00209 Risk Of Alteration Of The Maternal-Fetal Dyad

Domain 8: sexuality
Class 3: reproduction
Diagnostic Code: 00209
Nanda label: risk of alteration of the maternal-fetal dyad
Diagnostic focus: maternal-fetal dyad
Approved 2008 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of alteration of the maternal-fetal dyad is defined as: susceptibility of an alteration of the maternal/fetal symbiotic relationship as a result of comorbidity or conditions related to the pregnancy, which can compromise the health of the fetus.

Risk factors

  • Inadequate prenatal care
  • Inappropriate use of substances
  • Abuse not attended

Associated problems

  • Commitment to fetal oxygen transport
  • Glucose metabolism disorder
  • Complications of pregnancy
  • Therapeutic regime

Suggestions of use

(a) It seems that this diagnosis is defined with greater precision than the risk of attachment of attachment. This label specifies that the deterioration of attachment must be caused by comorbidity conditions or related to pregnancy. The diagnosis that best coincides with the patient’s risk factors, (b) should be chosen as this diagnosis is limited to the prenatal period, the risk of attachment of attachment can be used for the neonatal period and later stages, ((( c) Although it is not entirely clear, it seems that the risk of alteration of the maternal-fetal binomial refers to a risk in the maternal-fetal physical relationship (for example, to premature birth), rather than the psychosocial relationship (as in the case of risk deterioration).

Suggested alternative diagnostics

  • Attachment risk

NOC Results

  • Fetal state: childbirth: degree in which fetal signs are within normal limits from the beginning of labor to birth
  • Maternal status: Before childbirth: Degree in which mother’s well -being is within normal limits from conception to the beginning of labor

( Note : The two previous results are used to evaluate and measure the real incidence of the alteration of the maternal-fetal binomial. Other results may be required, depending on the risk factors present. A continues some of them).

  • Behavior to the suspension of alcohol abuse: personal actions to eliminate alcohol that represents a health risk
  • Behavior to the suspension of smoking: personal actions to eliminate the habit of smoking
  • Behavior to promote prenatal health: personal actions aimed at promoting health in pregnancy and newborn
  • Cardiopulmonary status: blood volume expelled from the ventricles and exchange of carbon and oxygen biopus at alveolar level
  • Blood glucose levels: Degree in which plasma and urine glucose levels remain within normal limits
  • Protection against abuse: protection of itself and/or other people dependent against abuse

Evaluation objectives and criteria

  • It does not experience alteration of the mathemo-fetal binomial, as evidenced by the fetal state: childbirth, and the state of the mother: childbirth
  • It demonstrates a satisfactory fetal state during childbirth, as manifested by the following indicators (specifying 1 to 5: severely, substantially, moderately, slightly or not diverted from normal limits):
    • Color and quantity of amniotic fluid
    • deceleration patterns in the electronic fetal monitor readings
    • Fetal heart rate (120-160 ppm)
    • Variability in the readings of the electronic fetal monitor
  • Fetal growth within normal limits
  • Pregnancy continues to term
  • The mother recognizes the risk factors that could affect pregnancy
  • The mother expresses emotional attachment to the fetus
  • Mother’s vital signs are normal during pregnancy
  • The mother does not present edema, headache, vaginal bleeding, or other symptoms or signs of pregnancy complication
  • NIC Interventions

    • Support for smoking cessation: Help with another person to stop smoking
    • Cardiac care: Limitation of complications resulting from the imbalance between the contribution and the needs of an oxygen supply patient to the myocardium, with symptoms of alteration of cardiac function
    • High risk pregnancy care: identification and management of a high -risk pregnancy to favor healthy results for the mother and the baby
    • Prenatal care: patient surveillance and management during pregnancy to avoid complications and favor a healthy result for both the mother and the baby
    • Risk identification: Analysis of possible risk factors, determination of health risks and prioritization of risk reduction strategies for a person or group
    • Monitoring of vital signs: Collection and analysis of cardiovascular, respiratory and body temperature data, to determine and prevent complications
    • Fetal electronic monitoring: before delivery: electronic assessment of the fetal pulse response to movement, external stimuli or uterine contractions during a prenatal test
    • Cardiac prevention: Prevention of an acute episode of deterioration of heart functioning by reducing myocardial oxygen consumption or the increase in myocardial oxygen supply
    • Protection against abuse: domestic couple: identification of dependent domestic actions and relationships, of high risk, to avoid possible or greater physical, sexual or emotional damage, or the exploitation of a domestic couple
    • Treatment of substance consumption: patient care and care and family members suffering from physical and psychosocial problems related to alcohol or drug use
    • Ultrasonography: Limited Obstetric: Performing ultrasound exams to determine the ovarian, uterine or fetal state
    • Surveillance: Advanced pregnancy: Collection, interpretation and synthesis of maternal-fetal data, continuously and intentionally, for therapeutic purposes, observation or admission

    Nursing Activities

    • Nursing activities for this diagnosis focus on identifying risk factors, and monitoring symptoms of alteration in the maternal-fetal binomial (for example, late deceleration or variable of fetal heart rate).

    Valuations

    • Review in the patient’s records reports of complications in previous pregnancies (such as premature labor, vaginal or urinary tract infections)
    • Review in the patient’s records family history that could affect pregnancy (for example, falciform anemia, Tay-Sachs disease)
    • Determine the quantity and moment of prenatal care and surveillance received
    • Evaluate the presence of comorbid conditions (hypertension, anemia, etc.)
    • Evaluate nutritional status
    • Monitor the presence of severe nausea or vomiting, especially after the first quarter
    • Inquire if the patient has been exposed to teratogens (such as lead, certain medications, illicit drugs, alcohol, etc.)
    • Evaluate exposure to infectious diseases (rubella, clamidia, etc.)
    • Review the laboratory results (hemoglobin, blood type and RH group, serum glucose, platelet count)
    • Support with an analysis to detect genetic disorders (for example, phenylcetonuria)
    • Evaluate the situation at home (for example, security); Verify the existence of abuse
    • Monitor the weight throughout pregnancy
    • Monitor fetal heart rate throughout pregnancy and childbirth work
    • Monitor the presence of premature uterine contractions
    • Evaluate ketones in urine

    Patient and family education

    • Inform about procedures such as amniocentesis, contraction test with stress and ultrasonography
    • Instruct the symptoms that the patient should inform the obstetrician (vaginal bleeding, persistent vomiting, headache, blurred vision and ankles edema)
    • Review medications with the patient and family
    • Teach self -care techniques, such as not loading heavy objects and programming rest periods during the day
    • Explain and demonstrate how to monitor blood glucose levels, as required
    • Comment on the impact that the preexisting problems of the patient could have on pregnancy

    Collaboration activities

    • Help in the treatment of comorbid conditions (for example, heart problems)
    • Channel to a psychological advisory service, if necessary

    Others

    • Develop a trusted therapeutic relationship with the patient and with the family
    • Help develop a nutritious diet plan, if necessary
    • Motivate the intake of at least two liters of liquids without caffeine a day
    • motivate the patient to stop smoking