ECLAMPSIA

____________________________________ Presented by: Benoza, Frances Joy Denia, Erlene Love Matienzo, Myrnelle Joy Guevarra, Stephanie Joy

INTRODUCTION

STEPHANIE GUEVARRA

ASSESSMENT

ERLENE LOVE DENIA

PATIENT DATABASE Name: JRC Age: 24 Status: Married Religion: Catholic Nationality: Filipino Occupation: Housewife Final Diagnosis: Eclampsia Cc: labor pains & seizure

BOOK PICTURE

Pt. Manifestations

Skin

 Generalized edema Increased BP: >160/110 Dyspnea Tachypnea Auscultation of crackles Pulmonary edema Increased RR Use of accessory muscles

 (+) Grade II general edema  (+) Increased BP:130/90 200/150  (+) Dyspnea  (+) Tachypnea  (+) Auscultation of crackles  (+) Pulmonary edema  (+) Increased RR  (+) Use of accessory muscles

 Cardiovascular      

Respiratory

BOOK PICTURE

Pt. Manifestations

Gastrointestinal Genitourinary Neurologic

 Epigastric pain  Oliguria  Urine output of <30cc/hr  Proteinuria Altered LOC Confusion Drowsiness Dizziness Blurred vision Nausea and vomiting  Hyperreflexia  Visual disturbances  Seizure      

 (-) Epigastric pain  (-) Oliguria  (-) Urine output of <30cc/hr  (+) Proteinuria

        

(-)Altered LOC (-)Confusion (+)Drowsiness (+)Dizziness (+)Blurred vision (-)Nausea and vomiting (-)Hyperreflexia (-)Visual disturbances (+) Seizure

PATHOPHYSIOLOGY

FRANCES JOY BENOZA

NURSING CARE PLAN

MHYLE, LOVE & STEPH

NURSING CARE PLAN

PROBLEM #1

Problem No. 1

High Blood Pressure

Objective Bp: 180/120mmHg (130-200/90150mmHg) Dizziness Headache Presence of edema

Subjective Lagi nga daw mataas ang BP ko e. Sumasakit ang batok ko tapos minsan kapag tumatayo ako, nahihilo ako, as verbalized by the pt.

Diagnosis

Ineffective tissue perfusion related to vasoconstriction of blood vessels.

Expected Outcome

NOC: Tissue perfusion:Cardiopulmonary

Short-term After 1 hour of nursing intervention, the patients blood pressure will be decreased from 180/120mmHg to 140/90mmHg. Long-term After 8 hours of nursing intervention the patient will continue to maintain decreased blood pressure.

Nursing Interventions

NIC: Circulatory Care: Arterial Insufficiency

Independent: Monitored blood pressure every 4hours. Instructed to have enough rest on semi fowlers position. Instructed to eat low fat and low salt diet.

Nursing Interventions

NIC: Circulatory Care: Arterial Insufficiency

Dependent: Administered Hydralazine. Administer Catapres. Administered Methyldopa. Administered Losartan.

Evaluation
Short-term Long-term

Goal met. After 1

hour of nursing intervention, the patients blood pressure was decreased from 180/120mmHg to 140/90mmHg.

Goal met. After 8

hours of nursing intervention the patient continued to maintain decreased blood pressure.

NURSING CARE PLAN

PROBLEM #2

Problem No. 2
Subjective

Difficulty of Breathing
Objective Crackles Dyspnea RR Use of accessory muscle while breathing Progression of pulmonary congestion and edema Altered chest excursion Nasal Flaring Increased anteriorposterior diameter

Nahihirapan akong huminga, as verbalized by the patient.

Diagnosis

Ineffective airway clearance related to presence of secretions secondary to pneumonia.

Expected Outcome

NOC: Respiratory Status: Airway patency

Short-term Long-term

After 30 minutes of nursing interventions, the patients respiration shall have improved and difficulty of breathing shall have been decreased.

After 4 hours of nursing interventions, the patient will have been able to continue to manifests relief in breathing.

Nursing Interventions

NIC: Airway Management

Independent: Assessed respiratory status, including v/s, breath sounds,Sao2, and skin color atleast every 4 hours. Assess cough and sputum(amount, color, consistency, and possible odor). Place in high Fowlers position. Encourage frequent position changes and ambulation as allowed. Encouraged to increase fluid intake.

Evaluation
Short-term Long-term

Goal met. After 30

minutes of nursing interventions, the patients respiration have improved and difficulty of breathing shall have been decreased.

Goal met. After 4

hours of nursing interventions, the patient have been able to continue to manifests relief in breathing.

NURSING CARE PLAN

PROBLEM #3

Problem No. 3
Subjective

Edema
Objective

Namamanas nga ang paa ko, tapos parang ang taba ko, as verbalized by the patient.

Generalized edema Grade II Grade III edema Poor skin turgor

Diagnosis

Deficient fluid volume related to fluid loss to subcutaneous tissue.

Expected Outcome

NOC: Fluid Balance

Short-term Long-term

After 8 hours of nursing interventions, patient will manifests improved skin turgor.

After 2 days of nursing interventions, the patients edema grade of +3 will be +2.

Nursing Interventions

NIC: Fluid Monitoring

Independent: Assessed for presence and condition of edema of the patient. Monitored intake and output of patient. Turned, repositioned, and provided skin car e at regular intervals. Weigh patient daily.

Evaluation
Short-term Long-term

Goal met. After 8

hours of nursing interventions, the patient manifests improved skin turgor.

Goal met. After 2

days of nursing interventions, the patients edema grade of +3 become +2.

NURSING CARE PLAN

PROBLEM #4

Problem No. 4
Subjective

Fall
Objective

Nag seizure na nga ako ng tatlong beses. Minsan nalaglag ako, as verbalized by the patient.

History of seizure episodes History of falling Dizziness Drowsiness

Diagnosis

Risk for injury related to seizure.

Expected Outcome

NOC: Safety Behavior: Personal

Short-term Long-term

After 4 hours of nursing intervention the patient will remain free of injuries.

After 8 hours of nursing intervention the patient will explain methods to prevent injury and still remain free of injuries.

Nursing Interventions

NIC: Surveillance: Safety

Independent: Evaluate all clients for fall risk and take appropriate actions to prevent falls. Avoid use of restraints if at all possible. Obtain a physicians order if restraints are necessary. Place an injury- prone client in a room that is near the nurse station. Teach how to safely ambulate at home, including using safety measures such as handrails in bathroom. Recommend client use a nightlight after dark.

Nursing Interventions

NIC: Surveillance: Safety

Independent: In place of retraints, use the following: Well- staffed and educated nursing personnel with frequent client contact Nursing units designed to care for clients with cognitive or functional impairments Increased observation of the client Low or very low height beds Remove all possible hazards in environment such as razors, medication and matches.

Evaluation
Short-term Long-term

Goal met. After 4

hours of nursing intervention the patient remain free of any injuries.

Goal met. After 8

hours of nursing intervention the patient explained methods to prevent injury and still the pt. remained free of any injuries.

NURSING CARE PLAN

PROBLEM #5

Problem No. 5
Subjective

Lack of Sleep
Objective

Hindi ako makatulog ng maayos tuwing gabi dahil nahihirapan akong huminga. Nakaupo nga lang ako kung matulog kasi hindi ako makahinga, as verbalized by the pt.

Restlessness Fatigue Irritable Moderate anxiety Drowsy eyes

Diagnosis

Disturbed sleeping pattern related to difficulty of breathing.

Expected Outcome

NOC: Comfort Level

Short-term Long-term

After 1 hour of nursing intervention the patient will verbalized plan to implement sleep promoting routines.

After 2 days of nursing intervention the patient will fall asleep without difficulty, and awaken refreshed and not be fatigued during day.

Nursing Interventions

NIC: Sleep Enhancement

Independent: Obtain a sleep history including betime routines, history of sleep problems, changes in sleep with present illness, and use of medications and stimulants. Determine level of anxiety. If the clients anxious, use relaxation techniques. Keep environment quiet and peaceful for sleeping.

Evaluation
Short-term Long-term

Goal met. After 1

hour of nursing intervention the patient verbalized plan to implement sleep promoting routines.

Goal met. After 2

days of nursing intervention the patient fall asleep without difficulty, and awakened refreshed and during day time

_________________________

THANK YOU!

ECLAMPSIA
____________________________________ Presented by: Benoza, Frances Joy Denia, Erlene Love Matienzo, Myrnelle Joy Guevarra, Stephanie Joy

_________________________

QUESTIONS???

Quiz
1-4 Give the 4 classic signs and symptoms of Eclampsia 5 Give 1 nursing intervention for patient with seizure in eclampsia