Nursing Care For Pregnant Women

NURSING CARE FOR PREGNANT WOMEN These two stages are carried out simultaneously. The following is an explanation of each assessment stage 1. Pregnancy process: a. The process of conception and formation of the placentaConception is the union of an egg (ovum) and sperm which marks the beginning of a pregnancy in the fallopian tube. Conception is also called fertilization or fertilization. Fertilization of XX zygotes will become a baby girl and XY zygotes will become a baby boy. b. Sign of pregnancy 1) Presumptive Sign - Menstrual suppression - Nausea, vomiting, morning sickness. - Frequent micturition - Swollen mammary feels full - Quickening (first movement felt by the mother) - Chadwicks ( + ) - Pigment on the skin 2) Possible Sign - Abdominal enlargement - Hegar sign - Ballotmen ( + ) - Changes in the cervix - Braxton Hicks - Pregnancy test 3) Sure Sign - DJJ sound, pulse 120 – 180t - Fetal movement - Ultrasound – results - Ro – there is skeletal c. Changes during pregnancy d. Fall of Fetus e. Factors that influence fetal loss 2. Adaptation of pregnant women a. Physiological adaptations of pregnancy Almost all women's bodies experience changes, especially the bladder and other organs. 1) Uterus - Size: due to hypertrophy and hyperplasia of the smooth muscles of the uterus, 30 x 25 x 20 cm with a capacity of 400 cc (at term). - Weight: from 30 gr – 1000 gr - Form and consistency: first month; avocado, 4 months; round, late pregnancy; ovoid. - Position: Beginning; anteflexion/retroflexion, 4 months; is in the pelvic cavity, end; stomach cavity to liver. - Cervix: becomes soft which is called the “boodell” sign 2) Ovaries (ovaries) - Ovulation stops - There is still a corpus luteum gravidas until urine is formed 3) Vagina and vulva - The vagina and vulva look redder and bluish - The lipid color of the vagina and cervical portio is called “Chadwick's sign”, hypervascularization. 4) Changes in other organs and systems: - Blood circulation system - Blood volume 5) Blood volume and plasma volume increase: blood protein, total protein, albumin decreases, in the first trimester it gradually increases until the end of pregnancy. Calculate type and Hb, hematocrit decreases because the volume of erythrocyte blood plasma increases for oxygen requirements. 6) Pulse and BP: BP decreased, pulse increased an average of 84x/min 7) Heart: heart pump increases in the first trimester until it decreases in the last week, ECG sometimes shows axis deviation to the left 8) Respiratory system - Shortness of breath and shortness of breath until the intestines are pressed against the diaphragm due to the enlargement of the uterus. - Lung vital capacity increases. - Deep breathing and more prominently chest breathing 9) Digestive system - Saliva increases, nausea and vomiting - The muscle tone of the digestive tract decreases resulting in motility - Vomiting (emesis gravidarum) during the day (morning sickness) - Bones and teeth - The hip joint feels looser and the ligaments soften - Maternal calcium in long bones decreases to meet fetal calcium needs. 10) Skin - Hyperpigmentation occurs in: - Face: cloasma gravid - Breasts: nipples and breast areola - Stomach: linea nigra 11) Endocrine glands - Thyroid gland: may be slightly enlarged - Pituitary gland: can enlarge, especially the anterior lobe - Adrenal glands: none affected (-) 12) Breasts - Breasts get bigger, tighter and heavier - Noduli can be felt due to hypertrophy of the alveolar glands - The vein shadow is more blue - Kaku squeezed out yellow colostrum. 13) Metabolism - BMR increases 15 – 20%, especially in the third trimester - Protein requirements increase for fetal and breast growth. Lactation - Frequent thirst, strong appetite, frequent urination. - Cholesterol increases because somatotoropin forms fat. - Pregnant women's weight increases by 6.5 – 16 kg due to - Fetus, urine, amniotic fluid, uterus - Breast, urine, blood, fat, protein, urine retention. - Calorie requirements increase during pregnancy and lactation b. Psychological adaptations of pregnancy 1). On mother - Focus attention on childbirth - Pay attention to childbirth 2) Psychological changes in father: - Anxiety increases Feeling of loss of personal freedom - Fantasy about changing roles - Talk to other fathers-to-be. 3. Leopold's Study a. Leopold I 1) The client's legs are bent at the knees and thigh crease 2) The examiner stands to the right of the client and looks at the client's face 3) The uterus is lower to the middle 4) The height of the uterine fundus is determined 5) Determine what parts of the child are contained in the uterine fundus. - The nature of the head is hard, round and bouncy, the nature of the buttocks is soft, less round and less bouncy, in the transverse position the uterine fundus is empty. - Variation according to Knebel: determine the position of the head or buttocks with one hand on the fundus and the other on the symphysis b. Leopold II 1) Both hands move to the side 2) Determine the left and right side borders of the uterus 3) Determine the location of the child's back 4) In latitude, determine where the fetal head is located 5) Leopold II to determine where the child's back is and where the small parts are located). 6) Variation according to Poudin: determine the position of the back with one hand pressing on the fundus c. Leopold III 1) Use only one hand 2) The bottom is determined between the thumb and the other fingers 3) Can the bottom part still be used? 4) Leopold III determines what is underneath and whether or not the child's lower part is held by the pelvic outlet) 5) Variation according to Ahlfeld: determine the position of the back with the edge of the left hand placed upright in the middle of the stomach. d. Leopold IV 1) The examiner changes his attitude, namely looking at the patient's feet. 2) With both hands determine what is the bottom. 3) Determine whether the lower part has entered the upper pelvic outlet and how much the lower part has entered the pelvic cavity. 4) If we put our hands together we will get 5) Both hands at the edge of the head are divergent (the largest measurement of the head has passed the upper pelvic inlet) 6) Both hands on the edge of the head convergent (the largest size of the head has not passed through the upper pelvic outlet) i. Leopold IV to determine the lowest part and how much the lower part enters the pelvic cavity. Usually, while palpating, you also pay attention to: the consistency of the uterus, fetal movements and uterine contractions (his), and whether there are Van Bandl circles. 4. Nursing care for pregnant women a. Nursing Assessment 1) Activity or rest Blood pressure is somewhat lower than normal (8 – 12 weeks), returning to pre-pregnancy levels during the last half of pregnancy. Pulse increases 10 – 15 cm. A short systolic murmur may occur in association with the increasevolume, varicose veins, slight lower extremity/hand edema may be present (especially in the last trimester). 2) Ego integrity Shows changes in self-perception 3) Elimination Changes in defecation consistency/frequency, increased frequency of urination, urinalysis, increased specific gravity, hemorrhoids 4) Food/fluids Nausea and vomiting especially in the first trimester: heartburn is common, weight gain of 2 - 4 kg in the first trimester. 5) Pain/discomfort Leg cramps, tenderness and swelling of the breasts, Braxton hicks contractions seen after 28 weeks, back pain. 6) Breathing Nasal congestion, mucosa thicker than normal, respiratory rate may increase relative to size/height of uterus, thoracic breathing. 7) Security Temperature 98 – 99.6 F (36.1 – 37.6 C), fetal heart rhythm heard with daptone (starting 10 – 12 weeks) or fetoscope (17 – 20 weeks), fetal movement felt on examination after 20 weeks, sensation fetal movement in the abdomen between 16 – 20 weeks, ballottement occurs in the fourth and fifth. 8) Sexuality Cessation of menstruation, changes in sexual response/activity, leukarea may be present, progressive increase in uterine size, breast changes: enlargement of adipose tissue, increased vascularity, tender to palpation, colostrum may occur after 12 weeks, pigmentation changes: chloasma, linea nigra, striae gravidarum , Goodell, Hegar, Chadwick signs are positive. 9) Social Interaction Confused/doubtful of anticipated changes, stages of maturation/development vary but may be reversed by pregnancy stressors. Other family members' responses can range from positive and supportive to dysfunctional. 10) Counseling/learning Individual expectations regarding pregnancy, labor/delivery depend on age, level of knowledge, experience, desire for children, economic stability. b. Diagnostic Examination 1) Blood type: ABO and RH to identify the risk of incompatibility 2) Vaginal/rectal swab: Tests for neisseria gonorrhoea, chlamydia 3) Serology test: Determines the presence of syphilis, a sexually transmitted disease. 4) Screening: Against HIV, hepatitis, tuberculosis 5) Rubella titer: Indicates immunity 6) Papanicoloan Smear: Identifies neoplasia, herpex simplex type II 7) Urinalysis: Screen for medical conditions (eg: confirmation of pregnancy, infection, diabetes, kidney disease). c. Nursing diagnoses 1) Anxiety is related to the presence of special risk factors, crisis situations, threats to selfconcept, conscious and unconscious conflicts about essential values and life goals, lack of information. 2) Nutrition less than body requirements is related to changes in appetite, nausea/vomiting, and increased metabolic needs. 3) Deficient fluid volume related to excessive output (vomiting), increased fluid requirements. 4) High risk of ineffective breathing patterns related to compression/shifting of the diaphragm. 5) Changes in urine elimination related to urinary bladder compression. 6) Sleep pattern disturbances related to psychological stress, changes in activity level patterns, shortness of breath. 7) Pain related to physical changes, hormonal influences 8) Excess fluid volume is related to changes in regulatory mechanisms, sodium/water retention. 9) Activity intolerance related to weakness.