants (e.g., alcohol, coffee).
            5. Perform “flying exercises.”
            6. Avoid lying flat.
            7. Take antacids without sodium or phosphorus.
            8. Sip milk or eat yogurt if heartburn occurs.
            9. Avoid sodium bicarbonate.
          4. Hemorrhoids
            1. Increase fluid and fiber intake.
            2. Maintain exercise regimen.
            3. Avoid constipation and straining to defecate.
            4. Take warm sitz baths.
            5. Apply witch hazel pads.
            6. Elevate hips and legs frequently.
            7. Use hemorrhoidal ointments only with advice of health care provider.

    2. Alterations affecting nutrition
      1. Physiological changes:
        1. Gastrointestinal system
          1. Gingivae soften and enlarge due to increased vascularity.
          2. Increased saliva production.
        2. Endocrine system
          1. Increased size and activity of pituitary, parathyroids, adrenals.
          2. Increased vascularity and hyperplasia of thyroid.
          3. Pancreas-increased insulin production during second half of pregnancy, needed to meet rising maternal needs; human placental lactogen (HPL) and insulinase deactivate maternal insulin; may precipitate gestational diabetes in susceptible women.
        3. Metabolism
          1. Basal metabolic rate (BMR)-increases 25% as pregnancy progresses, due to increasing oxygen consumption; protein-bound iodine (PBI) increases to 7-10 μg/dl; metabolism returns to normal by sixth postpartal week.
          2. Protein-need increased for fetal and uterine growth, maternal blood formation.
          3. Water retention-increased.
          4. Carbohydrates-need increases to spare protein stores.
            1. First half of pregnancy - glucose rapidly and continuously siphoned across placenta to meet fetal growth needs; may lead to hypoglycemia and faintness.
            2. Second half of pregnancy - placental production of antiinsulin hormones; normal maternal hyperglycemia; affects coexisting diabetes.
          5. Fat - increased plasma-lipid levels.
          6. Iron-supplements recommended to meet increased need for red blood cells (RBCs) by maternal/placental/ fetal unit.
      2. Assessment:
        1. Weight gain: 20-35 lb (11.5-16 kg); depends on Body Mass Index and prepregnant nutritional status.
        2. Normal pattern: first trimester, 2-5 lb (1-2.3 kg); remainder of gestation, approximately 1 lb/wk (0.4-0.5 kg/wk).
      3. Nursing care plan/implementation:
        4. Goal: health teaching
        1. Evaluate diet for adequacy of nutrient and caloric intake.
        2. Evaluate cultural, religious, and economic influences on diet.
        3. Review dietary recommendation for pregnancy with woman.
        4. Avoid dieting in pregnancy (even if obese).
        5. Supplement diet with vitamins, iron, or folic acid on advice of health provider.
        6. Ptyalism:
          1. Suck hard candies.

          2. Perform frequent oral hygiene.
          3. Maintain adequate oral intake (6-8 glasses/day).
          4. Use lip balm to prevent chapping.
        7. Epulis:
          1. Frequent oral hygiene.
          2. Use soft toothbrush.
          3. Floss gently.
          4. See dentist regularly.

    3. Alterations affecting protective functions - integumentary system
      1. Physiological changes - estrogen-induced vascular and pigment changes.
      2. Assessment:
        1. Increased pigmentation.
        2. Striae gravidarum (stretch marks).
        3. Increased sebaceous and sweat gland activity.
        4. Palmar erythema.
        5. Angiomas-vascular “spiders.”
      3. Nursing care plan/implementation:
        4. Goal: health teaching
        1. Bathe or shower daily.
        2. Reassure woman that skin changes decrease after pregnancy.

    4. Alterations affecting comfort, rest, mobility - musculoskeletal system
      1. Physiological changes
        1. Progesterone, estrogen, and relaxin-induced relaxation of joints, cartilage, and ligaments.
        2. Function in childbearing - increases anteroposterior diameter of rib cage and enlarges birth canal.
      2. Assessment:
        1. Complaint of pelvic “looseness.”
        2. Duck-waddle walk.
        3. Tenderness of symphysis pubis.
        4. Lordosis (exaggerated lumbar curve) - increased weight of pelvis tilts pelvis forward; to compensate, woman throws head and shoulders backward; complaint of leg and back strain and fatigue.
      3. Nursing care plan/implementation:
        4. Goal: health teaching
        1. Good body alignment - tuck pelvis under; tighten abdominal muscles.
        2. Pelvic-rock exercises.
        3. Squat; bend at knees, not at waist.
        4. Wear low-heeled, sturdy shoes.
        5. Avoid tight-fitting clothing that interferes with circulatory return in legs.

  1. Psychosocial-cultural alterations
    1. Emotional changes - affected by age, maturity, support system, amount of current stresses, coping abilities, physical and mental health status.
      2. Developmental tasks of pregnancy:
      1. Accept the pregnancy as real: “I am pregnant”; progress from symbiotic relationship with the fetus to perceiving the child as an individual.
      2. Seek and ensure acceptance of child by others.
      3. Seek protection for self and fetus through pregnancy and labor (“safe passage”).
      4. Prepare realistically for the coming child and for necessary role change: “I am going to be a parent.”
    2. Physical bases of changes
      1. Increased metabolic demands may result in anemia and fatigue.
      2. Increased hormone levels (steroids, estrogen, progesterone) - affect mood as well as physiology.
    3. Characteristic behaviors - behaviors commonly exhibited in each trimester.
    4. Sexuality and sexual expression - feelings and expressions of sexuality may vary during pregnancy due to maternal adaptations.
    5. Intrafamily relationships
      1. Pregnancy is a maturational crisis for the family.
      2. Requires changes in lifestyle and interactions:
        1. Increased financial demands.
        2. Changing family and social relationships.
        3. Adapting communication patterns.
        4. Adapting sexual patterns.
        5. Anticipating new responsibilities and needs.
        6. Responding to reactions of others.