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, NOC and NIC (NNN). You will be completing the blank care plan that
accompanies this scenario.

T. S. is a 30-year-old primigravida 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 placental function. Serial ultrasounds of the fetus 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

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
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”

Sexuality/reproductive: Planned pregnancy after preconception counseling and

achievement of euglycemia prior to conception

Coping/stress tolerance: “I’m scared about labor.”

Self-perception/self-concept: re: concerns about self: “I hope I live long enough to see my baby
grow up.”
 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 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.

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Step 2: Choosing the Nursing Outcomes (NOCs):

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

• 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

• 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.

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

• 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. 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
Provide pain relief for mother
Reinforce caregiver role behaviors.
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
infant transferred to another
hospital.
. Give parent(s) lock of infant’s hair
when shaved for IV.
Instruct parent(s) on signs of
overstimulation.
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.
Encourage parents to massage infant.
Provide assistance in selfcare to
maximize focus on infant.
Assist 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
to infant in another hospital.
Give parent(s) footprint of infant to
orientate to reality of size of
newborn.
Reinforce normal aspects of infant
with a defect.
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.
Reinforce eye contact with infant.
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
responsiveness to parent(s).
Discuss infant behavioral
characteristics with parent(s)

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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
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 Provide atmosphere of acceptance Convey accepting attitude
trust
Establish trusting relationship with Offer to be a listener Offer to be a listener for
parents(s) significant other
spend time with parents to convey spend time with parents to Provide step-by-step verbal support
acceptance contribute to feelings of selfworth in a calm, strong voice
Monitor current family situation Monitor psychosocial status of Monitor effects of newborn o family
family structure
Analyze role adaptations of family Determine strength of intrafamily Identify family interactions system
members bonds
Monitor family’s ability to perform Identify normal family coping Identify coping mechanisms of
tasks appropriate to family mechanisms individual family members
developmental stage
Assist family in identifying support Determine family’s relationship to Assist family in developing new
systems used by the family support systems support network
Offer to be an advocate for the Offer to be an advocate for the Prepare parents(s) for expected role
family child changes involved in becoming a
parent
Prepare parents(s) for Monitor parent’s adaptation to Determine parents’ self-esteem
responsibilities of parenthood parenthood
Reinforce positive parenting Monitor parent’s self-perception as Appraise parent’s perception of self
behaviors a parent as individual
Encourage parents(s) to maintain Provide parent(s) an opportunity to Encourage verbalization of feelings,
individual hobbies or outside express their feelings about perceptions and concerns about
interests parenthood prenatal experience
Discuss the grieving process Explain causes and manifestations of Provide for family and sibling
associated with the loss of “being postpartum depression visitation during postpartum period
pregnant”
Make siblings(s) feel special when Provide toys for siblings in waiting Determine how parent(s) prepared
visiting units room sibling(s) for coming of new baby
Provide information about sibling Encourage family to attend sibling Discuss reaction of sibling(s) to
preparation preparation classes newborn
Determine sibling reaction to Provide family with information Encourage parent(s) to observe
newborn about measures to assist sibling(s) sibling reaction to newborn
to feel important to the family
Give family information on how to Give family information on how to Develop policies that permit
prevent sibling rivalry deal with sibling rivalry presence of family members as much
as desired

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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. Write these 5 on the care plan in the activity section for Coping
Enhancement.
Appraise a patient’s adjustment Appraise the impact of the Encourage patient to identify a
to changes in body image, as patient’s life situation on roles realistic description of change in
indicated. and relationships. role
Appraise the patient’s Use a calm, reassuring approach. Provide an atmosphere of
understanding of the disease acceptance.
process.
Assist the patient in developing an Help patient to identify the Provide factual information
objective appraisal of the event information he/she is most concerning diagnosis, treatment
interested in obtaining. and prognosis.
Provide the patient with realistic Encourage an attitude of realistic Evaluate the patient’s decision-
choices about certain aspects of hope as a way of dealing with making ability.
care. feelings of helplessness.
Seek to understand the patient’s Discourage decision-making when Encourage gradual mastery of the
perspective of a stressful the patient is under severe situation.
situation. stress.
Encourage the patient in Explore the patient’s previous Explore the patient’s reasons for
developing relationships. achievements of success. self-criticism.
Foster constructive outlets for Arrange situations that encourage Assist patient in identifying
anger and hostility. patient’s autonomy positive responses from others.
Encourage the identification of Explore the patient’s previous Introduce patient to persons (or
specific life values. methods of dealing with life groups) who have successfully
problems. undergone the same experience.
Instruct the patient on the use of Support the use of appropriate Encourage verbalization of
relaxation techniques, as needed defense mechanisms feelings, perceptions, fears.
Encourage the patient to identify Assist the patient in identifying Assist the patient in examining
own strengths and abilities appropriate short and long-term available resources to meet the
goals goals
Appraise the patient’s Assist the patient to identify Encourage family involvement, as
need/desire for social support available support systems appropriate
Assist the patient to grieve & work through the losses of chronic
illness &/or disability, if appropriate

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NOC: Coping
NIC: Crisis Intervention
The following activities are part of the NIC: Crisis Intervention. Review the activities listed
below and select 5 that are appropriate to the situation and address the indicators identified
for the NOC: Coping. Write these 5 on the care plan in the activity section for
Crisis Intervention
Provide atmosphere of support Determine whether patient Initiate necessary precautions to
presents safety risk to self or safeguard the patient or others
others at risk for physical harm
Encourage expression of feelings Assist in identification of the Assist in identification of
in a nondestructive manner precipitants and dynamics of the past/present coping skill and
crisis their effectiveness
Assist in identification of Assist in development of new Assist in identification of
personal strengths and abilities coping and problem solving skill available support systems provide
that can be used in resoling the guidance about how to develop
crisis and maintain support system(s)
Introduce patient o persons (or Assist in identification of Assist in evaluation of the
groups)who have successfully alternative course of action to possible consequences of the
undergone the same experience resolve the crisis various course of action
Assist patient to decide on a Assist in formulating a time Evaluate with patient whether
particular course of action frame for implementation of crisis has been resolved by
chosen course of action 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
vocabularies of NANDA, NOC and NIC.

1. If you wish to received CE for this educational activity, please complete the evaluation form
and return along with $10 to:
Carol Williams, MS, RN, C
Educational Services for Nursing
University of Michigan Health System
300 North Ingalls , 6B12
Ann Arbor, Michigan 48109-0436
2. If you are working with a coordinator please give your quiz, evaluation and completed
nursing care plan to your coordinator.