Home Nursing Care Plan Eclampsia Nursing Care Plan-Altered tissue perfusion Eclampsia Nursing Care Plan-Altered tissue

ue perfusion Posted by Ira on April 25, 2012 in Nursing Care Plan 4 Among the most fatal part of pregnancy-induced hypertension iseclampsia. The status of having an eclampsia is an introductory phase for having convulsions when the case is not managed properly. Previous researchers attempted to cite out the cause of hypertension but until now they could not point it out. Only contributing factors are sited such as heredity, lifestyle and supporting vessels. Previously, eclampsia is called toxaemia since researchers thought a certain toxin may cause the hypertensive episodes on mothers. In diagnosing pregnant mothers in the pre-eclamptic stage, a triad of signs and symptoms are observed: 1. Intense Vasospasm 2. Local or disseminated intravascular coagulation 3. Plasma volume contraction

Eclampsia can only be squared down when the following signs and symptoms are present:
hypertension proteinuria edema

Predisposing factors: 1. Multiparity 2. Being pregnant under 20 years old 3. Being pregnant more than 30 years old 4. Being in a low socio-economic status 5. Previous diagnosed illness such as heart disease, diabetes mellitus and essential hypertension Eclampsia Nursing Care Plan-Altered tissue perfusion Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation

Nursing Diagnosis: Altered tissueperfusion(Ce rebral, peripheral and renal) Possible Etiologies: (Related to)

Goals/ Objectives: Short term goal: Client will demonstrate adequateperfusion, as evidenced by stable vital signs, palpable pulses, and alert and oriented, absence of seizure episodes, balanced intake and output, decrease in presence of edema and good fetal status evaluation within a week. Long term goal: Client will demonstrate readiness during the postpartal period in monitoring ones health and involving oneself to dietary restrictions and medical follow up checkups and intervention.

Arterial vasospam/ constriction of blood vessels Decreased prostaglandi n levels Sensitivity to angiotensin II Impaired glomerularpe rfusion Decreased uteroplacent al perfusion Increased cardiac workload Vascular damage Red blood cell damage Alteration inliver functionin severe cases Unusual sensitivity to blood loss probably because of

Nursing Actions 1. Monitor vital signs, palpate peripheral pulses and note capillary refill, assess urinary output, weigh client daily and evaluate changes in mentation. 2. Place client on left recumbent position.Monitor maternal wellbeing periodically. 3. Administer oxygen as prescribed. 4. Ensure safety by putting the side rails always up and monitor client for tonicclonic convulsions. 5. Insert foley catheter as indicated by the physician and monitor urine output. 6. Administer Magnesium Sulfate as ordered by the physician and monitor for signs for toxicity. 7. Administer fluids as

Outcome Criteria: Rationale 1. Indicators of adequacy of systemicperfusion, fluid/ blood, needs, and developing complications. This is to avoid uterine pressure on the vena cava and prevent supine hypotension syndrome. Womans BP should be taken at least every 4 hours to detect for increase which is a warning of worsening; if fluctuating, it should be done hourly. To ensure supply of oxygen to both the mother and the fetus. Convulsions are evident in Eclampsia so it should be watched out and monitored. Urine output should be in congruence with fluid intake. This drug is usually given to control the blood pressure of clients with pregnancy induced hypertension. Replacement of fluids maintains circulating volume and tissueperfusion.Delivery of the baby is considered the only cure for Eclampsia. Clients blood pressure is below 140/90mmHg, urine output of above 30ml/hour, fetal heart rate is between 120-160 beats per min, absence of seizure episodes, decrease in presence of edema. Client verbalizes plans upon discharge, participates during lecture- discussion sessions, and demonstrates willingness to perform monitoring measures.

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leakage of blood components into the extravascular space. Defining characteristics: (Evidenced by)

prescribed. 8. Assist in the delivery of the baby.

Elevated blood pressure Edema, especially of the hands and face Sudden weight gain Proteinuria (1+ up to 4+) Hyperreflexi a Headache Visual disturbances Epigastric pain Fetal status Decreased urine output Rales, if pulmonary edema is present Elevated BUN, creatinine, uric acid Decreased hematocrit and

haemoglobin Seizure

References: Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family Philippine Edition of Pillitteri, A.(1992) Phantom Notes in Nursing: Maternal Newborn 1st Edition of Glickman Jr., J. (1995). A s s e s s m e n t N u r s i v e n t i o n s R a t i o n Subjective: Patient mayver balize Palpitations Fatigue Shortness of breath/dyspnea n a g DiagnosisScientificExplanationP l e E v a l u a t i l a n o n n i n g I n t e r

anxiety Objective:Patientmanifested: Weight gain Edema Variations inBP reading Restlessness Patients fetusmay manifest: Jugular veindistention Cold clammyskin Arrhythmaia crackles Prolongedcapillary refillDecreasedCardiac output r/tdecreasedvenous returnsecondary toeclampsia AEBaltered BP andedemaInadequate bloodis pumped by theheart to meet themetabolicdemands of thebody. It resultedfrom a systemicvaso constriction inthe body causedby preeclampsia.Vasoconstriction isthe decrease in thediameter of theblood vesselswhich occur indiseases likepregnancy-inducedhypertension.Decreased bloodsupply leads to adecrease in venousreturn, thus thereis a relativelysmaller amount of blood expelled bythe ventricles of the heart. Short Term : After 3 hrs of nursinginterventions,the pt will displayhemodynamicstability AEBblood pressurewithin her normalrange Long Term : After 3 days of nursinginterventions,the pt willdemonstrateactivities thatreduce theworkload of theheart (stressmanagement,therapeuticmedicationregimenprogram,balancedactivity/ restplan) 1 . E s t a b l i s h rapport2 . M o n i t o r a n d assess VS3 . A s s e s s t h e p t s generalphysicalcondition4 . D e t e r m i n e baseline vitalsigns/hemodynamicparametersincludingperipheralpulses.5 . R e v i e w s i g n s o f impendingfailure /shock.6 . P o s i t i o n w i t h HOB flat orkeep trunkhorizontal whileraising legs 20to 30 degrees(contraindicated in congestivestate in whichsemi-fowlersposition ispreferred)7 . P r o m o t e adequate rest,by decreasingstimuli,1 . T o g a i n p t s trust andcooperation2 . T o o b t a i n baseline3 . T o determinepresence of abnormality4 . P r o v i d e s opportunities totrack changes5 . T o p r e v e n t hypovolemicshock6 . T o i n c r e a s e venous return7 . T o maximize sleepperiods8 . T o p r e v e n t Short Term : The pt shall havedisplayedhemodynamicstability (bloodpressure withincloser range) Long Term : The pt shall havedemonstratedactivities thatreduce theworkload of theheart (stressmanagement,therapeuticmedicationregimenprogram,balanced activity/rest plan)

ECLAMPSIA I. Definition Eclampsia is a Greek word meaning 'bolt from the blue'. It describes one or more convulsions occurring during or immediately after pregnancy, as a complication of pre-eclampsia. Eclampsia has been recognized since ancient times, but it wasn't until the mid-nineteenth century that doctors began to realize that the fits were normally preceded by a collection of circulatory disturbances now known as pre-eclampsia. Confusingly, however, very few cases of pre-eclampsia culminate in eclampsia, while eclampsia can sometimes precede pre-eclampsia. II. Causes Several factors are probably involved, including: reduced blood flow to the brain, caused by a combination of small clots and spasm of the small arteries; swelling in the brain (cerebral edema), possibly as a complication of excessive fluid retention; Bleeding from small arteries ruptured by the intensity of the blood pressure. III. Risk Factors The following are considered risk factors for eclampsia: Nulliparity Family history of preeclampsia, previous preeclampsia and eclampsia Poor outcome of previous pregnancy, including intrauterine growth retardation, abruptio placentae, or fetal death Multifetal gestations, hydatid mole, fetal hydrops, primigravida Teen pregnancy Primigravida Patient older than 35 years Lower socioeconomic status IV. Signs and symptoms Typically patients show signs of pregnancy-induced hypertension and proteinuriaprior to the onset of the hallmark of eclampsia, the eclamptic convulsion. Other cerebral signs may precede the convulsion such as nausea, vomiting, headaches, and cortical blindness. In addition, with the advancement of the pathophysiological process, other organ symptoms may be present including abdominal pain, liver failure, signs of

the HELLP syndrome, pulmonary edema, and oliguria. The fetus may already have been compromised by intrauterine growth retardation, and with the toxemic changes during eclampsia may sufferfetal distress. Placental bleeding and placental abruption may occur.

V. Pathophysiology The etiology of eclampsia remains unclear. It is thought that the underlying factor is hypoperfusion of the placenta. This may be due to the abnormal formation of uteroplacental spiral arteries, making them highly susceptible to vasoconstriction. Vasoconstriction of the placental vessels promotes ischemia or infarction. The hypoperfusion state of the placenta is thought to lead to the release of vasoactive substances causing an inflammatory response, vasoconstriction, coagulation disorders, an increase in capillary permeability and platelet dysfunction. All of these will contribute to organ dysfunction and clinical signs of the disease process. VI. Treatment The treatment of eclampsia requires prompt intervention and aims to prevent further convulsions, control the elevated blood pressure and deliver the fetus.
Prevention of seizure convulsion is usually done using magnesium sulfate. Antihypertensive management at this stage in pregnancy may consist of hydralazine (510 mg IV every 15-20 min until desired response is achieved) or labetalol (20 mg bolus iv followed by 40 mg if necessary in 10 minutes; then 80 mg every 10 up to maximum of 220 mg). If the baby has not yet been delivered, steps need to be taken to stabilize the patient and deliver her speedily. This needs to be done even if the fetus is immature as the eclamptic condition is unsafe for fetus and mother. As eclampsia is a manifestation of a multiorgan failure, other organs (liver, kidney, clotting, lungs, and cardiovascular system) need to be assessed in preparation for a delivery, often a cesarean section, unless the patient is already in advanced labor. Regional anesthesia for cesarean section is contraindicated when a coagulopathy has developed. Invasive hemodynamic monitoring may be useful in eclamptic patients with severe cardiac disease, renal disease, refractory hypertension, pulmonary edema, and oliguria.

VII. Nursing Management: The responsibilities of nursing staff in the management of preeclampsia and eclampsia include patient education and monitoring of patient compliance with the physician's instructions as well as assisting with emergency care. Patients resting at home should be visited and assessed periodically by a home health nurse. These functions are essential to good management of high-risk patients. Providing emotional support to patients with complications during pregnancy is also a critical function. If the patient requires hospitalization, a calm and quiet environment can help decrease the risk of seizure.
fter the data is collected and then analyzed so that the diagnosis may be found in severe preeclampsia clients are: 1. Fluid Volume Deficit related to plasma protein loss, decreased colloid osmotic pressure. (Marilyn Doenges, 2000) 2. Impaired tissue perfusion related to the occurrence of vasospasm arterioles (prene M Bobak, 1995:835) 3. Risk for Injury: the fetus related to inadequate placental blood perfusion (Prene M Bobak 1989:718)

4. Imbalanced Nutrition, Less Than Body Requirements related to inadequate food intake manifested by nausea and anorexia (Sharon J Reeder, 1987:747) 5. Anxiety: moderate: fear of pregnancy failure related to lack of knowledge (Marilyn Doenges, 2000)

Preeclampsia is a collection of symptoms that occur in pregnant women, maternity and childbirth consisting of hypertension, edema and proteinuria, but show no signs of vascular abnormalities or hypertension before, while the symptoms usually appear after age 28 weeks gestation or more. Predisposing factors

Molahidatidosa Diabetes mellitus Multiple pregnancy Hydrops fetalis Obesity

Age over 35 years Clinical manifestations Signs of preeclampsia usually arise in the order: excessive weight gain, followed by edema, hypertension, and proteinuria eventually. In the mild pre-eclampsia found no subjective symptoms. In the severe pre eclampsia found in the area prontal headache, diplopia, blurred vision, pain in the epigastric region, nausea or vomiting. These symptoms are often found in pre-eclampsia is increased and is an indication that eclampsia will occur. Diagnosis :

Clinical features: excessive weight gain, edema, hypertension, and proteinuria occur. Subjective symptoms: headache frontal area, epigastric pain; impaired visual acuity; blurred vision, scotoma, diplopia; nausea and vomiting. Other cerebral disorders: increased reflexes, and not quietly. Examination: high blood pressure, reflexes increased and proteinuria in the laboratory.

Nursing Diagnosis for Preeclampsia 1. 2. 3. Ineffective Cerebral Tissue Perfusion related to decreased cardiac output secondary to vascular vasopasme. Impaired Gas Exchange related to accumulation of fluid in the lungs: pulmonary edema. Decreased Cardiac Output related to decreased venous return, cardiac trouble.

4. 5. 6.

Excess Fluid Volume related to glomerular function impairment secondary to the decrease of cardiac output. Activity Intolerance related to weakness. Impaired Urinary Elimination related to impaired glomerular filtration: anuria and oliguria.

7. Imbalanced Nutrition Less Than Body Requirements related to inadequate intake. ursing Care Plan for Preeclampsia Preeclampsia is a collection of symptoms that occur in pregnant women, maternity and childbirth consisting of hypertension, edema and proteinuria, but show no signs of vascular abnormalities or hypertension before, while the symptoms usually appear after age 28 weeks gestation or more. Predisposing factors

Molahidatidosa Diabetes mellitus Multiple pregnancy Hydrops fetalis Obesity

Age over 35 years Clinical manifestations Signs of preeclampsia usually arise in the order: excessive weight gain, followed by edema, hypertension, and proteinuria eventually. In the mild pre-eclampsia found no subjective symptoms. In the severe pre eclampsia found in the area prontal headache, diplopia, blurred vision, pain in the epigastric region, nausea or vomiting. These symptoms are often found in pre-eclampsia is increased and is an indication that eclampsia will occur. Diagnosis :

Clinical features: excessive weight gain, edema, hypertension, and proteinuria occur. Subjective symptoms: headache frontal area, epigastric pain; impaired visual acuity; blurred vision, scotoma, diplopia; nausea and vomiting. Other cerebral disorders: increased reflexes, and not quietly. Examination: high blood pressure, reflexes increased and proteinuria in the laboratory.