V. NURSING MANAGEMENT
NURSING CARE PLAN
Cardiac Output, decreased r/t altered stroke volume
36
CUES
S: Ø
O:
Variation
s in
blood
pressure
,
edema,
shortnes
s of
breath.
NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
Cardiac
Output,
decreased
r/t altered
stroke
volume
Increased
blood
pressure
Vasospasm
Increased
vascular
resistance
PLANNING
After 8 hours of
nursing
interventions,
client will be able
to verbalize
knowledge of the
disease process,
individual risk
factors and
treatment regimen.
NURSING
INTERVENTION
>Monitor and
record BP and
pulse.
Difficulty of
the heart to
pump blood
Increased
cardiac
workload
Decreased
cardiac output
> Institute
bedrest with
client in lateral
position.
RATIONALE
> The client
with PIH does
not manifest
the
normal
cardiovascular
response to
pregnancy
(left
ventricular
hypertrophy,
increase in
plasma
volume,).
Hypertension
(the second
manifestation
of PIH after
edema) occurs
EXPECTED
OUTCOME
After 8 hours
of nursing
interventions,
client will be
able to
verbalize
knowledge of
the disease
process,
individual risk
factors and
treatment
regimen
.
to increased
sensitization
to angiotensin
II,
which
increases BP,
promotes
aldosterone
release
to increase
sodium/water
reabsorption
from
the renal
tubules, and
constricts
blood vessels.
37
> Increases
Ineffective Tissue Perfusion r/t impaired transport of oxygen
CUES
S: Ø
O: Altered
blood
pressure
outside of
acceptable
parameter
s.
NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
Ineffective
Tissue
Perfusion r/t
impaired
transport of
oxygen
increased
blood
pressure
vasospasm
vasoconstricti
on
intravascular
fluid
redistribution
decreased
oxygen to
different
organs
PLANNING
Short Term:
After 8 hours of
nursing
interventions,
client will be able
to verbalize
understanding of
condition,
therapy regimen,
side effects of
medications, and
when to contact
a health care
provider.
Long Term:
After a week of
nursing
interventions,
client will able to
demonstrate
behaviors/lifestyl
e changes to
improve
circulation such
as relaxation
techniques, and
NURSING
INTERVENTION
>Evaluate vital
signs, noting
changes in BP,
heart rate, and
respiration.
>Identify changes
related to
systemic and/or
peripheral
alterations in
circulation (e.g.
vital sign
changes)
>Determine
duration of
problem/frequenc
y of recurrence,
precipitating
factors.
RATIONALE
>Vital signs
will
determine if
there are
changes in
the health
status of the
pt.
>Alterations
in systemic
or peripheral
circulation
can be
assessed
primarily
with vital
sign
>This will
help
determine if
there is
improvement
in the
EXPECTED
OUTCOME
Short Term:
After 10 hours of
nursing
interventions,
client shall
verbalize
understanding of
condition,
therapy regimen,
side effects of
medications, and
when to contact
a health care
provider.
Long Term:
After a week of
nursing
interventions,
client will
demonstrate
behaviors/lifestyl
e changes to
improve
circulation such
as relaxation
techniques, and
38
exercise/dietary
program.
impaired
tissue
perfusion to
ongans
patients
condition
>Encourage quite,
restful
atmosphere.
>Caution client to
avoid activities
that increase
cardiac work load
(e.g. straining at
stool).
>Instruct the pt.
to take her
prescribed
medications (e.g.
antihypertensive
agents)
>Discuss
individual risk
factors (e.g.
family history,
age)
exercise/dietary
program
>This will
promote rest
and help in
the proper
distribution
of oxygen in
the body
>To
conserve
energy/lower
s tissue
oxygen
demand.
>Proper
medication
will help the
pt. condition
>To prevent
onset of
complication
s/ manage
symptoms
39
when
condition is
present.
>Instruct in blood
pressure
monitoring at
home.
>lifestyle changes
(e.g. to much
work)
>Encourage use
of relaxation
techniques.
>Review specific
dietary
>To facilitate
management
of
hypertension
.
>Lifestyles
of people
have a very
large effect
to the pt.
condition.
Modification
of it will help
improve the
pt. condition
>To
decrease
tension level
>Diet
modification
will help in
40
changes/restrictio
ns with the client
(e.g. reduction of
cholesterol and
triglyceride, high
or low protein
intake)
improving
the pt.’s
condition
Fluid Volume deficit [isotonic] related to: Plasma protein loss
CUES
S: Ø
O:
Edema
formation,
sudden
weight
gain,
headaches,
NURSING
DIAGNOSIS
Fluid Volume
deficit
[isotonic]
r/t
Plasma
protein loss,
SCIENTIFIC
EXPLANATIO
N
Pregnancy
induced
hypertension
Decreased
vascular
perfusion
Increased ECF
PLANNING
Short Term:
After 4 hours
of nursing
interventions,
client will be
able to
verbalize
understandin
g of need for
close
monitoring of
weight, BP,
urine protein,
and edema.
NURSING
INTERVENTION
> Weigh client
routinely.
Encourage client
to monitor
weight at home
between visits.
RATIONALE
> Sudden,
significant
weight gain
(e.g., more
than
3.3 lb (1.5
kg)/month in
the second
trimester or
more
than 1 lb (0.5
kg)/wk in the
third
trimester)
EXPECTED
OUTCOME
Short Term:
After 4 hours of
nursing
interventions,
client will be
able to verbalize
understanding
of need for
close
monitoring of
weight, BP,
urine protein,
and edema.
.
41
EDEMA
Decreased
water
absorption to
cells
maintaining
some sodium
inside
Cell or tissue
dehydration
Fluid volume
deficit
(isotonic)
.
Long Term:
After a week
of nursing
interventions,
client will able
to be free of
signs of
edema.
> Distinguish
between
physiological
and pathological
severe,
edema of
pregnancy.
Monitor location
and
3+ to 4+) of
face, hands,
legs, sacral
area, or abdodegree of
pitting.
> Note signs of
progressive or
excessive
edema
Assess for
possible
eclampsia.
> Reassess
reflects
fluid retention.
Fluid moves
from the
vascular to
interstitial
> space,
resulting in
edema.
Long Term:
After a week of
nursing
interventions,
client will able
to be free of
signs of edema.
> The
presence of
pitting edema
(mild, 1+ to
2+;3+ to 4+)
of face,
hands, legs,
sacral area, or
abdominal wall, or
edema that
does not
disappear
after 12 hr of
bedrest is
significant.
>monitor
Cerebral
edema,
possibly
leading to
seizures
42
dietary intake of
proteins and
calories.
Provide
information as
needed.
> Monitor intake
and output.
Note urine color
And measure
specific gravity
as indicated.
> Test clean,
> Adequate
nutrition
reduces
incidence of
prenatal
hypovolemia
and
hypoperfusion
; inadequate
protein/calorie
s increases
the risk of
edema
formation and
PIH. Intake of
80–100 g of
protein may
be required
daily to
replace losses
> Urine
output is a
sensitive
indicator of
circulatory
blood volume.
Oliguria and
specific
gravity of
43
voided urine for
protein each
visit,
daily/hourly as
appropriate if
hospitalized.
Report readings
of 2+, or
greater.
> Assess lung
sounds and
1.040
indicate
severe
hypovolemia
and kidney
involvement
> Aids in
determining
degree of
severity/
progression of
condition. A
2+ reading
suggests
glomerular
edema or
spasm.
Proteinuria
affects fluid
shifts from the
vascular tree.
Note: Urine
contaminated
by vaginal
secretions
may test
positive for
protein, or
dilution may
result in a
false-negative
result. In
44
respiratory
rate/effort.
addition, PIH
may be
present
without
significant
proteinuria.
>Monitor BP and
pulse.
> Dyspnea
and crackles
may indicate
pulmonary
edema, which
requires
immediate
treatment.
> Answer
questions and
review rationale
for avoiding use
of diuretics to
treat edema.
> Elevation in
BP may occur
in response to
catecholamine
s,
vasopressin,
prostaglandin
s, and, as
recent
findings
suggest,
decreased
levels of
prostacyclin.
> Diuretics
further
45
> Review
moderate
sodium intake of
up to 6 g/day.
Instruct client to
read food labels
and avoid foods
high in sodium
(e.g., bacon,
luncheon meats,
hot dogs,
canned soups,
and potato
chips).
>Refer to
dietitian as
indicated
> Place client on
strict regimen of
increase state
of dehydration
by
decreasing
intravascular
volume and
placental
perfusion, and
they may
cause
thrombocytop
enia,
hyperbilirubin
emia, or
alteration in
carbohydrate
metabolism in
fetus/newborn
.
> Some
sodium intake
is necessary
because
levels below
2–4 g/day
result in
greater
dehydration in
some clients.
However,
46
bedrest;
encourage
lateral position.
> Refer to home
monitoring/daycare program,
as appropriate.
excess sodium
may increase
edema
formation.
> Nutritional
consult may
be beneficial
in determining
individual
needs/dietary
plan.
> Lateral
recumbent
position
decreases
pressure on
the vena
cava,
increasing
venous return
and
circulatory
volume
>Replace fluids
either orally or
parenterally via
infusion pump,
as indicated.
> Some mildly
hypertensive
clients without
proteinuria
may be
managed on
an outpatient
47
basis if
adequate
surveillance
and support is
provided and
the
client/family
actively
participates in
the
treatment
regimen.
> Fluid
replacement
corrects
hypovolemia,
yet must be
administered
cautiously to
prevent
overload,
especially if
interstitial
fluid is drawn
back into
circulation
when activity
is reduced.
With renal
involvement,
fluid intake is
restricted; i.e.,
48
if output is
reduced (less
than 700
ml/24 hr),
total fluid
intake is
restricted to
approximate
output plus
insensible
loss.
Use of infusion
pump allows
more accurate
control
delivery of IV
fluids.
49
Risk for infection r/t inadequate primary defense secondary to broken skin
CUES
S=Ǿ
O = may
manifest
fever,
swelling on
the affected
part, pain
on the
affected
part.
NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
Risk for
infection r/t
inadequate
primary
defense
secondary
to broken
skin
Patient
undergone
episiotomy
PLANNING
Short
Term:
After 8
hours of
nursing
interventio
Patient has an
ns, client
open wound
will remain
can be a
free of all
source of
signs and
infection
symptoms
of infection.
Bacteria,
fungus and
viruses can
easily break in
NURSING
INTERVENTION
 Establish
rapport
 Monitor
Vital sign
 Report
fever
>38°c,
chills,
diaphoresi
s,
swelling,
heat, pain,
erythema,
exudates
RATIONALE
 To gain
trust and
cooperation
 Serves as
primary
indicators
of changes
in health
status
 Early
detection of
infection
facilitates
early
intervention
.
EXPECTE
D
OUTCOM
E
Short
Term:
Client
remains
free of all
signs and
symptoms
of
infection.
50
the body
Bacteria,
fungus and
viruses can
easily flow
through the
bloodstream
Patient is at
risk of
infection
on
anybody
surfaces.
 Initiates
measures
to
minimize
infection
 Discuss
with
patient
and family
the
importanc
e of
patient
avoiding
contact
with
people
who have
known or
recent
infection.
 Instruct all
 Exposure to
infection is
reduced
 Preventing
contact with
pathogens
helps
prevent
infection
 Hands are
significant
source of
51
personnel
in careful
hand
hygiene
before
and after
entering
the room
 Assist
patient in
practice of
meticulou
s personal
hygiene
 Avoid
insertion
of urinary
catheter,
if catheter
are
necessary
, use strict
aseptic
technique
contaminati
on
 This
prevents
skin
irritations
 Rates of
infection
greatly
increases
after
urinary
catheterizat
ion
52
Knowledge deficit [pregnancy induced hypertension] r/t lack of exposure to the present condition
CUES
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
PLANNING
NURSING
INTERVENTIO
N
RATIONALE
EXPECTED
OUTCOME
53
S: “hindi
ko alam
baket
ako nag
ka
ganito,
nung una
ok
naman
pagbubu
ntis ko”
O: Ø
Knowledge
deficit r/t
lack of
exposure to
the present
condition
Patient never
had PIH with
her previous
pregnancy
Knowledge
deficit
Short Term:
After 4 hours of
nursing
interventions,
client will be able
to verbalize
understanding of
disease process
and appropriate
treatment plan.
>Assess client’s
knowledge of
the disease
process.
Provide
information
about
pathophysiolog
y of PIH,
implications for
mother and
fetus; and the
rationale for
interventions,
procedures, and
tests, as
needed.
> Provide
information
about
signs/symptoms
indicating
worsening of
condition, and
instruct
client when to
notify
>Establishes
data base and
provides
information
about areas in
which learning
is needed.
Receiving
information can
promote
understanding
and reduce
fear, helping to
facilitate the
treatment plan
for the client.
Short Term:
After 4 hours
of nursing
interventions,
client will be
able to
verbalize
understanding
of disease
process and
appropriate
treatment
plan.
> Helps ensure
that client
seeks timely
treatment and
may prevent
worsening of
preeclamptic
state to
eclamptic state
or additional
complications.
> Encourages
54
healthcare
provider.
> Assist family
members in
learning the
procedure for
home
monitoring of
BP, as
indicated.
participation in
treatment
regimen,
allows prompt
intervention as
needed, and
may
provide
reassurance
that efforts are
beneficial.
> Reinforces
importance of
client’s
responsibility in
treatment.
> Review
techniques for
stress
management
and diet
restriction.
> Provide
information
about ensuring
adequate
protein in diet
for client with
possible or mild
preeclampsia.
> Protein is
necessary for
intravascular
and
extravascular
fluid regulation.
> A test result
of 2+ or
greater is
significant and
needs to be
55
> Review selftesting of urine
for protein.
Reinforce
rationale for
and implications
of testing.
reported to
healthcare
provider. Urine
specimen
contaminated
by vaginal
discharge or
RBCs may
produce
positive test
result for
protein.
56