NSG 210 VSim Olivia Jones/ VSim Olivia Jones( Download To Score An A)

Document Content and Description Below

Rebekah NSG 211 VSIM: Olivia Jones CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Preeclampsia is classified as generalized vasospasm... . This is characterized by a high blood pressure as well as other signs of damage to other organs (kidneys, liver). A woman can have normal blood pressure throughout her pregnancy and then after 20 weeks gestation begin to show signs of preeclampsia. Mild preeclampsia is a blood pressure of >140/90mmHg, and severe preeclampsia is a blood pressure of >160/110mmHg. If this is left untreated it can lead to complications for the patient and the baby. Usually the most effective treatment is to delivery the baby. Preeclampsia can cause pulmonary edema, seizures, abnormal liver enzymes, oliguria, and thrombocytopenia. Preeclampsia can devlop with or without symptoms. However, the most relevant one is the elevated blood pressure and the proteinuria. The patient can also experience severe headaches, vision changes, upper epigastric pain, decreased urine output, nausea and vomiting, decreased platelets, and SOB. Diagnosis is done by urine dip test to see if there is protein in the urine, blood test are done to check liver fuction and blood counts. Fetal ultrasound needs to be performed to monitor the baby’s growth as well as weight and the amount of amniotic fluid there is. Lastly, there is a biophysical profile that is performed to check the baby’s heart rate as it moves. As preeclampsia increases in severity so does the risk of seizures, stroke, placental abruption so the most effective treatment is delivery. **continued on page 8! DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Urine Test monitor for proteinuria Blood Test such as Hepatic function (AST/ALT) to monitor for organ damage CBC monitor for platelets, RBCs, MCH, MCHC Ultrasound: monitor baby ‘s growth: weight,amniotic fluid Nonstress test (biophysical profile): assessment of fetus: monitor FHR upon movement, breathing, muscle tone, amniotic fluid volume PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS Patient complains of nausea Patient complains of severe headache Blurred vision or vision changes SOB Increased weight gain Patient complains about right upper gastric pain Elevated Blood Pressure (>140 systolic) Increased urine output Facial puffiness Dependent Edema ANTICIPATED NURSING INTERVENTIONS Daily weights Assess vitals Q4H especially BP, HR Auscultate lung sounds Monitor FHR via tocoductor Monitor lab values daily: proteinuria, CBC, AST, ALT Obtain Ultrasound Assess for dependent edema Monitor SpO2 Monitor and limit visitors, light, sounds Apply nonrebreather Assess vision for any significant changes Assess pain level Monitor progession of preeclampsia Provide emotional support Administer medications as prescribed Initiate Seizure precautions Intitiate Fall Risk Maintain patient in side-lying position Side Rails up X2 and padded All emergency supplies at bedside (suction, O2, canister) Maintain adequate hand hygiene Assess neurological status Monitor I&O Assess DTR Provide patient education Rebekah Taylor NSG 211 VSim: Olivia Jones [Show More]

Last updated: 1 year ago

Preview 1 out of 12 pages