PIWIT, Leslie RAMOS, Alexis

RUBIO, Marissa SIMON, Joanna

SOTERO, Jannah VENTURA, Dania
WAGAWAG, Aldrin

defensive resources, which may

compromise health.

Ineffective Individual Coping: Inability to

- Women without adequate support form a valid appraisal of the stressors,
can have an experience so frightening inadequate choices of practiced
and stressful they can develop a responses, and/or inability to use
posttraumatic stress syndrome (Tam & available resources.
Chung, 2007).
Risk factors
Problems with the Psyche Factors
Alteration of muscle tone/contractile
1) Inability to bear down properly – A pattern.
pregnant mother whose psychosocial
Maternal fatigue.
ability has significantly changed due to
shocking and depressing experiences Mechanical obstruction to fetal
which has the propensity to diminish descent.
the quality of care she could give to
herself and her unborn baby Nursing Management

2) Fear/Anxiety – is a feeling induced by Optimize uterine activity. Monitor uterine

perceived danger; a mental shackle contractions for dysfunctional patterns;
that a pregnant mother may feel due to use palpation and an electronic monitor.
past experiences, or the fear of being Prevent unnecessary fatigue. Check the
not enough (as a caregiver), the fear client’s level of fatigue and ability to
of not having enough means to provide cope with pain.
her needs as well as the child’s;
fear of being alone. Prevent complications of labor for the
client and infant.
INABILITY TO BEAR DOWN
Assess urinary bladder; catheterize as
Possible diagnoses: Risk for Injury: needed.
Vulnerable for injury as a result of
Assess maternal vital signs, including
environmental conditions interacting
temperature, pulse, respiratory rates,
with the individual’s adaptive and
and blood pressure.
PIWIT, Leslie RAMOS, Alexis
RUBIO, Marissa SIMON, Joanna
SOTERO, Jannah VENTURA, Dania
WAGAWAG, Aldrin

Check maternal urine for acetone (an 12. Difficulty falling or staying asleep
indication of dehydration and 13. Decreased self-esteem
exhaustion).

Assess condition of fetus by monitoring DIAGNOSTIC/LAB TEST

FHR, fetal activity, and color of amniotic
fluid. - see psychiatrist for treatment
- Hamilton Rating Scale for Depression
Provide physical and emotional support. (Ham-D)- The scale is widely available
and has two common versions with
Promote relaxation through bathing and
either 17 or 21 items and is scored
keeping the client and bed clean, back
between 0 and 4 points. The first 17
rubs, frequent position changes
items measure the severity of depressive
(sidelying), walking (if indicated), and by
symptoms and as examples the
keeping the environment quiet.
interviewer rates the level of agitation
Coach the client in breathing and clinically noted during the interview or
relaxation techniques. how the mood is impacting on an
individual’s work or leisure pursuits. The
Provide client and family education.
extra four items on the extended 21-
Medical Managements: point scale measure factors that might
be related to depression, but are not
Narcotic or sedative, such as morphine,
thought to be measures of severity, such
pentobarbital (Nembutal), or as paranoia or obsessional and
secobarbital (Seconal), for sleep
compulsive symptoms. Scoring is based
ANXIETY/FEAR on the 17-item scale and scores of 0–7
are considered as being normal, 8–16
SIGNS AND SYMPTOMS suggest mild depression, 17–23
moderate depression and scores over
1. Anger
24 are indicative of severe depression
2. Poor impulse control
[3]; the maximum score being 52 on the
3. Emotional detachment or numbness
17-point scale
4. Hyper alertness, hyperarousal, and
- Ultrasonography
exaggerated startle reflex
5. Social withdrawal
NURSING DIAGNOSES
6. Self-destructive behavior
7. Survivor’s guilt 1. Anxiety related to fear of death and
8. Relationship problems change in health status as evidenced
9. Avoidance of people, places, and by verbal expression of worry
things associated with the traumatic (Domain: Perception/cognition)
experience 2. Hopelessness secondary to rape
10. Depersonalization (sense of loss of (Domain: Self-perception)
identity as a person) 3. Risk for compromised human dignity
11. Relationship problems (Domain: Self – perception)
PIWIT, Leslie RAMOS, Alexis
RUBIO, Marissa SIMON, Joanna
SOTERO, Jannah VENTURA, Dania
WAGAWAG, Aldrin

4. Social isolation related to shame, 9. Encourage client to accept

secondary to rape trauma (Domain: forgiveness from self and others.
Coping/ Stress Tolerance)
10. Emphasize with the client the
5. Rape- trauma syndrome (Domain:
importance of strict adherence to
Coping/ Stress Tolerance)
medications.

NURSING MANAGEMENT 11. Refer client to other sources of

support such as community
(Fear/Anxiety)
organizations and support groups.
1. Establish rapport with client to gain
12. Encourage client to express
trust. It is important that the nurse should
emotions verbally rather than physically.
accept client’s current level of
functioning. She should also be
consistent, positive, and honest as
well as adapt a nonjudgmental attitude
Medical Management
when working with the client.
2. Provide time and opportunity for - Antidepressants – nortriptyline,
client to express feelings. It is essential desipramine
that nurse should detect an ongoing - Psychotherapy- may be beneficial in
grieving process and help client to find women who prefer to avoid
conclusion. antidepressant medication.
3. To manage outbursts of anger, assist - Pain Management
client to identify sources of emotions. - Low-dose antipsychotic agents –
Assist client in regaining control. Haloperidol
Treatment
4. Assist client in using displacement
whenever emotional by providing things
Position and Posture
she can manipulate or destroy
• Can decrease pain/ increase comfort
such as clay.
• Facilitate gravity
5. After every outburst, discuss with the • Change pelvic diameters
client how fear or anxiety escalates. • Help in cardinal movements
6. Desensitize client to memories of • Facilitate descent
traumatic event.
Trust
7. Administer prescribed medications as
needed. Evaluate his responses to the 1. Recognizing the client’s
medications and if client is taking and feelings.
not hoarding them. 2. Honesty
8. Remind patient that setbacks on the 3. Respect for the client
process of treatment are not failures but 4. Non-judgmental attitude
an expected part of the therapy.
PIWIT, Leslie RAMOS, Alexis
RUBIO, Marissa SIMON, Joanna
SOTERO, Jannah VENTURA, Dania
WAGAWAG, Aldrin

Emphasize Positive Results

- Do not argue with the client.
- Recognize that the client is
experiencing pain but do not dwell on
that pain.

Medication prescribed by the

Physicians:
- Use of Buspirone (Buspar) which is
pregnancy safe is an appropriate
alternative medication option.
Cognitive behavioral therapy should be
considered as an alternate treatment
option
- use of haloperidol (Haldol) is preferred
during pregnancy as extensive data
suggests it is not associated with any
congenital malformations with first
trimester exposure.
- Tricyclic antidepressants (TCAs) and
selective serotonin reuptake inhibitor
(SSRI) fluoxetine (Prozac) have been
shown to be relatively safe for use during
pregnancy

REFERENCES:

M. Belleza. (2017). Postpartum Depression.

Retrieved February 15, 2021, fromL
https://nurseslabs.com/postpartum-
depression/
Pillitteri, A. (2010). Maternal and Child Health
Nursing Care of the Childbearing and
Childrearing Family (6th Edition).
Lippincott Williams & Wilkins. pp. 693-696
Caliva, K. (2017). Problems with the Psyche
Factors. Retrieved from https://prezi.com/mg-
6wf81o3i2/problems-with-the-psyche-
factors/?fbclid=IwAR0zAh4HbeDIC6dsY-
Bpw2f9ei92_kYCyiwy_S1896bPBU3ivKd2g
S8KEHU