Nursing Care Plan For Hellp Syndrome

NURSING CARE PLAN Assessment Subjective: “Nahihilo ako at ang sakit ng batok at nanlalabo yung mga mata ko.” – as verbalized by the patient.

Objective: V/S T: 36.6 C / axilla RR: 24 cpm PR: 95 bpm BP: 140/90 mmHg  Pale, cool, and clammy skin  Presence of non-pitting edema on

Diagnosis

Scientific Explanation

Ineffective tissue perfusion related to vasoconstriction of blood vessels secondary to Pre-eclampsia

Spiral artery doesn’t widen

Less blood gets in the placenta

Hypo-perfused placenta releases pro inflammatory proteins

Pro inflammatory proteins goes to mother circulation

Pro inflammatory proteins causes

Planning Short Term: After 4 hours of nursing intervention, the patient will be able to;  Decrease and maintain blood pressure within normal range. (from 140/90mmHg down to 120/80 mmHg)  Verbalize knowledge of disease process, individual risk factors, and treatment plan.  Identify signs of cardiac decompensation

Implementation

Rationale

Independent:

Evaluation Short Term:

a.) Establish rapport and explain procedures and expected outcomes.

- To gain patient’s trust and paticipation.

b.) Assess patient’s general physical condition. c.) Check patient’s V/S.

- To note for any abnormality. - To establish baseline data.

d.) Monitor BP periodically. e.) Note presence of quality of central and peripheral pulses.

- Pulses in the leg maybe diminished, implicating effects of vasoconstriction and venous congestion.

f.) Auscultate heart tones and breath sounds.

- S3 and S4 heart sounds may indicate atrial and venous hypertrophy and impaired functioning. Presence of adventitious breath sounds may

After 4 hours of nursing intervention, the goal was partially met as evidenced by the patient;  Blood pressure is still 140/90mmHg  Verbalized knowledge of disease process, individual risk factors, and treatment plan.  Identified signs of cardiac decompensati on.

both lower extremities  Restlessness  Capillary refill of 2-3 seconds LAB    

ALT: 74 U/L AST: 76 U/L LDH: 650 d/L Proteinuria: (30mg/dL)

vasoconstriction

Prolonged vasoconstriction damages endothelial cell

Endothelial cell injury

Blood vessels become dysfunctional

Causes vasospasm

Hypertension

Long Term: After 3 days of nursing intervention the patient will:  Maintained blood pressure within normal range. (From 140/90 mmHg down to 120/80 mmHg)  Absence of paleness, and cool and clammy skin  Reduced nonpitting edema on both lower extremities  Absence of restlessness  Normal capillary refill of 1-2 seconds

g.) Observe skin color, moisture, temperature, and capillary refill time.

h.) Note independent or general edema. i.) Provide a calm environment, minimizing noise, limiting visitors and length of stay. j.) Maintain activity restrictions (bed rest) and assist patient with self-care activities. k.) Provide comfort measures such as elevation of head or positioning in a semifowler’s. l.) Encourage relaxation techniques like guided imagery and distractions. m.) Monitor response to medications to control

indicate pulmonary congestion secondary to developing heart failure. - Presence of pallor, cool and moist skin and delayed capillary refill maybe due to peripheral vasoconstriction or decreased cardiac output. - It may indicate heart failure, vascular or renal impairment. - To promote comfort and relaxation. - It reduces physical stress stimuli that affect the blood pressure. - It decreases discomfort and peripheral venous pooling.

- It helps reduce stressful stimuli, thereby decreases BP. - Response to drug is dependent on both

Long Term: After 3 days of nursing intervention the goal was partially met as evidenced by the patient:  Decreased blood pressure but didn’t reach the normal range. (BP: 120/90 mmHg)  Absence of paleness, and cool and clammy skin  Reduced nonpitting edema on both lower extremities  Absence of restlessness  Normal capillary refill of 1-2 seconds

blood pressure.

n.) Instruct patient on fluid and diet requirements and restrictions of sodium. Also, encourage to avoid intake of caffeine, cola, chocolates, fats and cholesterol.

individual and the synergistic effect of the drug. It is also important to check for any untoward signs and symptoms of the medications. - Low intake of sodium can assist with decrease in fluid retention and hypertension, thereby improving cardiac output and foods like caffeine are cardiac stimulant and may adversely affect cardiac function.

Dependent: o.) Administer medications like diuretics, alpha and beta antagonists, calcium channel blockers, and vasodilators. (Methyldopa 250 mg tab now then TID)

- For pharmacological management.

Assessment Subjective: ““Sumasakit yung sa bandang gilid ng tiyan ko, parang pinipiga.” – as verbalized by the patient. Character:  Squeezing pain Onset:  January 20, 2019; sudden Location:  RUQ Duration:  Continuous pain and getting worse when moving, or doing physical activities such as walking.

Diagnosis Acute Pain related to inflammation or damage to the cells of the liver secondary to Preeclampsia (HELLP Syndrome)

Scientific Explanation Spiral artery doesn’t widen

Less blood gets in the placenta

Hypo-perfused placenta releases pro inflammatory proteins

Pro inflammatory proteins goes to mother circulation

Pro inflammatory proteins causes vasoconstriction

Prolonged vasoconstriction

Planning Short Term: After 30 minutes to 1 hour of nursing intervention, the patient will be able to;  Verbalize methods that provide relief.  Follow prescribed pharmacological regimen.  Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.  Report pain is relieved or reduced. (From pain scale of 8/10 down to 4/10)

Implementation

Rationale

Independent: a) Monitor patient’s V/S. b) Assess patient’s general physical condition. c) Listen and respect client’s expression about his condition. d) Monitor patient’s pain and note/investigate changes from previous reports. e) Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity, and precipitating factors of pain. f) Promote adequate rest, and provide comfort measures (e.g. touch, repositioning, nurse’s presence), quiet

Evaluation Short Term:

- Can be altered when the patient is in pain - To note for any abnormality. - Helps in alleviating anxiety and refocusing attention. - To rule out worsening of underlying condition or development of complications. - Pain is a subjective experience and must be described by the patient in order to plan effective treatment.

- To prevent fatigue and promote nonpharmacological pain management.

After 30 minutes to 1 hour of nursing intervention, the goal was partially met as evidenced by the patient;  Verbalized methods that provide relief.  Followed prescribed pharmacologic al regimen.  Demonstrated use of relaxation skills and diversional activities, as indicated, for individual situation.  Reported pain is reduced but didn’t reach the desired scale.

Severity:  Using the Universal Pain Assessment Tool, the scale is 8/10Severe; The pain is quite intense and is causing the patient to avoid, or limit physical activity, also, cannot concentrate on anything except pain. Pattern:  “Kapag gagalaw ako sumasakit, pero kapag nagpapahin ga ako nababawasa n yung sakit.” Associated factors:  The pain affects the activities of

damages endothelial cell

Endothelial cell injury

environment. g) Instruct, or encourage use of breathing relaxation exercise h) Encourage diversional activities such as listening to music and socializing with others.

- Helps reduce pain and promote relaxation. - To distract attention.

Dependent: Blood vessels become dysfunctional

Causes vasospasm

Narrowed hepatic artery

Hypoperfusion on the liver

Liver inflammation or damage

Acute Pain

i)

Administer pain reliever medication as ordered by the physician. (Paracetamol 500 mg)

- Pharmacological management to reduce pain.

(Pain scale of 6/10) .

the patient at home, “Ang sakit po, hindi nga ako nakapagluto ng baon para sa maga anak kong papasok ng school kasi pumunta na agad ako dito.”

Objective: V/S T: 36.2 C / axilla RR: 25, regular PR: 88, regular BP: 140/90 mmHg  Guarding behavior in the RUQ of the abdomen  Facial grimacing

 Irritability LAB  ALT: 74 U/L  AST: 76 U/L

Assessment Subjective: “Masakit yung tahi ko lalo na kapag gumagalaw ako. hindi ako komportable.” – as verbalized by the patient. Character:  Sharp pain

Diagnosis Acute pain related to postop surgical incision secondary to Pre-eclampsia

Scientific Explanation Abnormal placentation

Low prefunded placenta

Release of cytokines and other toxins

Onset:  PostOperation (January 21, 2019) Location:  Pain from incision

Vasoconstriction and platelet activation

Duration:  Continuous pain and getting worse when moving, or doing physical activities such as walking.

Impact on fetus: undernutrition because of uteroplacental vascular insufficiency

Generalized endothelial and vascular dysfunction

Growth restriction to fetus that may cause distress

Planning Short Term: After 30 minutes to 1 hour of nursing intervention, the patient will be able to;  Verbalize nonpharmacolo gical methods that provide relief.  Follow prescribed pharmacological regimen.  Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.  Report pain is relieved or reduced. (From pain scale of 7/10 down to 5/10)

Implementation

Rationale

Independent: a.) Check patient’s V/S.

Evaluation Short Term:

b.) Assess patient’s general physical condition. c.) Listen and respect client’s expression about his condition.

- Can be altered when the patient is in pain - To note for any abnormality. - Helps in alleviating anxiety and refocusing attention.

d.) Monitor patient’s pain and note/investigate changes from previous reports.

- To rule out worsening of underlying condition or development of complications.

e.) Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity, and precipitating factors of pain. f.) Promote adequate rest, and provide comfort measures (e.g. touch, repositioning, nurse’s presence), quiet environment. g.) Instruct, or encourage use of breathing relaxation exercise

- Pain is a subjective experience and must be described by the patient in order to plan effective treatment.

- To prevent fatigue and promote nonpharmacological pain management.

- Helps reduce pain and promote relaxation.

After 30 minutes to 1 hour of nursing intervention, the goal was met as evidenced by the patient;  Verbalized nonpharmacol ogical methods that provide relief.  Followed prescribed pharmacologic al regimen.  Demonstrated use of relaxation skills and diversional activities, as indicated, for individual situation.  Report pain is relieved or reduced.

Severity:  Using the Universal Pain Assessment Tool, the scale is 6/10Moderate; Interferes her concentratio n, and felt uncomfortab le Pattern:  Moving makes it worse, and relieved, when lying on bed and controlled when given pain medication. Associated factors: The pain affects:  “Hindi kasi ako masyadong makatulog dito sa

Age related: Possible complication

Stabilized mother and baby

Elective Surgery/CS

h.) Encourage diversional activities such as listening to music and socializing with others. Dependent: i.) Administer pain reliever medication as ordered by the physician. (Celecoxib 200mg tab BID)

Tissue Injury/Inflammatory Cell

Sense by Nociceptor

Converted to electro chemical signals

Transmitted to spinal cord by Dorsal Root Ganglia and then to the Brain

Acute Pain

- To distract attention or divert focus from pain.

- Pharmacological management to reduce pain.

(Pain scale of 5/10)

hospital at nararamdam an ko pa rin yung sakit dito sa tyan ko kapag gabi lalo kapag gagalaw ako, hindi ako komportable .”  20-25 minutes of sleep disturbance  (total 4hrs of sleep with interruption) Objective: V/S T: 36.7 C / axilla RR: 16, regular PR: 86, regular BP: 120/90 mmHg  Surgical incision of 13cm long and 15 stitches (low

transverse)  Guarding behavior on the abdomen  Positioning (to avoid pain)  Facial grimacing  Irritability

Assessment Subjective: “Inoperahan ako kaninang umaga.” – as verbalized by the patient.

Diagnosis

Scientific Explanation

Impaired skin integrity related to post-surgical incision

Surgical intervention (CS)

Incision on the lower abdomen (low transverse)

Objective: V/S T: 36.7 C / axilla RR: 16, regular PR: 86, regular BP: 120/90 mmHg  Surgical incision of 13cm long and 15 stitches (low transverse)  Intact dressing

Surgery involves cutting/ penetration of skin surface and skin layers

Impaired skin integrity

Planning Short Term: After 6-8 hours of nursing intervention, the patient will be able to;  Have reduced risk of further impairment of skin integrity.  Demonstrate understanding and ability to care for infection-prone site.  Demonstrate ability to perform hygienic measures like proper hand washing and body hygiene. Long term: After 3 days of nursing

Intervention

Rationale

Independent: a.) Support and instruct patient in incisional support when turning, coughing, deep breathing and ambulating. b.) Observe incision periodically, noting approximation of wound edges, hematoma formation and resolution, and presence of bleeding and drainage. c.) Provide routine incisional care, being careful to keep dressing dry and sterile. Assess and maintain patency of drains.

d.) Encourage frequent positional changes,

Evaluation Short Term:

- Reduces possibility of dehiscence and incisional hernia.

- Verifies status of healing, provides for early detection of developing complications requiring prompt evaluation and influencing choice of intervention. - Promotes healing. Accumulation of serosanguineous drainage in subcutaneous layers increases tension on suture line, may delay wound healing, and serves as a medium for bacterial growth. - Reduces pressure on skin, promoting

After 6-8 hours of nursing intervention, the goal was met as evidenced by:  Reduced risk of further impairment of skin integrity.  Demonstrated understanding and ability to care for infection-prone site.  Demonstrated ability to perform hygienic measures like proper hand washing and body hygiene. Long term: After 3 days of nursing

intervention the patient will:  Experience healing of wound/incision and regain skin integrity  Reduce risk for infection

inspect pressure points, and massage gently, as indicated. Apply transparent skin barrier to elbows and heels, if indicated. e.) Encourage intake of protein-rich and calorierich foods. f.) Emphasize the importance of proper hand/body hygiene techniques. Practice proper hand hygiene and teach the patient and SO to do so. g.) Maintain aseptic technique with any procedures. Provide routine wound care, as appropriate.

peripheral circulation and reducing risk of skin breakdown, Skin barrier reduces risk of shearing injury. - Help boost and support the immune system responsiveness. - It serves as a first line defense against infection and minimizes the risk of contamination and development of infection. - Aseptic technique decreases the chances of transmitting or spreading pathogens to the patient.

Dependent: h.) Emphasized necessity of taking antibiotics properly as ordered by the physician. (Co-amoxiclav 325 mg 1 tab OD)

- Antibiotics can be used as a prophylactic treatment

intervention the goal was met as evidenced by the patient:  Experienced healing of wound/incision and regain skin integrity  Reduced risk for infection

Assessment Subjective: “Medyo okay na pero nanghihina parin ako.” – as verbalized by the patient.

Objective: V/S T: 36.7 C / axilla RR: 16, regular PR: 86, regular BP: 120/90 mmHg  Weak-looking  Pale palpebral conjunctiva  LAB Platelet count: 90 x 10 9/L Hgb: 116 g/L Hct: 33% Prothrombin time: 20.7 seconds

Diagnosis

Scientific Explanation

Risk for bleeding related to decreased platelet count

Spiral artery doesn’t widens

Less blood gets in the placenta

Hypo-perfused placenta releases pro inflammatory proteins

Pro inflammatory proteins goes to mother circulation

Planning Short Term: Within the 8 hours shift, the patient will be able to:  Identify individual risks and engage in appropriate behaviors to prevent or reduce frequency of bleeding episodes.  Be free of signs of bleeding Long term:

Pro inflammatory proteins causes vasoconstriction

Prolonged vasoconstriction

After 3 days of nursing intervention the patient will:  Maintain reduced risk of bleeding as evidenced by normal platelet count and

Intervention

Rationale

Independent: a) Assess and monitor vital signs. b) Assess patient’s general condition and check for any signs of bleeding.

c) Check and monitor laboratory results especially the platelet count, PT, Hgb, and Hct. d) Maintain safe environment for the patient. e) Explain the different risks for bleeding. f) Explain the different factors to prevent bleeding. g) Restrain patient from any activities that could cause bleeding.

Evaluation Short Term:

- Increased heart rate and orthostatic changes accompany bleeding. - Bleeding maybe obvious (bruises/petechiae epistaxis, bleeding gums, abdominal pain, hematemesis, melena, hematuria). - To rule out worsening of underlying condition or development of complications. - To prevent injury and promote rest and comfort. - For the patient to become knowledgeable about the disease process.

Within the 8 hours shift, the goal was met as evidenced by the patient:  Identified individual risks and engage in appropriate behaviors to prevent or reduce frequency of bleeding episodes.  Free of signs of bleeding Long term: After 3 days of nursing intervention the goal was met as evidenced by the patient:  Maintained reduced risk of bleeding as evidenced by normal platelet

damages endothelial cell

Formation of thrombi (body will use massive amount of platelets)

Blood clots blocks RBC

RBC gets destroyed (hemolysis)

Risk for bleeding

clotting times and factors within normal range.

Dependent: h) Administer appropriate medications as ordered by the physician. i)

Transfused PRBC if prescribed.

Collaborative: j) Communicated need for platelet support to transfusion center.

- For pharmacological management (coagulation) - To restore Hgb/Hct level and to replace blood lost. - To assure availability and readiness of platelets when needed.

count and clotting times and factors within normal range. (Platelet count: 158 X 10 9/L PT: 12 seconds)

Assessment Subjective: “Hindi ako makatulog ng maayos dahil nararamdaman ko pa rin yung sakit dito sa tahi ko kapag gabi lalo na kapag gagalaw ako, hindi ako komportable.” – as verbalized by the patient.

Objective: V/S T: 36.7 C / axilla RR: 16, regular PR: 86, regular BP: 120/90 mmHg  Total hours of sleep at night: 4-5hrs with interruptions  Presence of eye bags

Diagnosis

Scientific Explanation

Disturbed sleep pattern related to pain and discomfort secondary to Surgery (CS)

Elective Surgery/CS

Tissue Injury/Inflammato ry Cell

Sense by Nociceptor

Converted to electro chemical signals

Transmitted to spinal cord by Dorsal Root Ganglia and then to the Brain

Planning Short Term: After 2 hours of nursing intervention, the patient will be able to;  Verbalize ways to improve sleep pattern.  Identify individually appropriate interventions to promote sleep. Long term: After 3 days of nursing intervention the patient will:  Report improved sleep  Report increased sense of well-being.

Intervention

Rationale

Independent:

Evaluation Short Term:

a. Determine presence of physical or psychological stressors.

b. Note environmental factors that affect sleep. c. Determine patient’s usual sleep pattern. d. Observe physical signs of fatigue.

- Sleep problems can arise from internal and external factors and may require assessment over time to differentiate specific causes. - These factors can reduce patient’s ability to rest and sleep when more rest is needed. - To provide comparative baseline and to ascertain intensity and duration of problems.

e. Recommend quiet activities such as listening to music.

- To help the patient have a better rest and sleep.

f.

- To provide a conducive environment for the patient to relax.

Provide calm, quiet environment

After 2 hours of nursing intervention, the goal was met as evidenced by the patient;  Verbalized ways to improve sleep pattern such as providing quiet activities (listening to music) and comfort measures (proper positioning, deep breathing exercises, back rub)  Identified individually appropriate interventions to promote sleep. Long term:

 Lack of concentration

Acute Pain

Affects sleep pattern

and manage controllable sleep-disturbing factors. g. Provide comfort measures such as proper positioning, deep breathing exercises, back rub. h. Arrange care to provide uninterrupted sleep. i. Recommend limiting intake of caffeine and chocolate prior to sleep. Collaborative: j.) Refer to sleep specialist for treatment when indicated.

After 3 days of nursing intervention the patient will: - This soothes and relaxes the patient. Also t promote physical comfort.

- To promote wellness.

- Because caffeine inhibits sleep.

- For specific interventions and/or therapies.

 Reported improved sleep  Reported increased sense of wellbeing.