Ncp- Ineffective Tissue Perfusion Eclamptic Seizure
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ASSESSMENT Objective: * Pale looking * edematous * Blood pressure: 200?140mmHg * Temperature: 39.5 degree Celsius. * Halt respirations 10cpm. * Pulse Rate: 96bpm * Hyperactive patellar reflex. * Nauseated * Urinary output of 20mL/hr. * delayed capillary refill. *twitching of facial muscle. * Arms flexed.
DIAGNOSIS
PLANNING
INTERVENTIO N
RATIONALE
EVALUATION
Ineffective tissue perfusion related to vasoconstriction of blood vessels secondary to eclamptic seizure.
After 10 minutes of nursing intervention the patient will manifest an increase in oxygenation as evidenced of normal skin color, pinkish mucosa, good capillary refill and good breathing pattern.
* Maintain a patent airway.
* The priority care for a woman with a seizure is to maintain a patent airway. This is necessary to maintain maternal and fetal adequate oxygenation and to prevent fetal bradycardia.
After 10 minutes of nursing intervention the client manifested an increase in oxygenation as evidenced of normal skin color, pinkish mucosa, good capillary refill and good breathing pattern. Therefore, the plan was met.
*Don’t put a tongue blade between a woman’s teeth.
* Doing so can cause broken teeth which could then be aspirated.
* Administer oxygen by face mask.
* To protect the fetus during eclamptic stage.
* Assess oxygen saturation via pulse oximeter.
* To measure oxygen saturation of the patient’s blood.
* Apply an external fetal heart monitor.
* To assess the condition of the fetus if one is not already in place to assess it.
* Give her nothing to eat or drink by mouth. * During the tonic phase turn a woman on her side to allow secretions to drain from her mouth.
* During clonic stage of a seizure Magnesium sulfate or diazepam may be administered.
* To prevent aspiration. * To prevent aspiration. If the woman was not placed on her side during tonic phase she may aspirate the saliva that collected from her mouth. * This drug prevents seizure. Administering this drug was an emergency measure at this time.
DIAGNOSIS
PLANNING
INTERVENTIO N
RATIONALE
EVALUATION
Ineffective tissue perfusion related to vasoconstriction of blood vessels secondary to eclamptic seizure.
After 10 minutes of nursing intervention the patient will manifest an increase in oxygenation as evidenced of normal skin color, pinkish mucosa, good capillary refill and good breathing pattern.
* Maintain a patent airway.
* The priority care for a woman with a seizure is to maintain a patent airway. This is necessary to maintain maternal and fetal adequate oxygenation and to prevent fetal bradycardia.
After 10 minutes of nursing intervention the client manifested an increase in oxygenation as evidenced of normal skin color, pinkish mucosa, good capillary refill and good breathing pattern. Therefore, the plan was met.
*Don’t put a tongue blade between a woman’s teeth.
* Doing so can cause broken teeth which could then be aspirated.
* Administer oxygen by face mask.
* To protect the fetus during eclamptic stage.
* Assess oxygen saturation via pulse oximeter.
* To measure oxygen saturation of the patient’s blood.
* Apply an external fetal heart monitor.
* To assess the condition of the fetus if one is not already in place to assess it.
* Give her nothing to eat or drink by mouth. * During the tonic phase turn a woman on her side to allow secretions to drain from her mouth.
* During clonic stage of a seizure Magnesium sulfate or diazepam may be administered.
* To prevent aspiration. * To prevent aspiration. If the woman was not placed on her side during tonic phase she may aspirate the saliva that collected from her mouth. * This drug prevents seizure. Administering this drug was an emergency measure at this time.
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