Care plan on pre eclampsia

NURSING PROCESS FOR MOTHER:

1. NURSING DIAGNOSIS : Risk of eclampsia related to pre-eclampsia as evidenced by Hypertension

B.P.=160/100 And protein urea +2

SUBJECTIVE DATA OBJECTIVE DATA Patient is saying she is felling weakness Blood pressure of the patient is 160/100 and

protein urea +2

DESIRED GOAL/ OUTCOME To reduce blood pressure to normal i.e., 120/80

AND reduce protein urea and thereby reducing risk of eclampsia.

PLANNING IMPLEMENTATION RATIONALE

Advised mother to take adequate rest.

Monitored intake output of the patient daily

Administered anti-hypertensive medicine as doctor’s prescription

Monitored blood pressure regularly

Monitored blood pressure regularly;

Administered magnesium sulphate as doctor’s prescription.

Advised mother to take adequate rest.

Monitored intake output of the patient daily

Advised low fat and low salt diet i.e., not to add extra salt in the diet.

Advised her postnatal excises

Provide objective data

As a prophylaxis of eclampsia

To prevent fluid and sodium retention in the body and thereby reducing the B.P.

To maintain B.P. and reduce weight.

EVALUATION OF GOAL

Patient has reduced risk of eclampsia as evidenced by Patient reduced blood pressure ; B.P.= 130/80& Protein urea nil.

2. NURSING DIAGNOSIS : Acute pain related cesarean section as evidenced by pain intensity=4

SUBJECTIVE DATA OBJECTIVE DATA Patient complain of pain at the LSCS site Pain analog scale pain intensity= 4

DESIRED GOAL/ OUTCOME

Patient will experience no pain or reduced pain to the level of acceptance


Administered analgesia as advised by doctor

Help her to ambulate Advised patient to take

sitz bath

Assessed patient vitals

Assessed the level of pain

Patient was administered analgesia Tab brufen 400mg B.D. for 5 days

Patient was give comfortable position i.e., propped up position

Told her to cross the legs in lying down position

Advised her to avoid sitting in crossed leg position.

Advised patient to carry out deep breathing exercise

To get objective data

To reduce pain

To provide sense of wellness

To reduce aggravating factors

To maintain intactness of the stiches

To improve respiration and circulation

EVALUATION OF GOAL Patient pain is reduced as verbalized by the patient and pain intensity =1

3. NURSING DIAGNOSIS : Fluid volume excess related to pre-eclacmptia as evidenced by the edema

over legs and ankle and decreased urine output

SUBJECTIVE DATA OBJECTIVE DATA Patient was saying that she is having swelling on foot, ankle and legs

Patient have edema over foot, leg and ankle and decreased output and proteinuria= + 2


Maintenance of ideal body weight without excess fluid through nursing intervention.


Identify potential source of fluid excess like medications. Food and intravenous fluids

Explained patient and family the rationale of the fluid limitation

Patient was encouraged to carry out daily oral hygiene.

Urinary Catheterization was done to maintaindaily intake and output charting. I= 2500 0=1500; balance= 1000ml.

Assessed skin turgor and pressure of edema

Limit fluid intake to prescribed volume i.e., 2 liter but not restrict

Assessed respirator rate daily

To Assessed fluid status daily by maintaining record of

To assessdecrees in pressure of edemadaily

Fluid limitation is done according to urine output of the mother

EVALUATION OF GOAL Patient has reduced edema and proteinuria= nil and I=2100 ml O=1800ml

4. NURSING DIAGNOSIS : Risk of infection related to LSCS, presence of urinary catheter and I.V. cannula

SUBJECTIVE DATA OBJECTIVE DATA

Patient complains of itching at the LSCS site, redness at cannula site.

Redness & presence of urinary catheter; and cannula site; W.B.C.= 13,000 mg/dl


To reduce level of infection so that patient don’t have any complication


Taught patient about self care

Removed cannula

Removed urinary catheter

Vitals checked daily Assessed LSCS site

daily.

Vitals checked daily

Perineal care giving and catheter care given using sterile techniques

Change the dressing at incision site.

Checked the sit of the cannula Cap amclox 500mg T.D.S. given to

the patient for 5 days

To reduce level of infection

Antibiotics reduce infection.

EVALUATION OF GOAL

Patient is free from infection as evidence by reduced redness and W.B.C= 7,000mg/dl

5. NURSING DIAGNOSIS : Imbalanced nutrition less than the body requirement related to the Anorexia, nausea and dietary restriction and altered oral mucus membrane


Patient complaining of nausea and decrease in appetite

Patient intake is reduced as compared to requirement during lactation.

DESIRED GOAL/ OUTCOME To maintain adequate nutrition status by reducing nausea and increasing appetite


Assess intake and out put

Assess regularly laboratory values like bun, creatitine, s. electrolytes.

Provide patient food as per dietary requirement

Promoted intake of high biological value protein food e.g.;- egg, dairy products etc.

Encouraged high calorie low

Increased dietary intake

To maintain positive nitrogen balance

Required during lactation

Provide patient food as per dietary requirement

Promoted intake of high biological value protein food

protein low sodium diet

Administered anti emetics Tab rantac 50 mg T.D.S

Alteration of medication so that they be give afar meals

Explain the rationale of dietary restrictions

Provide clean surrounding

Assess intake and out put

Assess regularly laboratory values like bun, creatitine, s. electrolytes.

To reduce feeling of nausea

To reduce bad taste ue to medications

To reduce anxiety

To increase appetite

To check the increase in the nutritional status of the patient.

EVALUATION OF GOAL

Patient is maintaining normal nutritional status according to lactation

6. NURSING DIAGNOSIS : Impaired skin integrity related to edema as evidenced by redness itching over

the area of edema and also dryness

SUBJECTIVE DATA OBJECTIVE DATA Patient is saying she is having redness, dryness and itching over the area of edema on the leg

Patient is having redness, dryness over the area of edema on the leg


To maintain normal skin integrity.


change the position hourly during day

Applied emollient over the area of dryness

fluid intake up to 2 liters

Maintain hygiene

Avoid to wear tight clothing

Advised the patient to change the position hourly during day

Applied emollient over the area of dryness

Advised fluid intake up to 2 liters Advised patient not to lie on the

pressure points for longer periods.

Advised her to keep clean and dry and change clothing daily

Advised her not to ear tight clothing

Advised her to remove rings and bangles

To prevent pressure sores

To reduce dryness and itching

To reduce edema

To prevent development of ulcers

To maintain personal hygiene To maintain skin integrity

EVALUATION OF GOAL Patient redness is reduced and itching also reduced

7. NURSING DIAGNOSIS : Anxiety related to care of the baby and herself after delivery

SUBJECTIVE DATA OBJECTIVE DATA Patient is asking about care of the care of the baby and herself

Patient looks anxious


To reduce anxiety of the patient.


Explain eye and cord care

Explain maintaining personal hygiene of herself and the baby

Explain about the breast care and keeping the breast clean dry

Explain about diet Explain about

contraceptives.

Advised mother to keep the baby close to her

Explained mother about eye and cord care

Explained mother about maintaining personal hygiene of herself and the baby

Explained about the breast care and keeping the breast clean dry

Explained about diet

Explained about contraceptives.

To increase mother and child relation

To reduce infection of baby

To reduce anxiety

EVALUATION OF GOAL Patient looks less anxious and carrying out of the baby effectively.

8. NURSING DIAGNOSIS : Altered temperature due to disease condition


The patient is complaining of body pain Patient is warm to touch. Temp:- 101.6 F


Patient’s temperature will be reduced.


checked the body

temperature Given injection

encouraged patient to have plenty of fluids

provided hydration therapy to patient.

sent urine and blood culture to lab

checked the body temperature

Given injection paracetamol 1amp i/v stat.

encouraged patient to have plenty of fluids

provided hydration therapy to patient.

sent urine and blood culture to lab

reassessed the temperature after one hour of giving .

To gain mothers cooperation

to have baseline data. to treat fever as paracetamol is

antipyretic.

to prevent dehydration

to find out the cause of fever to check the effectiveness of

treatment given.

EVALUATION OF GOAL Patient’s temperature was reduced when assessed again .Temp: 99 F

DRUG STUDY

S.N

O

NAME OF

THE DRUG

PHARMACOLOGICAL

NAME

ACTION Dosage SIDE EFFECTS NURSING

RESPONSIBILITIES

1.

2.

Magneon/ magnesium

sulphate

Cervix gell

magnesium

sulphate

Prostaglandin E2

Increases osmotic pressure, draws fluid into colon, neutralizes HCl. Stimulates uterine contractions, causing

Loading dose: 4 gm IV over 3–5 min

followed by 10

gm deep IM (5 gm in each buttock)Maintenance

dose:

5 gm IM 4 hourly in

alternate buttock

500 micro gm.

Intracevically.

CNS: Muscle weakness, flushing, sweating, confusion, sedation, depressed reflexes, flaccid paralysis, hypothermia CV: Hypotension, heart block, circulatory collapse, vasodilation GI: Nausea, vomiting, anorexia, cramps, diarrhea HEMA: Prolonged bleeding time META: Electrolyte, fluid imbalances RESP: Respiratory depression/paralysis CNS: Headache, dizziness, chills, fever, flushing CV: Hypotension, dysrhythmias, DIC

Assess: Eclampsia: seizure precautions, B/P, ECG (magnesium sulfate); magnesium toxicity: thirst, confusion, decrease in reflexes; I&O ratio; check for decrease in urinary output Evaluate: • Therapeutic response: decreased constipation; absence of seizures (eclampsia), normal serum calcium levels Teach patient/family: • That chilling improves taste of magnesium citrate • To shake suspension well • Cervical ripening: dilation, effacement of cervix and uterine contraction, fetal heart tones, check

3.

Tab amlog

amLODIPine

abortion; acts within 30 hr for complete abortion Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces

5 md o.d.

EENT: Blurred vision SYST: Anaphylactoid syndrome of pregnancy FETAL: Bradycardia (i.e., deceleration) GI: Nausea, vomiting, diarrhea GU: Vaginitis, vaginal pain, vulvitis, vaginismus INTEG: Rash, skin color changes MS: Leg cramps, joint swelling, weakness GEL: Uterine contractile abnormality, GI side effects, back pain, fever INSERT: Uterine hyperstimulation, fever, nausea, vomiting, diarrhea, abdominal Pain CNS: Headache, fatigue, dizziness, asthenia, anxiety, depression, insomnia, paresthesia, somnolence CV: Peripheral edema, bradycardia, hypotension, palpitations, syncope, chest painGI: Nausea, vomiting, diarrhea, gastric

for contractions over 1 min • For fever that occurs 1/2 hr after suppository insertion (abortion) • Respiratory rate, rhythm, depth; notify prescriber of abnormalities, pulse, B/P, temperature Vaginal discharge: check for itching, irritation; indicates vaginal infection Evaluate: • Therapeutic response: expulsion of fetus • To avoid hazardous activities until stabilized on product, dizziness is no longer a problemTo avoid OTC products unless directed by prescriber • To notify prescriber of irregular heartbeat; shortness of breath; swelling of feet, face, hands; severe dizziness; constipation; nausea; hypotension; if chest pain does not improve, use nitroglycerin when

4.

Cap.

Amclox

Ampicillin +

cloxacillin

relaxation of coronary vascular smooth muscle, peripheral vascular smooth muscle; dilates coronary vascular arteries; increasesmyocardial O2 delivery in patients with vasospastic angina Interferes with cell wall replication of susceptible organisms; the cell wall, rendered

500mg q.i.d

upset, constipation, flatulence, anorexia, gingival hyperplasia, dyspepsia GU: Nocturia, polyuria, sexual difficulties INTEG: Rash, pruritus, urticaria, alopecia OTHER: Flushing, muscle cramps, cough, weight gain, tinnitus, epistaxis CNS: Lethargy, hallucinations, anxiety, depression, twitching, coma, seizures GI: Nausea, vomiting, diarrhea, pseudomembranous colitis, stomatitis GU: Oliguria, proteinuria,

angina is severe • To use correct technique when monitoring pulse; to contact prescriber if pulse ,50 bpm • To avoid large amounts of grapefruit juice, alcohol • To change positions slowly to prevent orthostatic hypotension • To continue with good oral hygiene to prevent gingival disease • To use sunscreen, protective clothing to prevent photosensitivity • To notify all health care providers of use of this product Assess: • Infection: characteristics of wound, sputum, WBC; baseline, periodically; C&S before product therapy, product may be taken as soon as culture is taken Nephrotoxicity: I&O ratio;

5.

Tab. Brufen

ibuprofen

osmotically unstableswells, bursts from osmotic pressure; lysis mediated by cell wall autolysins Acts directly on cough center in medulla to suppress

400 mg B.D.

hematuria, vaginitis, moniliasis, glomerulonephritis HEMA: Anemia, increased bleeding time, bone marrow depression, granulocytopenia, leukopenia, eosinophilia, hemolysis INTEG: Rash, urticaria, erythema multiforme MISC: Anaphylaxis, serum sickness, Stevens-Johnson syndrome, toxic epidermal necrolysis CNS: Drowsiness, dizziness, light-headedness, confusion, headache, sedation, euphoria, dysphoria,

report hematuria, oliguria; renal studies: urinalysis, protein, blood, BUN, creatinine • Hepatic studies: AST, ALT • Blood studies: WBC, RBC, Hgb, Hct, bleeding time • Bowel pattern before, during treatment • Respiratory status: rate, character, wheezing, tightness in chest Anaphylaxis: rash, itching, dyspnea, facial swelling; stop product, notify prescriber,have emergency equipment available • To take oral ampicillin on empty stomach with full glass of water • That product must be taken in equal intervals around the clock to maintain blood levels Assess: • Pain: intensity, type, location, other characteristics before, 1 hr after giving

6

Tab rantac

Ranitidine

cough; binds to opiate receptors in CNS to reduce pain Inhibits histamine at H2-receptor site in parietal cells, which inhibits gastric acid secretion

50 mg B.D.

weakness, hallucinations, disorientation, mood changes, dependence, seizures CV: Palpitations, tachycardia, bradycardia, change in B/P, circulatory depression, syncope, cardiac arrest (children) EENT: Tinnitus, blurred vision, miosis, diplopia GI: Nausea, vomiting, anorexia, constipation, cramps, dry mouth, ulcers GU: Increased urinary output, dysuria, urinary retention INTEG: Rash, urticaria, flushing, pruritus RESP: Respiratory depression; pulmonary CNS: Headache, sleeplessness, dizziness, confusion, agitation, depression, hallucination (geriatric patients)CV: Tachycardia, bradycardia, PVCs EENT: Blurred vision, increased ocular

product; titrate upward by 25% until pain reduced by half; need for pain medication, physical dependence; opioid is more effective before pain is severe • CNS changes: dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction • B/P, pulse, respirations before, periodically; if respirations ,10/min, dose may need to be reduced, oversedation may occur • Bowel status: constipation; Assess: • GI complaints: nausea, vomiting, diarrhea, cramps, abdominal discomfort, jaundice; report immediately • I&O ratio, BUN, creatinine, LFTs, serum, stool guaiac before, periodically

7.

Ferrous

sulphate

Ferrous

sulphate

Replaces iron stores needed for red blood cell development as well asenergy and O2

pressure GI: Constipation, abdominal pain, diarrhea, nausea, vomiting, hepatotoxicity GU: Impotence, acute interstitial nephritis (rare) INTEG: Urticaria, rash, fever RESP: Pneumonia SYST: Anaphylaxis (rare) GI: Nausea, constipation, epigastric pain, black and red tarry stools, vomiting, diarrhea INTEG: Temporarily discolored tooth enamel and eyes SYST: Hypersensitivity reactions (Ferrlecit)

during therapy Evaluate: • Therapeutic response: decreased abdominal pain, heartburn Teach patient/family: • To avoid driving, other hazardous activities until stabilized on product • That product must be continued for prescribed time to be effective • To notify prescriber if pregnancy planned, suspected; to avoid breastfeeding • Not to take maximum OTC daily dose for .2 wk • To take once daily dose before bedtime Assess: • Blood studies: Hct, Hgb, reticulocytes, bilirubin before treatment, at least monthly; iron studies (Iron, TIBC, ferritin). • Elimination: if constipation occurs, increase

transport and use; sulfate, 20%; iron, 30%; ferrous sulfate exsiccated

water, bulk, activity • Nutrition: amount of iron in diet (meat, dark green leafy vegetables, dried beans, dried fruits, eggs) Teach patient/family: • That iron will turn stools black or dark green • Accidental exposure: to keep out of reach of children, pets; iron poisoning may occur if increased beyond recommended level • To avoid reclining position for 15-30 min after taking product to avoid esophageal corrosion

Education

Care plan on pre eclampsia