Nursing diagnosis – RISK FOR DISTURBED MATERNAL–FETAL Dyad

RISK  FOR  DISTURBED  MATERNAL–FETAL

DYAD

DEFINITION

At risk for disruption of the symbiotic maternal–fetal dyad as a

result of comorbid or pregnancy-related conditions

DEFINING CHARACTERISTICS

• Complications of pregnancy (e.g., premature rupture of

membranes, placenta previa or abruption, late prenatal care, multi-
ple gestation)

• Compromised O2 transport (e.g., anemia, cardiac disease, asthma,

hypertension, seizures, premature labor, hemorrhage)

• Impaired glucose metabolism (e.g., diabetes, steroid use)

• Physical abuse

• Substance abuse (e.g., tobacco, alcohol, drugs)

• Treatment-related side effects (e.g., medications, surgery,

chemotherapy)

RELATED FACTORS

• Mental health status

• Cultural background

• Psychosocial issues

• Fetal well-being

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Emotional

• Roles/relationships

EXPECTED OUTCOMES

The patient will

• Be compliant with recommendations for self-care activities to mini-

mize prenatal complications and optimize maternal–fetal health.

• Verbalize fears and uncertainty related to prenatal condition.

• Actively involve significant other/support systems with pregnancy

expectations and plan of care.

• Demonstrate the “maternal tasks of pregnancy” culminating in an

unconditional acceptance of the fetus before delivery.

SUGGESTED NOC OUTCOMES

Prenatal Health Behavior; Knowledge: Pregnancy; Role Performance;

Family Integrity

INTERVENTIONS AND RATIONALES

Determine: At each prenatal visit, assess physical condition,

psychosocial well-being, and cultural beliefs to be able to counsel

and/or refer as needed.

Perform: Encourage support/involvement of significant other(s) dur-

ing course of pregnancy to enhance maternal role adaptation.

Incorporate the cultural beliefs, rites, and rituals of the childbear-

ing family into the plan of care to foster feelings of normalcy with

pregnancy.

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Inform: Educate patient/significant other on role transition and

maternal tasks of pregnancy to provide anticipatory guidance on

expected psychosocial changes.

Teach trimester-specific risks/danger signs and emphasize

importance of self-monitoring to empower the patient and reduce

potential for adverse fetal effects.

Attend: Encourage patient to express disappointment/concerns

related to relationships, physical condition, and fetal well-being to

promote therapeutic communication.

Manage: Refer to community resources as needed (e.g., prenatal

classes, psychological counseling, pastoral care, social services) to

facilitate appropriate role adaptation.

SUGGESTED NIC INTERVENTIONS

Anticipatory Guidance; Childbirth Preparation; Coping

Enhancement; Role Enhancement

References

Olds, S., London, M., Ladewig, P., & Davidson, M. (2008). Maternal–

newborn nursing and women’s health care (8th ed.). Upper Saddle River,
NJ: Prentice-Hall Health.

Ward, S. L., & Hisley, S. M. (2009). Maternal–child nursing care: Optimizing

outcomes for mothers, children, and families. Philadelphia: F.A. Davis Com-
pany.

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