Nursing 209

N209: Reproductive Health Study Guide

3.13 The Nursing Process Assessment • Gather information regarding the patient’s medical and surgical health history, OB/GYN history, risk factors, cultural and religious beliefs, and socioeconomic factors that may influence health decisions. • Assess physical data related to pregnancy including pre-pregnancy weight, current weight gain, baseline vital signs, physical changes of pregnancy, obstetrical screen results, and ultrasound. • Assess knowledge base regarding pregnancy needs (nutritional, weight gain, teratogens, and potential complications). • Assess fetal status by reviewing results of diagnostic tests (Amniocentesis, NST, and BPP). Analysis/Diagnosis • Identify nursing diagnosis related to actual and potential problems, such as deficient knowledge, anxiety, and imbalanced nutrition. • Develop a plan of care based on the identification of patient needs. Plan • Determine expected outcomes/goals for patient/family regarding health promotion and safety for a healthy pregnancy (patient will verbalize nutritional changes that will increase promotion of a health pregnancy). • Formulate nursing actions/interventions based on evidence-based practice and standards of care to assist the patient in achieving a healthy pregnancy. Implementation • Initiate a plan of care to achieve expected outcomes (provide instruction on diet, smoking cessation, avoidance of teratogens, prevention of infections, weight gain, exercise, etc.). Evaluation • Assess and document the patient’s response to nursing interventions and revise the plan as needed (e.g., modify diet to prepare for breastfeeding). Nursing Diagnosis Pertinent to the Antepartal Period • Imbalanced nutrition related to low/high BMI; lack of knowledge regarding pregnancy nutritional needs • Risk for dysfunctional gastric motility related to pregnancy GI system changes • Deficient knowledge related to effects of teratogens and risk behaviors on fetal outcome and maternal health • Disturbed body image related to physical changes of pregnancy • Anxiety related to physical changes of pregnancy; concern for safe fetal outcome

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