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NCP for eclampsia

NCP for eclampsia

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Published by: Xtine Soliman Zamora on Aug 01, 2011
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09/27/2013

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Page| 8
AssessmentExplanation of the ProblemOutcome CriteriaNursing InterventionRationaleEvaluationPdx: PainS>”Nasakit daytoy sugatko”>Rated pain as 9 from apain scale of 0-10, 0 as nopain and 10 as worst painO>Guarding Behavior atthe abdomen noted> facial grimaces>Moaning>Hesitant torepositioning.>V/S as follows:BP: 170/150 mmHgRR:17 bpmPR:80 bpmTemp:37.8
o
cA>Pain related totissue trauma asmanifested by guardingbehavior noted at theabdomen andgrimacing secondary tolow segment caesariansection. The patient is a 42 yearold, G
3
P
3
delivered viacaesarian section. Thisprocedure includes incisionof the abdomen whichcauses tissue traumameaning the painreceptors are activatedand gives signals to thebrain. Therefore presenceof pain occurs.STO: After 8 hours of nursing intervention theclient will be able toverbalized decrease a painfrom 9/10 to 3/10.LTO: After 48 hours of nursing intervention theclient will be able to reportabsence of pain.Dx:
note location of surgical procedures
Observe non-verbal cuesof pain such as holdsbody, facial expression
Assess for referred painas appropriate
Monitor vital signs
Determine possiblepathophysiological /psychological causes of pain such asinflammation of surgery. Tx:
Perform painassessment each timepain occurs
Provide comfortmeasures such aschanging position
Use pain scale rating
Provide quiet and cleanenvironmentEdx:
Encourage adequaterest periods
Encourage verbalizationof feelings about pain
Encourage deepbreathing exercises
Emphasize importanceof wound care
Instruct to eat foods richin proteins
 This can influence theamount of postoperative painexperienced
Serves as effectivebasis in proper nursingintervention
 To help determinepossibility of underlyingcondition
Vital sign usuallyaltered in acute pain
Presence of known/unknowncomplicating may makethe pain more severe
 To rule out worseningof development of complications
 To avoid orthostatichypotension
 To determine theseverity of the pain
 To decrease stress
 To prevent fatigue
 To decrease worries
For relaxation
 To avoid colonization of bacteria
For fast recoverySTO: After 8 hours of nursing intervention theclient will be able toverbalize decrease of painfrom 9/10 to 3/10LTO: After 48 hours of nursing intervention theclient will be able to reportabsence of pain
 
Page| 9
AssessmentExplanation of the problemOutcome criteriaInterventionRationaleEvaluationPdx: HyperthermiaS>”mainit ako”O>V/S as follows: Temp.-38.2
o
CPR- 82 bpmRR- 24 bpm
Flushing of face
Irritability
Lost of appetite
Uncomfortable
Lost of appetiteA>Hyperthermia related totissue trauma asevidenced by increasetemperature.Hyperthermia is caused bythe tissue trauma. This is anormal response of thebody to fight for apersistent infection that iscaused by a certainbacteria which may haveentered the body of thepatient after the operation,that’s why there isimbalanced bodytemperature.STO: After 2 hours of nursing intervention theclient’s temperature willbe lower than 38
o
C.LTO: After 2 days of nursing intervention theclient should have anormal body temperature.Dx:
Measure and record theV/S of the patient asordered.
Monitor/record allsources of fluid losssuch as urine, vomiting,wounds/fistulas, andinsensible losses.
Notepresence/absence of sweating as bodyattempts to increaseheat loss byevaporation,conduction, anddiffusion. Tx:
Increase fluid intake
Provide TSB asneeded.
Administerantipyretics asordered.
Assist client inbathing and changinginto dry clothing whendiaphoresis is presentand if possible.
Administerreplacement fluidsand electrolytes
Maintain bed rest.
Provide high-
Recognizing thepattern of a fever canhelp determine source.
Potentiates fluidand electrolyte losses.
Evaporation isdecreased byenvironmental factors,that cause loss of ability to sweat orsweat glanddysfunction
Increasedmetabolic rate anddiaphoresis
Associated withfever – cause of bodyfluids
 To replace thefluids that are lost
 To lower down thebody temperature of the client
 This will helprelieve the symptomsaccompanied by feverand lower down thebody temperature
 To supportcirculating volume andtissue perfusion
 To reducemetabolic demands/oxygen consumption.STO: Goal met. After 2hours of effective nursingintervention the client’sbody temperature waslowered down to 37.5
o
CLTO: Goal met. After 2days of effective nursingintervention the clientshould have a normal bodytemperature.
 
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calorie diet, tubefeedings or parenteralnutrition.Edx:
Encourages thefollowing:A)Increase fluideintakeB)Report anyuntowardsymptomC)Limit activitiessuch as performingADL alone.D)Increase intake oproteins rich foods,iron and vitamin C.
 To meet increasedmetabolic demands
Bathing andclothing changingincrease comfort anddecrease thepossibility of continuedshivering caused bywater evaporationfrom the skin.
 To replace the lostof fluid in the body.
 To determine anycomplication and toprovide properintervention.
 To conserveenergy
 To facilitate woundhealing and boostimmune system

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