Chapter 41: Nursing Care of the Child With a Cardiovascular Disorder
1. Baby boy Ellis, 2 hours old, is being evaluated in the newborn nursery by the nursing staff. Findings include T 37°C; apical heart rate 140 bpm; respirations 58 breaths per minute; BP (arms) 70/47, (calves) 62/39; head circumference 34 cm; chest circumference 31 cm; length 48 cm; weight 2,700 g. The infant is crying. (Learning Objectives 1, 2, 3, 4, and 8)
a. Based on the physical findings, what should be the nurse’s priority?
b. What assessments/tests should the nurse expect to be done on this infant?
c. What should the nurse include in the teaching plan for the parents of this infant?
2. Jennifer Collins, 13 years old, is admitted to the pediatric floor with a diagnosis of probable acute rheumatic fever.
a. What would the nurse include when performing an initial assessment?
b. What tests would the nurse expect to be done on Jennifer?
The diagnosis of acute rheumatic fever is confirmed.
c. What would the nurse be sure to include in the discharge teaching plan for Jennifer and her family?
Running head: NURSING MANAGEMENT DURING PREGNANCY
NURSING MANAGEMENT DURING PREGNANCY 9
NAME: Adebola Amoo Ross
Beth (age 18) is experiencing her first pregnancy and is now 24 weeks gestation. She tells you that she is “amazed by the changes that have happened to my body already.” Beth wants to understand what additional changes are going to occur to her “besides just getting a really huge belly.” Additionally, Beth relates to you that she is in her senior year of high school, is no longer involved with the baby’s father, and lives at home with her mother and 12-year-old brother. (Learning Objectives 3 and 5).
Definition of the Medical Diagnosis
Pregnancy is a psychosocial phenomenon that is usually characterized by the changes in biological as well as psychosocial adaptations which evolve generally in a healthy manner (Susan, Terri & Susan, 2009). However, some pregnant women may experience some problems or complications due to specific factors or characteristics. These can classify their conditions as high-risk and may negatively affect the mother/child evolution. The detection of this risk calls for the provision of appropriate and quality care by the nurses as well as the healthcare team. The gravid-puerperal period requires a multidisciplinary care because the women require minimal interventions. However, emergencies or life-threatening complications in some situations may occur and thus there is need to identify them effectively. A multi-disciplinary approach consisting of health professionals as well as local administrators is required to ensure that effective actions are performed to ensure that there is a risk-free and quality mother and child assistance (Gaucha, 2016).
The maternal as well as the neonatal morbidity data have been used to improve the technical as well as the scientific knowledge of the nursing practitioners who usually have direct participation during this period and thus ability to create quality strategies. Monitoring pregnant women during prenatal care, or during labor, delivery, or offering assistance to high-risk pregnant women in maternal ICUs are the role of nursing practitioners in obstetrics. This calls for a clinical preparation on the side of nursing practitioners so as to identify the real as well as the potential problems, manage the diagnoses correctly and plan and implement the care (Dennis & Hardy, 2016).
Common Signs and Symptoms
The common signs and symptoms of pregnancy are both physiological as well as psychosocial. Some of the physiological changes are increase in the size of breasts, increased blood circulation in the genitalia area, stretchmarks in the abdomen, absence of menstruation, pelvic pain/discomfort, intermittent nausea, swollen feet and ankles, vomiting, tiredness, weight gain, increased frequency of urination, and possible heartburn/indigestion. The psychosocial changes may include changes in her social life, dramatic body alterations, fear of raising the child alone without a father, and fear of giving birth or fear of pain during delivery (WHO, 2015).
Pregnancy is a normal process in which the pregnant woman would be able to manage the problems and issues with the support of healthcare providers. However, there are some complications that might arise during pregnancy. Some of these complications include high blood pressure, preterm labor, gestational diabetes, preeclampsia, or a loss of pregnancy/miscarriage (ACOG, 2014).
Head to Toe Assessment
General: Steady movement, normal belly size at 24 weeks of pregnancy, impaired verbal communication due to anxiety.
Vital signs: Temperature, 98.6°F; heart rate, 99 bpm, blood pressure, 122/75 mm Hg; respiratory rate, 22 breaths/min
Excess dryness in hair.
Eyes: No eye pain, discharge or itchiness.
Ears: Normal external appearance.
Nose: Dry nasal mucosa with no purulent discharge.
Mouth/Throat: Dry oral mucosa without lesions, no sores or exudate. Healthy gums.
: Normal breast changes. Colostrum can be expressed.
: Clear to auscultation together with no coughs, rales, or rhonchi.
Cardiovascular: No history of syncope, murmur, palpitations or cyanosis.
Gastrointestinal: The client admits experiencing nausea and some instances.
: No vaginal odor, no swelling or redness observed.
: No visible scars, lesions or rashes.
: Fetal movements can be observed. No presence of scars, lesions or rashes.
Fundal height: Present at the upper margin of the umbicus and about three hand breadths from the symphysis pubis.
Abdominal girth: normal increase in abdominal girth. Normal liquor volume.
: The client reports instances of back pain. No history of fractures reported.
: Client is a bit disoriented. Disturbed sleep patterns.
Diagnostic and Lab Studies Expected Outcomes
There are a number of physiological adaptations that develop throughout normal pregnancy. Some of these changes are confirmed through laboratory tests. However, some of the symptoms and tests may be easily be misinterpreted by some healthcare professional, especially those who are not experts or specialized in pregnancy related problems. The hs-cT nI concentration is one of the factors that is used to test pregnancy complications. For instance, higher values of hs-cT nI is an indicative factor of preeclampsia (ACOG, 2014). Furthermore, hyponatremia can occur in preeclampsia which is indicated by low levels of sodium and potassium. Cardiac evaluation to evaluate history of hypertension or cardiac diseases are also done. 3-hr glucose test is also done to screen for diabetes (Cervellin, Comelli , Bonfanti, Numeroso , & Lippi, 2019).
All NANDA Nursing Diagnosis
2. Disturbed sleep pattern related to physical and emotional alterations
3. Anxiety related to labor
4. Imbalanced nutrition
5. Risk of altered breathing related to anxiety
6. Constipation related to pregnancy
7. Impaired urinary elimination related to urinary infection
8. Impaired skin integrity due to edema
3 NANDA Nursing Diagnosis, Goal Interventions and Rationale
1. Nausea is caused by changes in the gastrointestinal and stomach muscles relaxing as well as the pressure on the stomach as a result of the growing weight of the baby in the uterus. This can result from some foods becoming difficult to digest.
· Experience minimal or no nausea
· Reports satisfaction with care
· Assess the nature, frequency and nature of nausea
· Advise on dietary instructions
· Nausea may be caused by visual stimuli and odors thus need to assess on the nature.
· Foods rich in oils and fats as well as some beverages trigger nausea during pregnancy.
2. Disturbed sleep patterns related to physical or emotional alterations
· Ensure there is normal sleep patterns
· Counselling on positive self-image
· Advise on dietary observations.
· Counselling helps in ensuring that there is positive self-image to physical and emotional alterations.
· Beverages such as caffeine have an ability to disturb sleep patterns.
3. Imbalanced nutrition caused by insufficient intake of nutrients to meet metabolic demands
· Patient able to verbalize the understanding of dietary needs.
· Patient to develop a proper dietary plan within financial resources.
· Patient should display appropriate weight gain.
· Determine the patient’s nutritional status, condition of the hair as well as any instances of weight gain.
· Provide information about the patient’s normal weight gains in the course of the pregnancy which are modified to meet the patient’s needs.
· Provide information about the effect of reduced activity as well as bedrest on protein requirements
· Collaborate with a dietician
· Establishing the patient’s nutritional status helps in establishing the guidelines that are essential in determining dietary needs as well as educating the patients.
· The provision of information regarding normal weight gains are essential in determining whether underweight patients need a diet higher in calories. This is due to the fact that the fetus risks ketosis resulting from dieting that leads to obesity.
· The provision of information regarding to bedrest and reduced activity help in determine the protein needs which are reduced due to decreased metabolic activities.
· Collaborating with a dietitian helps in incorporating specific needs and restrictions to the patient.
The patient reports that she is able to have a positive image about pregnancy and towards oneself after counselling. Furthermore, dietary advices resulted to better sleep patterns and balanced nutrition.
American College of Obstetricians and Gynecologists (ACOG). (2014). Preeclampsia and high blood pressure during pregnancy. FAQ034. Retrieved May 31, 2016, from
Cervellin G., Comelli I., Bonfanti L., Numeroso F., & Lippi G. (2019). Emergency diagnostic testing in pregnancy. Journal of laboratory and precision medicine: 5(2). doi: 10.21037/jlpm.2019.10.04
Dennis A. & Hardy L. (2016). Defining a reference range for vital signs in healthy term pregnant women undergoing caesarean section. Sage journals. Doi 10.1177/0310057X1604400619
Gaucha E. (2016). Assessing nursing diagnoses and interventions in labor and high-risk pregnancies. SCIELO journals:37(3)
Susan S., Terri K., & Susan C. (2009). Maternity and Pediatric Nursing, 2nd ed. ISBN: 978-1-60913-747.