Nursing Interventions For Acute Pain
| Intervention | |
| Encourage the patient to take bed rest during acute pain. | It reduces stimulation and promotes relaxation. |
| Recommend or provide non-pharmacological measures like a calm and quiet environment, comfort measures (back massage, changing position, cold application at forehead or back, relaxation techniques such as deep breathing exercise, guided imagery and diversional activities. | These comfort measures reduce cerebrovascular pressure, blocks sympathetic nervous system response and relieves headache. |
| Minimize or if possible avoid vasoconstricting activities like prolonged coughing, straining during passing stool, and bending over. | Vasoconstricting activities increase cerebrovascular pressure and induce headaches. |
| Provide more liquids, and advise to take a soft diet. If nose bleeding occurs provide nasal packing. | These measures promote general comfort. Nasal packing makes the patient breathe through the mouth, so the mucus membrane becomes dry. To avoid that provide mouth care frequently. |
Classification Of Preeclampsia Pe
There are two types of preeclampsia, which have different pathogenesis:
Preeclampsia without proteinuria or other evidence of kidney disease is isolated preeclampsia. It usually develops after 20 weeks of gestation.
Preeclampsia with superimposed pre-existing chronic renal disease is termed pre-existing preeclampsia. It can occur at any time during pregnancy.
What Are The Nursing Diagnoses For Preeclampsia
The only way to prevent preeclampsia is by early diagnosis and management. A good history and physical exam are essential for accurate diagnosis. If signs and symptoms of preeclampsia are present, the patient should be seen every 4 hours until delivery. Any progress in signs or symptoms that would suggest changes in the condition should lead to more frequent assessments.
-Rest, reassurance, frequent monitoring of vital signs and fluid intake, administration of antihypertensive medications, prevention or management of seizures, and preparation for delivery.
Monitor BP daily
-Provide IV fluids if needed
According to the AACN Synergy Model for Critical Analysis and Resolution of Clinical Problems, six interrelated diagnoses may be applicable in planning care for a patient suffering from preeclampsia. They include:
-Deficient Knowledge
These diagnoses are organized into a nursing care plan.
Ps: We also have articles on diagnoses of C diff
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Nursing Diagnosis For Hypertension: What Is It
Normal blood pressure is when blood pressure is lower than 120/80 mmHg most of the time. A patient is diagnosed with hypertension, the medical term for high blood pressure, when their blood pressure is 140/90 mmHg most of the time.
There are several levels of hypertension:
- Normal Blood Pressure: Lower than 120/ 80
- Prehypertension: 120-139/80-89
- Stage 1 Hypertension: 140-159/90-99
- Stage 2 Hypertension: 160+/100+
Hypertension can be dangerous because it can make the heart work harder to pump blood to the body, which can increase the risk of heart failure, stroke, and hardening of the arteries.
Hypertension Nursing Care Plans
Hypertension is a chronic disease that requires long-term, ongoing care and attention. It is associated with and increases stroke, heart disease, kidney failure, blindness, peripheral vascular disease, and death. Chronic HTN results from damage to the small arteries in the kidneys, heart, and brain, leading to multiple organ dysfunction.
The nurses role in managing a patient with chronic HTN is as follows:
- Monitor blood pressure and heart rate daily measure weight weekly or bi-monthly assess for headaches, dizziness, fatigue, weakness, and decreased exercise tolerance.
- Teach the patient to avoid triggers that may cause anxiety, stress, and anger.
The home care nurses job is to work with the patient and their family or caregiver by providing education for self-care management of HTN.
To achieve this goal:
The nurse should review medications, diet, and activity level assess for side effects from chronic medicines. The patient should be evaluated for changes to the physical condition and mental statuses such as weight gain, edema, or shortness of breath.
Monitor blood pressure readings assess for irregularities in blood pressure level even when medication is constant. If so, make appropriate referrals to find an underlying cause of the abnormality.
-The patient should be taught relaxation techniques to control anxiety and anger.
Refer the patient to a physical therapist for an exercise program, including aerobic exercises and resistance training.
-Stair Climbing
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Nursing Intervention For Activity Intolerance
| Interventions | |
| If required, assist with self-care activities. | The intensity of the activity can also be reduced or adjusted. It reduces overexertion. |
| Gradually increase the intensity or activity levels. | Instruct patient to take rest 30% of the time of the total work time. It helps to conserve energy and do more activity. |
| Encourage the patients to express their feelings during and after the activity. Provide positive reinforcement to the patient acknowledging the difficult situation of the client. | Positive reinforcement helps to minimize frustration and rechannel energy. |
| Involve patients during the planning of activities. | It gives a chance to the client to perform the activity of their choice during the peak of their energy. |
| Provide asst devices and monitor the patient while performing any activity with those devices. | It provides smooth mobility and prevents injury. |
| Involve other disciplines and plan for graded exercise or rehabilitation programmes for the client. | It reduces excessive myocardial workload and the demand for oxygen. |
| Inform the client about his daily and weekly progression. | It sustains the motivation of doing the activity. |
Client Teaching In Decreased Cardiac Output
- Inform the client about his condition, therapies and expected outcome. If possible use various teaching styles and different types of audio-visual materials for clear understanding.
- While teaching the client, emphasize the importance of regular medical check-ups and follow up.
- Ask the client about the medication, dosing and time of taking.
- Inform the client about symptoms in which he/she has to contact the healthcare provider.
- Instruct the client, if possible show a demonstration of self-monitoring of weight, pulse and blood pressure.
- Take vaccines of seasonal influenza, pneumonia or other influenza.
- Discuss individual risk factors. Provide its management
- Smoking cessation
- Patient Identity factors affecting activity intolerance and try to reduce those factors effects, whenever possible.
- The patient demonstrates physiological signs of intolerance.
- The patient participates in desired activities of his/her interest.
- The patient verbalizes an increase in activity tolerance.
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Deficient Knowledge Care Plan
A lack of understanding of hypertension prevents the patient from making appropriate lifestyle choices and places them at risk for worsening health conditions.
- Lack of understanding of hypertension and its effect on the body
- Lack of knowledge of risk factors
- Poor health literacy
- Lack of interest or motivation
As evidenced by:
- Inability to recall information provided
- Incorrect follow-through with diet or lifestyle recommendations
- Development of a chronic condition due to uncontrolled hypertension
Expected Outcomes:
- Patient will teach-back education provided to them regarding how to manage their blood pressure
- Patient will state their personal risk factors for hypertension
- Patient will explain the action of their blood pressure medications and the importance of not missing doses
Deficient Knowledge Assessment
1. Assess the patients understanding of hypertension.Many patients do not understand the role high blood pressure plays in contributing to other conditions and placing them at risk for stroke or heart disease. Assess the patients knowledge deficit to fill in the gaps.
2. Assess barriers to learning.Assess for cognitive, cultural, or language barriers. Perception of the problem and motivation for change is also important. If the patient is not yet ready to learn or does not perceive a reason to, learning will not take place.
Deficient Knowledge Interventions
Preeclampsia Eclampsia Nursing Care Plans Diagnosis And Interventions
Preeclampsia NCLEX Review and Nursing Care Plans
Pre-eclampsia is a medical condition that arises from persistent high blood pressure at around 20 weeks of pregnancy, causing damage to organs such as kidneys and liver.
Kidney damage is characterized by the presence of protein in the urine, known as proteinuria.
If left untreated, pre-eclampsia can lead to eclampsia, a serious complication where in the high blood pressure results to the occurrence of seizures.
This is life-threatening for both the mother and her baby. One in every 200 pregnant women with pre-eclampsia develops eclampsia in the United States. The most effective treatment for pre-eclampsia or eclampsia is the delivery of the baby.
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Pre-eclampsia
It can be asymptomatic at first, and blood pressure may start creeping up slowly
- Persistently high blood pressure checked for at least 2 occasions, 4 hours apart
- Proteinuria
- Visual disturbances
- Upper abdominal pain
- Nausea / vomiting
- Swelling /edema usually seen on the face and hands and can also be in the lower limbs
- Shortness of breath
- Sudden weight gain
Eclampsia
In addition to the signs and symptoms of pre-eclampsia, a patient with eclampsia may have seizure symptoms such as:
- Staring
- Convulsions or violent shaking
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Sedentary Lifestyle Care Plan
A sedentary lifestyle is a risk factor for developing hypertension. Inactivity naturally contributes to a higher heart rate causing the heart to work harder. Those who exercise regularly normally have a lower heart rate, decreasing stress on the heart and arteries.
Nursing Diagnosis: Sedentary Lifestyle
- Lack of interest in physical activity
- Inability to participate due to health or physical limitations
- Lack of knowledge related to the benefit of exercise on blood pressure
As evidenced by:
- Abnormal heart rate or BP response to activity
Expected Outcomes:
- Patient will participate in physical activity within their capabilities at least 3 times per week
- Patient will report an improvement in their ability to exercise as evidenced by no shortness of breath with minimal exertion and heart rate within safe limits
- Patient will report a decrease in their blood pressure after 1 month of exercising
Sedentary Lifestyle Assessment
1. Build a rapport.Exercise can be a difficult subject to broach with patients. Those with a sedentary lifestyle may balk at changing their behavior. Its important for the nurse to first form a therapeutic relationship with the patient in order to understand and overcome resistance.
2. Assess their history and interests.Instead of simply telling the patient to move more, get to know what types of exercise or activities theyve done in the past. Patients are more likely to create a habit when they enjoy what theyre doing.
Sedentary Lifestyle Interventions
Research Studies On Nursing Intervention For Hypertension
Non-compliance to medication is a major barrier to the treatment of hypertension. A research study conducted by G Georgiopoulos and others found that nursing intervention increases compliance.
In this research study, home visits and telephonic conversations with patients were found effective for the reduction of hypertension.
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Nursing Assessment Of Deficient Knowledge Of Hypertension
| Assessment | Rationale |
| Ask the patient to tell what is his/her knowledge regarding disease and its management. Assessment helps to a depth of knowledge and prepare education according to that. | The patient should understand that hypertension is a chronic disease and requires constant effort for management. |
Nursing Care Plan For Preeclampsia 5
Deficient Knowledge
Nursing Diagnosis:Deficient Knowledge related to inadequate exposure, unawareness of available information sources, and misinterpretation of data secondary to Pre-eclampsia as evidenced by repetitive requests for an explanation, statement of misconception about the disease process, unable to follow instructions correctly, and complications of the disease that could have been avoided.
Desired Outcome: The patient will express verbally the comprehension of the disease process and therapeutic options. Thus, will promptly report signs or symptoms that necessitate medical attention, Will be able to maintain the blood pressure within acceptable limits, and the patient will strictly and correctly follow the instructions and will make lifestyle/behavioral modifications.
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Nursing Case Study Pre Eclampsia
What Causes Preeclampsia
Preeclampsia is an autoimmune disease that results from a failure of maternal-fetal tolerance. The exact cause remains unknown, but risk factors include: being over 35 years old, having previous preeclampsia/eclampsia, abnormal placentation, multiple gestations , Black race, preterm labor, intrauterine growth restriction, and abnormal maternal liver function.
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Bathing And Sitz Baths
To prevent infections after delivery, it is preferable to take showers rather than a tub baths for two weeks. If showers are not possible, fill the tub with three to four inches of water, and leave the drain open and the water running. This is called a sitz bath and may be continued as long as needed for comfort.
Related Nursing Diagnoses For Preeclampsia
- Risk for deficient fluid volume
- Anxiety related to fear of the unknown, threat to self and infant, new environment, hospitalization
- Death anxiety related to threat of preeclampsia
- Deficient knowledge related to lack of experience with situation
- Interrupted family processes related to situational crisis
- Impaired home maintenance related to hospitalization, bed rest
- Impaired physical mobility related to medically prescribed limitations
- Powerlessness related to complication threatening pregnancy, medically prescribed limitations
- Risk for disturbed maternal-fetal dyad related to interruption of bonding and attachment processes during separation from preterm and/or compromised newborn
- Situational low self-esteem related to loss of idealized pregnancy
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What Are The Risk Factors For Preeclampsia
Preeclampsia affects females more than males and non-Hispanic African American women at a higher rate. Other risk factors are family history of preeclampsia, previous early pregnancy loss or fetal death, chronic hypertension, renal disease, autoimmune disease, thyroiditis, lupus, primiparity, and increased parity.
The pathophysiology of preeclampsia is due to the resistance of the hypertrophied placenta to general vasodilation. This causes placental hypoperfusion with alterations in fetal-placental perfusion. The role of maternal factors and fetal factors has recently been reevaluated to determine those factors that may predispose women to the condition.
The possible etiologic role of maternal coagulation defects, genetic disorders, tissue hypoxia, alterations in immunoregulatory functions, and microangiopathy in the pathogenesis of preeclampsia is not yet elucidated. Multiple pregnancies, such as twins and triplets.
How Can You Prevent Hypertension
1. Dont smoke quitting smoking can reduce your blood pressure by up to 10 points.
2. Exercise regularly Regular exercise helps keep your heart and arteries healthy, improves blood flow, and reduces stress. An exercise plan that includes cardio and strength training is recommended for any physical activity.
3. Eat healthy- a diet that is high in fiber, fruits, and vegetables can help relieve some of the symptoms associated with hypertension.
4. Maintain a healthy weight if you are overweight, commit to losing weight through healthier eating and regular exercise.
5. Reduce stress learn how to manage your emotions and develop better-coping skills for dealing with stressful experiences.
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What Is The Complication Of Hypertension
The complications of hypertension consist mainly of target organ damage. Hypertension causes injury to the kidneys, eyes, heart, and brain.
High blood pressure can lead to heart failure, stroke, or renal failure. The risk for these problems increases depending on how high a persons blood pressure readings are and whether or not high blood pressure is well controlled.
-The kidneys are one of the bodys primary organs that help to excrete wastes. They also filter the blood and remove excess fluid from the body. High blood pressure can cause damage to these vital organs, which may lead to chronic kidney disease, failure, or even death.
-Erectile dysfunction is an inability for a man to achieve or maintain a penile erection sufficient for sexual performance. It is typically assessed by a health care professional with a physical examination and determined by the patients report of erections in certain situations, such as during waking hours.
- Manage stress
- A Patient with hypertension should get a physical on an annual basis.
-Based upon their pressures, a patient should be seen by a primary care provider at least twice a year and have lab work completed.
Working in tandem with the patients physician is critical to lowering the blood pressure.
Risk Factors For Developing Hypertension
There are several risk factors for developing hypertension:
- Age- hypertension can develop even in childhood and adolescence however, it is more prevalent among adults 50 years of age or older
- Gender hypertension is more common among men
- Family history having family members with high blood pressure or a first-degree relative who suffered from a stroke and coronary heart disease is a risk factor.
- Obesity people who are obese tend to have higher blood pressure levels
- High salt intake
- Smoking Liver problems
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Nursing And Breast Care
Initial attempts at nursing can be painful, but tenderness and discomfort should decrease once let-down has occurred and should cease altogether within a few days. However, if you have sore, cracked, or bleeding nipples, express a few drops of breast milk on the nipples after nursing and allow to air dry. To prevent future irritation, always keep your nipples clean, change the nursing pads when they become moist and avoid wearing pads with plastic liners.
For a more comfortable breastfeeding experience, experiment with different nursing positions to see what works best for you and your baby. For example, try holding your baby so that he is lying on his side with his head resting in the bend of your arm and make sure that his mouth covers one inch or more of your nipple and areola when sucking. For additional comfort, use pillows to help support your arm and baby.
If you are not nursing, wear a good support bra at all times while your breasts are engorged. You may use ice packs under the armpits and to the side of each breast during the first couple of days of engorgement and take Tylenol® or ibuprofen for discomfort. Do not be surprised if you have a slight elevation in temperature for a day or two while your breasts are engorged, and you should expect milk to lbe eaking from the breasts during this period. Read for more information.