NCP Prenatal Substance Dependence/Abuse

This disorder is a continuum of phases incorporating a cluster of cognitive, behavioral, and physiological symptoms that include loss of control over use of the substance and continued use of the substance, despite adverse maternal/fetal consequences (e.g., poor nutrition/weight gain, anemia, predisposition to infection, PIH, fetal defects/IUGR, fetal alcohol syndrome [FAS]). The drugs most often abused are alcohol, cocaine (crack), heroin, methamphetamine, barbiturates, marijuana, and phencyclidine (PCP). Care depends on the degree of abuse and whether the client is intoxicated or is in the withdrawal phase. The client who is addicted may not seek care during the prenatal period, compounding any existing or developing problems. In addition, negative attitudes on the part of society and often from caregivers affect the pregnant woman and her care.
A return to health consists of gaining a mastery and control over self and environment, and pleasure seeking that does not require the use of drugs.
(This plan of care is to be used in conjunction with the CP: The High-Risk Pregnancy.)

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Lack of energy/fatigue, malaise
Incoordination, unsteady gait
Sleeplessness/insomnia; hyperactivity
Yawning (beyond first trimester)

Circulation

Systemic hypertension; orthostatic hypotension
Tachycardia, palpitations
Ventricular arrhythmias
History of endocarditis, sudden coronary artery spasm, myocardial infarction (rare)

Ego Integrity

Pregnancy usually not planned
May express indecision about pregnancy (i.e., issues of abortion, adoption), concern regarding involvement of social/legal agencies
Labile mood, irritability, lack of motivation, denial of problem
Low self-esteem; feelings of guilt regarding substance use, or grandiose behavior
Presence of stressors (financial, changes in lifestyle)
Increased dependency needs
Inadequate coping skills/support systems

Elimination

Diarrhea or constipation
Burning on urination; frequency, hesitancy, lower abdominal or back pain (UTI)

Food/Fluid

Appetite changes, anorexia, nausea, vomiting
Inadequate nutritional/fluid intake
Low weight gain
Pathological edema

Hygiene
P
oor oral/body hygiene

Neurosensory

Dizziness
Slurred speech
Hyperactivity; tremors of hands, tongue, eyelids
Pupillary dilation or constriction, nystagmus, diplopia
Decreased attention span, impaired memory
Irritability, depression, confusion, hallucinations, delirium, coma
History of seizure activity

Pain/Discomfort

Low threshold for pain or decreased response to pain
Muscle pain, headache
Early uterine contractions
Pain on urination, vaginal itching

Respiration

Nasal sinus drainage, inflamed mucosa, nosebleeds, septal defect
Tachypnea
Frequent sore throats
Cigarette smoker/exposure to secondhand smoke
History of recurrent pneumonia
Gray mucus expectorated (signs of heavy “crack” cocaine smoking)

Safety

Hyperthermia, diaphoresis
Evidence of needle tracks on extremities
Presence of cellulitis, superficial abscesses, septic phlebitis
History or evidence of traumatic injuries; physical/emotional abuse
Inadequate maintenance of home environment
History of jaundice
Positive screen for hepatitis, STD, or HIV
Previous obstetric problems (e.g., PIH, abruptio placentae, premature rupture of membranes)
Fetal hyperactivity, bradycardia; or decreased fetal movement

Sexuality

Decreased libido
History of multiple sexual partners
Fundal height inappropriate for length of gestation
Vaginal spotting/bleeding; increased vaginal discharge
GPTPAL may reveal spontaneous abortion, premature birth/fetal death, meconium staining, LBW infant, fetal withdrawal/alcohol syndrome, infant death/sudden infant death syndrome (SIDS)

Social Interactions

Lack of support systems; self-imposed/forced isolation
Loss of job; financial problems
Relationship/family discord (manipulative behavior)

Teaching/Learning

Use of alcohol, prescription, OTC, and/or illicit drugs
Difficulty maintaining self drug-free; ineffective recovery attempts; drug hunger
Absence of/limited prenatal care or preparation
Lack of cooperation with therapeutic regimen

DIAGNOSTIC STUDIES

Toxicology Screen: Identifies drug(s) used and current status.
Various Blood Studies (e.g., Complete Blood Count with Differential [CBCD], Serum Glucose, Electrolytes): Determines presence of anemia and nutritional status.
Liver Studies: Detect presence and degree of involvement/damage.
Ultrasonography: Locates placental implantation; assesses fetal size in relation to length of gestation.
Chest X-Ray: Reveals presence of pneumonia, foreign body, emboli, or pulmonary edema.
Screening Tests/Cultures: Determine presence of infectious diseases.
Addiction Severity Index: Produces a “problem severity profile” of the client, including chemical, medical, psychological, legal, family/social, and employment/support aspects, indicating areas of treatment needs.

NURSING PRIORITIES

1. Promote physiological stability and well-being of client and fetus.
2. Support client’s acceptance of reality of situation.
3. Facilitate learning of new ways to reduce anxiety; strengthen individual coping skills.
4. Incorporate client into supportive community environment.
5. Promote family involvement in treatment process.
6. Provide information about condition, prognosis, and treatment needs.

DISCHARGE GOALS

1. Free of injury/complications to self and fetus/newborn.
2. Engaged in treatment modalities by identifying and using support systems.
3. Responsibility for own life and behavior assumed.
4. Abstinence from drug(s) maintained on a day-to-day basis.
5. Dependence condition and its impact on pregnancy, prognosis, and therapeutic regimen verbalized.
6. Participation in follow-up care by making and keeping all appointments, managing therapeutic regimen.