High-risk Pregnancy

A pregnancy in which the mother, fetus, or newborn is, or is anticipated to be, at increased risk for morbidity or mortality before or after delivery. High-risk is determined through the use of the Medical Insurance Company of Arizona (MICA) or American College of Obstetricians and Gynecologists (ACOG) standardized medical risk assessment tools.


Note level of anxiety and degree of interference
Unresolved stress may interfere with with ability to function/make decisions. accomplishment of the tasks of pregnancy, with normal acceptance of the pregnancy/fetus, and with decisions regarding future pregnancies versus sterilization.
Provide emotionally warm and supportive Facilitates development of trusting relationship. atmosphere; accept client/couple as they present Nonjudgmental acceptance promotes sense of themselves. trust.
Assume an unhurried attitude whenever dealing Fear of the unknown and fear of becoming a with the client/family. burden are incompatible with psychologic and emotional rest.
Provide 24-h access to healthcare team. Decreases sense of being alone. Anxiety can be reduced when information or help is readily available.
Review possible sources of anxiety (e.g., prior An uncomplicated pregnancy is associated with high-risk pregnancy or premature birth, some anxiety for the client/couple; a medical alterations in family life or role performance, complication/history of previous poor outcome financial concerns related to pregnancy, possible further intensifies feelings of uncertainty delivery of preterm infant, employment concerning the present pregnancy and may even restrictions).
cause couple to distance themselves emotionally from the fetus. Acknowledgment of the realities of what is happening can provide support.
Assess stress level of client/couple associated with Poor family relationships and unavailability of the medical complication, couple's relationship, the support systems may increase stress level. Client relationship of the client/couple to family members, may become dependent on other family members, and the availability of a support network.
which may affect her self-esteem and increase her feelings of anxiety, as well as add to the family's level of stress.
Encourage client/couple to express feelings of Client/couple needs frequent opportunities to frustration related to therapy regimen and/or vent anger/frustration about changes in family life lifestyle changes. Explain to client that verbalization in order to minimize anxiety levels. Allowing such is acceptable and important. (Be alert to expressions expression reassures client that these feelings are of concern regarding children at home and "wanting normal and expressing them is helpful. to deliver and get it over with.") Anxiety/frustration may interfere with making realistic decisions.
Observe for signs of emotional changes, imbalance, Provides opportunity for early intervention. or conflict with family/significant other(s).
Anxiety is "contagious" and may be transmitted between client, on the one hand, and family and staff members, on the other.
Assess physiologic response to anxiety Anxiety/stress may be accompanied by the release (e.g., BP, pulse).
of catecholamines, creating physical responses that affect the client's sense of well-being, thus increasing anxiety.
Provide individually appropriate information Helps to reduce anxiety associated with the regarding interventions or treatments (inpatient or unknown. May enhance cooperation with outpatient basis) and the potential impact of treatment regimen, promoting optimal pregnancy condition on client and fetus. outcome.
Reinforce positive aspects of maternal/fetal Increases confidence and hope for client and condition, if present, such as fetal growth significant other(s). and activity.

Collaborative
Coordinate team conference including client/ Promotes continuity of care and team approach to couple. Create ongoing plan of care.
situation. If hospitalization is necessary, stress levels tend to increase further after 2 wk and remain elevated for the remainder of the hospitalization.
Refer to community support group, such as the MS Decreases sense of being alone and can help Society, American Diabetes or Lung Associations, couple develop a positive outlook on pregnancy. or to couples who have successfully completed a high-risk pregnancy. risk.
Identify signs/symptoms of preterm labor.
List possible preventive measures. Participate in achieving the best possible pregnancy outcome.

Independent
Provide information related to specific high-risk Increases understanding of the impact of situation, including clear, simple explanations pregnancy on the disease process. Client's/ of pathophysiologic changes and maternal and significant other(s)' level of knowledge of, and fetal implications. involvement in, preventive measures appears to have a direct impact on the outcome of an at-risk pregnancy.
Provide appropriate information related to Understanding of tests can reduce anxiety and screening and testing methods and procedures. may increase client cooperation.
Emphasize the normalcy of pregnancy. Avoids/limits perception of "sick role" and provides support to client/couple to deal with their specific situation.
Assist client to identify individually appropriate Preventive problem solving promotes adaptations/self-care techniques: maintaining fluid participation in own care and enhances selfvolume (2-3 L/da), voiding every 2 h during the confidence, sense of control, and client/couple day, scheduling rest periods two to three times a day using satisfaction. Note: Bed rest may result in lateral position, avoiding overexertion or heavy generalized weakness, raising safety concerns lifting, and maintaining contact with family/daily when client is out of bed. life when bed rest is required.

Identify danger signals requiring immediate
Recognizing risk situations encourages prompt notification of healthcare provider (e.g., PROM, evaluation/intervention, which may prevent or preterm labor, vaginal bleeding). limit untoward outcomes.
Define labor and review possible symptoms of May help clarify misconceptions regarding "false preterm labor: painless or painful uterine labor" and aid client in distinguishing between contractions or rhythmic pressure, occurring 10 or preterm labor and Braxton Hicks contractions. fewer min apart; contractions lasting 30 s or longer Symptoms of preterm labor may be overlooked by for 1 h (unrelieved by rest, drinking fluids, or confusing them with normal "aches and pains" of emptying bladder); cramps resembling those of pregnancy. menstruation; abdominal cramping with or without diarrhea; and pressure or aching of the low back and/or vulva unrelieved by resting on left side (though may sometimes be relieved by sacral massage).
Describe potential implications of premature birth.
Increases understanding of need for prevention and motivation to follow therapeutic regimen.
Encourage client to assess uterine tone/contractions Although uterine contractions occur occasionally, for 1 h, once or twice a day.
cervical dilation can occur with contractions every 10 min or less for a period of 1 h.
Demonstrate technique and specific equipment used Provides opportunity for more detailed when FHR monitoring is done in the home setting.
information regarding fetal well-being in a less stressful environment. Enhances sense of active involvement.
Stress importance of reporting increased or altered May reflect cervical changes; indicates need to vaginal discharge. screen for vaginal infections, which may precipitate preterm labor or indicate PROM.

Discuss implications of unknown progression of
Conditions such as multiple sclerosis may degenerative neurologic conditions for occasionally complicate pregnancy or develop client/infant. afterward; however, exacerbations or remissions seem unrelated to pregnancy. If severely affected, client may elect to interrupt pregnancy or undergo sterilization. Note: Decreased sensation may alter client's ability to sense uterine contractions/presence of labor.
Review significance of symptoms of respiratory Peak prevalence of this motor endplate disorder difficulty, fatigue, and upper eyelid drooping in occurs at age 25 y, and pregnancy may increase client with myasthenia gravis. Discuss implications severity of symptoms. Myasthenia gravis is not an for care of self and infant after birth.
indication for therapeutic abortion, but adjustments may be required to care for infant and self.
Discuss impact of rheumatoid arthritis on pregnancy/ Severity of symptoms often subside during postpartal period, as well as need to avoid pregnancy, yet severe exacerbations may occur 1 nonsteroidal anti-inflammatory drugs such as aspirin.
mo after delivery, making infant care difficult. Aspirin is contraindicated owing to its effect on maternal/fetal platelets, coagulation, and corresponding anemia related to blood loss. Note: Extra rest is important to protect weight-bearing joints.

NURSING DIAGNOSIS: readiness for enhanced family Coping
May Be Related To: Needs sufficiently gratified and adaptive tasks effectively addressed to enable goals of self-actualization to surface

Possibly Evidenced By:
Attempts to describe growth impact of this crisis on own values, priorities, and goals; moving in direction of health-promoting and enriching lifestyle that supports and monitors maturational process; generally chooses experiences that optimize wellness

DESIRED OUTCOMES/EVALUATION
Verbalize fears/perceived disruptions in family life CRITERIA-FAMILY WILL: caused by high-risk pregnancy.
Seek assistance/counseling, as needed.

Independent
Assess perceived impact of complication on Family stress often occurs in an uncomplicated client and family members. Encourage pregnancy, and it is amplified in a high-risk verbalization of concerns. pregnancy, where concerns focus on the health of both the client and the fetus. Family is strengthened if all members have a chance to express fears openly and work cooperatively.
Provide primary caregiver for client and encourage Ensures continuity of care, enhances ongoing thorough documentation.
identification and prevention of additional problems, and ensures appropriate follow-up to assist during postpregnancy readjustment.
Help client/couple plan restructuring of roles/ Education, support, and assistance in maintenance activities necessitated by complication of pregnancy.
of family integrity help foster growth of its individual members and reduce stress that the client may feel from her dependent role.

Include partner/siblings in prenatal office visits
Helps family members to view the outcome of the or hospital visits if client is hospitalized. Arrange pregnancy as a cooperative effort. Proper place for family to stay overnight. management of stress at this time may promote growth within the family and individual members.

Listen for expressions of helplessness and concern
Medical problems necessitating special about how current situation is affecting the family therapy/restrictions at home or hospitalization and home. Problem-solve solutions.
significantly disrupt normal routines and cause stress and guilt feelings in the client, partner, and/or siblings. Creative solutions enhance self-esteem, may increase participation/cooperation with medical regimen, and can promote family involvement.
Focus on pregnancy milestones, "countdown to birth." Promotes sense of hope that modifications/ restrictions serve a worthwhile purpose. Helps client/significant others look forward instead of dwelling only on the concerns of the present.

Collaborative
Refer to community service agencies (e.g., visiting Community supports may be needed for ongoing nurse, social service); or resources, such as Sidelines.
assessment of medical problem, family status, coping behaviors, and financial stressors. Sidelines is a national telephone support group for pregnant women on bed rest.
Refer for counseling if family does not sustain May be necessary to promote growth and to positive coping and growth. (Refer to ND: Family prevent family disintegration. Processes, risk for altered.)

Risk Factors May Include:
Extremes of weight (<100 lb/> 200 lb), inability to ingest/digest food, excessive/inappropriate intake, limited financial resources

Possibly Evidenced By:
[Not applicable, presence of signs/symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION
Gain 24-28 lb during the pregnancy.

CRITERIA-CLIENT WILL:
Follow a well-balanced diet.
Be free of ketones in urine.

RATIONALE Independent
Ascertain current/past dietary patterns and practices.
Ascertaining the nutritional state before conception is critical to ensuring proper organ development, especially brain tissue, in the early weeks of pregnancy.
Weigh client. Compare current weight with Underweight clients are at risk for anemia, pregravid weight. Have client record weight inadequate protein/calorie intake, vitamin/ between visits. mineral deficiencies, and PIH. Overweight women are at risk for possible changes in the cardiovascular system that create risks for development of PIH, GDM, and hyperinsulinemia of the fetus, resulting in macrosomia. Research indicates increased risk of fetal distress and cesarean delivery. Sudden weight gain of 2+ lb in a week may indicate PIH; a weight loss of 3 lb or more near term suggests postmaturity.
Provide information about risks of weight reduction Prenatal calorie restriction and resultant weight during pregnancy and about nourishment needs loss may result in nutrient deficiency or of client and fetus. ketonemia, with negative effects on fetal CNS and possible intrauterine growth restriction (IUGR).
Test urine for presence of ketones. Indicates inadequate glucose utilization and breakdown of fats for metabolic processes.
Develop plan with client that provides necessary Prevents malnutrition and dehydration, which appear nutrients, including adequate fluid intake.
to compromise optimal uterine and placental Recommend at least 2 q of noncaffeinated functioning and increase uterine irritability, fluid per day.
which could potentiate premature labor.
Discuss importance of staying on low-This client should have begun the diet before phenylalanine diet for the woman with becoming pregnant and continue the diet phenylketonuria (PKU).
throughout the pregnancy to prevent elevated phenylpyruvic acid levels and reduce the risk of mental retardation, microcephaly, congenital heart defects, and growth retardation/ IUGR.
Encourage close monitoring of blood glucose Type I or insulin-dependent diabetes mellitus (IDDM) levels, as appropriate.
clients generally need to check blood glucose levels 4-12 times/day because insulin needs may increase two to three times above pregravid baseline.

DESIRED OUTCOMES/EVALUATION
Verbalize understanding of individual risk factors.

CRITERIA-CLIENT WILL:
Participate in screening procedures as indicated.
Display fetal growth within normal limits (WNL).

ACTIONS/INTERVENTIONS RATIONALE Independent
Note maternal conditions that affect fetal Any factor that interferes with or reduces maternal circulation, such as PIH, diabetes, cardiac or circulation/oxygenation has a similar impact on kidney disease, anemia, Rh incompatibility, or placental/fetal oxygen levels. The fetus who is unable hemorrhage, as well as maternal age. (Refer to to obtain sufficient oxygen for metabolic needs from appropriate plans of care.) Assess for excessive maternal circulation resorts to anaerobic metabolism, nausea/vomiting. which produces lactic acid, leading to an acidotic state. Maternal age above 35 y is associated with some increase in risk of abruptio placentae, preterm delivery/stillbirths, fetal chromosomal abnormalities, and IUGR. The most common maternal complications in this age group are PIH and gestational diabetes.
Exposes developing fetus to acidotic state and malnutrition and may contribute to IUGR and poor brain growth. Development of hyperemesis gravidarum may require hospitalization.
Ascertain use of thalidomide before conception. Clients with HIV/AIDS may have used this drug to prevent or reverse weight loss; however, it has potential for severe birth defects.
Determine use/abuse of substances such as tobacco, Depending on the extent of use, these substances may alcohol, and other drugs. Provide information about result in varying degrees of involvement ranging from negative effects on fetal growth.
an identifiable syndrome such as fetal alcohol syndrome to less specific developmental disorders/ delays.
Screen for occurrence of abuse during pregnancy. Prenatal abuse is a significant risk factor for low birth weight, preterm delivery, and other poor outcomes.
Note estimated date of birth (EDB)/estimated date Placental function is characterized by intense of delivery (EDD). metabolic activity and oxygen consumption, which increases until term and then begins to fall. A postterm placenta becomes calcified and degenerates, thereby reducing surface available for oxygen and nutrient transfer and increasing perinatal mortality.
Assist in screening for and identifying genetic/ Disorders such as PKU or sickle cell anemia chromosomal disorders. (Refer to CP: Genetic necessitate special treatment to prevent negative Counseling.) effects on fetal growth.
Discuss potential negative effects of identified Intrauterine or postnatal growth retardation/ condition (e.g., PKU) on fetus, and review options restriction, malformation, or mental retardation available to client. (Refer to ND: imbalanced Nutrition: may occur in PKU if pregnant woman does not less/more than body requirements; resume diet low in phenylalanine for the duration CP: Genetic Counseling.) of the pregnancy.
Assess FHR, noting rate and regularity. Have Tachycardia in a term infant may indicate a client monitor fetal movement daily as indicated.
compensatory mechanism to reduced oxygen Note presence of maternal conditions that may levels and/or presence of sepsis. A reduction in fetal also impact FHR (e.g., maternal hyperthyroidism, activity occurs before bradycardia. Although fetal Graves' disease).
thyrotoxicosis is rare, IUGR or tachycardia may result if maternal condition is untreated. Note: Fetal hypothyroidism may result from maternal low-dose antithyroid drug therapy; higher doses may produce a goiter or mental retardation.
Assess or screen for preterm uterine contractions, Occurs in 6%-7% of all pregnancies and may result which may or may not be accompanied by in delivery of a preterm infant if tocolytic cervical dilatation. (Refer to CP: Preterm Labor/ management is not successful in reducing uterine Prevention of Delivery.) contractility and irritability.
Monitor FHR during sickle cell crisis. Maternal acidosis/hypoxia, especially in third trimester, can result in fetal CNS disorders. Repeat crises predispose the client and fetus to increased mortality and morbidity rates.

Collaborative
Monitor maternal laboratory studies: Provide supplemental oxygen as appropriate.
Increases the oxygen available for fetal uptake, especially in presence of severe anemias or sickle cell crisis, or when maternal/fetal circulation is compromised.
Provide information and assist with procedures as indicated, for example: Aminocentesis; Aminocentesis may be performed for genetic purposes or to assess fetal lung maturity. Spectrophotometric analysis of the fluid may be done to detect bilirubin after 26 wk' gestation.

Administer RhIgG after amniocentesis
If serum titer is greater than 1:16, sensitization (based on results from Kleihauer-Betke test); occurs when maternal/fetal cells mix, creating an antigen-antibody response with hemolysis of fetal RBCs and release of bilirubin. Kleihauer-Betke test detects presence of fetal blood in maternal system. RhIgG may prevent procedural isoimmunization. Most common complication is preterm labor requiring ongoing monitoring by client following the procedure. Observe external fetal monitor for 20-30 min after Helps detect negative fetal/uterine response to amniocentesis, position client on side; procedure. Lateral position increases uteroplacental perfusion.

Intrauterine fetal exchange transfusion and
If excess fetal RBC hemolysis occurs, transfusion repeat transfusion every 2 wk as indicated into fetal peritoneal cavity with RhO-negative by titers (Kleihauer-Betke test) followed blood replaces hemolyzed RBCs when fetus is by administration of RhIgG. determined at risk of dying before 32 wk' gestation. Percutaneous uterine (fetal) blood sampling (PUBS); permits fetal blood sampling with identification of genetic or developmental problems such as sickle cell anemia, hemophilia, thalessemia major; immunologic problems, Rh isoimmunization; and NTD. Also provides direct access for exchange transfusion, etc.
Determine fetal maturity when early delivery is Fetal lung maturity is indicated by an L/S ratio of anticipated, using results from amniotic fluid 2:1 or greater, except in an infant of a diabetic analysis for surfactant PG, creatinine, bilirubin, mother. Presence of PG and creatinine levels of 2.0 and cytologic analysis. mg/100 ml reflect kidney maturity. Cornified cells are present at 36 wk' gestation. Bilirubin levels of 0.025 mg/dl in mothers having no Rh isoimmunization indicate fetal maturity.
Prepare for, and assist with, termination of Pregnancy may be terminated if desired for such pregnancy by induction or cesarean delivery conditions as toxoplasmosis occurring before 20 as indicated.
wk' gestation, rubella during the first trimester, or elevated AFP levels indicating NTD. In event of postterm placental calcification or deterioration of maternal condition, labor may be induced. Be free of maternal injury.

ACTIONS/INTERVENTIONS RATIONALE Independent
Review obstetric/medical history. Note maternal age. Helps identify individual risk factors. Women over age 35 y have an increased occurrence of PIH, GDM, spontaneous abortions, and bleeding problems.
Screen for abuse during pregnancy. Prenatal abuse is correlated with a low maternal weight gain, infections, anemia, and delay in seeking prenatal care until the third trimester.
Discuss the option of a VBAC in client with incision Potential for uterine rupture in subsequent into the lower uterine segment and potential risks pregnancies exists when incision is a classical associated with previous classical incision into uterus.
(vertical) incision or gestational age is not accurately determined, resulting in overdistension and stimulating onset of labor.
Refer client/couple for a VBAC or cesarean classes, Provides information/opportunity for asking as appropriate.
questions to prepare client for delivery.

DESIRED OUTCOMES/EVALUATION
Verbalize thoughts/feelings about situation.

CRITERIA-CLIENT/COUPLE WILL:
Express positive self-appraisal.
Seek appropriate referral as needed.

RATIONALE Independent
Encourage verbalization of feelings. Assess Helps detect problems and determine their perception of self in nonpregnant state and severity. Because pregnancy is thought to be a alteration in perception with pregnancy.
normal physiologic process, a high-risk situation can lead to alterations in self-concept, lowered selfesteem, and ego disintegration, especially if one or both members of the couple associate childrearing with success as a woman or man.
Note issues of lack of control. Client is often frustrated by a loss of control over her body as well as the pregnancy in general, with a sense that all control is in the hands of healthcare providers.
Facilitate positive adaptation to altered self-Helps in successful accomplishment of the concept through Active Listening, acceptance, psychologic tasks of pregnancy, although the and problem solving.
high-risk couple may remain ambivalent as a selfprotective mechanism against possible loss of the pregnancy/fetal death.
Encourage involvement in decisions about care Enhances sense of control and increased selfwhen possible. esteem. Note: Client is often required to undergo many procedures with few-if any-alternatives offered. Pressure may be perceived as implication that the procedure may be the only chance of delivering a viable infant; or if medical option is refused, insurance payor may deny benefits for costs associated with the pregnancy.
Promote attendance at classes/support groups, Provides information for client/couple and identify computer-based resources (e.g., e-mail, reassurance that they are not alone. on-line support groups) as appropriate.

Independent
Determine presence/frequency of excessive or Pernicious vomiting (hyperemesis gravidarum) persistent nausea and vomiting/retching. results in dehydration, hypovolemia, and metabolic changes, exposing the developing fetus to acidotic state and malnutrition, which may contribute to IUGR and poor brain growth or possibly death.
Note client reports of nervousness or heat intolerance Signs suggestive of hyperthyroid state may cause and presence of fine tremors, temperature elevation, excessive vomiting. excessive diaphoresis, or tachycardia.
Monitor BP and pulse.
Dehydration/hypovolemia may cause hypotension or tachycardia.
Recommend pacing of activities, adequate sleep, and Conserves energy; allows closer monitoring of bed rest, as appropriate.
physical status.
Record intake/output; measure urine specific gravity. Provides information regarding hydration and effectiveness of fluid replacement.
Encourage frequent oral care. Dehydration and acid emesis may cause drying and irritation of mucous membranes.
Note signs of mucosal bleeding or hemorrhage.
Severe vitamin deficiencies and Recommend use of soft toothbrush, alcohol-free hypothrombinemia may alter coagulating ability. mouthwash, and ingestion of soft foods.
Preventing trauma to mucous membranes reduces likelihood of bleeding.
Review need for and/or use of antithyroid drugs, such Interferes with synthesis of thyroid hormone and as PTU or methimazole (Tapazole).
helps overcome intractable vomiting (hyperemesis) caused by hyperthyroid state. However, fetal consequences may include hypothyroidism, goiter, or mental retardation.

Collaborative
Monitor laboratory studies as indicated: Electrolytes; Electrolyte/acid-base imbalances are common and may be life-threatening. Hct; Elevated in dehydration. May be useful in assessing fluid needs. BUN; Hypovolemia reduces renal perfusion and function, elevating BUN. Thyroid studies and serum thyroxine levels.
Elevated in client with hyperthyroidism/Graves' disease.
Administer prochlorperazine (Compazine) or Provides sedative action and prevents vomiting, hydroxyzine (Vistaril) as indicated, or monitor but may have teratogenic effects. low-dose promethazine (Phenergan) infusion.
Administer parenteral fluids, electrolytes, glucose, Helps reverse or prevent possible hypokalemia, or supplemental vitamins, as indicated.
severe protein/vitamin deficiencies, or acidosis, which may negatively affect maternal/fetal well-being.
Provide diet as tolerated (may be nothing by Allows the gastrointestinal tract an initial period of mouth [NPO] for 24-48 h) starting with small/dry rest. Gradually increasing oral feedings may feedings followed by clear liquids and progressing improve food tolerance. to low-fat, soft, then regular foods.

Refer to psychologic counseling if no
There may be a psychologic component to the improvement occurs.
problem of vomiting.

Prepare for therapeutic abortion if warranted by
Early recognition and treatment should prevent patient's condition.
such a severe situation from developing, but it may be indicated when mother's life is threatened, as evidenced by jaundice, prolonged fever greater than 101°F (38.3C°), tachycardia, retinal hemorrhage, and delirium.

DESIRED OUTCOMES/EVALUATION
Verbalize understanding of individual risk factors.

CRITERIA-CLIENT WILL:
Identify and use interventions to reduce risks.
Display BP, pulse, respiratory rate, and hemoglobin (Hb) and hematocrit (Hct) within normal limits.
Refer to discussion of circulatory considerations in CPs: Pregnancy-Induced Hypertension; Cardiac Conditions.

Independent
Assess for respiratory disorders, such as asthma or tuberculosis, Any condition, either preexisting or developing that may interfere with lung function.
during the pregnancy, that reduces or interferes Note maternal respiratory rate or effort and with oxygen-carrying capacity impairs normal gas adventitious lung sounds.
exchange. Such conditions may be a result of problems related to respiration, circulation, or cellular components.
Note conditions potentiating vascular changes/ Extent of maternal vascular involvement and reduced placental circulation (e.g., diabetes, PIH, reduction of oxygen-carrying capacity have a cardiac problems) or those that alter oxygen-carrying direct influence on uteroplacental circulation and capacity (e.g., anemias, hemorrhage). (Refer to gas exchange. IUGR and birth of an LBW or smallspecific plans of care as needed).
for-gestational-age infant are associated with maternal vascular changes.
Monitor BP and pulse. Elevated BP may indicate PIH; reduced BP and increased pulse may accompany hemorrhage.
Promote bed/chair rest. Position in upright or semi-Reduces respiratory effort and increases oxygen Fowler's position when respiratory effort is consumption as diaphragm falls, increasing compromised; otherwise, encourage client to assume vertical chest diameter. Side-lying position lateral position.
increases renal/placental perfusion; either position is effective in preventing supine hypotensive syndrome.
Monitor maternal kidney function, noting overall Kidney function may deteriorate during intake/output, and measure urine-specific gravity, as pregnancy, negatively affecting cardiovascular indicated.
function, elevating BP, and reducing placental circulation.
Encourage increased fluid intake as appropriate/ Prevents dehydration, enhances organ tolerated.
perfusion/function, and liquefies respiratory secretions to facilitate expectoration.
Review dietary sources of vitamin C, iron, and Inadequate nutrition results in iron deficiency protein. Discuss individual need for sufficient anemia and may lead to problems of oxygen calories. Identify substances that foster iron transport. absorption (acid medium, vitamin C) and those that reduce absorption (alkaline medium, milk).
Reduce stressors precipitating allergic/asthmatic Decreases incidence of attacks. Impact of asthma response in susceptible client.
on pregnancy is questionable, although it may be associated with increased incidence of abortion and preterm labor.
Encourage maternal avoidance of potential stressors Maternal acidosis/hypoxia, especially in third (e.g., hypoxia, dehydration, acidosis, exposure to cold) trimester, can result in fetal CNS disorders. Repeat that may precipitate sickle cell crisis crises predispose the client/fetus to increased rates of mortality/morbidity.

Collaborative
Monitor maternal laboratory studies as indicated: Hb/Hct using electrophoresis; Any reduction in Hb levels or circulating blood volume reduces oxygen available for maternal tissues. Treatment depends on the cause of the anemia as diagnosed by electrophoresis. BUN, creatinine clearance, 24-h protein, and Evaluates adequacy of renal function. uric acid levels; Arterial blood gases (ABGs).
Determines oxygenation and therapy needs.
Administer medications, as indicated: Theophylline; Assists in bronchial dilation but may be associated with side effects of tachycardia in client/fetus.
Iron dextran (Imferon); Parenteral administration may be necessary in presence of severe iron deficiency anemia to increase maternal oxygen-carrying capacity. Isoniazid/ethambutol/rifampin. Active tuberculosis requires treatment. Isoniazid crosses the placenta but does not appear to have teratogenic effects. Rifampin also crosses the placenta, but studies of fetal effects are still in progress. Streptomycin is avoided owing to association with vestibular/auditory defects. Note: Isoniazid therapy requires supplementation of pyridoxine (vitamin B 6 ).
Provide supplemental oxygen. May be indicated in presence of severe anemias or during sickle cell crisis.
Assist with prophylactic exchange transfusion or Helps maintain maternal hemoglobin S (HbS, crisis/anemia transfusion as indicated. abnormal sickle cell) level at less than 50%-60% of total Hb, or Hct at 30%, to improve oxygen-carrying capacity.

Risk Factors May Include:
Presence of circulatory/respiratory problems, uterine irritability

Possibly Evidenced By:
[Not applicable; presence of signs/symptoms establishes an actual diagnosis]

DESIRED OUTCOMES/EVALUATION
Report an awareness of level of tolerance of CRITERIA-CLIENT WILL: activity.
Plan necessary alterations in lifestyle/daily activities.
Be free of excessive fatigue or uterine irritability/sustained contractions.

ACTIONS/INTERVENTIONS RATIONALE Independent
Encourage client to pace activities and allow Conserves energy and avoids overexertion to sufficient rest. minimize fatigue/uterine irritability.
Review home/employment situation, noting Promotes collaborative problem solving and may activity levels and individual responses.
enhance participation in modifications of activity.
Discuss activity prescription/limitations. Therapeutic regimen may dictate specific modifications depending on symptoms and previous history.
Encourage adequate rest and use of lateral position.
Increases uterine blood flow and may decrease uterine irritability/activity.
Instruct client to avoid heavy lifting, strenuous Previously tolerated activity may not be indicated activity/housework, sports, and motor trips longer for women at risk. Aerobic exercise/abdominal than 1-2 h. (Note: Client with cardiac condition muscle strain may decrease uterine blood flow and may have more severe restrictions.) increase uterine irritability.
Instruct client to modify or eliminate any type of Sexual activity, including orgasms and breast sexual activity in the presence of symptoms of stimulation, appears to increase uterine irritability, preterm labor, cervical changes, or bleeding.
owing to release of oxytocin.
Recommend avoiding travel and altitude changes in Motion of travel, prolonged sitting position, and the third trimester.
decreased oxygen appear to increase uterine irritability.
Stress importance of quiet diversional activities. Prevents boredom and enhances cooperation with activity restrictions.

Collaborative
Encourage modified/complete bed rest as indicated. Activity level may need modification, depending on symptoms of uterine activity, cervical changes, or bleeding. Note: Generalized weakness may develop as a result of prescribed total bed rest with concerns for self-care and independence in the postpartal period.

DESIRED OUTCOMES/EVALUATION
Identify ineffective coping behaviors and CRITERIA-CLIENT/FAMILY WILL: consequences.
Verbalize awareness of own strengths/coping abilities.
Demonstrate coping by discussing fears and dealing positively with the situation.
Seek help appropriately.

Independent
Assess past and present coping strategies and In coping with a high-risk pregnancy, the client/ emotional response to event/diagnosis. couple/family often uses denial, then guilt, blame, or feelings of ambivalence as emotional protection from possible loss of the pregnancy and fetus/newborn.
Evaluate client's/couple's support systems, Often, as a protective mechanism, the client and including ability to comfort one another. Note her partner do not form positive emotional negative coping, and discuss consequences. attachment ("give of themselves") to the fetus. Lack of adequate support systems and failure to achieve the normal developmental tasks of pregnancy may result in continuation of high-risk situation into the childrearing phase and may create potential problems associated with physical or emotional child abuse and high-risk parenting.
Discuss normalcy of feelings; encourage couple Helps assure client/couple that feelings are to verbalize (separately and together) their feelings appropriate in high-risk situation; promotes open and concerns.
lines of communication. Note: One member of the couple may be reluctant to discuss fears openly in front of partner; may require additional support to facilitate interaction with one another.
Note client reports of increasing fatigue and Lack of family's assistance may indicate a need for inability to manage daily household activities.
help to resolve situation. Client may be reluctant to relinquish responsibilities and/or significant other(s) may be preoccupied with own emotional conflicts/personal suffering and express lack of understanding/knowledge about how to be helpful.
Encourage family to restructure daily activities to Family may need assistance in recognition of the meet client's needs without negating their own needs.
importance of time planning to meet such needs as increased rest during pregnancy. However, family needs to work as a group to problem-solve solutions that meet individual needs and prevent negative feelings and "sabotage behaviors." Obtain/review history of increasing severity of Problems may require a reduction in activity level symptoms, especially if hospitalization is necessary. and/or hospitalization, necessitating changes in family life.