Nursing Care Plan

Name: D. L. Cues Nursing Diagnosi s Increased cardiac output related to severe preeclam psia as manifeste d by the blood pressure reading and the admitting diagnosis of the patient Age: 34 y/o Analysis Sex: Female Goals & Objectives Nursing Interventions Rationale Evaluation

Objective Cues: -BP reading: 160/110 -the patient has an admitting diagnosis of chronic hypertensio n with superimpos ed preeclampsia -edema from both higher & lower extremities with moderate indention (2+) -marked protenuria (3+) Subjective Cues: -the patient said that she is hypertensiv e even

A woman has severe preeclampsia when her blood pressure has risen to 160 mm Hg systolic and 110 mm Hg diastolic or above. Marked protenuria, 3+ or 4+ on a random urine sample. Extreme edema will be noticeable as puffiness in a womans face or hands. If Cerebral edema occurs, reports may be voiced of visual disturbances such as blurred vision or seeing spots before

Goal: After 8 hours shift the clients condition will not progressed to eclampsia Objectives: 1. After nursing 5 minutes of Intervention clients due antihypertensive medications will be administered effectively as doctors order Effectiveness - The clients blood pressure was stabilized - All predisposing factors of seizure were eliminated - The client did not experienced seizures Efficiency All resources were available to solve the health problem. Adequacy The Interventions were adequate to solve the The woman is placed on bed health problem. rest, primarily on her left side, Appropriateness to decrease pressure on the All interventions were vena cava, thereby increasing appropriate to solve the venous return, circulatory health problem. Acceptable volume and renal perfusion. Improved renal blood flow All interventions were helps decrease Angiotensin II acceptable to the client to levels, promotes dieresis, and solve the health problem. lowers blood pressure. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Drugs used to treat hypertension work to alter the normal reflexes that control blood pressure. Treatment for essential hypertension does not cure the disease but aimed at maintaining the blood pressure within normal limits to prevent the damage that hypertension can cause. Focus on Nursing Pharmacology by Amy M. Karch page 674

Administer due antihypertensive medications as doctors order

2. After 5 minutes of Assist the client nursing to her left side intervention the lying position. client will be assisted appropriately on her left side lying position.

before she got pregnant -the patient said that her blurry vision worsened

the eyes.

Davidson Chapter 15 page 343 Provide an environment conducive to rest. Bed rest must be complete. Stimuli that may bring on a seizure should be reduced. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 15 page 343 Stress is another stimulus capable of increasing blood pressure and evoking seizures in a woman with severe preeclampsia. Allow her opportunities to express her feelings about what is happening. Clear explanations help her accept the need for visitor restrictions and not to cheat on bed rest. Maternal & Child health Nursing: Care of the Childbearing and Childbearing Family by Adele Pillitteri Unit 3 Chapter 15 paeg 430 Magnesium sulfate is the treatment of choice for convulsions. Its depressant action on the CNS reduces the possibility of seizure. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 15 page 343

Ref.: Maternal 3. After 5 minutes of & Child nursing Health intervention the Nursing: Care client will be able of the to rest Childbearing comfortably. & Childbearing Family by Adele Pillitteri 4. After 10 minutes Unit 3 of nursing Chapter 15 pg intervention 427 -438. stress causing seizures will be eliminated effectively.

Give clear explanation of what is happening and what is planned to the client. Allow her to express her feelings.

5. After 5 minutes of nursing intervention the clients due anticonvulsions medications will be administered effectively as doctors order.

Administer due anti-convulsions medications as doctors order.

6. After nursing intervention the client will be given meals appropriate for her condition.

Check if the meal given to the client is appropriate for the clients condition.

A High-protein, moderate sodium diet is given as long as the woman is alert and has no nausea or indication of impending seizure. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 15 page 343

Cues

Nursing Diagnosi s Excessiv e fluid volume related to excess sodium intake as manifeste d by -swelling of the lower and upper extremitie s -Input and Output differenc e

Analysis

Goals & Objectives

Nursing Interventions

Rationale

Evaluation

SUBJECTIV E - The patient noticed that her feet became swollen at her third trimester until now. OBJECTIVE -Weak appearance -Swelling of the lower extremities and upper extremities -Test on the physical exam to determine

Goal: After 8 hours Fluid volume excess (FVE) shift the clients fluid refers to an volume will be isotonic balanced as expansion of evidenced by the balanced I & O, and ECF caused free of signs of by the edema abnormal retention of Objectives: water and sodium in 1. After 8 hours shift approximately the clients I & O the same will be monitored proportions in and recorded which they accurately. normally exist in the ECF. It is always 2. After nursing secondary to intervention the an increase in clients fluid the total body volume will be

Monitor and record I & O.

Provides a comparative baseline and evaluates the effectiveness of diuretic therapy. Nurses Pocket Guide page 329 Diuretics are routinely used in heart failure to remove excessive sodium and water to relieve symptoms

Administer diuretic medications as doctors order.

Effectiveness - The clients excess fluid were excreted - The clients I &O was balanced - The clients extremities had no signs of edema Efficiency All resources were available to solve the health problem.

whether it is pitting/ nonpitting edema. MEASURE MENT: -I&O q 2 (Refer on the Lab results part)

sodium stabilized by content, administering her which, in turn, due diuretic leads to an medications increase in effectively as total body doctors order. water. Because 3. After nursing there is intervention the isotonic clients fluid retention of volume will be body stabilized by substances, positioning her to the her left side lying serum sodium position. concentration remains essentially normal.

associated with pulmonary congestion and edema. Basic Pharmacology for Nurses by Clayton, Stock, Harroun; Chapter 29 page 463 Assist the client to her left side lying position. The woman is placed on bed rest, on her left side, to decrease pressure on the vena cava, thereby increasing renal perfusion. Improved renal blood flow helps decrease Angiotensin II levels and promotes dieresis. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 15 page 343 Promoting diuresis helps relieve fluid retention. Helping the postpartal woman use the toilet, if possible, or the bedpan prevents urinary retention and bladder overdistention in most cases. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 30 page 816 Increase venous blood flow; reduce tissue pressure and risk of skin breakdown. Nurses Pocket Guide page 330

Adequacy The Interventions were adequate to solve the health problem. Appropriateness All interventions were appropriate to solve the health problem. Acceptable All interventions were acceptable to the client to solve the health problem.

4. After nursing intervention the clients fluid volume will be stabilized by assisting her to void appropriately and adequately.

Assist the client use the toilet, if possible, or the bedpan.

5. After nursing the clients extremities will be relieved from edema

Elevate edematous extremities.

Cues

Nursing Diagnosi s Acute pain related to surgical incision as manifeste d by the verbalizat ions of the client.

Analysis

Goals & Objectives

Nursing Interventions

Rationale

Evaluation

SUBJECTIV E - The patient had undergone LTCS. - Pain on incision site. - The patient said that she cannot sleep because of pain felt on incision site. - she said that that the pain is in the rate of 7 out of 10 OBJECTIVE - The patient was ordered of Mefenamic acid. - The patient was wearing an abdominal binder. - difficulty in moving and positioning

Goal: After 30 Unpleasant sensory and minutes of nursing emotional intervention the experience clients pain will be arising from alleviated as actual or verbalized by the potential client tissue Objective damage or describe 1. After 5 minutes of terms of such nursing damage; intervention the sudden or clients due slow onset of analgesics will be any intensity administered from mild to effectively as severe with doctors order an anticipated or predictable end and 2. After 5 minutes of duration of nursing less than 6 intervention the months clients pain will be managed effectively by nonpharmacologic pain management

Administer analgesics as needed as doctors order.

Use of analgesics relieves the womans pain and enables her to be more mobile and active. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 30 page 826 Promote comfort through proper positioning, and reduction of noxious stimuli such as noise and unpleasant odors to promote nonpharmacological pain management. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 30 page 826 These visits distract the woman from painful sensations and help reduce her fear and anxiety.

Provide comfort measures.

Effectiveness - The client was relieved from pain - The client was able to verbalize/report changes of intensity of pain Efficiency All resources were available to solve the health problem. Adequacy The Interventions were adequate to solve the health problem. Appropriateness All interventions were appropriate to solve the health problem. Acceptable All interventions were acceptable to the client to solve the health problem.

3. After nursing intervention the client will be provided proper

Encourage visits of significant others.

distraction from pain

A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 30 page 826 Educate client how to use breathing techniques. Breathing techniques increase womans pain threshold, permit relaxation, provide sense of control and allow the uterus to function more efficiently. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 19 page 459 Instruct patient to report pain as soon as it begins as timely intervention is more likely to be successful in alleviating pain. Nurses Pocket Guide page 502

4. After 10 minutes of nursing intervention the client will be able to properly utilize breathing techniques to alleviate pain.

5. After 3 minutes of nursing intervention the client will verbalize her perception of pain

Instruct client to verbalize/report changes of intensity of pain