Nursing care plan

On
PRE- eclampsia

Submitted to: SUBMITTED BY:

Resp.gagandeep Kaur ma’am Simarjeet kaur
Assistant professor Msc.(n) 1st year
Ucon, fdk UCON, Fdk

IDENTIFICATION DATA OF THE PATIENT

 Name of the patient: Nandini

Age: 28 years

Sex: Female

Address: Mamdot, Firozpur

Date of admission: 5-2-2023

Ward no: Maternity ward

Bed no: 01

Diagnosis: Pre- Eclampsia

Periods of gestation: 37 weeks

Dr. Incharge: Dr. Parveen

Marital status: Married

Occupation: House wife

CHIEF COMPLAINTS:

Headache……………× 5days

Vomiting……………. × 3 days

Increased blood pressure…………×From 8th month of POG

Sleep disturbance…………………×2 days

PRESENT HISTORY: Patient came through emergency and admitted to the hospital with the chief complaints of moderate hypertension, headache
and vomiting She had complaint of pain in abdomen and leaking per vagina from yesterday night . Now she is admitted in the maternity ward.

PAST HISTORY:
 Past Medical history: No history of diabetes mellitus, hypertension, allergy, TB, and asthma.

Past Surgical history: Patient has not undergone any surgery in her past.

FAMILY HISTORY: No significant family history of the patient is found. Patient’s all family members are well and healthy; they have no any
Medical or Surgical history. Not any history of drug abuse.

FAMILY TREE:

Gurdeep Singh Mandeep Kaur

(Father-in-law) (mother-in-law)

Ramandeep (sister-in-law)

Sagar

(Husband) Nandini ( Patient)

Sukhmandeep (daughter)

PERSONAL HISTORY: Patient is vegetarian and is not addicted to any kind of drug or abusive material.

 Oral hygiene : Good

 Bath : Regular
 Fluid : 3-4 glasses per day
 Sleep & Rest : Inadequate sleep pattern
 Bowel per day : Normal
 Urine frequency : Frequent urination

Menstrual history:
  Age of menarche - 14 year
 Menstruation Cycle - 28 days
 Duration - 4- 5 days
 Dysmenorrhea - Yes
 Metrorrhagia - No

OBSTETRIC HISTORY: G2 P1 A0 L1

 Year of delivery : 2019

 Duration of pregnancy : 38 weeks

 Abnormalities in pregnancy: No any abnormality

 Mode of delivery : NVD

 Puerperium : Normal

 Infant : Female baby, weight was 2.5kg

GENERAL EXAMINATION

 Height : 5’4”
 Weight : 68 kg
 BP : 140/100mm hg
 Pulse : 92b/min
 Respiration rate : 22b/min
 Temperature : 99°f
 General appearance : Lethargy
 Built : Average
 Gait : Normal

PHYSICAL EXAMINATION
  Head & scalp : Healthy hair and scalp
 Face : Chloasma present
 Eyes : No any abnormality
 Ears : No discharge
 Nose : Normal
 Mouth : Secretions present
 Lips : Pigmented
 Neck : No lymph node enlargement
 Limbs : Pedal oedema is present
 Breast examination : Engorged breast, Well-formed nipples
 Shape of uterus : Oval

ABDOMINAL EXAMINATION

 Inspection : Striae gravidarum Present

 Palpation : No organomegaly
 Presentation : cephalic
 Auscultation : Fetal heart sound (148b/min)

VAGINAL EXAMINATION

 Bleeding/Leakage : Present
 Infection : Absent

SYSTEMATIC EXAMINATION
NERVOUS SYSTEM

 Patient is conscious and fully oriented to place, person and time.

 Speech and articulation: Normal
 Cranial nerve : All the nerves under function normally
  Muscle power : Weak response
 Sensory system : Normal Sensory response
MUSCULOSKELETON SYSTEM

 Range of motion is weak

 Deep tendon reflexes is normal
 Superficial reflex is normal
RESPIRATORY SYSTEM
 Inspection : Bilaterally symmetrical movement of chest wall
 Percussion : Absence of fluids
 Auscultation : No adventitious sound, wheezing etc.
 Respiratory rate : 22 b/min.
CIRCULATORY SYSTEM

 Heart rate : 90b/min

 BP : 140/100mmHg
 Inspection : Generalised vasospasm present
 Palpation : Peripheral pulsation increased
 Auscultation : Rapid heart rate
GASTROINTESTINAL SYSTEM
 Inspection : Tenderness over abdominal area
 Auscultation : Impaired bowel movement
 Percussion : No fluid/gas is present
URINARY SYSTEM

 Patient is on catheter and urine output is inadequate

ENDOCRINE SYSTEM

No enlargement or abnormality is seen.

VITAL SIGNS-

SR NO. VITALS PATEINT VALUE

1. Temperature 99° F
 2. Pulse 93 b/min
3. Respiration 22 b/min

4. Blood pressure 140/100 mm Hg

INVESTIGATIONS

TEST PAETIENT VALUE NORMAL RANGE REMARKS

Hb 11.6 12-14gm Normal
TLC 10.1 4-11 Normal
PLT Count 176 150-450 Normal
PTI/INR 1.0 1.1 Normal
HbsAg Non- reactive Non-reactive Normal
H1V1&2 Non-reactive Non-reactive Normal
HCV Non-reactive Non-reactive Normal

MEDICATION

DRUG DOSE ROUTE TIME ACTION

Inj. Gramocef 1gm Oral BD Antibiotic
Inj. Pantop 40mg IV BD Anta- acid
Inj. Magnesium sulphate 5 mg IV OD Anticonvulsant
Inj. Labetalol 2omg IV BD Antihypertensive

NURSING MANAGEMENT

NURSING ASSESSMENT
 Assessment of the general condition, investigations should be done promptly.
 Assessment of the level of consciousness of the patient.
  Assessment of the airway breathing and circulation pattern.
 Assessment for any signs of both external or internal damage.

NURSING DIAGNOSIS
1. Decreased cardiac output related to decreased venous return evidenced by variation in blood pressure.
2. Altered tissue perfusion related to arterial vasospasm/constriction of blood vessels as evidenced by monitoring.
3. Imbalanced nutritional status less than body requirement due to indigestion as evidenced by vomiting, weakness.
4. Fear related to hospitalization as evidenced by increased blood pressure and facial expression of patient.
5. Sleep pattern disturbance related to disease condition as evidenced by patient complaint that she having irregular sleep.

NURSING GOALS
SHORT TERM GOALS

1. To maintain efficient cardiac output.

2. To maintain fluid volume deficit.
3. To maintain nutritional balance.
4. To promote comfort and decreased weakness.
5. To maintain sensory perception.

LONG TERM GOALS

1. To make the patient understand about the disease condition.

2. To prevent the patient from further complications.
3. To reduce anxiety and fear of the patient.
4. To instruct the patient for follow-up.

SR ASSESSMENT DIAGNOSE GOAL PLANNING INPLEMENTATION RATIONALE EVALUATION

NO.
1. Subjective data: Decreased cardiac To maintain Assess the Assessment reveals It provides Cardiac output
I am feeling output related to efficient condition of the restlessness in early baseline data of is decreased to
anxious. decreased venous cardiac output patient. stages, severe anxiety the patient. some extent and
return evidenced and confusion. patient is able to
 Objective data: by variation in respond well to
On observation I blood pressure. Assess heart rate Sinus tachycardia and It provides interventions.
found patient is and BP. increased blood baseline for
having peripheral pressure is seen. comparison to
edema. follow up and
evaluate
response to
intervention.

Assess the skin Cold, clammy skin

color and and lower cardiac It helps to
temperature. output is there. reduce blood
pressure and
minimize
Restrict the Established dietary dehydration.
sodium intake. and fluid sodium
restriction.

Provide adequate Comfortable or It decreases

rest by adequate position oxygen
positioning. provided to patient. consumption
and risk for de-
compensation
and for
maintain
maximum
comfort.

2. Subjective data: Altered tissue To maintain Monitor the vital Vital signs are It provides the Circulation of
Patient complains perfusion related adequate signs, palpate recorded every half status of the patient is
about difficulty to arterial circulation and peripheral pulses. hourly. patient. improved to
in breathing. vasospasm/constri reduce Blood pressure is some extent.
ction of blood Vasospasm. being reduced.
Objective data: vessels as
 On observation I evidenced by
found that patient monitoring. Assess the urinary Urinary output It provides base
is in restlessness. output and weight assessment done and data for further
client daily. record is maintained management.
on chart.

Place the client in Patient is placed in It provides

comfortable left recumbent comfort to
position. position. patient.

Monitor fatal and It helps to

maternal Fetal and maternal detect any
wellbeing wellbeing is guarded. complications
periodically. at first stage.

Administer It improves and

oxygen as Patient is provided maintain tissue
prescribed. with oxygen therapy. perfusion.

Ensure safety of It provides

the patient Safety is maintained protection to
by putting side rails patient from
up and monitored for injury.
tonic – conic seizures.

Assess for the It provides Nutritional

3. Subjective Imbalanced To maintain a physical signs of On assessment patient baseline data pattern is
data: Patient says
nutritional status healthy poor nutritional found with deficiency for further maintained to
I am unable to less than body nutritional intake. of vitamins and interventions. some extent.
wake up from requirements status as per minerals, so patient is
bed. related to inability the body’s provided with
to digest food as requirement. adequate amount of
Objective data: evidenced by fresh fruit juices twice
On Observation I weakness and a day.
 found that vomiting.
patient is feeling
weak and Review the Laboratory
lethargic. laboratory values Laboratory values values provide
that indicate well- reviewed and information
being or determines increase in which types of
deterioration. protein and sodium nutrients is add
values. in patient diet
Revealing anaemia or also which
also for this patient is one excluded in
limited for high diet.
calories and iron rich
sources.

Provide patient It helps to

with proper oral Patient is willing to originate a good
hygiene and eat and is provided taste after
comfortable with good oral care proper oral
positioning. along with upright hygiene.
position while eating
Consider the use food. It improve
of seasoning and nutritional
likes and taste of Small, frequent meals pattern of
the patient and are advised for the patient.
discourage patient to her relatives
caffeinated to be given as per
beverages. patient demand with
Monitor blood avoidance of tea, It provides data
pressure of the coffee for patient Fear related to
Fear related to To reduce the patient. Monitored blood condition. hospitalization
4. hospitalization as fear of patient pressure of the patient is reduced to
Subjective data: evidenced by due to anxiety. that is 180/110mmHg. some extent.
Increase tension. increased tension, Consult with It controls or
increased systolic doctor reduce high
Objective data: blood pressure immediately and Antihypertensive blood pressure.
Fear due to 180/110mmHg. provide therapy is provided to
hospitalization antihypertensive patient.
and treatment. drugs to patient.
 Provide It helps to
psychological reduce anxiety
support and Psychological support of patient.
counsel the is provided to patient.
patient from free
of hospitalized
fear.

HEALTH EDUCATION

 Patient is encouraged to avoid any type of stress and strain on the body.
 Avoiding lifting heavy objects and standing for prolonged periods.
 Explanation regarding medication regimen which is to be followed by the patient.
  The patient is reassured regarding her disease condition, false reassurance is avoided.
 The patient is instructed regarding any type of pain, headache or any other abnormality is to be reported immediately.
 Encourage patients on deep breathing exercises.
 Move extremities when lying.
 Elevate the head part when sleeping, to promote increase peripheral circulation.
 Encourage patient for sodium restriction.
 Encourage to avoid foods rich in oil and fats.
 Encourage patient to limit her daily activities and exercises.

BIBLIOGRAPHY

1. Dutta D.C., “Textbook of Obstetrics”, 6th Edition, Central publishers, Pg-588-598.

2. Gupta Sadhana, “A Comprehensive Textbook of Obstetrics & Gynaecology, “Edition 3rd, Jaypee Brothers Medical Publishers, Pg-565-567.
3. Dawn C.S., “Textbook of Obstetrics and Neonatology” 15th Edition, Dawn books, Pg-362-367.
4. Jacob Annamma, “A Comprehensive Textbook of Midwifery & Gynaecological Nursing.3rd Edition, Jaypee Brothers, Pg-396-399.