Nursing Concep Map

Cultural considerations.

Patient is Hispanic. Patient works part-time teaching English at the local community college. She is married and her husband is a Firefighter engineer who works full time and is occasionally out of town for work. Her parents live in the same town and are supportive

Diagnostic Test/ Lab Results

Radiology:

Non-stress Test: The non-stress test is non-reactive.

Fetal heart rate baseline 130, with minimum variability and no accelerations. No decelerations are noted.

(Perinatology.com,n.d)

Patient Education & Discharge Planning

-“Educate the patient about sign and symptoms of preeclampsia like high blood pressure, protein in the urine, persistent severe headache, visual problems (blurred or double vision, blind spots, flashes of light or squiggly lines, loss of vision) kidney, seizure and new-onset shortness of breath (due to fluid in the lungs). Also teach patient that can cause slowed in fetus grow, decreased in amniotic fluid and decreased blood flow through the umbilical cord.” (Up to Date, n.d)

-“Teach risk for preeclampsia like chronic hypertension, kidney disease, lupus, or diabetes prior to pregnancy, also gestational diabetes, multiple gestation (eg, twins or triplets), family history of preeclampsia in a sister or mother and obesity (Up to Date, n.d)

-Make sure the patient understood the life style changes she has to do at home like lowering sodium intake and keeping weight in the ideal range.

-Make sure patient understood to call 911 immediately if she experienced seizure and/ or chest pain

-Teach Patient to call Physician if she has severe abdominal pain with or without nausea and vomiting, severe headache that does not go away with medicine. (Preeclampsia during pregnancy, discharged care, n.d)

Admitting Dx

“Patient is a 30-year-old woman, she is 34 weeks gestation. Her blood pressure has been increasing the past month and is currently 146/88. Last week she had 1+ non-pitting edema of both lower extremities (BLE) and her urine was negative for protein. Today during her clinic visit, patient’s BP was 168/90. She had 3+ proteinuria and 4+ pitting edema BLE. She also complained of a moderate headache in the center of her forehead, and seeing “spots.” Fetal heart tones via Doppler are 136/minute in the lower left quadrant. Abdominal measurement from pubic bone to top of fundus is 31 cm.

The primary care provider was concerned, and Patient has been admitted to the community hospital labor and delivery unit to be evaluated for severe preeclampsia.”

“Preeclampsia is a hypertensive, multisystem disorder of pregnancy whose etiology remains unknown. Characterized by a new-onset hypertension after 20 weeks’ gestation with two blood pressure readings at least 140 mm Hg systolic and/or at least 90 mm Hg diastolic taken at least 4 hours apart. In addition, a woman will have proteinuria greater than 300 mg in 24 hours (protein/creatinine ratio ≥ 0.3 mg/dl) or new-onset systemic disease”. (Maternal-newborn nursing: the critical components of nursing care, 2019)

Medical History

Patient is generally healthy, without any chronic illnesses.

Surgical History

N/A

Social History

Patient has two children, ages two and four.

She is married and both she and her husband are excited to have another baby but have been concerned about this pregnancy. Patient‘s previous two pregnancies were healthy, without incident, resulting in the vaginal

She does not smoke or use recreational drugs.

She reports drinking socially but refrains while pregnant.

Obstetric History

GTPAL

Multigravida G-3 T-2 P-0 A-0 L-2

Patient is 34 weeks gestation

Erickson’s Developmental Stage

“Intimacy vs. Isolation: This stage takes place during young adulthood between the ages of approximately 18 to 40 yrs. During this stage, the major conflict centers on forming intimate, loving relationships with other people.

In this stage patient begin to share themselves more intimately with others. Explore relationships leading toward longer-term commitments with someone other than a family member.

Successful completion of this stage can result in happy relationships and a sense of commitment, safety, and care within a relationship.”

(Erik Erikson's Stages of Psychosocial Development, n.d)

Chief Complaint

Patient’s BP was 168/90. She had 3+ proteinuria and 4+ pitting edema BLE. She also complained of a moderate headache in the center of her forehead, and seeing “spots.”

Admitting Diagnosis

“Severe preeclampsia.”

Patient Information

(1)

Name: Camelia Cabello

Age: 30 y/o

Height/Weight: N/A

Allergies: NKA

Gestational Age: 34 weeks

Concept Map

Student Name: Adidley Garcia

Instructor: Claudia Barriel-Goslin

Priority nursing diagnosis

-Patient is at risk for Decreased Cardiac Output relate to increased systemic vascular resistance

As evidence by change in blood pressure/hemodynamic readings.

Cardiovascular

Pink, warm/dry, 3+ non-pitting edema of BLEs with generalized edema of hands, face, and sacrum, heart sounds regular with no abnormal beats radial/pedal/post-tibia landmarks equal

PC Outcomes/Goal

-Lower Blood pressure and decreased proteinuria

Interventions

· Record and graph vital signs especially BP and pulse.

· Institute bedrest with patient in lateral position.

· Check for invasive hemodynamic parameters.

· Give antihypertensive drug such as labetalol

(Pregnancy Induced Hypertension Nursing Care Plans, 2019)

Priority nursing diagnosis

-Patient is at risk for Impaired Tissue Perfusion related to Interruption of blood flow (progressive vasospasm of spiral arteries) as evidenced by Premature delivery

Respiratory

Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort

Vital Signs

T: 98.4 F/36.9 C (oral)

P: 84 (regular)

R: 20 (regular)

BP: 164/98

O2 sat: 95% room air

Integumentary

Skin integrity intact

Assessment/ Evaluation

· Patient concerning was addressed and the home assessment about fetus movement was explained.

· Factor affecting fetal movement was teach to patient like cigarette smoking, medication/drug use, serum glucose levels, environmental sounds, time of day, and sleep-wake cycle of the fetus can increase or decrease fetal movement.

· Fetal growth and fundal was measure to patient

· Fetal and mother well-being was evaluated.

· Goal was met

Pregnancy Induced Hypertension Nursing Care Plans, 2019)

PC Evaluation Plan

· Patient Blood pressure was monitored

· Magnesium sulfate was administer and deep tendon reflexes was assessed.

· Input and output was monitored

· Patient was weight daily in the morning

· Goal was met

PC Interventions

· Monitor Blood pressure regularly

· Administer Magnesium Sulfate as doctor order.

· Advise mother to take adequate rest

· Assess deep tendon reflexes and clonus after magnesium sulfate administration

· Monitor intake and output

· Weight patient daily

Psychosocial

Appears uncomfortable

Endocrine

No endocrine issue detected

GU

Voiding without difficulty, urine clear/yellow, urine 2+ by dipstick

GI

Abdomen soft/non-tender, slight epigastric discomfort, bowel sounds audible per auscultation in all four quadrants, no contractions palpated, uterus soft.

Nutrition/Hydration

Patient was well nourished.

Rest/ Exercise

Patient mobility is within normal limited, for 34 week gestation

Neurological

Alert and oriented to person, place, time, and situation (x4). Reflexes are brisk with no clonus, c/o headache and continues to see “spots”

Outcome/Goal

-Patient remains normotensive throughout remainder of pregnancy.

-Patient reports absence and/or decreased episodes of dyspnea.

Outcome/Goal

-Patient demonstrates normal CNS reactivity on nonstress test (NST)

-Patient is free of late decelerations;

Misc. Pain (V.S)

Provoking: one

Stabbing/throbbing

Radiation: Eyes, forehead

Severity: 5/10

Timing: Constant, unrelieved by acetaminophen

Interventions

· Present information to patient/couple concerning home assessment or noting daily fetal movements and when to seek immediate medical attention.

· Name factors affecting fetal activity

· Present contact number for patient to direct questions, address changes in daily fetal movements, and so forth.

· Evaluate fetal growth; measure progressive fundal accompany growth at each office visit or periodically during stress home visits, as appropriate.

(Pregnancy Induced Hypertension Nursing Care Plans, 2019)

Potential Complications/ at risk for seizure (eclampsia) related to elevated blood pressure

Assessment/ Evaluation #1

· Blood Pressure and pulse was recorded during assessment

· Patient was positioned in her lateral side to improve venous return, cardiac output, and renal/placental perfusion.

· Hemodynamic parameter was check like vascular constriction and cardia output.

· Antihypertensive medication was given to promote relaxation of cardiovascular smooth muscle and help increase blood supply to cerebrum, kidneys, uterus, and placenta.

· Goal was met.

(Pregnancy Induced Hypertension Nursing Care Plans, 2019)

Medical Management

References:

(n.d.). Retrieved from http://perinatology.com/Reference/Reference Ranges/White Blood Cell.htm

(n.d.). Retrieved from https://www.uptodate.com/contents/preeclampsia-beyond-the-basics

Durham, R. F., & Chapman, L. (2019). Maternal-newborn nursing: the critical components of nursing care. Philadelphia, PA: F.A. Davis Company.

Mcleod, S. (n.d.). Erik Erikson's Stages of Psychosocial Development. Retrieved from https://www.simplypsychology.org/Erik-Erikson.html

Preeclampsia during Pregnancy (Discharge Care) - What You Need to Know. (n.d.). Retrieved from https://www.drugs.com/cg/preeclampsia-during-pregnancy-discharge-care.html

Urine Protein and Urine Protein to Creatinine Ratio. (n.d.). Retrieved from https://labtestsonline.org/tests/urine-protein-and-urine-protein-creatinine-ratio

Wayne, G., Wayne, G., & Wayne. (2019, June 1). 6 Pregnancy Induced Hypertension Nursing Care Plans. Retrieved from https://nurseslabs.com/pregnancy-induced-hypertension-nursing-care-plans/#decreased_cardiac_output