THE PREGNANTCLIENT WITH SPECIAL NEEDS.pptx

lecture

1. The Pregnant Adolescent, The Sexually A bused, The Elderly Primi , Physically/Cognitively Ch a llenged and the The Substance Abused

2. Definition Adolescent pregnancy is pregnancy in girls age 19 or younger.

3. ADOLESCENT PREGNANCY

4. Causes, incidence, and risk factors Reasons: Earlier age of menarche in girls (the average age is 12.4 years; many girls begin menstruating at age 10 and so are ovulating and able to conceive by age 11 )

5. Causes, incidence, and risk factors Reasons: Increase in the rate of sexual activity among teenagers Lack of knowledge about (or failure to use) contraceptives or abstinence Desire by young girls to have a child

6. Adolescent pregnancy is a complex issue with many reasons for concern. Kids age 12 - 14 years old are more likely than other adolescents to have unplanned sexual intercourse . They are more likely to be talked into having into sex. Up to two-thirds of adolescent pregnancies occur in teens age 18 - 19 years old.

7. Risk factors Younger age Poor school performance Economic disadvantage Older male partner Single or teen parents

8. Symptoms Pregnancy symptoms include: Abdominal distention Breast enlargement  and  breast tenderness Fatigue Light-headedness  or actual  fainting Missed period Nausea/vomiting Frequent urination

9. Signs and tests The adolescent may or may not admit to being involved sexually. If the teen is pregnant, there are usually weight changes (usually a gain, but there may be a loss if nausea and vomiting are significant). Examination may show increased   abdominal girth , and the health care provider may be able to feel the fundus (the top of the enlarged uterus).

10. Pelvic examination may reveal bluish or purple coloration of vaginal walls, bluish or purple coloration and softening of the  cervix , and softening and enlargement of the uterus. A  pregnancy test  of urine and/or  serum HCG  are usually positive. A  pregnancy ultrasound  may be done to confirm or check accurate dates for pregnancy.

11. Treatment

12. All options made available to the pregnant teen should be considered carefully, including abortion, adoption, and raising the child with community or family support. Discussion with the teen may require several visits with a health care provider to explain all options in a non-judgmental manner and involve the parents or the father of the baby as appropriate.

13. Early and adequate prenatal care, preferably through a program that specializes in teenage pregnancies, ensures a healthier baby. Pregnant teens need to be assessed for smoking, alcohol use, and drug use, and they should be offered support to help them quit.

14. Adequate nutrition can be encouraged through education and community resources. Appropriate exercise and adequate sleep should also be emphasized. Contraceptive information and services are important after delivery to prevent teens from becoming pregnant again.

15. Pregnant teens and those who have recently given birth should be encouraged and helped to remain in school or re-enter educational programs that give them the skills to be better parents, and provide for their child financially and emotionally. Accessible and affordable child care is an important factor in teen mothers continuing school or entering the work force.

16. Prognosis

17. Having her first child during adolescence makes a woman more likely to have more children overall. Teen mothers are about 2 years behind their age group in completing their education. Women who have a baby during their teen years are more likely to live in poverty

18. Teen mothers with a history of substance abuse are more likely to start abusing by about 6 months after delivery. Teen mothers are more likely than older mothers to have a second child within 2 years of their first child.

19. Infants born to teenage mothers are at greater risk for developmental problems. Girls born to teen mothers are more likely to become teen mothers themselves, and boys born to teen mothers have a higher than average rate of being arrested and jailed.

20. Complications

21. Pregnant teens are at much higher risk of having serious medical complications such as: Placenta previa Premature delivery Significant  anemia Toxemia

22. Infants born to teens are 2 - 6 times more likely to have  low birth weight  than those born to mothers age 20 or older.   Prematurity  plays the greatest role in low birth weight, but  intrauterine growth retardation  (inadequate growth of the fetus during pregnancy) is also a factor.

23. Teen mothers are more likely to have unhealthy habits that place the infant at greater risk for inadequate growth, infection, or chemical dependence. The younger a mother is below age 20, the greater the risk of her infant dying during the first year of life.  

24. Nursing Management

25. Adolescent girls may respond to health teaching that is directed to their own health more than to that of a fetus inside them: “ Eat a high-protein diet because protein makes your hair shiny (or prevents split fingernails)” often leads to better adherence than a statement such as “Protein is good for your baby .”

26. “Taking the iron supplement should make you feel less tired” is better than “It will help build the baby’s blood supply,” for the same reason. These are truthful statements and they appeal to an adolescent’s preoccupation with self. This type of health teaching is the only form to which an adolescent who is denying her pregnancy can respond.

27. Nutrition Lack of good nutrition can result in preterm birth and low-birth-weight newborns. The younger the girl is, the more likely she is to have a low-birth-weight infant. Otherwise , protein, iron, folic acid, and vitamin A and C deficiencies may become acute. She may need to gain more weight than does the mature woman to supply adequate nutrients.

28. Adolescents traditionally do not take medicine conscientiously , so they may need frequent reminders that vitamin and iron supplements intended to complement nutrition during pregnancy must not only be purchased but also must be taken. Be sure a girl posts a medication reminder chart at home or in her school locker to help increase adherence

29. Activity and Rest Adolescents vary greatly in their level of activity. Assess a girl’s participation in sports and determine which ones ( if any ) may have to be discontinued during pregnancy (e.g ., diving , gymnastics, touch football). Many girls practice sports not for the enjoyment of the sport but for the feeling of “team” or companionship.

30. You may need to suggest alternative activities (joining the drama or language club, inviting friends over once a week to watch a movie) so they do not suffer from the loss of companionship. Adolescent girls may not plan enough rest time during pregnancy , especially if they are acting as if nothing is happening to them. It may help to explore a typical day and suggest ways to rest without compromising social relationships (sitting, talking after school rather than walking through the park).

31. Physiologic Changes A young girl may have distorted beliefs about her body. All adolescent girls need substantial education on the physiologic changes that occur during pregnancy. Despite all the health information given to children in school, it is not uncommon to find an adolescent who thinks her baby is growing in her stomach . Such a girl may be unwilling to eat large meals during pregnancy for fear of suffocating or drowning her fetus .

32. In addition, specific information about labor and delivery is essential to counteract all the “scare stories” girls may be hearing from their peers. Gaining this type of knowledge is another way that pregnancy can be a growth experience . At the end of the pregnancy, this adolescent will know a great deal more about her body and her ability to monitor her health than her average classmate.

33. Childbirth Preparation Adolescents have a strong need for peer companionship . When they become pregnant, they often are cut off from fellow adolescents. This makes them “ripe,” therefore, to join a class of adolescents in preparation for childbirth.

34. Childbirth Preparation They are excellent students because being a student is age-appropriate for them. They have enough childish magical belief operating that they are not skeptical about whether prepared child-birth will work. In fact, believing that prepared childbirth will work is an important component in a successful prepared childbirth experience, so this becomes a self-fulfilling prophecy .

35. Birth Decisions Pelvic measurements should be taken early and carefully in adolescent girls as cephalo -pelvic disproportion is a real possibility because of the girl’s incomplete pelvic growth ( Shields et al., 2007). Most girls who are told their baby will have to be born by cesarean birth respond well to the news, and many are relieved, because surgery seems controlled and simple compared with the agonies of labor they imagine.

36. Birth Decisions When a cesarean birth must be scheduled because of cephalo -pelvic disproportion or poor fetal growth, the information should be shared with the girl and her parents as soon as possible. Adolescents want to know the truth. They tend to regard the withholding of information not as protection but as an indication they are being treated as children

37. Plans for the Baby Adolescents may need additional time at prenatal visits to talk to a good listener about how they feel about being pregnant and becoming a mother. Scared? Bewildered? Numb? Happy ? Be certain they know all the options available to them : keeping the baby, placing the baby in a temporary foster home or adoption. Adolescents , like all women, should be encouraged to breastfeed (Britton et al., 2009). Breast tissue matures with pregnancy , so even the very young adolescent is physically capable of breastfeeding .

38. SEXUAL ABUSE/ SEXUAL VIOLENCE

39. Definition Any sexual act , attempt to obtain a sexual act, unwanted sexual comments or advances or acts to traffic , or otherwise directed , against a persons sexuality using coercion , by any person regardless o their relationship to the victim, in any setting including but not limited to home and work.

40. Sexual violence includes rape , defined as physically forced or otherwise coerced penetration – even if slight – of the vulva or anus using a penis, other body part or an object.. The attempt to do so is known as attempted rape. Rape of a person by 2 or more perpetrators is known as gang rape.

41. Forms and contexts of sexual abuse

42. Rape within marriage or dating relationships Rape by strangers Systematic rape during armed conflict Unwanted sexual advances or sexual harassment , including demanding sex in return for favors

43. Sexual abuse of mentally or physically disabled people. Sexual abuse of children Forced marriage or cohabitation , including the marriage of the children. Denial of the rights to use the contraception or to adopt other measures to protect against sexually transmitted diseases.

44. Types of sexual abuse

45. Non-consensual, forced physical  sexual behavior  ( rape  and  sexual assault ). Unwanted touching, either of a child or an adult. Sexual kissing, fondling, exposure of genitalia, and  voyeurism ,  exhibitionism  and up to  sexual assault .

46. Exposing a child to pornography. Saying sexually suggestive statements towards a child ( child molestation ). Also applies to non-consensual verbal sexual demands towards an adult.

47. The use of a  position of trust  to compel otherwise unwanted sexual activity without physical force (or can lead to attempted rape or sexual assault). Incest  (  sexual deviancy ). Certain forms of  sexual harassment .

48. Spousal sexual abuse is a form of  domestic violence . When the abuse involves forced sex, it may constitute  rape  upon the other spouse, depending on the jurisdiction, and may also constitute an assault. Sexual misconduct  can occur where one person uses a position of authority to compel another person to engage in an otherwise unwanted sexual activity.

49. Sexual harassment in education  might involve a student submitting to the sexual advances of a person in authority in fear of being punished, for example by being given a failing grade. For example,  sexual harassment  in the workplace might involve an employee being coerced into a sexual situation out of fear of being dismissed. 

50. Child sexual abuse

51. It  is a form of  child abuse  in which a child is abused for the sexual gratification of an adult or older adolescent.  In addition to direct  sexual contact , child sexual abuse also occurs when an adult  indecently exposes their genitalia  to a child, asks or pressures a child to engage in sexual activities, displays  pornography  to a child, or uses a child to produce child pornography

52. Effects of child sexual abuse

53. It include  guilt  and  self-blame ,  flashbacks ,  nightmares , insomnia , fear of things associated with the abuse (including objects, smells, places, doctor's visits, etc.), 

54. self-esteem  issues,   sexual dysfunction ,  chronic pain ,   addiction ,   self-injury ,  suicidal ideation

55. somatic complaints,  depression , post-traumatic stress disorder ,   anxiety ,  other   mental illnesses  (including  borderline personality disorder ) propensity to  re-victimization  in adulthood, and physical injury to the child, among other problems. 

56. Victims of child sex abuse are over six times more likely to attempt suicide and eight times more likely to repeatedly attempt suicide.  The abusers are also more likely to commit suicide. Much of the harm caused to victims becomes apparent years after the abuse happens.

57. Sexual abuse by a family member is a form of  incest , and results in more serious and long-term  psychological trauma , especially in the case of parental incest. Approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were children. 

58. Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often fathers, uncles or cousins; Around 60% are other acquaintances such as friends of the family, babysitters, or neighbors ; Strangers are the offenders in approximately 10% of child sexual abuse cases.

59. Most child sexual abuse is committed by men; women commit approximately 14% of offenses reported against boys and 6% of offenses reported against girls.  Most offenders who abuse pre-pubescent children are   pedophiles ; however, a small percentage do not meet the diagnostic criteria for pedophilia.

60. Sexual abuse of people with developmental disabilities People with developmental disabilities are often victims of sexual abuse. According to research, people with disabilities are at a greater risk for  victimization  of sexual assault or sexual abuse because of lack of understanding ( Sobsey & Varnhagen , 1989).

61. Identifying Abused Children

62. No child is psychologically prepared to deal with ongoing or intensive sexual stimulation. Even very young children, two or three years old, may sense that the sexual activity is "wrong," but they are unable to stop it. Children are frequently threatened that if they tell anyone, they will be killed or sent away, or their puppy will be killed; or their whole family will breakup.

63. Children subjected to sexual over-stimulation, with or without threats, will develop problems. Those older than five years of age become caught between loyalty to or dependence on the perpetrator, and shame at doing something "wrong.“ Over time, the child develops low self-esteem, feelings of being worthless or "dirty," and an abnormal view of sexuality

64. Identifying signs

65. Withdrawal and mistrust of adults Suicidal tendencies Difficulty relating to others except in sexual or seductive ways Unusual interest in or avoidance of all things sexual or physical Sleep problems, nightmares, fears of going to bed Forcing sexual acts on other children Extreme fear of being touched Unwillingness to submit to physical examination

66. Frequent accidents or self-injurious behaviors Refusal to go to school, or to the doctor, or home Secretiveness or unusual aggressiveness Sexual components to drawings and games

67. Neurotic reactions (obsessions, compulsiveness, phobias) Habit disorders (biting, rocking) Wears long sleeves in hot weather (to hide bruises?) Unusual sexual knowledge or behavior Prostitution

68. Specific physical indicators of recent sexual abuse

69. Difficulty in walking or sitting Torn, stained or bloody clothing Pain or itching in genital area Bruises or bleeding in genital area or mouth Pregnancy or sexually transmitted diseases, especially in pre-teens Repeated urinary infections or genital blockages

70. THE ELDERLY PRIMIGRAVIDA

71. The elderly primigravida is a patient going through her 1 st pregnancy at or over the age of 40 years. This definition may be adopted in the developing countries but it must be remembered that the reproductive activity of the women in developing countries starts at a much earlier age than that of the women in developed countries.

72. Although the age limit is being raised from 35-40 years in Britain and other European countries , it may be wise to regard as an elderly primigravida , any women who is pregnant for the 1 st time at the age of 30years or more in developing countries.

73. Nursing Management

74. Pregnancy Education Childbirth education classes oriented toward the older woman provide important information on pregnancy and bring these women and their support people together. A woman over age 40, like any other pregnant woman, needs access to health care personnel who can supply her with factual information during a pregnancy.

75. Nutrition Assess the number of meals a woman eats outside her home each week, including those she packs for lunch or eats in restaurants . She may need tips on how to adjust pregnancy nutrition so she can obtain the same nutrition whether she prepares meals at home or eats them at an office or community function.

76. Nutrition Urge her to substitute a caffeine-free soft drink in place of an alcoholic beverage. In some offices, large amounts of coffee are consumed. Urge her to substitute milk or juice or decaffeinated coffee. Many women this age normally drink little milk. Rather than getting used to milk again , a woman may appreciate suggestions on other ways to ingest calcium, such as puddings or yogurt.

77. Prenatal Classes Because a pregnant woman over age 40 may be unique in her circle of friends, she may feel shut out of her usual group because of the pregnancy . This makes her ready, therefore, to join a childbirth preparation or prenatal exercise class where she is “one of the group ”.

78. Prenatal Classes Be certain a woman plans (or the couple plans together) to set aside a specific time every day to do breathing exercises in preparation for labor. A busy woman may never find time to get to them and will be unprepared in labor.

79. C omplications Tendency to abort Increased incidence of hypertension, pre- eclampsia . This is understandable because the older the women, gets the more likely to develop hypertension. The long period of infertility may induce the development of uterine fibroids which may complicate the pregnancy.  

80. Labor tends to be longer in the elderly primigravida than in the multipara . Posterior position of the occiput are also common .Abnormal uterine action may complicate labor.. There is increased need for obstetric intervention because of the rigid perineum and prolonged labor .

81. The neonatal morbidity and mortality are increased because of prematurity, prolonged labor and the need to intervene, as well as the increase evidence of congenital fetal abnormalities ( eg : Down’s Syndrome , hydrocephaly, anencephaly etc. ) with increase maternal age

82. Maternal morbidity and mortality are higher in elderly primigravida than in young primigravida is faced the nurse midwife must refer all elderly primigravida to the big hospital for delivery.

83. THE PHYSICALLY/ COGNITIVELY CHALLENGED

84. In the past, women with conditions such as vision, hearing, cognitive , neurologic, or orthopedic challenges were sheltered by their families to such an extent that women with even moderately physically challenging conditions could not meet potential sexual or marriage partners and so did not become pregnant.

85. In addition, most people believed these individuals should not become pregnant. Today , women with varying degrees of disability attend public schools, work in offices , join community organizations, establish sexual relationships , marry, and plan pregnancies just like everyone else .

86. NOTE: Urge women with a physical or cognitive disability or illness to come for pre-conceptual care so medicines they are taking can be evaluated and careful planning for safe pregnancy care can be started early (Thierry, 2007).

87. Rights of the Physically or Cognitively Challenged Person There are ethical and legal considerations related to women with disabilities and pregnancy . Physically disabled persons must have freedom of access to public buildings by means of ramps or handrails.

88. Rights of the Physically or Cognitively Challenged Person All public health care facilities must be in compliance with these laws both in terms of physical facilities and in the true spirit of the law: that is, people should be made to feel psychologically welcome as well as physically able to reach the inside of the building.

89. Rights of the Physically or Cognitively Challenged Person Under the same law, a hospital cannot deny care to a person with a disability even though the disabling condition complicates treatment considerably, possibly requiring extra personnel and time. A woman with a disability has full rights to her child, so the baby cannot be taken from her at birth with-out her full consent .

90. Rights of the Physically or Cognitively Challenged Person Likewise, she cannot be forced to terminate a pregnancy or undergo sterilization unless that is her informed decision

91. Modifications for Pregnancy Explore with women at a first prenatal visit the exact nature of their disability and their general self-image to identify what modifications they may need in care during pregnancy.

92. Modifications for Pregnancy Some women who are physically or cognitively challenged maintain high self-esteem despite severe limitations and are able to modify, grow, and learn with a pregnancy, whereas others have a poor sense of self-esteem that will make this particularly difficult for them.

93. Modifications for Pregnancy For many of them, pregnancy will become a special event, a 9-month announcement to everyone that, despite their seeming limitations, they are equal to other women and capable of participating in one of life’s miracles. If a woman is housebound, be certain that she is taking a prenatal vitamin containing vitamin D as she is probably not receiving as much sun exposure as usual (More, 2007).

94. Safety Measures to Explore Safety is a key area of concern when caring for a pregnant woman who is physically or cognitively challenged. Be sure to assess areas such as emergency contact persons, suppliers of transportation , and individual considerations such as mobility , elimination, and possible autonomic responses .

95. Safety Measures to Explore Be certain that a woman reviews any medicine she is taking for her primary condition with her primary care provider to be certain that this will continue to be safe during pregnancy. Women with recurrent seizures, for example, may need to have their dose of anti-seizure medicine reduced during pregnancy because these may be teratogenic ( Adab et al., 2009).

96. Safety Measures to Explore 1. Emergency Contacts. Evaluate the client’s ability to contact someone in case of pregnancy-related emergency. Does a woman have a telephone she can reach readily? Does she know how to activate the emergency medical system (911) in her community ?

97. Safety Measures to Explore 1. Emergency Contacts. If a woman’s speech is not clear, evaluate whether she will be understood while using a telephone to call for help in an emergency. Some women with limited mobility , such as those with spinal cord injury or cerebral palsy, have a specially designed telephone contact system in their home that connects to a paramedic or hospital emergency service through a beeper system.

98. Safety Measures to Explore 1. Emergency Contacts. Check that they intend to maintain this throughout pregnancy. Women who are hearing challenged use a specially equipped telephone (a TDD device) that prints out messages for them.

99. Safety Measures to Explore 2 . Transportation Assess a client’s ability to come for prenatal care . If a woman depends on a support person for transportation to a health care facility, appointments may have to be arranged according to that person’s schedule to prevent missed appointments.

100. Safety Measures to Explore 2 . Transportation If a woman does not drive, who would transport her if a pregnancy emergency should occur? Women with cognitive or vision challenges, for example, may not qualify for a driver’s license and so may need someone, such as a family member or friend, to drive.

101. Safety Measures to Explore 3. Mobility All women who use wheelchairs are taught to press with their hands against the armrests and lift their buttocks up off the wheelchair seat for 5 seconds every hour. This prevents the formation of pressure ulcers on the buttocks and posterior thighs.

102. Safety Measures to Explore 3. Mobility Encourage a pregnant woman to continue to perform this maneuver during pregnancy as the increased weight of a fetus increases her risk for pressure ulcer formation from compression. In addition, severe hip flexion from sitting in a wheelchair limits venous return from the lower extremities.

103. Safety Measures to Explore 4 . Elimination When mobility is an effort, a woman may not drink as much as usual or use a bathroom as frequently as she would if those actions were effortless. Encourage a high fluid intake and frequent voiding, however, to prevent urinary tract infections.

104. Safety Measures to Explore 4 . Elimination Women with spinal cord injury who use an indwelling catheter are at especially high risk for contracting urinary tract infections during pregnancy. Women who perform self-catheterization or change their own indwelling catheter may be unable to continue to do this late in pregnancy because the increasing size of their abdomen interferes with their ability to see or reach their perineum comfortably .

105. Prenatal Care Modifications to Meet Specific Needs To help a woman move to the table, a ramp from the physical therapy department may be necessary so the wheelchair can be elevated to the level of the table.

106. Prenatal Care Modifications to Meet Specific Needs Woman with spinal cord injury or cerebral palsy may be unable to maintain their legs in a lithotomy position because of either hip flexion contracture or laxness of leg support. This means a dorsal recumbent, rather than a lithotomy, position may be required for a pelvic examination.

107. Prenatal Care Modifications to Meet Specific Needs Women who are cognitively challenged may not be aware how they became pregnant. If a woman became pregnant because she was taken advantage of sexually, she may need some time to talk and work through this experience before she can allow a pelvic examination.

108. Prenatal Care Modifications to Meet Specific Needs When interviewing or teaching visually challenged women, be certain not to use your hands to illustrate points (“I’ll need a urine sample of at least this much urine [measured with your fingers]”). Do not use colors as descriptions of objects (“put on the blue gown”).

109. Prenatal Care Modifications to Meet Specific Needs Use demonstration aids that allow a woman to feel or touch instead. When helping with or performing physical assessment, let a woman know you are closing the door or drawing a curtain to ensure privacy.

110. Prenatal Care Modifications to Meet Specific Needs Always alert a woman when you are going to touch her, so as not to startle her. Otherwise, you may find yourself facing a growling guide dog that rises to protect her.

111. Prenatal Care Modifications to Meet Specific Needs If a woman is hearing impaired, she may not be able to see the examiner’s face during a pelvic examination. This means any question asked of her during this time will not be understood because she cannot see the examiner’s lips to lip read ( O’Hearn , 2007)

112. Pregnancy Education Modify health teaching to meet each woman’s specific needs. For a woman who is cognitively challenged, for example, instructions about pregnancy may need to be limited to those few items crucial for safety, such as “do not drink alcohol or take any medicine.”

113. Pregnancy Education Activity and exercise, important for any pregnant woman, are crucial for a woman who is physically challenged. If mobility is a concern, exercise can be very reduced in bad weather . In this case, be sure a woman understands that walking around her home or apartment can provide the same level of exercise as if she were walking around the block or exercising at a health club

114. Pregnancy Education If a woman is severely hearing challenged, she may not have heard the many spot television announcements on not smoking or drinking alcohol during pregnancy; she may need more time at prenatal visits so this can be discussed.

115. Pregnancy Education In addition, lip reading is a difficult skill to learn, so many hearing-challenged persons cannot do this with ease. Even if a woman is skilled at this, she may not be able to decipher new words such as amniotic, gestation, or edema.

116. Pregnancy Education Show her the printed words so she can see what your lip motion represents when presenting new pregnancy terms. If a woman uses sign language, she may bring an interpreter with her to translate. Be certain to talk to her, not the interpreter, when interviewing.

117. Modifications for Labor and Birth A woman with a spinal cord injury may not be able to feel uterine contractions. Late in pregnancy, she will need to palpate her abdomen periodically for tightening or the presence of contractions so she is aware of beginning labor. Women with muscle spasticity or spinal cord injury may not be able to push effectively for the second stage of labor and so may need cesarean or forceps birth.

118. Modifications for Labor and Birth If a woman cannot assume a lithotomy position because of hip contracture, vaginal delivery from a Sims’ or dorsal recumbent position is best. Braille watches used by visually challenged persons may not have second hands. They may need to time the length of contractions by counting rather than timing them by a watch.

119. Modifications for Labor and Birth During labor, the hearing-challenged woman cannot hear information on how she is progressing if you are not directly facing her. If she needs to communicate with her support person in sign language, act as an advocate to keep her hands unencumbered by equipment such as intravenous lines. Remember she cannot hear her infant cry at birth. Hand the infant to her as soon as possible after birth so she can see and feel the baby is crying and breathing well.

120. Modifications for Labor and Birth Be certain to identify the usual sounds of birthing rooms (the beeping of a monitor, the swish of a central supply routing system, and so forth) for the visually challenged woman . Hearing sounds and not being able to identify them can be frightening.

121. Modifications for Postpartum Care After birth, be sure to assess and teach: Whether a woman desires contraceptive information. Whether she needs additional support to be successful at breastfeeding . Whether she has a return appointment for both herself and her infant for follow-up care and that the arrangements are within her capabilities, transportation, and understanding .

122. Modifications for Planning Child Care Allow for extra time during the first days after birth for mother–child interaction. For example, after birth, a woman who is cognitively challenged may need extra time to understand the transition from “being pregnant” to “having a baby .” She may have difficulty learning to judge when her infant is hungry. She may need extra supervision to be certain she does not leave the baby unprotected on a bed.

123. Modifications for Planning Child Care A woman with a spinal cord disability may be particularly interested in inspecting her baby’s back. A visually challenged woman will probably want to reassure herself her baby can see. Be sure to give her baby to her as soon as possible after birth so she can touch the baby and feel for intact body parts.

124. Modifications for Planning Child Care If the birthing room is cold, explain to her that you want to re-wrap the baby to prevent chilling, not because her touching is wrong or because you are trying to hide an imperfection in the baby .

125. Modifications for Planning Child Care Breastfeeding has special advantages for women who are physically or cognitively challenged because it is the method of feeding that is not only best for the baby, but also requires the least preparation effort on the mother’s part. For a woman who is visually challenged and unable to read printed instructions , breastfeeding eliminates formula errors. For a woman who uses a wheelchair, it eliminates trips to the refrigerator .

126. Modifications for Planning Child Care Urge a visually challenged woman to make eye contact when talking to her infant. Many visually challenged people do not turn on lights in their home because they do not perceive the difference between light and dark. Encourage a woman to develop a habit of turning on lights after dinner because her infant will need light to develop vision. If her support person also is visually challenged, suggest she check with a close friend or neighbor monthly to see that light bulbs have not burned out…

127. Modifications for Planning Child Care One of the biggest worries for the hearing-impaired woman is that she will not be able to hear her baby crying. Help her plan to bring the infant’s crib or bassinet close to her bed so she can feel the vibration of the baby’s stirring and waking . Urge her to talk to her infant as she gives care so the infant is introduced to sounds and words.

128. Modifications for Planning Child Care Some women whose speech is severely affected by their hearing disorder are reluctant to speak to strangers. Assure her that her infant is not a stranger and will quiet readily to the sound of her voice. The child may develop her speech pattern because of this. Being spoken to and sung to during the first year is important for overall development, however, so this is still preferable to living in a world of silence

129. SUBSTANCE ABUSE

130. Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance (drug) that is not considered dependent.  Substance abuse/drug abuse is not limited to mood-altering or psycho-active drugs.

131. Activity is also considered substance abuse when inappropriately used (as in steroids for performance enhancement in sports). Therefore, mood-altering and psychoactive substances are not the only drugs of abuse. Substance abuse often includes problems with impulse control and impulsivity.

132. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in non-medical contexts. The terms have a huge range of definitions related to taking a  psychoactive drug  or  performance enhancing drug  for a non-therapeutic or non-medical effect.

133. Some of the drugs most often associated with this term include: alcohol ,  amphetamines , barbiturates , benzodiazepines  ( particularly temazepam ,  nimetazepam , and  flunitrazepam ),  cocaine ,  methaqualone , and opioids .

134. Use of these drugs may lead to criminal penalty in addition to possible physical, social, and psychological harm, both strongly depending on local jurisdiction. 

135. Causes

136. Family history factors that influence a child's early development have been shown to be related to an increased risk of drug abuse, such as chaotic home environment, ineffective parenting, lack of nurturing and parental attachment.

137. Factors related to a child's socialization outside the family may also increase risk of drug abuse, including inappropriately aggressive or shy behavior in the classroom, poor social coping skills, poor school performance, association with a deviant peer group or isolating self from peers altogether, perception of approval of drug-use behavior.

138. Symptoms and Signs

139. Depending on the actual compound, drug abuse including alcohol may lead to health problems,  social problems ,  morbidity ,  injuries ,  unprotected sex ,  violence ,  deaths ,  motor vehicle accidents ,  homicides ,  suicides ,  physical dependence  or  psychological addiction .

140. Signs to Watch Giving up past activities such as sports, homework, or hanging out with new friends Declining grades Aggressiveness and irritability Significant change in mood or behavior Forgetfulness

141. Disappearing money or valuables Feeling rundown, hopeless, depressed, or even  suicidal Sounding selfish and not caring about others Use of room deodorizers and incense Paraphernalia such as baggies, small boxes, pipes, and rolling paper

142. Physical problems with unclear cause (for example, red eyes and slurred speech) Getting drunk or high on drugs on a regular basis Lying, particularly about how much alcohol or other drugs he or she is using Avoiding friends or family in order to get drunk or high

143. Planning drinking in advance, hiding alcohol, and drinking or using other drugs alone Having to drink more to get the same high Believing that in order to have fun you need to drink or use other drugs Frequent hangovers Pressuring others to drink or use other drugs

144. Taking risks, including sexual risks Having "blackouts," forgetting what he or she did the night before Constantly talking about drinking or using other drugs Getting in trouble with the law Drinking and driving Suspension or other problems at school or in the workplace for an alcohol- or drug-related incident

145. When to Seek Medical Care

146. Mild  tremors  or an alcohol withdrawal seizure  not accompanied by hallucinations or confusion Jaundice  (yellow skin and eyes) Increasing abdominal girth Leg  swelling Cough  that won't go away Continuing feelings of sadness or depression Pain at an injection site Fever Chest pain

147. If any of the following occur, admit the patient to a near by hospital immediately: Thoughts of harming yourself or others Chest pain , rapid heartbeat, difficulty breathing, or  light-headedness Severe  abdominal pain Confusion or ongoing hallucinations Severe  tremors  or  recurrent  seizures

148. Difficulty speaking, numbness, weakness, severe  headache , visual changes, or trouble keeping balance Severe pain at an injection site (may be accompanied by redness, swelling, discharge , and fever) Dark, cola-colored  urine

149. Medical Treatment

150. Most substances abusers believe they can stop using drugs on their own, but a majority who try do not succeed. Research shows that long-term drug use alters brain function and strengthens compulsions to use drugs. This craving continues even after your drug use stops.

151. Because of these ongoing cravings, the most important component of treatment, also called recovery, is preventing relapse. Treating substance abuse depends on both the person and the substance being used.

152. In behavioral treatment, a counselor provides you with strategies to cope with your drug cravings and ways to avoid relapse. Your doctor may prescribe medications, such as nicotine patches and  methadone , to control withdrawal symptoms and drug cravings.

153. Often, a drug user has an underlying behavioral disorder or other mental illness, one that increases risk for substance abuse. Such disorders must be treated medically and through counseling along with treatment of the drug abuse.

154. Prevention of Substance Abuse

155. Substance abuse may start in childhood or adolescence . Abuse prevention efforts in schools and community settings now focus on school-age groups.

156. Programs seek to increase communication between parents and their children, to teach  resistance  skills, and to provide information in order to correct children's misperceptions about cigarettes, alcohol, and drugs and the consequences of their use. Most importantly, officials seek to develop, through education and the media, an environment of social disapproval from children's peers and families.

157. Prognosis of Substance Abuse Individuals who suffer from substance abuse tend to be more successful in recovery when they are highly motivated to be in treatment, are actively engaged in their own recovery, and receive intensive treatment services. Prognosis for substance abuse recovery is further improved by being able to easily access community-based social supports.

158. Negative impact of drug and alcohol use

159. Crime : More than half of the economic cost of alcohol and drugs is due to crime. A substance abuser is 18 times more likely to be involved in illegal activity than someone in the general population. Many violent crimes have been linked to the mind-altering effects of drugs.

160. Disease : Most abused substances have harmful health effects. For some substances, such as tobacco, effects are caused by long-term use. For other drugs, a single use can cause death, disability, or significant disease.

161. Behavior: In addition to their direct effects on health, drugs produce other indirect effects. Many drugs lessen inhibitions and increase the likelihood that a person will participate in risky behavior.

162. Studies show that the use of alcohol and drugs among teenagers increases chances for teen  pregnancy  and contracting HIV/AIDS or other  sexually transmitted diseases . Any injected drug is associated with contracting HIV/AIDS and  hepatitis B  and  C .

163. Substance abusers often commit thefts to support their drug habits. Drugs and alcohol have been linked to  domestic violence  and  sexual assault . At colleges, 75% of date rapes are alcohol-related. Among jailed sex offenders, 43% say they were under the influence of drugs or alcohol at the time of their crime.

164. Trauma: Up to 75% of injured people treated at emergency departments test positive for illicit or  prescription  drugs . Alcohol is strongly associated with both intentional and unintentional   injury . Drug use also puts people at risk of violence. Nearly half of assault victims are cocaine users.