NURSING CARE PLANS

GESTATIONAL HTN – PREECLAMPSIAECLAMPSIA- 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 Subjective: “Luya kaayo ko og kalipongon ko” as verbalized Objective: Temp - 38.2 oC PR - 88 bpm RR - 18 bpm BP – 130/100 Cyanotic 92% O2 Sat

OBJECTIVES STO: After a total of 18 hours of auscultation of lungs, observation skin color, monitoring of vital signs, assessing level of consciousness and activity intolerance, head elevation, administration of supplemental oxygen, medication(anticoagulants), providing fluids either IV or PO as indicated. The client will demonstrate adequate ventilation/oxygenation as evidence by absence of nasal 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 Independent Embolus Care Note respiratory rate and depth, work of breathing (use of accessory muscles/nasal flaring, pursed-lip breathing). Airway Management Institute measures to restore /maintain patent airways; e.g., coughing, suctioning. Elevate head of bed as client requires/tolerates. Assist with frequent changes of position, and get client out of bed/ambulate as tolerated Collaborative Airway Management Administer supplemental oxygen by appropriate method. Administer medication as indicated: Thrombolytic agents; e.g., alteplase; anistreplase; reteplase; streptokinase; tenecteplase; urokinase

RATIONALE Tachypnea and dyspnea accompany pulmonary obstruction. Dsypnea and increased work of breathing may be fist or only sign of subacute pulmonary embolus (PE). Severe respiratory distress/failure accompanies moderate to severe loss of functional lung units. Plugged/collapsed airways reduce number of functional alveoli, negatively affecting gas exchange. Promotes maximal chest expansion, making it easier to breathe and enhancing physiologic/psychologic comfort Turning and ambulation enhance aeration of different lung segments, thereby improving oxygen diffusion. . Maximizes available oxygen for gas exchange, reducing work o0f breathing. Note: If obstruction is large or hypoxemia does 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 Subjective: “Hawoy kaayo ako tiil og mga kamot” as verbalized by the client. Objective: Temp - 38.2 oC PR - 88 bpm RR - 25 bpm BP – 130/100 Tissue edema present pitting +2 Weak peripheral pulses on all extremities Varicosities present bilaterally Pale, dry, and poor turgor skin Dry oral mucosa Laboratory Tests: CBC: 50% Hct (increased)

OBJECTIVES STO: After 8 hours of performing leg elevation, early ambulation when permitted, performing active and initiating passive ROM exercises, and increasing fluid intake from 1 liter to 2 liters a day the client will demonstrate improved perfusion as evidence by peripheral pulses present/equal, pink skin color, temperature decrease to 37.8 oC, moist oral mucusa, and absence of tissue edema. LTO After 2 days of continuous evaluation, examination, assessment, and nursing interventions, body temperature will remain within normal range (36.7 to 37.8 oC), be able to walk unaided, free of tissue edema, strong peripheral pulses, and display increasing tolerance to activity.

NURSING INTERVENTIONS Independent: Promote early ambulation as soon as client is able and with physician’s approval.

RATIONALE Short frequent walks are determined to be better for extremities and prevention of pulmonary complications than one long walk. If client is confined to bed, ensure ROM exercises. 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. These measures are designed to increase venous return from lower extremities and reduce venous stasis, as well as improve general muscle tone/strength. They also promote normal organ function and enhance general well-being. This activity potentiates risk of fragmenting/dislodging thrombus causing embolization, and increasing risk of complications

Elevate legs when in bed or chair as indicated.

Initiate active or passive exercises while in bed (e.g., flex/extend/rotate foot periodically). Assist with gradual resumption of ambulation (e.g., walking 10 min/hr) as soon as client is permitted out of bed. Instruct client to avoid rubbing /massaging the affected extremity.

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: Administer anticoagulants Apply/regulate graduated compression stockings, intermittent pneumatic compression if indicated. Inhibits the vitamin K conversion cycle, thereby causing hepatic production of partially carboxylated and decarboxylated proteins with 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. Encourage changing position slowly Instruct to avoid or limit activities that may stimulate valsalva response (rectal stimulation bearing down B.M) Encourage deep breathing exercises Educate to avoid high salt intake/diet To promote adequate rest. To reduce risk for orthostatic hypotension.

To prevent in changes in cardiac pressures or impede blood flow. To reduce anxiety High salt intake tends to lead to water retention and may worsen edema

NURSING INTERVENTIONS Independent: Use pillow or cushions to raise feet and legs above heart when you are sitting or lying down Collaborative: Administer cousmarin as prescribed

RATIONALE

To promote good circulation

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 Subjective: Shock:, sighing breaths, dizziness Fainting, apprehension, restlessness Objective: Thrombocytopenia (a platelet count below 100,000/mm3) paleness, and low blood pressure clammy and cold to touch skin Fainting Rapid, rhythmical pulse V/S as follows: PR: 92BPM T: 36.5C RR: 20 BPM, sighing sounds

Objectives STO: Within 2 hours of educating the patient, she will be able to understand and be aware that she’s at risk for hemorrhage; and will participate in measures to prevent injury and also to take precautionary measures. LTO: Within 2 days of implementing effective health teachings and performing precautionary measures to prevent injury, the patient will be able to put into action or perform some preventive 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 Analyzing and discussing with the patient potential risk. 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 INDEPENDENCE: Assess patient response to activity. Educate and encourage rest periods/limit activities to patient tolerance. Educate the patient to rest in a position with her chest and head elevated. Tourniquets may be placed on one arm or leg at a time and then moved to a different arm or leg after short time (3 minutes) Educate and encourage the patient to have a regular prenatal check-up especially w/ her condition. COLLABORATIVE: For severe pulmonary edema, perform mechanical breathing help to the patient as ordered.

Rationale Adequate rest balanced with activity can prevent respiratory compromise.
 

- Elevating her chest allows edema to settle to the bottom of her lungs and frees space for gas exchange. - This is done to pool the blood in the arms and legs, thereby reducing the load on the heart. -To monitor her pregnancy or status.

- Helps aid patient’s breathing.

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