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NCP- Ineffective tissue perfusion ECLAMPTIC SEIZURE

NCP- Ineffective tissue perfusion ECLAMPTIC SEIZURE

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Published by khanepot

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Published by: khanepot on Jul 30, 2009
Copyright:Attribution Non-commercial

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02/20/2013

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONRATIONALE EVALUATION
Objective:* Pale looking* edematous* Blood pressure:200?140mmHg* Temperature:39.5 degreeCelsius.* Halt respirations10cpm.* Pulse Rate:96bpm* Hyperactivepatellar reflex.* Nauseated* Urinary output of 20mL/hr.* delayed capillaryrefill.*twitching of facialmuscle.* Arms flexed.Ineffective tissueperfusion related tovasoconstriction of blood vesselssecondary toeclamptic seizure.After 10 minutes of nursingintervention thepatient willmanifest anincrease inoxygenation asevidenced of normal skin color,pinkish mucosa,good capillary refilland good breathingpattern.* Maintain a patentairway.*Don’t put atongue bladebetween awoman’s teeth.* Administeroxygen by facemask.* Assess oxygensaturation via pulseoximeter.* Apply an externalfetal heart monitor.* The priority carefor a woman with aseizure is tomaintain a patentairway. This isnecessary tomaintain maternaland fetal adequateoxygenation and toprevent fetalbradycardia.* Doing so cancause broken teethwhich could thenbe aspirated.* To protect thefetus duringeclamptic stage.* To measureoxygen saturationof the patient’sblood.* To assess thecondition of thefetus if one is notalready in place toassess it.After 10 minutes of nursingintervention theclient manifestedan increase inoxygenation asevidenced of normal skin color,pinkish mucosa,good capillary refilland good breathingpattern. Therefore,the plan was met.

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