Risk for Injury Nursing Care Plan Preeclampsia

Nursing Care Plan Preeclampsia

There are certain conditions that arise during the pregnancy that can lead to a high incidence of birth injuries. One of those conditions is preeclampsia. It is important that the mum is given the right treatment before the birth so that the risk of injury is minimized in the majority of cases. It is said that about seven out of one thousand babies suffer birth injuries.

Preeclampsia signs can persist for as long as 3 months after birth but usually disappear entirely in most women.

If preeclampsia is left untreated the blood pressure can become so high that the woman is at increased risk of seizures. Symptoms of preeclampsia are right upper abdominal pain, headache, disturbance in vision and alteration in mental state. Permanent injury to the brain, liver and kidneys have been reported in uncontrolled preeclampsia. Reduced placental blood flow leads to less oxygen and nutrient supply to the baby. Fetal growth slows and a preterm delivery is associated with breathing difficulties for the baby when it is born.

Risk Factors For Preeclampsia

• Previous kidney disease.
• Teenage mothers and women over 35 year of age.
• Twins or more.
• History of Lupus.
• Assisted reproduction.
• Barrier methods of contraception.
• First pregnancy or first pregnancy with a new partner.
• History of diabetes.
• Presence of essential hypertension (high blood pressure).

Nursing Diagnosis for Preeclampsia : Risk for Injury: the fetus is related to an inadequate blood perfusion to the plasma

Goal: Injury did not occur in the fetus

Nursing Interventions for Preeclampsia:

1. Instruct the patient to Rest
Rational: By resting the client, is expected to decrease the body's metabolism and blood circulation to the placenta to be more adequate to the need of oxygen to the fetus can be met.

2. Encourage clients to sleep on their left
Rationale: With the left side sleeping is expected vena cava on the right is not depressed by the enlarged uterus so that the flow palasenta darh to be smooth.

3. Monitor blood pressure
Rationale: The client can monitor blood pressure condition known as placental blood flow to high blood pressure, blood flow to the placenta is reduced so that the supply of oxygen to the fetus is reduced.

4. Monitor the client's heart sounds
Rational: By monitoring the fetal heart sounds can be known to the state of the fetal heart is weak or declining indicating reduced supply of oxygen to the placenta so that action can be planned in advance.

5. Give anti-hypertensive drugs will lower the tone of the arteries and cause a decrease in cardiac afterload by vasodilatation of blood vessels so that blood pressure down.
Rationale: By decreasing blood pressure so that blood flow to the placenta becomes more adequate.

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Risk for Injury related to Parkinson's Disease

Parkinson's Disease

Parkinson's disease is a common disorder, that arises due to some imperfection, that amends the normal functioning of the central nervous system. Parkinson's disease is a complex Constellation of symptoms requiring the care of a neurologist. The prompt symptoms of the disease are problems related with movement like shaking, rigidity, slowness of movement and difficulty in walking and gait. As the disease progresses the patient suffers from cognitive impairment as well as behavioral problems.

Causes of Parkinson's disease. It is not clear as to what makes these nerve cells break down. But Scientists are doing a lot of research to look for the answer. Abnormal genes seem to lead to Parkinson's disease in some people. But so far, there is not enough proof to show That it is always Inherited.
 

Risk for Injury related to Parkinson's Disease

Nursing Diagnosis: Risk for injury related to decreased visual ability

Goal:
Having given nursing care, patients are expected to express an understanding of the factors involved in possible injury.

Expected outcomes are:
Shows changes in lifestyle behaviors to reduce risk factors and to protect themselves from injury.

Nursing Interventions - Risk for Injury related to Parkinson's Disease

1. Reduce the risk of environmental harm from clients such as:

• Lock the wheels of the bed.
• Provide adequate lighting.
• Down from the bed of the eye is not sore and a bed in low position.
• Pairs of bed in low position.
• Remove objects that easily falls (such as bins, seats without backrest)
• Put your tools such as call bell, tissue, telephone, or controller, easily accessible place on the client side is not affected.
• Encourage clients to use the handle of the bathroom if possible.
• Clean the floors of small objects such as pins, pencils and needle.

2. Tell the client to change positions slowly.

3. Encourage clients to use adaptive equipment such as canes and walkers for ambulation as needed.

4. Tell the importance of using protective eyewear when performing high risk activities such as ambulation at night or when you are in the midst of children or pets.

Rational:

1. Prevent dizziness
2. Prevent falls due to changes in depth perception. Object or objects may not be located in a visible place such as a client, who took over the center of gravity will change which will cause the client to fall.
3. Gave the source of stability.
4. Increase the sense of balance.
5. Prevent injury.

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Nursing Interventions for Risk for Injury

Risk for Injury

NANDA Definition:

The risk of injury as a result of the interaction of environmental conditions with individual adaptive response and defense sources.

Related To :
[Substance intoxication]
[Substance withdrawal]
[Disorientation]
[Seizures]
[Hallucinations]
[Psychomotor agitation]
[Unstable vital signs]
[Delirium]
[Flashbacks]
[Panic level of anxiety]

Goals

• Short-Term Goal : Client’s condition will stabilize within 72 hours.
• Long-Term Goal : Client will not experience physical injury.

Nursing Intervention for Risk for Injury

1. Maintain a closed central IV system using Luer-Lok connections and taping of all connections. Rationale: Inadvertent disconnection of central IV system can result in lethal air emboli.
2. Administer appropriate TPN solution via peripheral or central venous route, including peripherally inserted central catheter (PICC) lines and tunneled catheters. Rationale: Solutions containing high concentrations of dextrose more than 10% must be delivered via a central vein because they result in chemical phlebitis when delivered through small peripheral veins.
3. Monitor for potential drug and nutrient interactions. Rationale: Various interactions are possible, such as digoxin in conjunction with diuretic therapy, which can cause hypomagnesemia; hypokalemia may result from chronic use of laxatives, mineralocorticoid steroids, diuretics, or amphotericin.
4. Assess catheter for signs of displacement out of central venous position: extended length of catheter on skin surface, leaking of IV solution onto dressing, client complaints of neck arm pain, tenderness at catheter site, or swelling of extremity on side of catheter insertion. Rationale: Central venous catheter tip may slip out of superior vena cava and migrate into smaller innominate and jugular veins, causing a chemical thrombophlebitis. Incidence of subclavian or superior vena cava thrombosis is increased with extended use of central venous catheters.
5. Inspect peripheral TPN catheter site routinely and change sites at least every other day or per protocol. Rationale: Peripheral TPN solutions, although less hyperosmolar, can still irritate small veins and cause phlebitis. Peripheral venous access is often limited in malnourished clients, but site should still be changed if signs of irritation develop.
6. Investigate reports of severe chest pain or coughing in clients with central line. Turn client to left side in Trendelenburg position, if indicated, and notify physician. Rationale: Suggests presence of air embolus requiring immediate intervention to displace air into apex of heart away from the pulmonary artery.
7. Maintain an occlusive dressing on catheter insertion sites for 24 hours after subclavian catheter is removed. Rationale: Extended catheter use may result in development of catheter skin tract. Once the catheter is removed, air embolus is still a potential risk until skin tract has sealed.

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