Prenatal substance dependence involves phase of group of behavioral, cognitive, and physiological symptoms such as inability to control over drug abuse and repetitive use of the substance inspite of adverse maternal and fetal effects. These consequences include poor nutrition/weight gain, anemia, predisposition to infection, pregnancy induced hypertension, low birth weight, intrauterine growth restriction, fetal alcohol syndrome (FAS). The drugs most commonly abused are nicotine, alcohol, marijuana, heroin, phencyclidine (PCP), opiates, cocaine, and methamphetamine. Treatment depends on the degree of abuse and whether the client is addicted or is in the withdrawal phase. The client who is intoxicated 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.

Nursing Care Plans

Nursing care plan goals for a pregnant client experiencing substance abuse may include promoting physiological stability and well-being of mother and fetus, supporting client’s acceptance of reality of situation, facilitating learning of new ways to decrease anxiety, strengthening individual coping skills, incorporating client into supportive community environment, promoting family involvement in treatment process and providing information about condition, prognosis, and treatment needs.

Here are six (6) nursing care plans (NCP) and nursing diagnosis for prenatal substance dependence/abuse:

Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.

May be related to

  • Inadequate dietary consumption in fulfilling metabolic needs for physiological, psychological, or economic purposes

Possibly evidenced by

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  • Decreased subcutaneous fat/muscle mass
  • Lack of appetite and loss of interest in food
  • Below maternal Prepregnant weight
  • Protein and vitamin deficiencies
  • Reported altered taste sensation
  • Sore, inflamed buccal cavity
  • Weak muscle tone

Desired Outcomes

  • Client will verbalize understanding of effects of substance dependence and insufficient dietary intake on the nutritional status and pregnancy.
  • Client will demonstrate behaviors and lifestyle changes to regain/maintain an appropriate weight for pregnancy.
  • Client will demonstrate progressive weight gain toward goal, with normalization of laboratory values and absence of signs of malnutrition
Nursing InterventionsRationale
Assess condition of the oral cavity. Note and record age, height/weight, body build, strength, and activity/rest pattern.Guides the formation of the dietary plan.  The condition of mucous membranes and teeth may be affected by the type of food intake.
Determine anthropometric measurements such as BMI, waist-to-hip ratio, skin-fold test and bioelectrical impedance.Measures subcutaneous fat and muscle mass to help in planning dietary needs.
Note total daily calorie intake. Encourage client to keep a journal of intake, frequency, and patterns of eating.Information about client’s dietary pattern will determine nutritional strengths, needs, and insufficiencies.
Review and discuss prenatal nutritional needs and develop a dietary plan. Assist with developing a grocery budget and provide an opportunity to select food items to meet dietary plan.Facilitate involvement in the plan and resolves nutritional deficiencies.
Assess energy expenditure (such as pregnancy needs, pacing or sedentary activities) and set an individualized exercise program.Pregnant state and activity level affect nutritional needs. Exercise improves muscle tone, may promote appetite and raises sense of well-being.
Note and record client’s weight weekly.Provides information regarding current status or effectiveness of dietary plan
Collaborate with a dietitian.Helps in establishing individual dietary needs. Provides an additional resource for learning about the importance of nutrition in nonpregnant and pregnant states.
Review laboratory studies as indicated such as glucose, serum albumin, and electrolytes.May reveal electrolyte imbalances, anemia and other abnormalities that may be present, requiring specific therapy.
Assist client in consultation with a dentist as necessary.Healthy teeth are important in having a good nutritional intake, and dental hygiene is often overlooked in this population

Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

  • Lack/misinterpretation of information
  • Lack of recall
  • Cognitive limitations/interference with learning

Possibly evidenced by

  • Statements of concern
  • Questions/misconceptions
  • Inaccurate follow-through of instructions
  • Development of preventable complications
  • Continued use in spite of complications/bad trip

Desired Outcomes

  • Client will verbalize understanding of own diagnosis, prognosis, and management plan.
  • Client will identify/initiate necessary lifestyle changes to remain drug-free with optimal pregnancy outcome.
  • Client will participate in the treatment program.
  • Client will recognize health problems as they arise and initiate steps to resolve.
Nursing InterventionsRationale
Assess client’s knowledge of own condition (pregnancy, complications, and lifestyle changes).Assists in planning for long-range changes necessary for maintaining drug-free status. Client may have street knowledge of the drug but unfamiliar of medical facts and reltionship to pregnancy.
Assess the level of anxiety of client and significant others.Anxiety can be a hindrance in obtaining and processing information.
Encourage regular physical examination, including vaginal culture to detect the presence of STD.Vaginal cultures can identify the presence of microorganisms that can be potentially dangerous to the fetus or newborn such as group B streptococcus (GBS), chlamydia, syphilis, and gonorrhea.
Review sonogram results of the client.Assesses fetal growth and development to reveal possibility of intrauterine growth restriction or fetal alcohol syndrome and future needs.
Provide information about the maternal and fetal effects of drugs. Review drinking/drug history of client/partner.Recognition of the negative effects of alcohol/other drugs on pregnancy may encourage the client to stop. When client is pregnant, identification of potential problems aids in planning for future fetal needs/concerns.
Provide various information, as indicated. Include list of articles, books, tapes, and videos related to client/family needs, and encourage reading and discussing what they learn.Guides individuals to make informed choices about future. Bibliotherapy can be a useful addition to other therapy approaches if materials chosen consider the individual’s educational and cognitive abilities.
Review condition and prognosis/future expectations.Provides data base on which client can make options for their care.
Provide an active role for the client/partner in the learning process through discussions, group participation, and role playing.Actively participation enhances learning.
Discuss the relationship of drug use to current situation/pregnancy.In many cases, client has misperception or denial of real reason for admission to the medical or psychiatric setting when hospitalized.
Time activities to individual needs.Facilitates learning because information is more readily assimilated when individual learning pace is considered.
Provide information regarding available organizations and programs for assistance/referral.Long-term support is needed to maintain optimal recovery and assist with pregnancy needs. Psychosocial needs as well as other issues may require addressing.

Ineffective Coping

Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

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May be related to

  • Anxiety/fear
  • Personal vulnerability
  • Difficulty managing new situations
  • Previous ineffective coping skills with substitution of drug
  • Lack of support systems

Possibly evidenced by

  • Altered social patterns
  • Decreased ability to handle stress of illness/hospitalization
  • Impaired adaptive behavior and problem-solving skills
  • Lack of acceptance that drug use is causing the present situation
  • Financial affairs in disarray
  • Scholastic or employment difficulties
  • Use of manipulation to avoid responsibility for self

Desired Outcomes

  • Client will verbalize awareness of the relationship of substance abuse to the current situation.
  • Client will identify ineffective coping behaviors and their consequences.
  • Client will use effective coping skills/ problem-solving.
  • Client will initiate necessary lifestyle changes.
  • Client will attend support group (e.g., Cocaine/Narcotics/Alcoholics Anonymous) regularly.
Nursing InterventionsRationale
Assess client’s understanding of pregnancy and current situation and previous methods of coping with life’s problems.Provides information about degree of denial; reveals coping skills that may be utilized in present plan of care.
Provide positive feedback when client expresses awareness of denial in self and recognizes it in others.Denial is the major defense mechanism in addictive disease and may hinder progress of therapy until client accepts reality of the problem. Positive feedback is important to enhance self-esteem and to reinforce insight into behavior.
Maintain firm expectation that client will participate recovery support/therapy groups regularly.Attending is related to admitting need for help, to working with denial and for an optimal outcome of the pregnancy, as well as maintenance of a long-termdrug-free existence.
Approach client in a nonjudgmental manner. Observe behavioral changes such as restlessness, increased tension.Confrontation can result into increased agitation, which may compromise safety of client/staff.
Provide information about addictive use versus experimental, occasional use of drugs; biochemical/genetic disorder theory (genetic predisposition); and use activated by the environment, pharmacology of stimulant, or compulsive desire as a lifelong guilt and blame, and may help awareness of occurrence.Progression of use continuum in the addict is from experimental/recreational to addictive use. Comprehending this process is important in combatting denial. Education may relieve client of recurring addictive characteristics
Encourage and support the client’s taking responsibility for own recovery.When client accepts the reality of own responsibility, denial can be replaced with responsible action.
Set limits and confront efforts to get a caregiver to grant special privileges, making excuses for not following through on behaviors agreed on, and attempting to continue drug use.Client has learned manipulative behavior throughout life and needs to learn a new way of getting needs met. Following through on consequences of failure to maintain limits can help the client to change ineffective behaviors.
Be aware of family/staff enabling behaviors and feelings.Lack of understanding of enabling and codependence can result in no therapeutic approaches to addicts.
Assist client to learn relaxation skills, guided imagery, or visualizations; encourage her to use them.Helps client to relax and develop new ways to deal with stress and problem-solving.
Administer medications as prescribed:
  • Methadone
Weakens the craving for, and decrease the effects of heroin and is used to assist in withdrawal and long-term maintenance programs. It has lesser side effects than heroin and permits the client to maintain daily activities and ultimately withdraw from drug use.
Treat alcohol withdrawal and prevent/ reduce frequency and severity of seizures
Encourage involvement with self-help associations; e.g., Alcoholics/Narcotics Anonymous.Allows client to have direct exposure with support systems needed for managing sobriety/drug-free life. Self-help groups are essential for learning and promoting abstinence in each member with understanding and support as well as peer pressure.

Situational Low Self-Esteem

Situational Low Self-Esteem: Development of a negative perception of self-worth in response to a current situation.

May be related to

  • Social stigma attached to substance abuse
  • Social expectation that one control own behavior
  • Biochemical body change
  • Situational crisis of pregnancy with loss of control over life events

Possibly evidenced by

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  • Not taking responsibility for self/self-care
  • Lack of follow-through, self-destructive behavior
  • Change in usual role patterns or responsibility (family, job, legal)
  • Confusion about self, purpose, or direction in life
  • Denial that substance use is a problem

Desired Outcomes

  • Client will identify feelings and methods for coping with a negative perception of self.
  • Client will verbalize acceptance of self “as is” and an increased sense of worth.
  • Client will set goals and participate in realistic planning for lifestyle changes necessary to live without drugs and bring pregnancy to the desired outcome
Nursing InterventionsRationale
Assess for changes in mentation. Observe for presence of other psychiatric disorders.May alter decisions about pregnancy. Some clients utilize substances to seek relief from psychiatric disorders such as depression or anxiety.
Provide an opportunity to vent own situation.Client usually has difficulty expressing self and even more difficulty accepting the degree of importance substance has assumed in life and its relationship to present situation/pregnancy.
Encourage expression of feelings of anger, guilt, and shame.The client often has lost respect for self and has notion that the situation is hopeless. Expression of these feelings enables the client begin to accept responsibility for self and initiate steps to make changes.
Assess family dynamics and effectiveness of support.Substance abuse is a family disease, and how the members act and react to the client’s pregnancy and her behavior affects the course of the disease and how the client sees herself. Many unconsciously become “enablers,” helping the individual to cover up the consequences of the abuse.
Provide reinforcement for positive actions, and encourage client to accept this input.Failure and lack of self-esteem have been problems for this client, who needs to learn to accept self as an individual with positive attributes.
Discuss client’s behavior and substance use in a nonjudgmental way.Presence of the nurse conveys acceptance of the individual as a worthwhile person. Discussion provides opportunity for insight into the problemsthat substance abuse has created for the client
Help the client to acknowledge that substance use is the problem and that problems can be dealt with, without the use of drugs. Confront the use of defenses (e.g., denial, projection, rationalization).When drugs can no longer be blamed for the problems that exist, the client can begin to deal with them and live without substance use. Confrontation helps the client accept the reality of the problems as they exist.
Use techniques of role rehearsal.Assists client to practice the development of skills to cope with new role as a person who no longer uses or needs drugs to handle life’s problems.
Administer antipsychotic medications as prescribed, noting precautions of use in pregnancy.Prolonged psychosis following d-lysergic acid diethylamide (LSD) or phencyclidine (PCP) use can be treated with antipsychotic drugs due to an underlying functional psychosis that has now emerged.
Allow client to involve in group therapy.Group sharing allows members to speak about their own personal experiences on addiction. The client then can attain new skills, hope, and a sense of belonginess  from participating in a group therapy.
Formulate plan to treat other mental illness problems.Clients who seek relief for other mental healthproblems through drugs will continue to do so. Boththe substance use and the mental health problemsneed to be treated together to maximize abstinence potential.

Powerlessness

Powerlessness: The lived experience of lack of control over a situation, including a perception that one’s actions do not significantly affect an outcome.

May be related to

  • Substance addiction with or without periods of abstinence
  • Episodic compulsive indulgence
  • Failed attempts at recovery
  • Lifestyle of helplessness
  • Self-imposed or forced isolation

Possibly evidenced by

  • Ineffective recovery attempts
  • Statements of inability to stop behavior (even with awareness of effects onpregnancy) and/or requests for help
  • Continuous/constant thinking about drug and/or obtaining drug
  • Alterations in personal, occupational, and social life

Desired Outcomes

  • Client will admit inability to control drug habit, surrender to powerlessness over addiction.
  • Client will involve self in treatment and verbalize awareness that will power alone cannot maintain abstinence.
  • Client will engage in peer support.
  • Client will demonstrate active participation in program.
  • Client will maintain healthy state during pregnancy with an optimal outcome.
Nursing InterventionsRationale
Utilize crisis intervention techniques:Client is more amenable to acceptance of need for treatment in the crisis presented by the pregnancy.
  • Assist client to acknowledge an existence of a problem.
It is easier to accept the drug problem if a client is hurting and recognizing that substance abuse is harmful to her fetus, .
  • Assess dynamics with significant other. Note domination by parents or client’s unwillingness to respond in partner’s presence.
A woman can experience self-imposed or forced isolation as a result of drug dependence and/or societal rejection of drug use during pregnancy
  • Assist client in formulating plan to leave abusive situation.
Potential volatility of situation may require careful consideration of safety issues.
  • Identify goals for change.
Helpful in planning direction for care and promoting belief that change can occur.
  • Review other alternative options.
Brainstorming helps creatively identify possibilitiesand provides sense of control.
  • Assist in choosing most appropriate alternative.
As possibilities are discussed, the most useful solution becomes clear.
  • Support decision and implementation of selected alternative.
Helps the client to persevere in process of change.
Discuss need for help in a caring, nonjudgmental manner.A caring, non confrontational approach is more therapeutic because the client may respond defensively to a moralistic attitude, blocking recovery.
Assist client to learn assertive communication.Effective in assisting in ability to refuse use, to stop relationships with users and dealers, to build healthy relationships, and to regain control of ownlife.
Assist in self-examination of spirituality and faith.Surrendering to a power greater than oneself andfaith in that power have been found to be effective insubstance recovery; may decrease sense of powerlessness.
Assist client to assimilate ways to improve health, meet pregnancy needs, and structure healthy diversion from drug use (e.g., adequate rest, good nutrition, meditation techniques, acupuncture, biofeedback, and exercise, such as low-impact aerobics, brisked walking, swimming, or other activity safe for pregnancy).Learning to empower self in constructive areas can enhance ability to continue recovery. These activities help restore natural biochemical balance, aid detoxification, and manage stress, anxiety, and use of free time as well as promote positive pregnancy outcomes. These diversions can increase self-confidence, thereby improving self-esteem.
Discuss ways in which drug use has affected with life, employment, and interpersonal relationships.Awareness of how the drug has controlled the client’s life is important in destroying sense of powerlessness.
Assist client to make appointment with a treatment program, e.g., partial hospitalization drug treatment programs, Narcotics/Alcoholics Anonymous; shelter for abused women.Follow-through on appointments may be easier than making the initial contact, and continuing treatment is essential to positive outcome of both ubstance abuse problem and pregnancy. Note: To date, treatment programs admitting pregnant clientshave been very limited in number, reducingtreatment options and jeopardizing client/fetal outcomes.
Discuss possibility of private addiction counseling.Private counseling may be needed, especially whenisolation has occurred, until client feels comfortablein group setting.

Compromised Family Coping

Compromised Family Coping: A usually supportive primary person (family member, significant other, or close friend) insufficient, ineffective, or compromised support, comfort, assistance or encouragement that may be needed by the individual to manage or master adaptive tasks related to his or her health challenge.

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May be related to

  • Personal vulnerability of individual family members
  • Codependency issues
  • Situational crises of drug abuse and pregnancy
  • Compromised social systems, family disorganization/role changes
  • Prolonged disease progression that exhausts supportive capability of family members
  • Significant person(s) with chronically unexpressed feelings of guilt, anger, hostility, or despair

Possibly evidenced by

  • Denial, or belief that all problems are caused by substance use
  • Severely dysfunctional family (family violence, spouse/child abuse, separation/divorce,children displaying acting-out behaviors)
  • Financial affairs in disarray
  • School/employment difficulties
  • Altered social patterns/participation
  • Significant other demonstrating enabling or codependent behaviors (avoiding and shielding, attempting to control, taking over responsibilities, rationalizing and accepting, cooperating and collaborating, rescuing and self-serving)

Desired Outcomes

  • Client will verbalize understanding of dynamics of codependence and participate in individual and family programs.
  • Client will identify ineffective coping behaviors/consequences.
  • Client will demonstrate/plan for necessary lifestyle changes.
  • Client will take action to change self-destructive behaviors and/or alter behavior that contributes to client’s addiction.
Nursing InterventionsRationale
Assess family history; explore roles of family members and circumstances involving drug use, strengths, and areas for growth. Note attitudes/beliefs regarding pregnancy and parenting.Determine areas for focus and potential for Determine areas for focus and potential for change.
Assess current level of functioning of family members.Affects individual’s ability to cope with situation.
Determine understanding of current situation/pregnancy and previous methods of coping with life’s problemsIdentifies misconceptions/areas of need on which to base present plan of care.
Determine extent of enabling behaviors being evidenced by family members; explore with individual and client.Enabling is doing for the client what she needs to do for herself. People want to be helpful and do not want to feel powerless to help their loved one tostop substance use and change the behavior that is sodestructive. However, in many cases the substance abuser relies on others to cover up his or her owninability to cope with daily responsibilities.
Explore how the family/significant other has coped with the client’s habit (e.g., denial, repression, rationalization, hurt, loneliness, projection).The codependent person suffers from the same feelings as the client (e.g., anxiety, self hatred,  helplessness, low self-worth, guilt) and needs help inlearning new/effective coping skills
Provide information about enabling behavior and addictive disease characteristics nonuser person who is codependent.Awareness and knowledge provide opportunity for both user and for individuals to begin the process of change.
Provide factual information to client and family about the effects of addictive behaviors on the family and what to expect regarding abstinence from drugs and course of pregnancy.Many individuals are not aware of the nature of addiction, the involvement of the family, and the effects on pregnancy/fetus. Note: If client is using legally obtained drugs, user and family members may believe this does not constitute abuse.
Encourage family members to be aware of their own feelings and to look at the situation with perspective and objectivity. They can ask themselves, “Am I being conned? Am I acting out of fear, shame, guilt, or anger? Do I have a need to control?”When the codependent family members become aware of their own actions that perpetuate the addict’s problems, they can decide to change themselves. If they change, the client can then face the consequences of her own actions and may choose to get well.
Involve significant other in referral plans.Drug abuse is a family illness. Because the family hasbeen so involved in dealing with the substance abuse behavior, they need help adjusting to the new behavior of sobriety/abstinence. Incidence of recovery is almost doubled when the family is treated along with the client.
Be aware of staff’s enabling behaviors and feelings about client, pregnancy, and partners who are codependent.Lack of understanding of enabling and codependence can result in nontherapeutic approaches to addicts and their families. Staff members may feel angry toward client who uses or continues to use drug, even though she has been given information regarding the possibility of damage to the developing fetus.
Encourage involvement with self-help associations (e.g., Alcoholics/Narcotics Anonymous, Al-Anon, Al-Ateen) and professional family therapy.Puts client/family in direct contact with support systems necessary for continued sobriety and assistance with learning problem resolution

See Also

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Maternal and Newborn Care Plans


Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:

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