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Assessment: initial physical aspects:
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Height and weight.
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Vital signs.
- Blood work - hematocrit and hemoglobin for anemia; type and Rh factor; tests for sickle cell trait, syphilis, rubella antibody titer, and hepatitis B screen.
- Urinalysis - glucose, protein, ketones, signs of infection, and pregnancy test (HCG).
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Breast examination.
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Pelvic examination.
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Signs of pregnancy.
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Adequacy of pelvis and pelvic structures.
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Size and position of uterus.
- Papanicolau smear.
- Smears for mondial and trichomona! infections.
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Signs of pelvic inflammatory disease.
- Tests for STD: Gonorrhea (Gonococcus-GC), chlamydia.
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Validation of pregnancy - physician or midwife makes differential diagnosis between presumptive/probable signs/symptoms of early pregnancy and other signs.
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Presumptive symptoms - subjective experiences.
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Amenorrhea - more than 10 days past missed menstrual period.
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Breast tenderness, enlargement.
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Nausea and vomiting.
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Quickening (wk 16-18).
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Urinary frequency.
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Fatigue.
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Constipation (50% of women).
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Presumptive signs
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Striae gravidarum, linea nigra, chloasma (after wk 16).
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Increased basal body temperature (BBT)
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Probable signs - examiner’s objective findings.
- Positive pregnancy test.
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Enlargement of abdomen/uterus.
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Reproductive organ changes (after sixth week):
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Goodell’s sign - cervical softening.
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Hegar’s sign - softening of lower uterine segment.
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Vaginal changes (Chadwick’s sign): purple hue in vulvar/vaginal area.
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Ballottement (after 16-20 wk).
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Braxton-Hicks contractions.
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Positive signs of pregnancy:
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Fetal heart tones.
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Doptone: wk 10-12.
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Fetoscope: wk 20.
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Examiner visualizes and feels fetal movements (usually after wk 24).
- Sonographic examination (after wk 14) when fetal head is sufficiently developed for accurate determination of gestational age. Pregnancy may be detected as early as fifth or sixth week after LMP.
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Assessment: nutritional status:
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Physical findings suggesting poor nutritional status:
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Skin: rough, dry, scaly.
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Lips: lesions in corners.
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Hair: dull, brittle.
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Mucous membranes: pale.
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Dental caries.
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Height, weight, age - average weight gain approximately 24 lb. Range from 24 to 32 lb is best for mother and neonate.
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Laboratory values - Hemoglobin: . < 10.5/100 mg. Hct < 32% indicates anemia.
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Nutrition history.
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Analysis/nursing diagnosis:
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Altered nutrition: less than body requirements related to anemia, vitamin/mineral deficit.
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Altered nutrition: more than body requirements related to obesity.
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Nursing care plan/implementation:
Goal: health teaching. Nutritional counseling for diet in pregnancy and/or lactation.
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Evaluation/outcome criteria:
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If underweight at conception: should gain 28-42 lb (12.5-18 kg).
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If overweight at conception: 15-25 lb (7-11.5 kg).
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If obese at conception: 15 lb (7 kg) or more.
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Assessment: psychosocial aspects:
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Pregnancy: planned or not; desired or not.
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Present plans:
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Carry pregnancy, keep baby.
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Carry pregnancy, adoption.
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Abortion.
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Cultural, ethnic influences on decisions: will influence range of activities, types of safeguarding actions, diet, and health-promotion behaviors.
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Parenting potential: actively seeking medical care and information about pregnancy, childbirth, parenthood
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Family readiness for childbearing and child rearing:
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Physical maintenanc
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Allocation of resources: identify support system.
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Division of labor.
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Socialization of family members.
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Reproduction, recruitment, launching of family members into society.
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Maintenance of order (relationships within family).
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Perceptions of present and projected family relationships.
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Review lifestyle for smoking, drugs, alcohol (ETOH), attitudes to pregnancy, health care practices, and risks for hepatitis and human immunodeficiency virus (HIV).
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Analysis/nursing diagnosis:
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Altered role performance
related to stress imposed by developmental tasks.
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Ineffective coping: individual, family
related to stress caused by developmental tasks/crises.
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Altered family process
related to developmental tasks. First baby may precipitate individual or family developmental crisis.
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Nursing care plan/implementation:
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Goal:
anticipatory guidance/support.
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Discuss mood swings, ambivalent feelings, negative feelings.
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Reinforce “normalcy” of such feelings.
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Goal:
increase individual/family coping skills, reduce intrafamily stress.
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Reinforce family strengths (both partners), sense of family identity.
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Encourage open communication between partners; share feelings and concerns.
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Increase understanding of mutual needs, encourage mutuality of support.
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Increase tendency of mother to turn to partner as most significant person (as opposed to physician).
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Enhance bond, success of childbirth preparation classes.
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Promote understanding/acceptance of role chang
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Facilitate/support achievement of developmental tasks.
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Reduce probability of postpartal psychological problems.
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Promote family bondin
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Goal:
health teaching
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Siblings:
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Alert parents to sibling needs for security, love
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Include sibling in pregnancy experience
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Provide clear, simple explanations of happenings.
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Continue demonstrations of love
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Describe increased status (“big sister/ brother”).
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Discuss possible misbehavior to gain attention.
- Relatives:
alert parents to possible negative feelings of in-laws.
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Referral to childbirth preparation/parenting classes.
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Appropriate community referrals for financial relief to decrease stress and provide aid.
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Evaluation/outcome criteria:
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Actively participates in pregnancy-related decision making
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Expresses satisfaction with decisions mad
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Demonstrates growth and development in parenting role
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Prepared for the birth and for early parenthood