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Decreased Cardiac Output Eclampsia

Decreased Cardiac Output Eclampsia

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Published by: NursesLabs.com on Jan 25, 2010
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08/11/2013

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Medical Diagnosis: Pre-Eclampsia Problem: Decreased Cardiac Output RT Decreased Venous Return Assessment

Subjective: Patient may verbalize

Nursing Diagnosis Decreased Cardiac output r/t decreased venous return secondary to severe preeclampsia AEB altered BP and edema

Scientific Explanation Inadequate blood is pumped by the heart to meet the metabolic demands of the body. It resulted from a systemic vaso
constriction in the body caused by preeclampsia. Vasoconstriction is the decrease in the diameter of the blood vessels which occur in diseases like pregnancy-induced hypertension. Decreased blood supply leads to a decrease in venous return, thus there is a relatively smaller amount of blood expelled by the ventricles of the heart.

Planning
Short Term:

Interventions

Rationale

Evaluation
Short Term:

• • •

Palpitations Fatigue Shortness of breath/dyspn ea anxiety

After 3 hrs of nursing interventions, the pt will display hemodynamic stability AEB blood pressure within her normal range
Long Term:

1. Establish rapport 2. Monitor and assess VS 3. Assess the pt’s general physical condition 4. Determine baseline vital signs/hemodyn amic parameters including peripheral pulses.

1. To gain pt’s trust and cooperation 2. To obtain baseline 3. To determine presence of abnormality

The pt shall have displayed hemodynamic stability (blood pressure within closer range)
Long Term:

Objective: Patient manifested: • • • • Weight gain Edema Variations in BP reading Restlessness

Patient’s fetus may manifest: • Jugular vein distention

After 3 days of nursing interventions, the pt will demonstrate activities that reduce the workload of the heart (stress management, therapeutic medication regimen program,

4. Provides opportunitie s to track changes

5. Review signs of impending failure /shock. 5. To prevent hypovolemi c shock

6. Position with HOB flat or keep trunk horizontal while raising legs 20 to 30 degrees

The pt shall have demonstrated activities that reduce the workload of the heart (stress management, therapeutic medication regimen program, balanced activity/ rest plan)

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• • • •

Cold clammy skin Arrhythmaia crackles Prolonged capillary refill

balanced activity/ rest plan)

(contraindicate d in congestive state in which semi-fowler’s position is preferred)

6. To increase venous return

7. Promote adequate rest, by decreasing stimuli, providing quiet environment

8. Maintain patency of invasive intravascular monitoring and infusion lines. Tape connections.

7. To maximize sleep periods

9. Avoid activities such as isometric exercises, rectal stimulation, vomiting, and

8. To prevent air embolus and/or exsanguinat

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spasmodic coughing. Administer stool softener as indicated.

ion.

10. Encourage pt to breathe deeply in/out during activities that increase risk for valsalva effect.

9. May stimulate a valsalva response

11. Provide psychological support. Maintain calm attitude butadmit concerns if questioned by the client.

12. Encourage relaxation techniques.

13. Elevate

10. This prevents exertion of too much workload to the heart.

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edematous extremities and avoid restrictive clothing. 11. Honesty can be reassuring when so much activity and “worry” are apparent to the patient.

14. Provide for diet restrictions.

15. Monitor intake and output. 12. To reduce anxiety 16. Discuss significant signs and symptoms that need to be reported to the healthcare provider ( e.g. muscle cramps, d/a, dizziness, skin rashes).

13. To promote comfort

17. Encourage

14. To enhance pt’s

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changing positions slowly, dangling legs before standing.

therapeutic regimen

18. Give information about positive signs of improvement such as decreased edema, improved vital signs / circulation). 19. Administer supplemental oxygen as indicated.

15. To determine fluid balance

16. May be sign of drug toxicity and/or mineral loss , especially potassium.

20. Administer due meds. 17. To reduce risk of orthostatic hypotension

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18. To provide encourage ment.

19. To increase oxygen available to tissues

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