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NURSING CARE

PLANS
GESTATIONAL HTN – PREECLAMPSIA-
ECLAMPSIA- HELLP SYNDROME
NCP 1 :
IMPAIRED GAS EXCHANGE R/T ALTERED BLOOD
FLOW TO ALVEOLI SECONDARY TO
PULMONARY EMBOLISM
Nursing Diagnosis: Impaired Gas Exchange
r/t altered blood flow to alveoli secondary to
pulmonary embolism 
Cause analysis: Pulmonary embolism is
usually caused by a thrombus fragment
(embolus) carried by venous circulation to the
right heart When the embolus occludes the
pulmonary artery, it obstructs the passage of
passage of blood into the lungs, either wholly
or in part, and the patient may die of
asphyxia within a few minutes. (Maternity
Nursing 7th Edition by Reeder, Martin, and
Koniak pg.1016)

CUES OBJECTIVES
Subjective: STO:
“Luya kaayo ko og kalipongon ko” as verbalized After a total of 18 hours of auscultation of lungs, observation
Objective: skin color, monitoring of vital signs, assessing level of
Temp - 38.2 oC consciousness and activity intolerance, head elevation,
PR - 88 bpm administration of supplemental oxygen,
RR - 18 bpm medication(anticoagulants), providing fluids either IV or PO
BP – 130/100 as indicated. The client will demonstrate adequate
Cyanotic ventilation/oxygenation as evidence by absence of nasal
92% O2 Sat flaring, decreased body temp from 38.2 oC to 37.5 oC, pink
skin, decresed BP to 120/90 mmHg, and an O2 saturation of
95% or above.
LTO:
After 2 days of continued nursing interventions the client will
report/display resolution or absence of symptoms of
respiratory distress as evidence by absence of dyspnea, ability
to relax with ease, pink skin and an O2 saturation of 95% or
above.
NURSING INTERVENTIONS RATIONALE
Independent
Embolus Care Tachypnea and dyspnea accompany pulmonary obstruction.
Note respiratory rate and depth, work of breathing (use of Dsypnea and increased work of breathing may be fist or only
accessory muscles/nasal flaring, pursed-lip breathing). sign of subacute pulmonary embolus (PE). Severe respiratory
Airway Management distress/failure accompanies moderate to severe loss of
Institute measures to restore /maintain patent airways; e.g., functional lung units.
coughing, suctioning. Plugged/collapsed airways reduce number of functional alveoli,
Elevate head of bed as client requires/tolerates. negatively affecting gas exchange.
Assist with frequent changes of position, and get client out of Promotes maximal chest expansion, making it easier to breathe
bed/ambulate as tolerated and enhancing physiologic/psychologic comfort
Collaborative Turning and ambulation enhance aeration of different lung
Airway Management segments, thereby improving oxygen diffusion.
Administer supplemental oxygen by appropriate method. .
Administer medication as indicated: Maximizes available oxygen for gas exchange, reducing work
Thrombolytic agents; e.g., alteplase; anistreplase; reteplase; o0f breathing. Note: If obstruction is large or hypoxemia does
streptokinase; tenecteplase; urokinase not respond to supplemental oxygenation, it may be necessary to
move client to critical care area for intubation and mechanical
ventilation.
Indicated in massive pulmonary obstruction when client is
seriously hemodynamically threatened. Note: These clients will
probably be initially cared for in/transferred to the critical care
setting.
NCP 2 :
INEFFECTIVE TISSUE PERFUSION R/T
ARTERIOLAR VASOSPASM SECONDARY TO
PREGNANCY INDUCED HYPERTENSION
Nursing Diagnosis: Ineffective tissue
perfusion r/t arteriolar vasospasm secondary
to Pregnancy Induced Hypertension (PIH)
Cause analysis: Arteriolar circulation is
disrupted by alternating segments of
constriction and dilation. The vasospastic
action causes damage to the blood vessels
by decreasing their blood supply. The
vasospasm existing in women with PIH is
attributed to the extreme sensitivity of the
vasculature to vasopressors (Maternity
Nursing 7th Edition by Reeder, Martin, and
Koniak pg. 802)
CUES OBJECTIVES
Subjective: STO:
“Hawoy kaayo ako tiil og mga kamot” After 8 hours of performing leg elevation, early
as verbalized by the client. ambulation when permitted, performing active
Objective: and initiating passive ROM exercises, and
Temp - 38.2 oC increasing fluid intake from 1 liter to 2 liters a
PR - 88 bpm day the client will demonstrate improved
RR - 25 bpm perfusion as evidence by peripheral pulses
BP – 130/100 present/equal, pink skin color, temperature
Tissue edema present pitting +2 decrease to 37.8 oC, moist oral mucusa, and
Weak peripheral pulses on all absence of tissue edema.
extremities LTO
Varicosities present bilaterally After 2 days of continuous evaluation,
Pale, dry, and poor turgor skin examination, assessment, and nursing
Dry oral mucosa interventions, body temperature will remain
Laboratory Tests: within normal range (36.7 to 37.8 oC), be able to
CBC: 50% Hct (increased) walk unaided, free of tissue edema, strong
peripheral pulses, and display increasing
tolerance to activity.
NURSING INTERVENTIONS RATIONALE
Independent:
Promote early ambulation as soon as client is able and Short frequent walks are determined to be better for
with physician’s approval. extremities and prevention of pulmonary
complications than one long walk. If client is
confined to bed, ensure ROM exercises.

Elevate legs when in bed or chair as indicated. Reduces tissue swelling and rapidly empties
superficial and tibial veins preventing overdistention
and thereby increasing venous return. Note: Some
physicians believe that elevation may potentiate
release of thrombus, thus increasing risk of
embolization and decreasing circulation to the most
distal portion of the extremities.

Initiate active or passive exercises while in bed (e.g., These measures are designed to increase venous
flex/extend/rotate foot periodically). Assist with gradual return from lower extremities and reduce venous
resumption of ambulation (e.g., walking 10 min/hr) as stasis, as well as improve general muscle
soon as client is permitted out of bed. tone/strength. They also promote normal organ
function and enhance general well-being.

Instruct client to avoid rubbing /massaging the affected This activity potentiates risk of
extremity. fragmenting/dislodging thrombus causing
embolization, and increasing risk of complications
NURSING INTERVENTIONS RATIONALE
Independent:
Increase fluid intake to atleast Dehydration increases blood
2000mL/day, within cardiac tolerance viscosity and venous stasis,
predisposing to thrombus formation.

Collaborative: Inhibits the vitamin K conversion


Administer anticoagulants cycle, thereby causing hepatic
Apply/regulate graduated compression production of partially carboxylated
stockings, intermittent pneumatic and decarboxylated proteins with
compression if indicated. reduced procoagulant activity.
Sequential compression devices may
be used to improve blood flow
velocity and empty vessels by
providing artificial muscle –pumping
action.
NCP 3 :
DECREASED CARDIAC OUTPUT R/T DECREASED

VENOUS RETURN AEB EDEMA



Nursing Diagnosis: Decreased cardiac
output r/t decreased venous return AEB
edema (hands)
Cause analysis: Pregnancy Induced
Hypertension is a condition in which
vasospasms occur. It is caused by altered
cardiac output that injures endothelial
cells of the arteries. Blood vessels
becomes less resistant to pressor
substances. This results to
vasoconstriction and increases BP
dramatically(Maternity Nursing 7th Edition
by Reeder, Martin, and Koniak)
CUES OBJECTIVES
Subjective: STO:
Ring in the finger feels tighter than Within 4 hours of bed rest, providing quiet

in the past environment and changing position slowly


Vertigo PRN, the patient will display hemodynamic
Dizziness stability BP from 160/100 to
Anxiety 140/100mmHg.
Objective: LTO
Facial grimaces Within 2 to 3 days of giving cousmarin as
BP: 160/100 mmHG prescribed and avoiding high salt diet, the
Difficulty in putting shoes patient will have a normal BP ranging from
HR: 62 BPM 140/100 to 120/80mmHg
PR: 14BPM
NURSING INTERVENTIONS RATIONALE
Independent:
Keep client on the bed and in comfortable position Decreases oxygen consumption.

Decrease stimuli; provide quiet environment.


To promote adequate rest.
Encourage changing position slowly
Instruct to avoid or limit activities that may
stimulate valsalva response (rectal stimulation To reduce risk for orthostatic hypotension.
bearing down B.M)

Encourage deep breathing exercises


To prevent in changes in cardiac pressures or
impede blood flow.
Educate to avoid high salt intake/diet
To reduce anxiety
High salt intake tends to lead to water retention
and may worsen edema
NURSING INTERVENTIONS RATIONALE

Independent:
Use pillow or cushions to raise To promote good circulation
feet and legs above heart when
you are sitting or lying down
Collaborative:
Administer cousmarin as
prescribed
NCP 4 :
RISK FOR HEMORRHAGE R/T LOW PLATELET COUNT

SECONDARY TO DISSEMINATED INTRAVASCULAR


COAGULATION

Nursing Diagnosis: Risk for hemorrhage r/t low
platelet count secondary to disseminated
intravascular coagulation (DIC)
Cause Analysis: DIC occurs when the body’s
clotting mechanism are activated throughout
the body in response ti an injury or a
disorder, instead of being isolated to the area
of initial onset. Platelets circulating
throughout the body from small blood clots
(thrombi) primarily in the area of the
capillaries. (Oncology Encyclopedia, by Linda
K. Bennington, C.N.S, M.S.N

Cues Objectives
Subjective: STO:
Shock:, sighing breaths, dizziness Within 2 hours of educating the patient,
Fainting, apprehension, restlessness she will be able to understand and be
Objective: aware that she’s at risk for hemorrhage;
Thrombocytopenia (a platelet count and will participate in measures to
below 100,000/mm3) prevent injury and also to take
paleness, and low blood pressure precautionary measures.
clammy and cold to touch skin LTO:
Fainting Within 2 days of implementing effective
Rapid, rhythmical pulse health teachings and performing
V/S as follows: precautionary measures to prevent
PR: 92BPM injury, the patient will be able to put into
T: 36.5C action or perform some preventive
RR: 20 BPM, sighing sounds measures such as removing sharp objects
(e.g., nails) that might harm her or
wound and be free of hazards and avoid
hazardous activities that involves
physical contact..
Nursing Intervention Rationale
Educate the patient about her status and let Help the patient be aware of her status and

her understand her risk for hemorrhage due plan or think of some preventive measures
to her low platelet count each time a to avoid herself from any potential injuries.
hazardous situation is present or foreseen
potential risk. Analyzing and discussing with the patient

Let the patient or her significant others promotes nurse-patient interaction.


think or analyze some preventive measures Removing sharp objects helps ensure the
or actions such as removing all patient’s safety.
sharp/pointed objects that might contribute 
to an injury or wound.
Make sure that she does not wound herself To prevent further injuries or

by limiting her activities that require complications.


physical contact.
Educate the patient that if external To help control the bleeding.

hemorrhage occurs, they must apply 

pressure directly to the wound.


Encourage the patient to visit a doctor if - To provide and give emergency or medical
serious bleeding or hemorrhage might occur treatment to the patient.
as soon as possible
NCP 5 :
ACTIVITY INTOLERANCE R/T IMBALANCE BETWEEN 02

SUPPLY AND DEMAND SECONDARY TO PULMONARY


EDEMA

Nursing Diagnosis: Activity intolerance
r/t imbalance between O2 supply and
demand secondary to Pulmonary
edema
Cause Analysis: Activity intolerance is
a condition of general weakness,
sitting much of the time, oxygen
imbalance, or bed rest. The patient
may have weakness, blood pressure
changes, and shortness of breath
when activity is tried. (Mosby’s
Medical Encyclopedia- Activity
intolerance)
Cues Objectives

Subjective: STO:
The patient may verbalized, “Bisag After 2 hours of educating the patient
gamay ra nga lihok, hangakon nako and encouraging rest periods and limit
dayon or usahay pud maglisod nakog her activities, she will be able to
ginhawa.” understand her status and apply what
Objective: she had learned.
Restlessness LTO:
Weakness After 2 days of implementing effective
Breaths quickly, shallowly, and nursing intervention, the woman will
difficulty be able to do some physical activities
RR – 22BPM, use of accessory organs that are tolerable for her and will no

during breathing longer experience excessive fatigue or


shortness of breathing.
Nursing Intervention Rationale
INDEPENDENCE:
Assess patient response to activity. Educate Adequate rest balanced with activity can

and encourage rest periods/limit activities to prevent respiratory compromise.


patient tolerance. 

Educate the patient to rest in a position with

her chest and head elevated. - Elevating her chest allows edema to settle
Tourniquets may be placed on one arm or to the bottom of her lungs and frees space for
leg at a time and then moved to a different gas exchange.
arm or leg after short time (3 minutes) - This is done to pool the blood in the arms
Educate and encourage the patient to have a and legs, thereby reducing the load on the
regular prenatal check-up especially w/ her heart.
condition. -To monitor her pregnancy or status.
COLLABORATIVE:
For severe pulmonary edema, perform

mechanical breathing help to the patient as


ordered.
- Helps aid patient’s breathing.

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