SAINT MARY’S UNIVERSITY

Bayombong, Nueva Vizcaya

SCHOOL OF HEALTH AND NATURAGL SCIENCES

NURSING DEPARTMENT

COURSE NO: Nursing Care Management 107

SUBJECT: Care of Mother, Child and Adolescent (well Client)
YEAR LEVEL: BSN 2
UNITS: 4
UNIT 3: MODULE 6
NURSING CARE RELATED TO PSYCHOLOGICAL
AND PHYSIOLOGIC CHANGES OF PREGNANCY

I. Introduction
This chapter discusses the common psychological and physiological changes that
occur during pregnancy. It focuses on the assessment of the woman’s overall health
status and the care plan appropriate during the course of pregnancy.

II. Learning Objectives:

At the end of the discussions, the students will be able to:
1. Describe the common psychological and physiological changes that occur
during pregnancy
2. Assess a woman for psychological adjustment and physiologic changes that
occur during pregnancy
3. Formulate nursing diagnoses and identify expected outcomes in relation to a
family’s psychological and physiological adaption to pregnancy
4. Plan, implement and evaluate the effectiveness of care being rendered

III. Core Content of the Chapter

PSYCHOLOGICAL CHANGES DURING PREGNANCY

Psychological changes of pregnancy occur as a response not only to the physiologic alteration
but also to the increase responsibility associated with welcoming a new member in the family.

How a woman adjust to pregnancy depends on the psychological aspect and the environment she was
raised to.
Influences to psychological adaptation
1. Social Influences- During the 19th century, pregnancy was viewed as a 9-month long illness. At
the time of birth, the pregnant woman is separated from her family and hospitalized alone. Today,
it is viewed as a healthy span best shared with the partner and the family members.
2. Cultural Influences- Woman’s cultural background, including her beliefs and practices may
influence the role she wants to take during pregnancy and during the childrearing stage.
 3. Family influences- The family in which the woman was raised can be influential to her beliefs
about pregnancy. If the woman was loved in the family, it more likely that she will develop
positive attitude about pregnancy.
4. Individual/ personal differences- The past experiences could be and influence on how a woman
perceive pregnancy. The ability to cope and adapt to stress differs from one person to the other.

PSYCHOLOGICAL ADAPTATIONS OF PREGNANCY

First trimester: Acceptance of Pregnancy
-The woman and her partner spend time recovering from the surprise of learning about the
pregnancy.
- “I am pregnant.”
-The first task that a woman is about to face is to become a mother.
-Pregnancy confirmation may leave some couples with disbelief, shock or amazement
-Most couple experience some degree of ambivalence
Second trimester: Acceptance of the Baby
- “I am going to have a baby.”
-Woman becomes preoccupied with fantasies about her unborn child.
-Quickening by 20 weeks helps the woman realize that there is a separate individual to care for
-Woman and partner begin active preparations for baby
-Partner may feel left out with all the information focused on the woman and fetus
Third trimester: Preparation for Parenthood
“I am going to be a mother.”
Couple work on preparing to become parents
Couple demonstrate “nesting” behaviors
Couple may attend childbirth education classes
Review their relationships with parents and fantasizes about being a parent

PSYCHOLOGICAL RESPONSES TO PREGNANCY

AMBIVALENCE - Discomforts of pregnancy cause mixed feelings of fear

-Woman may desire to be pregnant but may not enjoy the experience
GRIEF -Occurs as a result of changes in women’s role as a wife and a mother.
NARCISSISM -Woman focuses on self and changing body
-Spends more time of self-care activities (to protect body and fetus)
INTROVERSION OR EXTROVERSION
-Woman turns inward to focus on self or become more outgoing
STRESS REACTION - To some pregnancy can be a time of stress. Adequate support systems can help
to alleviate some of this stress
EMOTIONAL LABILITY - Mood changes can be influenced by hormones. Avoiding fatigue and
reducing stress can help. This maybe the result of introversion and narcissism
COUVADE SYNDROME- Partner identifies with the woman’s pregnancy. May experience discomforts
such as nausea, vomiting, fatigue and weight gain. This is however, temporary
and rarely problematic
CHANGES IN SEXUAL DESIRE
1st trimester- libido decreases
2nd trimester- libido and sexual excitement rise markedly
3rd trimester – libido is high\
CHANGES IN THE EXPECTANT FAMILY- older children should be prepared
 SIGNS & SYMPTOMS OF PREGNANCY
I. Presumptive Signs- least indicative, subjective, cannot be documented by the examiner
1. Nausea and vomiting
2. Melasma, chloasma
3. Amenorrhea
4. Breast changes
5. Uterine enlargement
6. Urinary frequency
7. Linea Nigra Melasma Striae Gravidarum Linea Nigra

8. Striae Gravidarum
9. Quickening
10. Fatigue

II. Probable Findings- can be documented by the examiner

More reliable than the presumptive sign
1. Serum laboratory test
2. Chadwick’s sign
3. Goodle’s sign
4. Hegar’s sign
5. Sonographic evidence of gestational sac
6. Ballotement
7. Braxton Hicks sign
8. Fetal outline felt by the examiner

III. Positive Findings- indicates positive pregnancy

1. Sonographic evidence of fetal outline
2. Audible fetal heart tone
3. Fetal movement felt by the examiner

PHYSIOLOGIC SIGNS OF PREGNANCY

Uterus
-At the end of pregnancy, uterus is large, thin-walled organ, weighing 1,000 g.
-Can hold 3,175 g of fetus plus 1000 ml of amniotic fluid= 4000 g
-Braxton-Hicks contractions -Irregular painless uterine contractions at the 12 th week of
pregnancy.
-Hegar’s sign- softening of the uterine isthmus about the 6th week.
- 12th week – can be palpated to assess the uterine growth
- 16th -20th week- Ballottement can be assessed
20th-24th week- can trace fetal outline
Cervix
-Increase in cell numbers due to estrogen
-Secretes a thick, sticky mucus that forms a plug in the cervix (operculum).
-Goodell’s sign- softening of the cervix.
-Chadwick’s sign- purplish-blue color of the cervix and vagina due to an increased vascularity
noted at 8 weeks.
-Ph level- 4-5 (lactobacillus acidophilus)
Ovaries
Follicles stops to mature so ovulation does not occur
Corpus luteum produces progesterone and estrogen for about 12 weeks.

Chadwick’s sign
Vagina
-Increase in vaginal secretions called leukorrhea
-Increased levels of glycogen in cells and may enhance growth of organisms such as
Trichomonas vaginalis or Candida albicans.
-Increase in vascularity change in violet color (Chadwick’s sign)
-pH of vagina changes from the normally acidic to alkaline (due to increased levels of estrogen).

WAYS TO COPE WITH LEUKORRHEA

 Encourage the woman to bathe daily and avoid using soap on the vulvar area
 Reinforce the need to wipe from front to back.
 Urge her to wear loose, absorbent cotton underwear and to avoid tight pants and panty hose
Breast
-The breast starts to enlargement and increase in vascularity
-Nipples erect, areolas darken, Montgomery’s tubercles enlarge
-At 16th week- COLOSTRUM can be expelled from the nipple

WAYS TO COPE WITH BREAST CHANGES

1.Wear a well-fitting bra with a wide shoulder strap. Darkened Areola
2. Maintain a good posture
3. Wash breast and nipple area with water only.

CARDIOVASCULAR CHANGES
-Cardiac output increases up to 25-50%
-Heart rate at 80-90 beats per min
-Blood Volume increases to 5250 ml Montgomery’s Tubercle

-RBC 4.65million
-Leucocytes elevates to 25,000-30,000mm
-BP: Decreases during the 2nd trimester, rises to pre pregnancy level during the 3rd trimester
-Iron- needs increases to 800ug daily
-Folic acid- 400g
-Peripheral blood flow-blood returns to the lower extremities
-Supine hypotension syndrome occurs because lying position compresses the vena cava and
blood returning to heart decreases
- There is an increase in blood clotting factors.
HEART
-Heart displaced to the left and upward
-Slight cardiac enlargement by 10% due to increased blood volume
-Palpitations occurs
-CO increased when in left lateral position

Consequences of Increased Total Cardiac Blood Volume

 Easy fatigability and shortness of breath
 Slight hypertrophy of heart causing it to be displaced to the left
 Systolic murmurs are common due to lowered blood viscosity
 Nosebleeds may occur because of marked congestion of the nasopharynx
Ways to fight fatigue
 Have frequent rest periods
 Obtain rest during the day.
 Eat a balanced diet and take iron supplements
 Engage in moderate regular exercise
Pregnant women should not be massaged since blood clots can be released and cause thromboembolism
(increased in clotting factors, venous stasis and vessel wall injury).

Ways to avoid ankle edema

 Lie on the left side in bed to enhance glomerular filtration rate of the kidneys
 Avoid wearing tight, constrictive clothing.
 Elevate legs during rest periods.
 Dorsiflex the feet when standing or sitting for prolonged periods.
 Get up and move about every 1 to 2 hours when sitting for long periods

GASTROINTESTINAL SYSTEM CHANGES

NAUSEA AND VOMITING

-morning sickness occurs on the first trimester
Causes:
a) Increased HCG levels
b) Increased estrogen and progesterone levels
c) Decreased maternal glucose levels as glucose is utilized by fetus

Hyperemesis gravidarum- excessive vomiting in pregnancy persisting beyond 3 months.

Reduce gastric acidity

PICA- Abnormal cravings

PATIENT TEACHING TO PREVENT MORNING SICKNESS

1. Instruct patients to avoid greasy; highly seasoned foods
2. Encourage her to eat small, frequent feedings
3. Advise her to eat dry toast or crackers before getting out of bed in the morning.
4. Instruct her to get out of bed slowly; avoid sudden movements.
5. Suggest to eat foods high in protein, such as eggs, cheese, nuts, and meats as well as fruits and
fruit juices.
6. Drink soups and other liquids between, instead of with, meals.

CONSTIPATION AND FLATULENCE

-Due to the displacement of the stomach and intestines, thus slowing peristalsis and gastric
emptying time
-It can also be caused by increased progesterone (sluggish peristalsis) and due to intake of oral
iron as supplements

WAYS TO AVOID CONSTIPATION

a) Increase fluid intake and roughage in the diet
b) Establish regular elimination time
c) Adequate exercises
d) Avoid enemas
e) Avoid harsh laxatives
f) Do not take mineral oil

HEMORRHOIDS
Causes: Pressure on the pelvic veins by the enlarging uterus and increased pressure secondary to
constipation
WAYS TO AVOID HEMORRHOIDS
1. Avoid prolonged standing.
2. Lie on left side with feet slightly elevated.
3. Avoid constrictive clothing

HEARTBURN - Due to relaxation of esophageal sphincter caused by high levels of progesterone

WAYS TO AVOID HEARTBURN
a) Avoid fried, fatty foods and chocolate.
b) Acidic foods such as tomato products, citrus fruits, spicy foods and coffee must be eliminated
from the diet.
c) Eat smaller meals.
d) Refrain from eating for 3 hours before bedtime, and stay upright for 2 hours after meals.
e) Avoid tight clothing and avoid bending
CHANGES IN THE ORAL CAVITY
(due to high estrogen levels)
Ptyalism – increased salivation
Gums usually become soft and edematous and may bleed with brushing; tooth decay

CHANGES IN APPETITE
Increase in appetite to compensate for the growing needs of the fetus.
Pica describes dietary cravings or aversions for non-nutritional substances.
Ex: clay, starch, coal, soap, toothpaste, ice and newspaper.

RESPIRATORY SYSTEM CHANGES

Top 3 Respiratory Changes During Pregnancy
1. Increased tidal volume
2. Upward displacement of diaphragm- causes shortness of breath and chest crowding
3. Slight hyperventilation- causes congestion or stuffiness of the nasopharynx

URINARY SYSTEM CHANGES

1.Increased urinary output/ urinary frequency

Causes:
-Uterus exerts pressure on the bladder as it enlarges (First trimester)
-relieved in the second trimester by the uterus moving into the abdominal area
-Pressures of the presenting part on the bladder after lightening (third trimester)
-Increased blood flow to the kidney which increases glomerular filtration rate, thus urinary output
increases
WAYS TO BEAT URINARY URGENCY AND FREQUENCY
1. Decrease fluid intake in the evening.
2. Limit intake of caffeinated beverages
3. Promptly respond to the urge to void.
4. Perform Kegel’s exercises
2. Glycosuria - Glucose spills in urine
3. Increased in glomerular filtration without an increase in tubular re-absorptive capacity
4. Increased aldosterone production resulting in sodium and water retention
5. Dilated ureters and renal pelvis due to progesterone and pressure from enlarging uterus
6. Nocturia- increase urination at night
INTEGUMENTARY SYSTEM CHANGES
1. Increased melanin production. Anterior pituitary gland produces more melanotropin stimulating
hormone
a) Chloasma (mask of pregnancy)
An increase in pigmentation on the forehead and around the eyes
Aggravated by sun exposure
Due to increase production of melanocytes
b). Striae gravidarum or stretch marks
Appear as reddish streaks on trunk and thighs. These generally change to a shiny gray-white color
after delivery. They do not disappear.
c). Linea nigra- Brown line running from umbilicus to symphysis pubis.

2. Estrogen effects
Palmar erythema – redness and itching of the hands
Vascular spider nevi- prominent capillaries under the skin
Activation of sweat gland and sebaceous gland
Palmar Erythema
MUCULOSKELETAL CHANGES
1. Relaxation of the pelvic joints results in the classic “waddling” gait seen in pregnancy
2. Physiologic lordosis (“pride of pregnancy”)
Curvature of the lumbar spine increases to compensate for the weight of the gravid uterus.
Results in low back pain
WAYS TO BEAT BACKACHES
1. Use proper body mechanics.
2. Maintain a good posture.
3. Wear low-to-mid heel shoes.
4. Walk with pelvis tilted forward.
5. Use a board under the mattress to add firmness.
6. Perform pelvic or tilting exercises.

3.Leg cramps
Causes: increase pressure of gravid uterus on lower extremities
Poor circulation
Fatigue
Low calcium, high phosphorus intake
Management:
Dorsiflex the foot

WAYS TO RELIEVE LEG CRAMPS

1. Frequent rest periods with feet elevated
2. Wear warm, more comfortable clothing
3. Increase calcium intake
4. Do not massage- blood clots can cause embolism.
5. Most effective relief is press knee of the affected extremity and dorsiflex the foot.

ENDOCRINE SYSTEM CHANGES

1.Increased basal metabolic rate
Average weight gain is 3 to 5 pounds in the first trimester and 12 to 15 pounds in each of the following
trimester.
Increase in total weight is 22-25 lbs
Water retention occurs during pregnancy due to increased sex hormones and decreased serum protein.
2. Increased production of prolactin
3. Increased estrogen levels
4. Increased cortisol levels

Distribution of weight gain during pregnancy

Fetus 7 lbs
Placenta 1 lb
AF 1.5 lbs
Increased weight of uterus 2 lbs
Increased blood volume 1 lb
Increased weight of the breasts 1.5-3 lbs
Weight of additional fluid 2 lbs
Fat and fluid accumulation 4-6 lbs

DANGER SIGNS DURING PREGNANCY

Vaginal bleeding (Any type)
Chest pain
Sudden gush of fluid from the vagina
Gestational Hypertension
Rapid weight gain ( 2lbs/week in 2nd tri)
Severe, continuous headache
Swelling of face, hands, legs, feet when arising in morning
Visual disturbances: blurring, double vision, flashes of light, spots before eyes
Dizziness
Fever over 100oF (37.8oF) and chills
Pain in the abdomen or cramping
Epigastric pain
Irritating vaginal discharge
Uterine contraction before 37 weeks
Noticeable reduction or absence of fetal movements

Nursing Diagnoses
1. Altered breathing patterns related to respiratory system changes of pregnancy
2. Disturbed body image related to weight gain from pregnancy
3. Deficient knowledge related to normal changes of pregnancy
4. Imbalanced nutrition, less than body requirements, related to early morning nausea
5. Powerlessness related to unintended pregnancy
6. Possible impaired health and prenatal care behaviors associated with cultural beliefs

Reference:

Pilliteri, A. & Silbert-Flagg, J. (2018). Maternal and child health nursing 8th edition. Philadelphia:
Wolters Kluwer.