6 Substance Abuse in Pregnancy Nursing Care Plans

Substance dependence is a growing health problem in clients of childbearing age, so its incidence during pregnancy is also increasing. The number of women who use illicit substances during pregnancy is unknown, but as many as 375,000 infants may be affected yearly. As many as 10% to 20% of pregnant women admit to using illicit substances during pregnancy. Adolescents have an increased rate of inhalant abuse and binge drinking.

Substance use during pregnancy involves a phase of a group of behavioral, cognitive, and physiological symptoms such as the inability to control drug abuse and repetitive use of the substance in spite 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, and 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 mastery and control over self and environment, and pleasure-seeking that does not require the use of drugs.

Nursing Care Plans and Management
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Nursing Care Plans and Management

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

Nursing Problem Priorities

The following are the nursing priorities for patients on substance abuse during pregnancy:

Ensure maternal and fetal safety
Provide non-judgmental and supportive care
Assess and manage withdrawal symptoms
Ensure access to appropriate prenatal care
Promote healthy lifestyle choices
Facilitate substance abuse treatment referrals
Advocate for the rights and best interests of the mother and baby

Nursing Assessment

Assess for the following subjective and objective data:

Changes in appetite or sudden weight loss/gain
Poor personal hygiene and neglect of physical appearance
Bloodshot or glassy eyes, dilated or constricted pupils
Slurred speech or impaired coordination
Frequent mood swings or noticeable changes in behavior
Social withdrawal or isolation from friends and family
Financial difficulties or unexplained borrowing of money
Neglecting responsibilities, such as missing work or school
Secretive behavior or lying about activities and whereabouts
Increased tolerance or needing larger amounts of the substance
Withdrawal symptoms when attempting to stop or reduce substance use
Engaging in risky behaviors, such as driving under the influence
Experiencing legal problems related to substance use
Relationship difficulties or conflicts with loved ones
Neglecting prenatal care or missing appointments

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with substance abuse during pregnancy based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Nursing Goals

Goals and expected outcomes may include:

The client will verbalize understanding of the effects of substance dependence and insufficient dietary intake on the nutritional status and pregnancy.
The client will demonstrate behaviors and lifestyle changes to regain/maintain an appropriate weight for pregnancy.
The client will demonstrate progressive weight gain toward a goal, with normalization of laboratory values and absence of signs of malnutrition.
he client will verbalize awareness of the relationship of substance abuse to the current situation.
The client will identify ineffective coping behaviors and their consequences.
The client will use effective coping skills/ problem-solving.
The client will attend a support group (e.g., Cocaine/Narcotics/Alcoholics Anonymous) regularly.
The client will verbalize acceptance of self “as is” and an increased sense of worth.
The client will set goals and participate in realistic planning for lifestyle changes necessary to live without drugs and bring the pregnancy to the desired outcome.
The client will admit her inability to control her drug habit and surrender to powerlessness over addiction.
The client will involve herself in treatment and verbalize awareness that willpower alone cannot maintain abstinence.
The client will demonstrate active participation in the program.
The client will maintain a healthy state during pregnancy with an optimal outcome.
The client will verbalize an understanding of the dynamics of codependence and participate in individual and family programs.
The client will take action to change self-destructive behaviors and/or alter behavior that contributes to the client’s addiction.
The client will verbalize awareness of the relationship of substance abuse to pregnancy.
The client will acknowledge the inappropriate use of illicit substances.
The client will identify and perform interventions to correct and overcome substance dependency.
The client will remain abstinent during and after the pregnancy.
The client will avoid developing complications associated with substance abuse.
The client will demonstrate the absence of untoward effects of withdrawal.
The fetus will develop no/minimal complications.
The fetus will be delivered at full term.
The fetus will display no withdrawal symptoms upon birth.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients on substance abuse during pregnancy may include:

1. Maintaining Adequate Nutrition

Many women with substance dependency come late in their pregnancy for prenatal care because they are worried their substance use will be discovered and they will be reported to the authorities. She may have difficulty following prenatal instructions for proper nutrition because, although she may desire to eat well, if she only has enough money to buy either drugs or food, she may choose drugs over food. She may not have money for supplemental vitamins or iron preparations for the same reason.

Assess the condition of the oral cavity. Note and record age, height/weight, body build, strength, and activity/rest pattern.
This guides the formation of the dietary plan. The condition of mucous membranes and teeth may be affected by the type of food intake. Methamphetamine users describe their teeth as ‘blackened, stained, rotting, crumbling, or falling apart. Poor oral hygiene, high intake of refined carbohydrates, and increased acidity in the oral cavity from oral intake of amphetamine, GI regurgitation, or vomiting also lead to an increased number and severity of carious lesions in clients who abuse methamphetamine (Hamamoto & Rhodus, 2008).

Determine anthropometric measurements such as BMI, waist-to-hip ratio, skin-fold test, and bioelectrical impedance.
This measures subcutaneous fat and muscle mass to help in planning dietary needs. The majority of clients who abuse drugs present below-normal BMI, biochemical values, and clinical signs of nutrient deficiency because of the consumption of poor quality nutrient-deficient foods. It was found that pregnant women addicted to methamphetamine had smaller biceps skinfold thickness, a measure of body fat, and they had significantly lower BMI compared to non-addicted pregnant women (Sebastiani et al., 2018).

Note total daily calorie intake. Encourage the client to keep a journal of intake, frequency, and patterns of eating.
Information about the client’s dietary pattern will determine nutritional strengths, needs, and insufficiencies. Metabolic problems are often associated with heroin, cocaine, and ecstasy drug although they produce a variety of medical problems. Heroin addicts consume less than the minimum daily quantity of vegetables, fruits, and grains recommended by the food pyramid and eat more portions of sweets (Sebastiani et al., 2018).

Assess energy expenditure (such as pregnancy needs, pacing, or sedentary activities).
Pregnant state and activity level affect nutritional needs. Prenatal exposure to methamphetamine was associated with neurobehavioral patterns of decreased arousal, increased stress, and poor quality of movement in a dose-dependent manner. Chronic abuse of methamphetamine alters the activity of the dopamine system in the brain leading to reduced motor function that can lead to significant social, occupational, and medical impairments (Hamamoto & Rhodus, 2008).

Note and record the client’s weight weekly.
This provides information regarding the current status or effectiveness of the dietary plan. Cocaine acts as an appetite suppressant that tends to reduce body weight due to its anorexigenic effect (Sebastiani et al., 2018).

Review and discuss prenatal nutritional needs and develop a dietary plan.
The use of illicit drugs suppresses appetite and affects food habits leading drug-dependent clients to crave ‘empty-energy’, potentially nutrient-deficient foods that cause micronutrient deficiency. The carbohydrate-metabolism health problems could be reversed by increasing the dietary intake of protein and reducing simple carbohydrates in the form of vegetables and whole grains (Sebastiani et al., 2018).

Assist with developing a grocery budget and provide an opportunity to select food items to meet dietary plans.
This facilitates involvement in the plan and resolves nutritional deficiencies. Nutrition is a protective factor against alcohol and drug abuse teratogenicity. Recent research is focusing on nutritional intervention in order to reverse the detrimental effects of alcohol and drug abuse on the nutritional status of the mother. Some experimental studies suggest treating women with minerals and antioxidants (like vitamin E or C) in order to substitute the nutritional deficits described in substance-dependent mothers and to protect the fetus (Sebastiani et al., 2018).

Set an individualized exercise program.
Exercise improves muscle tone, may promote appetite, and raises a sense of well-being. Available evidence indicates moderate-to-vigorous intensity exercise may improve substance use disorder (SUD) abstinence rates and anxiety/depressive symptoms across multiple SUDs. Exercise may be an effective adjunct treatment for those with substance use disorders in terms of abstinence and withdrawal and also improves mood (Ashdown-Franks et al., 2019).

Promote intake of essential micronutrients and multivitamins.
Micronutrient supplementation would in part reverse the toxic effect of alcohol and drugs on fetal neurological development, although it is difficult to establish the optimal range of micronutrients during pregnancy. Nutrients such as choline, vitamin E, betaine, folic acid, methionine, and zinc can attenuate alcohol-induced changes to the epigenome and oxidative damage (Sebastiani et al., 2018).

Collaborate with a dietitian.
This helps in establishing individual dietary needs and provides an additional resource for learning about the importance of nutrition in nonpregnant and pregnant states. A partnership should be created with the client, and a plan for compromises and treatment should be developed. Dietary support, monitoring of the client’s weight gain, and fetal assessment promote better pregnancy outcomes.

Review laboratory studies as indicated such as glucose, serum albumin, and electrolytes.
This may reveal electrolyte imbalances, anemia, and other abnormalities that may be present, requiring specific therapy. Studies about opiate addiction disorders showed extreme nutritional deficiencies of key proteins, fats, vitamins, and minerals like zinc, iron, calcium, chromium, magnesium, potassium, and other essential nutrients. The use of heroin has been implicated in blood sugar disorders with different mechanisms. Fasting insulin levels were found to be four times higher in heroin addicts than in control subjects and insulin resistance caused by opioid use may be coupled with beta-cell dysfunction (Sebastiani et al., 2018).

Educate the client about outreach and food assistance programs.
Management of pregnant substance abusers must address the needs of poorly nourished, homeless, and/or incarcerated pregnant substance dependents. In addition to education about nutrition and weight gain, some of these women may need a referral to food assistance programs and shelters, and the provision of transportation vouchers and prenatal multivitamins (Sebastiani et al., 2018).

Assist the 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. Dental management for a client who abuses drugs is always a challenge. Dentists need to be aware of the clinical presentation and medical risks presented by these clients and attempt to get the client to seek professional help (Hamamoto & Rhodus, 2008).

2. Promoting Effective Coping

Pregnant patients coping with substance abuse may experience challenges in decision-making, as substance use can impair judgment and cloud their ability to make sound choices for themselves and their baby’s well-being. Substance abuse can also have a detrimental impact on self-esteem, leading to feelings of guilt, shame, and a negative self-image. Moreover, family dynamics may be strained as substance abuse can disrupt trust, communication, and support systems, affecting the overall functioning and stability of the family unit.

Assess the client’s understanding of pregnancy, current situation, and previous methods of coping with life’s problems.
This provides information about the degree of denial; reveals coping skills that may be utilized in the current plan of care. In contrast to situations where pregnancies are unplanned, some clients had planned to get pregnant but moderated their drug use in the pre-conception period. Study findings showed that clients’ decision to use or inject drugs was mitigated by their perception of its potentially deleterious impact on their ability to conceive (Mburu et al., 2019).

Identify possible and actual triggers for relapse.
Employment and financial stressors, isolation, unhealthy relationships, being around substance-using friends or partners, hearing certain songs, premenstrual syndrome- the list of possibilities depends on the individual. Being aware of the triggers provides an opportunity to plan for ways to avoid and deal with them.

Provide positive feedback when the client expresses awareness of denial in self and recognizes it in others.
Denial is the major defense mechanism in addictive diseases and may hinder the progress of therapy until the client accepts the reality of the problem. Positive feedback is important to enhance self-esteem and reinforce insight into behavior. A category of emotional support that emerged in a study was women in recovery reported that network members gave them praise for their hard work and told them that they were happy and proud. Comments revealed that women valued the recognition that they received from network members for their efforts to get better in treatment (Tracy et al., 2010).

Maintain firm expectations that the client will participate in recovery support/therapy groups regularly.
Attending is related to admitting the need for help, working with denial and for an optimal outcome of the pregnancy, as well as maintenance of a long-term drug-free existence. Responses in a research study revealed that social network members who helped keep these clients on the right track were viewed as supportive of treatment and recovery, revealing the quality of consistent support that was initiated every day. Comments also revealed that network members often were perceived as making sure the clients have what they need, making sure they remain in treatment and keep appointments, and also maintaining their recovery (Tracy et al., 2010).

Approach the client in a nonjudgmental manner. Observe behavioral changes such as restlessness, and increased tension.
Confrontation can result in increased agitation, which may compromise the safety of the client/staff. Stigma from health care providers toward female drug users is particularly strong during pregnancy and may hinder the client from seeking the appropriate services (Mburu et al., 2019).

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 lifelong guilt and blame, and may help awareness of occurrence.
The 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 the client of recurring addictive characteristics Outreach services could be particularly useful in enabling pregnant women to mitigate drug use, by providing education and close support during pregnancy. The use of lay outreach workers to educate and assess has been successful in the context of alcohol abuse in other countries (Mburu et al., 2019).

Enforce teachings specific to the disease.
Information about the disease of addiction and how to fight it was reported as supportive of the client’s recovery. Examples of the client’s responses were that their support network makes them aware of what the disease does to them, taught them the disease of addiction and how to live their life without the use of drugs, gave them knowledge about drugs and alcohol, and taught them how not to use on a daily basis (Tracy et al., 2010).

Encourage and support the client’s taking responsibility for their own recovery.
When the client accepts the reality of their own responsibility, denial can be replaced with responsible action. One of the most frequently discussed forms of emotional support is encouragement. Clients in a study reported support in the form of general encouragement and encouragement specifically related to treatment and recovery. The clients’ reports of network members’ encouraging comments suggested that they felt inspired and assured (Tracy et al., 2010).

Encourage the client to express their feelings and display active listening.
Talking with clients during the treatment and recovery process is a predominant form of emotional support for many clients in a study. The clients specifically reported that it was helpful to their recovery to talk with their support network about their problems. Listening is also an important aspect of emotional support. The client will need a support network that she can identify as a good listener and individuals who will listen and give opinions and moral support (Tracy et al., 2010).

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.
The client has learned manipulative behavior throughout life and needs to learn a new way of getting needs met. Following through on the consequences of failure to maintain limits can help the client to change ineffective behaviors. Many clients reported that they valued talk that was direct, and honest, and held them accountable for their behaviors. “Making sure” and “being there” reveal that some network members provided consistent emotional support to women in recovery from addiction (Tracy et al., 2010).

Be aware of family, partner, or staff enabling behaviors and feelings.
A lack of understanding of enabling and codependence can result in no therapeutic approaches for addicts. Among clients who were in a relationship when they got pregnant, the use of drugs during pregnancy was often mediated- for better or for worse- by their intimate partners. In several instances, intimate partners indirectly caused women to start using drugs. There were instances in which these clients commenced their engagement with drugs in the pursuit of intimacy, or to fulfill their perceived ideals of a good relationship (Mburu et al., 2019).

Assist the client to learn relaxation skills, guided imagery, or visualizations; encourage her to use them.
These interventions help clients to relax and develop new ways to deal with stress and problem-solving. Tangible support that includes “doing things together” such as watching movies about recovering people or doing enjoyable things was reported to be supportive of the client’s recovery. These actions also provided clients support as they felt an emotional connection to individuals who did things for and with them (Tracy et al., 2010).

Educate the client about coping skills.
The client can be taught how to cope with their emotions, thoughts, and behaviors that surround recovering from substance dependence. Data elements suggest that the client can be helped to identify, deal with, and express emotions. Being helped with identifying behaviors related to these difficult thoughts and emotions is important as well (Tracy et al., 2010).

Encourage involvement with self-help associations; e.g., Alcoholics/Narcotics Anonymous.
This allows the client to have direct exposure to support systems needed for managing a 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. Social and community-based support services, such as educational and awareness-raising activities, as well as parenting classes and workshops, could be useful to inform women regarding the risks of drug use during pregnancy (Mburu et al., 2019).

Assess for changes in mentation. Observe for the presence of other psychiatric disorders.
The findings may alter decisions about pregnancy. Some clients utilize substances to seek relief from psychiatric disorders such as depression or anxiety. Screen pregnant women using a tool like the Patient Health Questionnaire for depression risk identification. Subsequently, undiagnosed clinical depression in pregnancy may lead to serious perinatal complications such as inadequate maternal weight gain, preterm birth, and low infant birth weight.

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. Social network members can either support or undermine participation in treatment and recovery from drug use. Both peer support within the treatment setting and social support outside of treatment appear significant factors in treatment progress and outcome (Tracy et al., 2010).

Monitor for psychosocial issues including lack of support system, loneliness, depression, lack of confidence, maternal powerlessness, domestic violence, and socioeconomic problems.
A study that compared psychosocial assessment versus routine care for pregnant women concluded that the health care providers who assessed psychosocial factors were more likely to identify psychosocial concerns. In two trials, women identified they did not want to feel so alone, be judged, or misunderstood, and they wanted to feel an increased sense of their own worth.

Provide reinforcement for positive actions, and encourage the client to accept this input.
Failure and lack of self-esteem have been problems for this client, who needs to learn to accept herself as an individual with positive attributes. Women value the recognition that they receive from supportive networks for their efforts to get better in treatment. Women find it supportive when their support network reveals their happiness, gladness, and joy to women in recovery (Tracy et al., 2010).

Discuss the client’s behavior and substance use in a nonjudgmental way.
Mothers diagnosed with substance use disorder perceive stigma from healthcare providers, the general public, loved ones, and themselves. The presence of the nurse conveys acceptance of the individual as a worthwhile person. The discussion provides an opportunity for insight into the problems that substance abuse has created for the client. Women frequently discussed the importance of high-quality, supportive relationships, consistently identifying non-judgemental, positive relationships as contributing to their ability to discontinue use (Latuskie et al., 2019).

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. Warm, caring, and supportive service providers enable women to be honest about their substance use, which allowed them access to and benefits from appropriate counseling and treatment (Latuskie et al., 2019).

Use techniques of role rehearsal.
Assists the client to practice the development of skills to cope with a new role as a person who no longer uses or needs drugs to handle life’s problems. Women identified that having confidence in their ability to achieve their goals was important. Women in a study were clear that self-efficacy was the foundation for changing substance use behavior (Latuskie et al., 2019).

Administer antipsychotic medications as prescribed, noting precautions of use in pregnancy.
See Pharmacological Management

Allow the client to involve in group therapy.
Group sharing allows members to speak about their own personal experiences with addiction. The client then can attain new skills, hope, and a sense of belongingness from participating in group therapy. Connecting a client diagnosed with substance use disorder (SUD) treatment with educational and job opportunities might provide structure, and support motivation to stay in recovery while building important skills (Frazer et al., 2019).

Formulate a plan to treat other mental illness problems.
Clients who seek relief from other mental health problems through drugs will continue to do so. Both substance use and mental health problems need to be treated together to maximize abstinence potential. Specific interventions involving coping strategies could provide different therapies depending on the presence or absence of anxiety, depression, or both to reduce substance use or prevent a relapse (Ribadier & Varescon, 2019).

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. There are instances in which women commenced their engagement with drugs in the pursuit of intimacy, or to fulfill their perceived ideals of a good relationship with intimate partners, especially in the context of pregnancy. In a study, participants’ use of drugs was prompted by the need to get along with the biological fathers of their children, who were using drugs (Mburu et al., 2019).

Utilize crisis intervention techniques.
The client is more amenable to acceptance of the need for treatment in the crisis presented by the pregnancy. The 5 A’s Intervention was developed by the U.S. Public Health Service and is a best-practice guideline supported by the ACOG and the National Cancer Institute. The intervention is designed to take about 5 to 15 minutes and should be implemented with every client who is smoking or who has recently quit.

Assist the client to acknowledge the 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. Women frequently discussed the importance of high-quality, supportive relationships, consistently identifying non-judgmental, positive relationships as contributing to their ability to discontinue use. For instance, warm, caring, and supportive service providers enabled women to be honest about their substance use, which allowed them to access and benefit from appropriate counseling and treatment (Latuskie et al., 2019).

Assist the client in formulating a plan to leave an abusive situation.
The potential volatility of the situation may require careful consideration of safety issues. Some of the women in abusive episodes may not perceive these situations as abusive events perpetrated by their partners. Therefore, it may not be surprising to find higher rates of abuse later on in treatment when substance-abusing pregnant women become aware of their abusive relationships and feel more comfortable disclosing to healthcare professionals the reality of their everyday lives (Velez et al., 2006).

Identify goals for change.
This is helpful in planning the direction of the care and promoting the belief that change can occur. Women identified that having confidence in their ability to achieve their goals was important. Women were clear that self-efficacy was the foundation for changing substance use behavior (Latuskie et al., 2019).

Review other alternative options.
Brainstorming helps creatively identify possibilities and provides a sense of control. In a study, women were asked to discuss their recommendations for improvements to health care support for pregnant and parenting women diagnosed with substance use issues. They identified the need for comprehensive services and suggested the establishment of inpatient treatment for pregnant women with wraparound programming ranging from detoxification to aftercare. This ideal program would offer essential skills classes, parenting groups, and provision of other instrumental needs (Latuskie et al., 2019).

Assist in choosing the most appropriate alternative.
As possibilities are discussed, the most useful solution becomes clear. Women emphasized that healthcare professionals should have comprehensive information on the full range of services that pregnant women diagnosed with substance use disorders might need, including detoxification centers, treatment programs, shelters, food banks, pregnancy outreach programs, aftercare services, parenting programs, and childcare services (Latuskie et al., 201).

Support the decision and implementation of the selected alternative.
This helps the client to persevere in the process of change. There are programs for addicted pregnant women that provide support for them from a holistic perspective. The health care professionals provide a trusting relationship and collaborate with the woman throughout the pregnancy. The nurses are viewed as caring when they took the time to communicate on a personal level. A study found that when there is better collaboration, improved education, and partnership in addiction treatment decisions, the clients are more likely to remain in treatment (Stiffler et al., 2019).

Discuss the need for help in a caring, nonjudgmental manner.
A caring, nonconfrontational approach is more therapeutic because the client may respond defensively to a moralistic attitude, blocking recovery. Nurses must understand that substance abuse is an illness and that these clients deserve to be treated with patience, kindness, consistency, and firmness when necessary.

Assist the client to learn assertive communication.
Assertive communication is effective in assisting in the ability to refuse use, stop relationships with users and dealers, build healthy relationships, and regain control of own life. A positive relationship with the service provider can supply the client with objective, professional advice, and comfort that may not always be available in her personal life (Latuskie et al., 2019).

Assist in self-examination of spirituality and faith.
Surrendering to a power greater than oneself and faith in that power have been found to be effective in substance recovery; may decrease the sense of powerlessness. Spirituality/religiosity (S/R) has been identified as a protective factor against substance use, and S/R is commonly employed in substance use interventions. Examples of S/R interventions include spiritually modified cognitive behavioral therapy, 12-step-oriented interventions, prayer, and Rites of Passage (an Africentric intervention used for preventing substance abuse among African-American adolescents, which includes a spiritual component adapted from traditional African spirituality (Hang Hai et al., 2019).

Assist clients to assimilate ways to improve health, meet pregnancy needs, and structure healthy diversion from drug use.
Learning to empower self in constructive areas can enhance the ability to continue recovery. Alternative therapies, such as acupuncture, can be offered. The client may also be encouraged to develop a new social network to avoid contact with acquaintances, friends, and family members who continue in the drug lifestyle (Gopman, 2014). 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 life, employment, and interpersonal relationships.
In a lot of studies, it was alarmingly clear that many clients lack knowledge of the effects of drug use on themselves, their fetuses, and how quickly one can fall into addiction. The literature describes the quickness with which the client becomes obsessed with the drug and how the drug becomes more important than anything else in their life- even their children. They lose the ability to think rationally (Stiffler et al., 2019). Awareness of how the drug has controlled the client’s life is important in destroying the sense of powerlessness.

Assist the client to make an appointment with a treatment program, e.g., partial hospitalization drug treatment programs, Narcotics/Alcoholics Anonymous; or a shelter for abused women.
Follow-through on appointments may be easier than making the initial contact, and continuing treatment is essential to the positive outcome of both substance abuse problems and pregnancy. The client may require more frequent appointments and may miss more appointments due to transportation difficulties and lack of child care compared to women without substance abuse disorders. Multidisciplinary care, including using substance abuse counselors, social workers, case managers, psychiatrists, and opioid replacement therapy providers, is required for the optimization of care (Gopman, 2014).

Discuss the possibility of private addiction counseling.
Private counseling may be needed, especially when isolation has occurred until the client feels comfortable in a group setting. A key component of substance abuse treatment includes counseling. Counselors and substance abuse treatment programs may use a variety of techniques, including motivational interviewing, identification of triggers for relapse, stress reduction education, meditation, cognitive behavioral therapy, positive reinforcement of abstinence, and contingency management (Gopman, 2014).

Assist and support the client in preparing for parenthood.
By accessing prenatal care and disclosing substance abuse, the client is taking the first of many potential steps toward improving their health and investing in the health of their children and families. Assistance in preparing for parenthood is key for the client and their partners in these circumstances, and referrals to educational programs should be provided. Preparation for parenting also includes education regarding neonatal abstinence syndrome (NAS) and its diagnosis and treatment, including the expected length of hospital stay for the infant (Gopman, 2014).

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.
This determines the areas of focus and potential for change. Many studies and reports have documented the negative effects on family, marital, financial, and emotional stability; parental competence; how the family functions within and outside of the family; and on the physical and mental health of individual members (Daley et al., 2018).

Assess the current level of functioning of family members.
This affects an individual’s ability to cope with a situation. Parenting behaviors can be affected. Parents diagnosed with SUD may be absent or unable to provide nurturing to children that are needed for healthy child development. Roles in the family can also change as a result of the recovery (Daley et al., 2018).

Assess for social and environmental stressors.
Assessment of social and environmental stressors is indicated for all pregnancies; however, women with substance abuse disorders may be at higher risk for these problems. Screening for issues such as intimate partner violence, homelessness, and food insecurity, should be performed routinely on initial presentation, periodically over the course of prenatal care, and when changes in social circumstances occur (Gopman, 2014).

Determine the understanding of the current situation or pregnancy and previous methods of coping with life’s problems
This identifies misconceptions/areas of need on which to base the present plan of care. There was an understanding of the statistics of opioid dependence in pregnancy, but there was little understanding of how quickly an addiction can occur in the client’s life and the power it could hold over her life (Stiffler et al., 2019).

Determine the 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 ones to stop substance use and change the behavior that is so destructive. However, in many cases, the substance abuser relies on others to cover up his or her own inability 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 in learning new/practical coping skills. The emotional burden can be quite high, and some family members need professional help for clinical depression or an anxiety disorder too (Daley et al., 2018).

Provide information about enabling behavior and addictive disease characteristics of nonuser person who is codependent.
Awareness and knowledge provide opportunities for both users and for individuals to begin the process of change. Many tangible support systems discussed in a study were also discussed as negative support that enabled the clients to continue using. For example, in regard to child care, “she kept my kids, “watched my daughter”, and “took care of my kids while I was using”, and shelter, “supplied the place to get high” and “gave me a place to use”. These situations are identified as harmful to recovery (Tracy et al., 2010).

Provide factual information to the client and family about the effects of addictive behaviors on the family and what to expect regarding abstinence from drugs and the course of pregnancy.
Many individuals are not aware of the nature of addiction, the involvement of the family, and the effects on pregnancy/fetus. If the client is using legally obtained drugs, the user and family members may believe this does not constitute abuse. Families benefit from education on SUDs (symptoms, causes, effects), treatments, recovery challenges for members diagnosed with SUD, relapse, mutual support programs, the impact of SUDs on families and members, and professional services and mutual support programs available for families (Daley, 2013).

Encourage family members to be aware of their own feelings and to look at the situation with perspective and objectivity.
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. Families can help themselves by discussing their experiences with the member with the SUD, examining and changing their own behaviors and emotional reactions, and examining the ways to make changes within the family system (Daley et al., 2018).

Involve significant other in referral plans.
Drug abuse is a family illness. Because the family has been so involved in dealing with the substance abuse behavior, they need help adjusting to the new behavior of sobriety/abstinence. The incidence of recovery is almost doubled when the family is treated along with the client. If possible, engage the family during the assessment process and early in the treatment. Numerous effective interventions have been used with families to increase their rate of involvement with the family member with SUD in treatment (Daley, 2013).

Be aware of staff’s enabling behaviors and feelings about clients, pregnancy, and codependent partners.
Lack of understanding of enabling and codependency can result in non therapeutic approaches to addicts and their families. Staff members may feel angry toward the client who uses or continues to use drugs, even though she has been given information about the possible damage to the developing fetus. Women diagnosed with opioid use disorder fear stigma related to feelings of judgment from the nurses and providers who cared for them. These clients need emotional support, but support is not always received. Many women interviewed in the various articles discussed how the nurses and providers judge and blame them (Stiffler et al., 2019).

Facilitate or provide the family treatment.
Couple or family sessions can help families address their questions and concerns, change how they interact within the family system, and improve communication. Family members can also benefit from addressing their own emotional burdens and behaviors that can interfere with the recovery of the member with SUD (Daley, 2013).

Assist the family in supporting the client diagnosed with SUD.
Members can attend sessions together to learn ways to help the client diagnosed with SUD without “enabling” the individual. Family members can be empowered by learning about potential relapse warning signs or actual episodes of substance use and how to intervene early in the relapse process (Daley, 2013).

Promote the client’s focus on their children.
Families can be helped to understand the impact of SUDs on children and examine how their own children may have been harmed by the SUDs. Parents diagnosed with SUDs can be encouraged to talk with their children about its impact on their families and on the children, and to maintain an open dialogue with their children to address the children’s feelings, questions, or concerns. Other ways of helping the family are establishing normal routines and rituals in the home, taking an active interest in the child’s life, engaging children in family activities, and facilitating an evaluation of a child with a psychiatric disorder or SUD (Daley, 2013).

3. Accepting the Situation

One of the oldest and most frequently adduced explanations for the failure of many individuals to recognize, address, and eventually overcome their substance-related problems is denial. Various accounts alternatively suggest that denial is a conscious or unconscious process contributing to substance abuse, a symptom or consequence of such abuse, or a characteristic feature of the substance abuser’s personality or social or familial environment (Howard et al., 2011).

Identify the reason for beginning abstinence and involvement in therapy.
This may provide insight into the client’s willingness to commit to the treatment and whether the client believes that she can change. The decision to quit is an important step to success in therapy.

Assess the client’s level of acceptance versus denial.
Denial interferes with the client’s ability to participate in the treatment. Additionally, women diagnosed with substance abuse disorders are often afraid to seek prenatal care due to concerns about legal ramifications, including involvement of child protective services. They may have difficulty establishing trusting relationships with their prenatal care providers, which can impede their ability to discuss important aspects of their health (Gopman, 2014).

Convey an attitude of acceptance, separating the client from unacceptable behavior.
This promotes feelings of dignity and self-worth. Healthcare providers should treat each client as an individual. As each woman is an individual, each addicted woman is also an individual and will have individual needs. If the client feels that she can trust health care providers, they are more likely to reach out for help (Stiffler et al., 2019).

Provide honest and factual answers to the client’s questions.
This creates trust, which is the basis of the therapeutic relationship. Clients diagnosed with opioid abuse have difficulty with trust. They have difficulty trusting themselves, and if they could not trust themselves, it is not possible to trust others. These clients are worried that health care providers around them would contact authorities about them-police regarding their addiction, or CPS to come and take the infant (Stiffler et al., 2019).

Educate the client regarding the effects of addiction on mood and personality.
The client may mistake the effects of addiction and use this to justify or excuse their drug use. Women diagnosed with substance abuse disorders often suffer from a lack of general health care prior to pregnancy. Underlying mental health disorders, such as depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, schizophrenia, and personality disorders, may go undiagnosed or untreated (Gopman, 2014).

Discuss with the client the impact of substance abuse on her pregnancy.
The first step in decreasing the use of denial is for the client to see the relationship between substance use and personal problems. Pregnancies complicated by substance abuse are at risk for miscarriage, preterm delivery, intrauterine growth restriction, placental abruption, fetal intraventricular hemorrhage, intrauterine fetal demise, neonatal abstinence syndrome (NAS), and other infant developmental effects (Gopman, 2014).

Remain nonjudgemental and observant of restlessness and increased tension.
Clients who are addicted to opioids fear stigma related to the feelings of judgment from the nurses and providers who care for them. These clients need emotional support, but support is not always received. Many of the women interviewed in various articles discussed how the nurses and providers judged and blamed them. The American Nurses Association is very clear in the Code of Ethics for Nurses that nurses should “practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (Stiffler et al., 2019).

Provide positive feedback for expressing awareness of denial in self and others.
Women in recovery reported that social support members gave them praise for their hard work and told them that they were happy or proud. These praises and positive feedback reveal that clients value the recognition that they receive for their efforts to get better. Clients found it supportive when their support network revealed their happiness, gladness, and joy to clients in recovery (Tracy et al., 2010).

Encourage the client to self-admit to a treatment program.
Self-admittance is preferred because the element of denial has been addressed to a certain degree. Many clients entering treatment are not yet ready to make the changes required for recovery and are often unprepared or sometimes unwilling to modify their behavior. If lack of motivation is a common phenomenon in treatment. This may impact treatment outcomes (Opsal et al., 2019).

Assure the client that substance abuse is a physiologic, chronic illness and not a moral problem.
This demonstrates a nonjudgemental attitude; it is easier to accept treatment for an illness than it is for what may be perceived as a moral weakness or flaw.

Instruct the client to compile a list of deleterious consequences and situations influenced by substance abuse over the time she has been using.
These interventions help break through the process of denial. It also helps identify which situations triggered the relapse of substance use in the past. Ask the client to show the list to another nurse, peer, or member of their treatment program.

Encourage the client to develop alternative behaviors to drug use and abuse.
Assist the client to learn their own responsibility for recovering. Denial can be replaced with positive actions when the client accepts the reality of her own responsibility.

Be aware of your own enabling behaviors.
Caregiving lends itself to “taking care” of clients which can backfire in substance abuse treatment. Enablers might deny the severity of the addiction, making excuses for the addicts and justifying or rationalizing their irresponsible behavior. Enablers may pay the addict’s bill or bail them out of jail. They may hide the damage that addicts do and avoid talking about addiction as a problem, pretending instead that this is normal behavior. In these ways, enablers help addicts avoid doing the one thing that has the best chance of ending the harmful acts, confronting their underlying cause, the addiction itself (Moore & Moore, 2012).

Encourage involvement with self-help associations (e.g., Alcoholics/Narcotics Anonymous, Al-Anon, Al-Ateen) and professional family therapy.
This puts the client and family in direct contact with support systems necessary for continued sobriety and assistance with learning problem resolution. Families often benefit from mutual support programs such as Al-Anon or Nar-Anon which provide families the opportunity to learn from others who are affected by a loved one’s SUD. These programs primarily aim to get family members to focus on themselves and what they can do to make positive changes (Daley, 2013).

4. Preventing Injuries and Promoting Safety

Large numbers of women of childbearing age abuse potentially addictive and mood-altering drugs. The use of substances can lead to chemical dependency. Chemical dependency is a chronic, relapsing, and progressive disease. Without treatment or participation in recovery activities, it can progress and result in disability or premature death. Furthermore, substance abuse during pregnancy, particularly in the first trimester, has a negative effect on the health of the mother and the growth and development of the fetus. The fetus experiences the same systemic effects as the mother, but often more severely. The fetus cannot metabolize drugs as efficiently as the expectant mother and will experience the effects long after the drugs have left the woman’s system.

Identify the illicit substance that the client is or has been using.
All pregnant women should be screened at their first prenatal visit regarding their past and present use of tobacco, alcohol, and other drugs, including recreational use of prescription and over-the-counter medications as well as herbal remedies. Information about drug use should be obtained b first asking about the client’s intake of over-the-counter and prescribed medications. Next, her use of legal drugs such as caffeine, nicotine, and alcohol should be determined. Finally, she should be questioned about her use of illicit drugs such as cocaine, heroin, and marijuana.

Use validated screening tools and questionnaires during screening.
The use of validated screening questionnaires, along with the assurance of confidentiality, improves client-provider communication and can increase the truthfulness of client responses. The 4Ps Plus is a screening tool designed specifically to identify pregnant women who need in-depth assessment. It consists of five questions and takes less than a minute to complete.

Monitor the client’s vital signs regularly.
When cocaine is sniffed into the nose or smoked in a pipe, it is absorbed across the mucous membranes to affect the central nervous system. As a result, sudden vasoconstriction occurs. Respiratory and cardiac rates and blood pressure increase rapidly in response to vasoconstriction. Some women may use marijuana to counteract nausea in early pregnancy, but this is not advised. When smoked, they produce tachycardia and a sense of well-being. Smoking marijuana also causes a reduction in blood pressure, resulting in orthostatic hypotension.

Assess and document the client’s history thoroughly.
Because substance-abusing pregnant women are at risk for a variety of infections and medical conditions, a comprehensive medical history should be obtained, and a complete physical examination performed. Using “accepting” terminology may encourage the client to give honest answers without fear of reproach.

Review the client’s laboratory assessment results.
Laboratory assessments likely include screening for syphilis, hepatitis B and C, and human immunodeficiency virus (HIV). a complete blood count and a skin test to screen for tuberculosis may also be ordered. In addition, the client may be tested for other common sexually transmitted infections such as gonorrhea and chlamydia.

Assess for barriers to seeking treatment.
Social stigma, labeling, and guilt are significant barriers to receiving necessary care. Barriers within the drug treatment system can also deter the client from receiving the help they need. Long waiting lists and lack of health insurance present further barriers to treatment.

Use a nonjudgemental approach when communicating with the client.
In many instances, pregnant women who use psychoactive drugs receive negative feedback from society and health care providers, who not only may condemn them for endangering the life of the fetus but may also even withhold support as a result. Being nonjudgemental is a key to success; a client is more apt to trust and reveal patterns of abuse if the nurse does not judge her and her lifestyle choices.

Develop a standardized, consistent plan of care.
Developing a standardized plan of care so clients have limited opportunities to play staff members against one another is helpful. Nurses must understand that substance abuse is an illness and that these clients deserve to be treated with patience, kindness, consistency, and firmness when necessary.

Educate the client regarding the effects of prenatal exposure to illicit substances.
If the client’s drug screen is positive, use this as an opportunity to discuss prenatal exposure to substances that may be harmful. The discussion may lead the nurse to refer the client for a diagnostic assessment or identify an intervention such as counseling that may be helpful.

Explain to the client the legal considerations of her situation and how it may affect her pregnancy.
Women often do not seek help because of the fear of losing custody of their child or children or criminal prosecution. Assure the client that sharing information of a confidential nature with health care providers will not render them liable to criminal prosecution. However, some states may vary in their requirements for the evidence of drug exposure to the fetus or newborn to report a case to the child welfare system. Health care providers may be required to report positive drug results in pregnant women or their newborns to the state’s child protection agency.

Educate the client regarding the effects of illicit substances if planning to breastfeed.
Advice regarding breastfeeding must be individualized. Although all abused substances appear in breast milk, some in greater amounts than others, breastfeeding is definitely contraindicated in clients who use amphetamines, alcohol, cocaine, heroin, or marijuana. For some women, the desire to breastfeed can provide strong motivation to achieve and maintain sobriety.

Assist the client diagnosed with alcohol withdrawal with ambulation and self-care activities.
This prevents falls with resultant injury. Alcohol withdrawal results in severe symptoms such as poor gait and motor incoordination, severe tremors, altered mental status, and a high risk for seizures.

Educate the clients regarding the effects of smoking during pregnancy.
Smoking is associated with adverse pregnancy outcomes. However, these outcomes can be avoided if the client stops smoking before becoming pregnant. Smoking increases the risk of spontaneous abortion, preterm labor and birth, maternal hypertension, placenta previa, and abruptio placenta.

Counsel the client regarding the maternal effects of illicit drugs.
Studies suggest that perinatal cocaine use increases the risk of preterm labor, abortion, abruptio placenta, seizures, withdrawals, uterine ruptures, and cerebral infarcts. Marijuana increases the risk of spontaneous abortion and preterm delivery. Narcotic dependence leads to medical, nutritional, and social neglect by the woman due to long-term risks of physical dependence, malnutrition, compromised immunity, hepatitis, and fatal overdose. It also increases the risk for preterm labor and preeclampsia. Chronic use of methamphetamines can lead to psychosis, including paranoia, hallucinations, memory loss, and aggressive or violent behavior.

Assist with the implementation of contingency management.
One recommended treatment is contingency management, in which participants are given incentives, such as small cash amounts, privileges, or prizes, for maintaining abstinence. Compared to a standard treatment condition, motivational incentive approaches appear to increase treatment retention and prolong abstinence in pregnant clients with cocaine, opiate, and nicotine dependence.

Administer medications for opioid dependence as prescribed.
Maintenance programs with methadone can sustain opioid concentrations in the mother and fetus to minimize opioid craving and prevent fetal stress. Methadone maintenance treatment (MMT) has been used in opioid-dependent pregnant women for many years and is considered the standard of care for pregnant women who are dependent on heroin or other narcotics. Buprenorphine, a synthetic opioid, has been found to be equally effective and as safe as methadone in the adult outpatient treatment of opioid dependence. Buprenorphine, either alone or in combination with naloxone is used as both a first-line treatment of heroin addiction and a replacement drug for methadone.

Administer medications for alcohol withdrawal syndrome.
Antabuse is an agonist medication used as a deterrent to impulsive drinking. Naltrexone is a narcotic antagonist originally used as a treatment for heroin abuse but has now been approved for the treatment of alcoholism. The drug reduces the cravings for alcohol and works best when accompanied by psychosocial treatment. Ondansetron is a serotonin receptor antagonist and is useful in reducing alcohol consumption and craving in clients with early-onset alcohol use disorders.

Assist the client with enrollment in smoking cessation programs.
Women are more likely to attempt to stop smoking during pregnancy than at any other time in their lives. Smoking cessation programs during pregnancy are effective and should be offered to all pregnant smokers. These programs should continue throughout the postpartum period as well because many women resume smoking after birth. The 5A’s Intervention was developed by the US Public Health Service and is the best practice guideline supported by the ACOG and the National Cancer Institute. The intervention is designed to take about 5 to 15 minutes and should be implemented with every client who is smoking or who has recently quit.

Offer information about treatment options for alcohol and drug abuse rehabilitation.
Detoxification, short-term inpatient or outpatient treatment, long-term residential treatment, aftercare services, and self-help support groups are all possible options for alcohol and drug abuse rehabilitation. Women for Sobriety may be a more helpful organization for women than Alcoholics Anonymous or Narcotics Anonymous, which were originally developed for male substance abusers.

Assess fetal heart rate regularly.
Ongoing use of substances of abuse, in particular stimulants, is associated with an increased risk of intrauterine growth restrictions and perinatal death. One approach is to institute weekly fetal heart rate monitoring at 32 weeks gestational age for women with ongoing use of stimulants and to consider induction of labor at 38 weeks gestational age, balancing risks of induction with risks of continued stimulant exposure (Gopman, 2014,).

Screen the mother for alcohol problems.
Fetal alcohol syndrome (FAS) can be prevented by screening women of reproductive age for alcohol problems. FAS is often apparent in newborns of mothers with chronic alcoholism and sometimes appears in newborns whose mothers are low to moderate consumers of alcohol.

Determine the mother’s specific drug use and drug intake.
Critical determinants of the effect of the drug on the fetus include the specific drug, the dosage, the route of administration, the genotype of the mother or fetus, and the timing of the drug exposure. Determining the specific effects of individual drugs on the fetus is made difficult by the common practice of polydrug use, errors or omissions in reporting drug use, and variations in the strength, purity, and types of additives found in street drugs.

Review ultrasound results to determine fetal growth and gestational age.
Initial and serial ultrasound studies are usually performed to determine the gestational age and fetal growth because the woman may have had amenorrhea as a result of her drug use or have no idea when her last menstrual period occurred. The fetus is at high risk for intrauterine growth restriction because of nicotine’s vasoconstrictive effects on the placenta and umbilical vessels, which contribute to fetal hypoxia and undernourishment.

Assess for fetal exposure to illicit drug substances.
Umbilical cord tissue and meconium can be analyzed to determine past drug use over a longer period of time. Both substances can be used to assess fetal exposure to amphetamines, opiates, cocaine, cannabinoids, and alcohol.

Assess fetal growth perinatally and postnatally.
Predictable abnormal patterns of fetal and neonatal morphogenesis are attributed to severe, chronic alcoholism in women who continue to drink heavily during pregnancy. The pattern of growth deficiency begun in prenatal life persists after birth, especially in the linear growth rate, rate of weight gain, and growth of head circumference.

Assess for signs of fetal alcohol syndrome (FAS).
FAS is based on minimal criteria of signs in each of three categories: prenatal and postnatal growth restriction; CNS malfunctions, including cognitive impairment; and craniofacial features such as microcephaly, small eyes, or short palpebral fissures, thin upper lip, flat midface, and an indistinct philtrum.

Assess for symptoms of alcohol withdrawal.
Alcohol withdrawal can occur in neonates, particularly when maternal ingestion occurs near the time of birth. Signs and symptoms include jitteriness, increased tone and reflex responses, and irritability.

Assess the neonate for withdrawal symptoms from drug exposure.
Newborns of mothers addicted to cocaine, heroin, methadone, or other drugs are born addicted, and many of these infants suffer withdrawal symptoms during the early neonatal period. Withdrawal symptoms include tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea, disturbed sleep patterns, and a shrill, high-pitched cry. Ineffective sucking and swallowing reflexes create feeding problems, and regurgitation and vomiting occur often after feeding.

Include the parents in the planning of care.
Planning for the care of the infant born to a substance-abusing mother presents a challenge to the health care team. Parents are included in the planning for the newborn’s care and for the care and support of the mother and her newborn at home.

Increase the mother’s awareness of the detrimental effects of alcohol.
FAS can be prevented by increasing awareness of the detrimental effects of alcohol use during pregnancy. The mother should be advised to remain abstinent from alcohol consumption during pregnancy because there is no known safe threshold for use. Health care providers should advise women that low-level consumption of alcohol in early pregnancy is not an indication of pregnancy termination. However, women who have already consumed alcohol during a current pregnancy should be advised to stop to minimize further risk.

Decrease environmental stimuli and plan care activities carefully.
Nursing care for a newborn diagnosed with FAS is supportive and focuses on preventing complications such as seizures. To minimize stimulation of the newborn, environmental stimuli are decreased, such as keeping the room dimly lit, and activities should be planned and performed carefully.

Wrap or swaddle the infant snugly.
If the infant is cocaine-exposed, position to avoid eye contact and swaddle the infant snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Wrap the infant securely in a small blanket with the arms across the chest to quiet the agitated newborn. Use vertical rocking techniques and a pacifier to counter poor organizational response to stimuli and depressed interactive behaviors.

Provide adequate nutrition to support weight gain.
Feed the newborn in frequent, small amounts while elevating the head during and after feeding. This will diminish vomiting and aspiration. The newborn’s sucking reflex may be weak and may be too irritable to feed, therefore, the nurse may experiment with various nipples to find one most effective in compensating for poor suck reflex.

Explain in a nonjudgmental way the effects of maternal drug use on the newborn and the withdrawal process.
Education will provide understanding and reality concerning the effects of drug use. Pregnant women who use cocaine should be advised to stop using it immediately. These women need a great deal of assistance such as an alcohol and drug treatment program, individual or group counseling, and participation in self-help support groups to accomplish this major lifestyle change successfully.

Encourage open communication with the parents, especially the mother.
Inform the parents of the ongoing condition, procedures, and treatments to provide a sense of respect and support. Answer the parent’s questions and correct their misconceptions, and actively listen to their concerns to encourage a sense of control.

Encourage the mother to interact with the newborn.
Encourage the mother to interact with the newborn and to become involved in care routines to foster an emotional connection. Explain how to do care procedures and how to avoid excess stimulation to enhance the mother’s care abilities and her sense of confidence and control.

Administer medications to the newborn diagnosed with neonatal abstinence syndrome (NAS).
Newborns are observed for 3 to 7 days for the development of NAS, and those who require pharmacologic treatment are generally administered oral morphine or methadone. Once a dose is achieved that effectively ameliorates signs and symptoms of opioid withdrawal, the dose is weaned over several days and then discontinued, with a period of observation after the last dose to assure clinical stability. Infants of women who are treated with buprenorphine may have less risk of requiring pharmacologic treatment of NAS, and treatment periods may be shorter in duration (Gopman, 2014).

Administer opioid replacement therapy to the mother.
See Pharmacological Management

Instruct the mother to avoid breastfeeding if using street drugs.
Although breast milk remains the optimal source of nutrition for these infants, care must be taken to avoid exposing the infant to additional drugs through breast milk. According to the American Academy of Pediatrics (AAP), mothers who use street drugs should not breastfeed. They also recommend that women enrolled in a supervised methadone treatment program can breastfeed if they are adequately nourished and have a negative screening for illicit drugs.

Administer intravenous fluids as prescribed.
The infant may experience vomiting and diarrhea due to withdrawal. To maintain fluid balance, the nurse may administer oral and parenteral fluids as ordered by the healthcare provider.

5. Initiating Patient Education and Health Teachings

A lack of pregnancy-related knowledge among pregnant women, especially adolescent girls, can adversely affect their lives as well as those of their unborn children. Therefore pregnant women should be equipped with knowledge so that they will be able to engage in good health practices during pregnancy. The age and maturity level of pregnant women may impact their susceptibility to antenatal education and their ability to identify danger signs associated with their pregnancy (Govender et al., 2019).

Assess client’s knowledge of own condition (pregnancy, complications, and lifestyle changes).
This assists in planning for long-range changes necessary for maintaining drug-free status. The client may have street knowledge of the drug but is unfamiliar with medical facts and its relationship to pregnancy. Pregnant women diagnosed with opioid use disorder (OUD) often have little social capital and experience stressors such as financial and residential instability, interpersonal violence, and psychiatric comorbidities, which can increase substance abuse severity during pregnancy (Preis et al., 2020).

Assess for signs and symptoms of depression including a history of substance abuse.
Assess the pregnant woman using a Patient Health Questionnaire (PHQ-9) for depression risk identification. When comprehensive screening is not included during antepartum care, there is less likelihood that significant information will be revealed. Undiagnosed clinical depression in pregnancy may lead to serious perinatal complications such as inadequate maternal weight gain, preterm birth, and low infant birth weight.

Assess the level of anxiety of the client and significant others.
Anxiety can be a hindrance in obtaining and processing information. Women who use addictive substances face exceptional stigma. These negative attitudes are even greater during pregnancy. Shame brought on by social scrutiny, misconceptions about the safety of prescription opioids, and secrecy due to fear of the involvement of Child Protection Services often lead OUD to go undiagnosed and untreated (Preis et al., 2020).

Encourage regular physical examination, including vaginal culture to detect the presence of STDs.
Vaginal cultures can identify the presence of microorganisms that can be potentially dangerous to the fetus or newborns such as group B streptococcus (GBS), chlamydia, syphilis, and gonorrhea. If the client uses injected drugs, the risk for HIV infection and hepatitis increases. Additionally, if the client earns money to buy illicit substances through prostitution, this increases the risk for STI and poses yet another threat to a fetus.

Review sonogram results of the client.
Ultrasonography results assess fetal growth and development to reveal the possibility of intrauterine growth restriction or fetal alcohol syndrome and future needs. Alcohol crosses the placenta in the same concentration as is present in the maternal bloodstream so may result in fetal alcohol exposure or fetal alcohol spectrum disorder (FASD). Characteristics that mark this syndrome include prenatal and postnatal growth restriction, cognitive challenge, microcephaly, and cerebral palsy.

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. For some clients who are substance dependent, pregnancy may be the impetus they need to stop their substance abuse. Others may only be able to reduce their substance use. When a client is pregnant, identification of potential problems aids in planning for future fetal needs/concerns.

Provide various information, as indicated. Include a list of articles, books, tapes, and videos related to client/family needs, and encourage reading and discussing what they learn.
Pregnant women who abuse substances commonly have little understanding of the ways in which these substances affect them, their pregnancies, and their babies. Provision of information guides individuals to make informed choices about the future. Bibliotherapy can be a useful addition to other therapy approaches if the materials chosen consider the individual’s educational and cognitive abilities.

Provide an active role for the client/partner in the learning process through discussions, group participation, and role-playing.
Active participation enhances learning. Many participants in a study reported partners who encouraged treatment and some studies have shown that increased social support is liked to have higher self-efficacy in parenting. The potential positive impact of partner support, therefore, suggests that connecting women’s partners with treatment may improve motivation (Frazer et al., 2019).

Discuss the relationship of drug use to the current situation/pregnancy.
In many cases, the client has misperceptions or denial of the real reason for admission to the medical or psychiatric setting when hospitalized. The first step in decreasing the use of denial is for the client to see the relationship between substance use and personal problems.

Promote and schedule activities specific to individual needs.
This facilitates learning because the information is more readily assimilated when individual learning pace is considered. In a study, half of the participants talked about the positive effect of day-to-day structure on their recovery. People in substance use disorder recovery derive a sense of meaning and pride from consistently attending a job once they are able to do it. Connecting the client with educational and job opportunities might provide structure, and support motivation to stay in recovery while building important skills (Frazer et al., 2019).

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. Women from a study emphasized that healthcare professionals should have comprehensive information on the full range of services that pregnant women diagnosed with substance abuse might need, including detoxification centers, treatment programs, shelters, food banks, pregnancy outreach programs, aftercare services, parenting programs, and child care services (Latuskie et al., 2019).

Educate the client regarding medications used as adjuncts to alcohol disorders treatment, such as disulfiram, naltrexone, and ondansetron.
Teach the client about the risks of drinking while taking disulfiram. This antagonist medication is used as a deterrent to impulsive drinking. Responses to taking alcohol while on disulfiram include severe nausea, vomiting, hypotension, headache, heart palpitations, seizures, or death. Naltrexone reduces the cravings for alcohol and works best when accompanied by psychosocial treatment. Its side effects include difficulty sleeping, anxiety, nervousness, headache, low energy, abdominal pain, joint and muscle pain, etc.

6. Administer Medications and Provide Pharmacologic Support

Utilizing medications such as methadone or buprenorphine can help to treat opioid dependence and reduce withdrawal symptoms. Antipsychotic medications may be prescribed for patients with substance abuse during pregnancy to help manage symptoms such as psychosis, hallucinations, or severe mood disturbances. Phenobarbital, on the other hand, may be prescribed in specific cases such as seizure disorders. The specific medications prescribed for patients with substance abuse during pregnancy should be determined by healthcare providers based on individual needs, potential risks, and benefits.

Antipsychotic
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. Individuals who have taken large doses of LSD are at risk for residual psychotic symptoms and are therefore managed with antipsychotic drugs if symptoms manifest and persist (Baquiran & Al Khalili, 2022).

Methadone
Methadone prescriptions are for detoxification and maintenance therapy. Methadone weakens the craving, decreases 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 (Durrani & Bansal, 2022).

Phenobarbital
This drug treats alcohol withdrawal and prevents or reduces the frequency and severity of seizures. Phenobarbital is a class C-IV control substance. The syndrome resulting from alcohol withdrawal has a better clinical outcome when treated with benzodiazepines, according to significant evidence-based studies (Lewis & Adams, 2022).

Opioids
Opioid replacement therapy is associated with longer gestation and higher infant birth weight. The specific benefits of opioid replacement therapy in pregnancy include avoiding the cycles of intoxication and withdrawal that are common in those with dependence on short-acting opioids, such as heroin or oxycodone, thereby avoiding the effects of these cycles on the fetus, including preterm delivery, IUGR, and intrauterine fetal demise (Gopman, 2014).

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

References and Sources

Recommended journals, books, and other interesting materials to help you learn more about prenatal substance abuse nursing care plans and nursing diagnosis:

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Reviewed and updated by M. Belleza, R.N.

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