Perfusion Preeclampsia Care Plan Postwork

Care Plan: Perfusion-Preeclampsia Nursing Diagnosis (3-part statement) Goals (1 per diagnosis and SMART) Interventions (include 5 for each goal) Rationale (1 reason for each intervention) Evaluation (Met, partially met, not met and explain progress) 1) Pt participate in tx and/or environmental Risk for maternity injury modifications to r/t tissue edema as protect self and evidenced by peripheral enhance safety by end edema. of shift. 1) Check for alterations in LOC. 2) Assess for signs of impending eclampsia. 3) Emphasize importance of pt reporting S/S of CNS involvement. 4) Enforce seizure precautions per protocol. 5) Assess fetal well-being, noting FHR. 1) Goal met by pt participating in tx and/or environmental modifications to protect self and enhance safety by end of shift. 2nd Diagnosis: 1) Record and graph VS, especially BP and HR. 2) Instruct pt to rest and lay in lateral position. 3) Assess for crackles, wheezing, dyspnea, and not RR/effort. 4) Check for invasive hemodynamic parameters. 5) Prepare for birth of fetus 1) In progressive PIH, vasoconstriction and vasospasms of cerebral blood vessels reduce O2 consumption by 20% and result in cerebral ischemia. 2) Generalized edema/vasoconstriction manifested by severe CNS, kidney, liver, cardiovascular, and respiratory involvement, precede convulsive state. 3) Delayed tx of progressive onset of symptoms may result in tonic-clonic convulsions or eclampsia. 4) If seizure occurs, this reduces the risk of injury. 5) If seizure occurs, fetal bradycardia may occur. 1) Pt w/PIH does not display normal cardiovascular response to pregnancy. HTN occurs secondary to manifestations of PIH after edema. 2) Improves venous return, CO, and renal/placental perfusion. 1st Diagnosis: Decreased cardiac output r/t increased systemic vascular resistance as evidenced by change in blood pressure and edema. 1) Pt remains normotensive throughout remainder of pregnancy. 1) Goal met as evidenced by pt remaining normotensive throughout remainder of pregnancy. Care Plan: Perfusion-Preeclampsia by cesarean delivery, when severe preeclampsia condition is stabilized but vaginal delivery is not possible. 3rd Diagnosis: (psychosocial) Pt exhibits anxiety r/t knowledge deficit as evidenced by verbal concern. 1) Pt will verbalize having a decrease in anxiety by end of shift. 1) Assess for presence of culture-bound anxiety states. 2) Assess pt’s level of anxiety. 3) Assess physical reactions to anxiety. 4) Validate observations by asking pt, “Are you feeling anxious now?” 5) Teach pt coping skills and observe how pt uses coping techniques and defense mechanisms to cope with anxiety. 3) Pulmonary edema may transpire with modification in peripheral vascular resistance and drop in plasma colloid osmotic pressure. 4) Provides precise picture of vascular changes and fluid volume. Prolonged vascular constriction, increased hemoconcentration, and fluid shifts can decrease CO. 5) If conservative tx is ineffective and labor induction is ruled out, then surgical procedure is the only means of halting HTN problems. 1) Anxiety is experienced, and responses to it are culturally medicated. 2) Mild anxiety will have minimal or no physiological symptoms of anxiety. VS will appear normal but pt may report feelings of nervousness. 3) Anxiety plays a role in somatoform d/o which are characterized by physical symptoms such as pain, nausea, weakness, or dizziness that have no physical cause on the 1) Goal met by pt verbalizing a decrease in anxiety by end of shift. Care Plan: Perfusion-Preeclampsia body. 4) Anxiety is highly individualized, normal physical and psychological response to internal or external life events. 5) Asking questions requiring informative answers helps identify the effectiveness of coping strategies.