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 woman¶s 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 probability of having seizures is eliminated Objectives: 1. After nursing 5 minutes of Intervention client¶s due antihypertensive medications will be administered effectively as doctor¶s order
Administer due antihypertensive medications as doctor¶s order
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 The woman is placed on bed rest, primarily on her left side, to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume and renal perfusion. Improved renal blood flow helps decrease Angiotensin II levels, promotes dieresis, and lowers blood pressure. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London,
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.
Effectiveness - The client¶s 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 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.
before she got pregnant -the patient said that her blurry vision worsened
the eyes. 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 Unit 3 4. After 10 minutes Chapter 15 pg of nursing 427 -438. intervention stress causing seizures will be eliminated effectively. Provide an environment conducive to rest.
Davidson Chapter 15 page 343 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 ³cheat´ 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
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 client¶s due anticonvulsions medications will be administered effectively as doctor¶s order.
Administer due anti-convulsions medications as doctor¶s 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 client¶s 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 shift the client¶s fluid volume will be stabilized as evidenced by balanced I & O, and free of signs of edema Objectives: 1. After 8 hours shift the client¶s I & O will be monitored and recorded accurately. 2. After nursing intervention the client¶s fluid volume will be
Monitor and record I & O.
Provides a comparative baseline and evaluates the effectiveness of diuretic therapy. Nurse¶s Pocket Guide page 329 Diuretics are routinely used in heart failure to remove excessive sodium and water to relieve symptoms
Administer diuretic medications as doctor¶s order.
Effectiveness - The client¶s excess fluid were excreted - The client¶s I &O was balanced - The client¶s extremities had no signs of edema 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
whether it is pitting/ nonpitting edema. MEASURE MENT: -I&O q 2 (Refer on the Lab results part)
stabilized by administering her due diuretic medications effectively as doctor¶s order. 3. After nursing intervention the client¶s fluid volume will be stabilized by positioning her to her left side lying position. Assist the client to her left side lying position.
associated with pulmonary congestion and edema. Basic Pharmacology for Nurses by Clayton, Stock, Harroun; Chapter 29 page 463 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. Nurse¶s Pocket Guide page 330
acceptable to the client to solve the health problem.
4. After nursing intervention the client¶s 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 client¶s 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
Unpleasant Goal: After 30 sensory and minutes of nursing emotional intervention the experience client¶s pain will be arising from alleviated as actual or verbalized by the potential client tissue damage or Objective describe 1. After 5 minutes of terms of such nursing damage; intervention the sudden or client¶s due slow onset of analgesics will be any intensity administered from mild to effectively as severe with doctor¶s order an anticipated or predictable 2. After 5 minutes of end and nursing duration of intervention the less than 6 client¶s pain will be months managed effectively by nonpharmacologic pain management
Administer analgesics as needed as doctor¶s order.
Use of analgesics relieves the woman¶s 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
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
Encourage visits of significant
positioning
client will be provided proper distraction from pain
others.
sensations and help reduce her fear and anxiety. A look at Contemporary Maternal-Newborn Nursing Care by Ladewig, London, Davidson Chapter 30 page 826 Breathing techniques increase woman¶s 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. Nurse¶s Pocket Guide page 502
4. After 10 minutes of nursing intervention the client will be able to properly utilize breathing techniques to alleviate pain.
Educate client how to use breathing techniques.
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