Nursing Care Plan 3 Risk for Altered Parenting

Case Scenario # 6 Perinatal Nursing INSTRUCTIONS: For this case scenario, you will develop a Nursing Care Plan using SNL, the Standardized Nursing Languages of NANDA, NANDA, NOC and NIC and NIC (NNN). You will be completing the blank care plan that

accompanies this scenario. T. S. is a 30-year-old primigravida presenting presenting for inpatient care at 37 weeks gestation following nonreassuring fetal testing. She is a Type I diabetic of 20 years duration. She has received prenatal care in the antepartum diabetes clinic and was hospitalized twice in the first trimester of pregnancy, once in diabetic ketoacidosis. Blood glucose levels and hemoglobin A1c have been essentially within normal limits since then, though insulin needs have decreased in the last week, indicating compromised compromised placental function. function. Serial ultrasounds of the fetus have have indicated no identified cardiac or CNS anomalies and fetal weight at the time of admission is estimated at the 40th percentile for gestational age. Functional Health Patterns

Nursing assessment data is organized by functional health patterns as well as by initial physical assessment at the time of admission. Relevant FHP data for T.S. are: Nutritional/metabolic:: 2200 Cal. ADA diet in pregnancy Nutritional/metabolic Insulin: NPH qhs, regular insulin to scale ac, hs, 3 AM Last meal: breakfast, with 6u regular insulin (time now 11AM) Activity/exercise:: Activity ad lib until one week ago, then bedrest at home for Activity/exercise increasing blood pressure Cognitive/perceptual : Did not finish childbirth preparation classes r/t bedrest Decreasing visual acuity r/t diabetic retinopathy (uses magnifying glass on syringe to draw up insulin) Role/relationship:: “I hope my baby is OK” Role/relationship Sexuality/reproductive:: Planned pregnancy after preconception counseling and Sexuality/reproductive achievement of euglycemia prior to conception Coping/stresss tolerance Coping/stres tolerance:: “I’m scared about labor.” Self-perception/self-concept:: re: concerns about self: “I hope I live long enough to see my baby Self-perception/self-concept grow up.”

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Admission Physical Assessment

Temp. 37C, P 80, BP 150/102, R 18. (lungs clear to auscultation) Baseline fetal heart rate per continuous external monitoring: 122; no accelerations, minimal baseline variability, questionable subtle late deceleration with rare r are uterine contractions of mild intensity Cervical exam: 1-2 cm. Dilated, minimally effaced, vertex at –1 station. Membranes intact Deep tendon/patellar reflexes: 3+ Pain: Headache since 3 AM pain scale 3/10; no epigastric pain Edema: 3+ pretibial; patient reports face “puffy” since 2-3 days ago

Step 1: Choosing the Nursing Diagnoses: Appropriate nursing diagnoses include, but may not be limited to, the following:

Nursing Diagnosis: Childbearing, maladaptive: antepartum/intrapartum status Defining characteristics: There is a deviation from physiologic adaptive changes that support the health of mother and/or fetus during pregnancy Related factors: Maternal vascular compromise related to long-term diabetes exacerbation of maternal carbohydrate intolerance/insulin resistance related to Type I diabetes of long duration Fetal compromise secondary to decreasing placental function

Nursing Diagnosis: Risk for altered parenting Defining characteristics: Risk for inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child. Related factors: Physical illness For purposes of working through this exercise, the second diagnosis,

Risk for Altered Parenting , will be used. •

On the nursing careplan form, write in the nursing diagnosis, the defining characteristics & related factors.





Step 2: Choosing the Nursing Outcomes (NOCs): •

The next step is to select the nursing outcomes that can best affect this nursing diagnosis.

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Listed below are two appropriate nursing outcomes for the diagnosis

Risk for Altered Parenting NOC Parent-Infant Attachment. Indicators: Parents verbalize positive feelings toward infant Parents touch/stroke/pat infant Parents use eye contact Parents respond to infant cues Parents console/sooth infant

NOC Coping Indicators: Identifies effective coping patterns Uses effective coping strategies Adapts to developmental changes Uses available social support •

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Select ONE of the above-listed nursing outcomes for this care plan exercise, go to the nursing care plan and check the indicators that you think will best measure your patient’s progress toward the outcome that you’ve chosen. You will need to RATE your patient’s current status, according to the assessment data provided, for each indicator you have just selected. Date and initial the outcome section of the care plan.





Step 3: Choosing the Nursing Interventions (NICs) (NICs) If you have chosen the NOC: Parent-Infant Attachment , continue below.

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If you have chosen the NOC: Coping, continue to that section of the learning module to select your interventions and activities.

NOC: Parent-Infant Attachment NIC: Attachment Promotion The following activities are part of the NIC: Attachment Promotion. Promotion . Review

the activities listed below and select 5 that are appropriate for this situation and which address the indicators selected for the NOC: Parent-Infant Attachment. Write these five activities on the care plan in the activity section for Attachment Promotion. Discuss parents’ reaction to pregnancy Discuss parent’s reaction to fetal movement Encourage parent(s) to note fetal movement Assist father/significant other during participation in labor and delivery Provide father opportunity to hold newborn. Place pictures of family in isolette so infant can “see” family Prov rovide pain ain re relie lief fo for mo mothe ther Rein Reinfo forc rcee care caregi give verr role role beha behavi vior ors. s. Encourage parent(s) to bring toys or clothing for newborn. Explain equipment used to monitor infant in nursery. Take Polaroid picture of infant to leave with mother before transporting infant to another hospital Point out infant state changes to parent(s) Encourage parent(s) to accompany

Determine the image mother has of her unborn child Identify body parts of infant on ultrasound image Provide parent(s) the opportunity to hear fetal heart tones as soon as possible. Ascertain before birth whether the parent(s) has names picked out for both sexes. Provide opportunities for parent(s) to see, hold, and examine newborn immediately after birth. Encourage parent(s) to hold infant close to body. Encou ncoura ragge pa parent rentss to to mas massa sagge in infant fant.. Prov Provid idee assi assist stan ance ce in in self selfca care re to to maximize focus on infant. Assist parent(s) parent(s) in planning for early discharge. Encourage parent(s) to visit infant in the nursery Encourage parent(s) to bring personal items, such as toy or picture, to be put in isolette or at bedside of infant Assist parent(s) in planning infant care during alert state. Inform parent(s) of care being given

Place infant on mother’s body immediately after birth Discuss parent’s reaction to viewing ultrasound image of fetus. Encourage father/significant other to participate in labor and delivery. Encourage mothers to hold, touch, and examine the infant while cord is being cut. Encourage parents to identify family characteristics observed in newborn Assist parent(s) to participate in infant care. Reinfo inforrce eye con conta tact ct with with infa infant nt.. Provide roomingin in hospitals Refer for further follow-up care, when appropriate. Demonstrate ways to touch infant confined to isolette. Inform parent(s) of behavioral characteristics infant exhibits while being cared for in another hospital Encourage parent(s) to see and touch newborn before transport. Point out infant cues that show





NOC: Parent Infant Attachment NIC: Family Integrity Promotion: Childbearing Family The following activities are part of the NIC: Family Integrity Promotion: Childbearing Family.. Review the activities listed below and select 5 that are appropriate for this Family situation and which address the indicators selected for the NOC: Parent-Infant Attachment. Write these 5 activities on the care plan in the activity section. NIC: Family Integrity Promotion: Childbearing Family Create an atmosphere to facilitate trust Establish trusting relationship with parents(s) spend time with parents to convey acceptance Moni Monito torr cur curre rent nt fam family ily sit situa uati tion on Analyze role adaptations of family members Monitor family’s ability to perform tasks appropriate to family developmental developmental stage Assist family in identifying support systems used by the family Offer to be an advocate for the family Prepare parents(s) for responsibilities responsibilities of parenthood Reinforce positive parenting behaviors Encourage parents(s) to maintain individual hobbies or outside interests Discuss the grieving process associated with the loss of “being pregnant” Make siblings(s) feel special when visiting units Provide information about sibling preparation Determine sibling reaction to

Prov Provid idee atm atmosp osphe here re of acce accept ptan ance ce

Conv Convey ey acce accept ptin ingg att attit itud udee

Offer to be a listener

Offer to be a listener for significant other Provide step-by-step verbal support in a calm, strong voice Monitor effects of newborn o family structure Identify family interactions system

spend time with parents to contribute to feelings of selfworth Moni Monito torr psy psych chos osoc ocia iall sta statu tuss of of family Determine strength of intrafamily bonds Identify normal family coping mechanisms Determine family’s relationship to support systems Offer to be an advocate for the child Monitor parent’s adaptation to parenthood Monitor parent’s self-perception as a parent Provide parent(s) an opportunity to express their feelings about parenthood Explain causes and manifestations of postpartum depression Provide toys for siblings in waiting room Encourage family to attend sibling preparation classes Provide family with information

Identify coping mechanisms of individual family members Assist family in developing new support network Prepare parents(s) for expected role changes involved in becoming a parent Determine parents’ self-esteem Appraise parent’s perception of self as individual Encourage verbalization of feelings, perceptions and concerns about prenatal experience Provide for family and sibling visitation during postpartum period Determine how parent(s) prepared sibling(s) for coming of new baby Discuss reaction of sibling(s) to newborn Encourage parent(s) to observe





NOC: Coping NIC: Coping Enhancement

The following activities are part of the NIC: Coping Enhancement. Review the activities listed below and select 5 that are appropriate to the situation and address the indicators identified for the NOC: Coping. Coping. Write these 5 on the care plan in the activity section for Coping Enhancement.. Enhancement Appraise a patient’s adjustment to changes in body image, as indicated. Appraise the patient’s understanding understanding of the disease process. Assist the patient in developing an objective appraisal of the event

Appraise the impact of the patient’s life situation on roles and relationships. Use Use a cal calm, m, reas reassu suri ring ng app appro roac ach. h.

Help patient to identify the information he/she is most interested interested in obtaining. Provide the patient with realistic Encourage an attitude of realistic choices about certain aspects of hope as a way of dealing with care. feelings of helplessness. Seek to understand the patient’s Discourage decision-making when perspective of a stressful the patient is under severe situation. stress. Encourage the patient in Explore the patient’s previous developing relationships. achievements of success. Foster constructive outlets for Arrange situations that encourage anger and hostility. patient’s autonomy Encourage the identification of Explore the patient’s previous specific life values. methods of dealing with life problems. Instruct the patient on the use of Support the use of appropriate relaxation techniques, as needed defense mechanisms Encourage the patient to identify Assist the patient in identifying own strengths and abilities appropriate short and long-term goals Appraise the patient’s Assist the patient to identify need/desire for social support available support systems Assist the patient to grieve & work through the losses of chronic illness &/or disability, if appropriate

Encourage patient to identify a realistic description of change in role Prov Provid idee an atmo atmosp sphe here re of of acceptance. Provide factual information concerning diagnosis, treatment and prognosis. Evaluate the patient’s decisionmaking ability. Encourage gradual mastery of the situation. Explore the patient’s reasons for self-criticism. Assist patient in identifying positive responses from others. Introduce patient to persons (or groups) who have successfully undergone the same experience. Encourage verbalization of feelings, perceptions, fears. Assist the patient in examining available resources to meet the goals Encourage family involvement, as appropriate







NOC: Coping NIC: Crisis Interventio Interventionn

The following activities are part of the NIC: Crisis Interventio Intervention. n. Review the activities listed below and select 5 that are appropriate to the situation and address the indicators identified for the NOC: Coping. Coping. Write these 5 on the care plan in the activity section for Crisis Intervention Prov Provid idee atmo atmosp sphe here re of supp suppor ortt

Encourage expression of feelings in a nondestructive manner Assist in identification of personal strengths and abilities that can be used in resoling the crisis Introduce patient o persons (or groups)who have successfully undergone the same experience Assist patient to decide on a particular course of action

Dete Determ rmin inee whet whethe herr pati patien entt presents safety risk to self or others Assist in identification of the precipitants and dynamics of the crisis Assist in development of new coping and problem solving skill

Assist in identification of alternative course of action to resolve the crisis Assist in formulating a time frame for implementation of chosen course of action

Initiate necessary precautions to safeguard the patient or others at risk for physical harm Assist in identification of past/present coping skill and their effectiveness Assist in identification of available support systems provide guidance about how to develop and maintain support system(s) Assist in evaluation of the possible consequences of the various course of action Evaluate with patient whether crisis has been resolved by chosen course of action

Plan with patient how adaptive coping skills can be use to deal with crises in the future

Congratulations! You have successfully completed your first nursing care plan using the standardized nursing

Nursing Care Plan 3 Risk for Altered Parenting

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