Author: Dr. Prince

Nursing Care Plans for Unstable Blood Glucose Level – Best Nursing Care Plans(2022)

This article discusses Nursing Care Plans for Unstable Blood Glucose Level plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Unstable Blood Glucose Levels mean that blood sugar levels swing frequently and can be severe. This version is rare and happens mainly to people with Type 1 diabetes. It is also called Brittle diabetes. It is challenging to manage and often disrupts everyday life. The swings can cause frequent episodes of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Nursing Care Plans for Unstable Blood Glucose Level – What’s the difference between diabetes and unstable diabetes?

With treatment and lifestyle changes, most people with diabetes can live healthy lives. But people with brittle diabetes have frequent problems managing the disease that can:

Affect their ability to live life normally.
Cause anxiety and depression.
Lead to hospitalization or even death.

Nursing Care Plans for Unstable Blood Glucose Level – How common is brittle diabetes?

Brittle diabetes is rare. It affects only about 3 of every 1,000 people with insulin-dependent diabetes.

Nursing Care Plans for Unstable Blood Glucose Level – Who might get brittle diabetes?

Brittle diabetes occurs most often in people with Type 1 diabetes (in Type 1, the body does not produce insulin). For reasons not fully understood, it’s most common in women in their 20s and 30s.

Nursing Care Plans for Unstable Blood Glucose Level – Symptoms of Unstable Blood Glucose Levels

People with brittle diabetes experience sudden and frequent changes in blood glucose levels for no obvious reason. The swings lead to hypoglycemia or hyperglycemia.

Symptoms of hypoglycemia include:

Dizziness, weakness, or shaking.
Fast heart rate.
Irritability or confusion.
Pale skin.
Restless sleep.
Sweating.
Sudden hunger.

Symptoms of hyperglycemia include:

Blurry vision.
Fatigue (feeling weak, tired).
Frequent urination (peeing).
Headache.
Skin infections and slow-healing cuts.
Thirst or hunger.

Untreated hyperglycemia can lead to diabetic ketoacidosis, a complication of diabetes, which can cause:

Confusion.
Dehydration.
Fast heart rate.
Fruity-smelling breath.
Trouble breathing.
Vomiting.
Coma.

Nursing Care Plans for Unstable Blood Glucose Level – Causes of Unstable Blood Glucose Levels

Brittle diabetes occurs when diabetes is especially difficult to manage. Diabetes can be hard to manage for many reasons:

Celiac disease is an autoimmune disorder that affects the intestine.
Drug or alcohol use.
Eating disorders.
Gastroparesis is a condition in which nerve damage prevents the stomach from emptying food properly.
Hormonal imbalances, such as adrenal insufficiency and hypothyroidism.
Problems in the way the body absorbs insulin or nutrients from food.
Stress, anxiety, depression, and other psychological issues can make the body resist insulin.

Nursing Care Plans for Unstable Blood Glucose Level – Diagnosis of Unstable Blood Glucose Levels

Brittle diabetes is diagnosed after severe, frequent episodes of hypoglycemia or hyperglycemia that disrupt life or lead to hospitalizations. A healthcare provider specializing in diabetes (endocrinologist) can diagnose brittle diabetes by reviewing blood glucose levels over time.

Nursing Care Plans for Unstable Blood Glucose Level – Treatment of Unstable Blood Glucose Levels

Several treatments and technologies can help people with brittle diabetes manage the condition. They include:

Continuous glucose monitor.
Insulin pump.
Islet cell transplantation: A healthcare provider takes healthy insulin-producing cells from a deceased person’s pancreas and infuses them into the liver.
Pancreas transplant: A surgeon implants a donated pancreas.

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Nursing Care Plans for Unstable Blood Glucose Level – Prevention of Unstable Blood Glucose Levels

It’s not always possible to prevent brittle diabetes, depending on the underlying cause. Monitoring blood glucose regularly and closely following healthcare providers’ instructions can help.

Nursing Care Plans for Unstable Blood Glucose Level

Nursing Care Plans for Unstable Blood Glucose Level: Nursing Care Plan 1 – Diagnosis: Diabetes Mellitus

Desired Outcome

The patient will maintain a blood glucose level of less than 180 mg/dL and an A1C level below 5.7

Intervention	Rationale
Assess for signs of hyperglycemia or hypoglycemia.	To determine the appropriate treatment in maintaining target blood glucose levels. Symptoms of Hyperglycemia: 3P’s (polyphagia, polyuria, and polydipsia), fatigue or blurred vision Hypoglycemia: dizziness, headache, fatigue, diaphoresis, and tachycardia
Monitor blood glucose levels. Note that the frequency of blood glucose checks depends on the treatment plan.	To ensure that the blood glucose level is within a target range.
Administer diabetic medication (oral and/or insulin therapy) as prescribed.	To keep the glucose levels within normal range, effectively controlling diabetes and reducing the risk for blood vessel damage, nerve damage, kidney injury, and other complications of diabetes.
Advise the patient to adhere to his/her dietary plan.	Low fat, low calories, and high fiber foods are ideal for diabetic patients.
Encourage the patient to increase physical activity, particularly aerobic exercise.	Exercise decreases blood glucose levels as the cells’ demand for glucose (energy) increases with physical activity.

Nursing Care Plans for Unstable Blood Glucose Level: Nursing Care Plan 2 – Diagnosis: Side effect of Medications

Related to steroid use (steroid-induced diabetes)

Desired Outcome

The patient will maintain a blood glucose level of less than 180 mg/dL.

Intervention	Rationale
1. Assess for signs of hyperglycemia or hypoglycemia.	To determine the appropriate treatment in maintaining target blood glucose levels. Symptoms of Hyperglycemia: 3P’s (polyphagia, polyuria, and polydipsia), fatigue or blurred vision Hypoglycemia: dizziness, headache, fatigue, diaphoresis, and tachycardia
2. For a patient without pre-existing diabetes, monitor blood glucose levels at least once a day, ideally before lunch or evening meal. For a patient with pre-existing diabetes, monitor capillary blood glucose levels 4 times a day – before or after meals and before bedtime.	To ensure that the blood glucose level is within the target range.
3. Commence diabetic management as prescribed. This can be either: Non-insulin therapy – administer sulphonylureas which promote insulin release from the beta cells of the pancreas, or Insulin therapy – administration of subcutaneous basal human insulin in the morning	To keep the glucose levels within normal range, effectively controlling steroid-induced diabetes and reducing the risk for blood vessel damage, nerve damage, kidney injury, and other complications of diabetes.
Encourage the patient to adhere to his/her dietary plan as set by the diabetes specialist dietitian.	Low fat, low calories, and high fiber foods are ideal for patients with steroid-induced diabetes.
Advise the patient to increase physical activity, particularly aerobic exercise.	Exercise decreases blood glucose levels as the cells’ demand for glucose (energy) increases with physical activity.
Inform the patient that the blood glucose levels may gradually return to normal once the steroid dose is tapered down and stopped.	To provide reassurance to the patient and carer that blood glucose concentrations may become normal after steroid therapy.

Nursing Care Plans for Unstable Blood Glucose Level: Nursing Care Plan 3- Diagnosis: Hypoglycemia

Related to non-adherence to the therapeutic regimen for diabetes

Desired Outcome

The patient will demonstrate adherence to the diabetes regimen as evidenced by a reduction to less than 3 episodes of hypoglycemic episodes a week.

Intervention	Rationale
Assess the patient’s blood sugar diary readings with a focus on the following: The number of hypoglycemic episodes The number of hyperglycemic episodes	The patient’s blood sugar levels give healthcare workers an idea of the patient’s activities and practices surrounding his/her diabetes. To begin with, signifying the number of times the patient tests his/her blood sugar level. Also, the number of hypoglycemia or hyperglycemia can indicate the number of times the patient may have missed his/her medications. The patient’s diary can also give information if his/her hypoglycemic episodes were treated properly and if there is a pattern as to when the abnormal readings occur.
Assess and record the patient’s diabetes medications and other medications.	Patients with diabetes require a regular review of their diabetes medications, including any other medications for other conditions. This allows for the assessment of the appropriateness of medications to manage the patient’s diabetes and blood glucose levels. Other medications are also recorded and reviewed to ensure no untoward drug interactions occur. Also, other medications can affect blood sugar levels.
Assess the patient’s understanding of their diabetes management.	Diabetes can occur at any age. A thorough understanding of the condition allows for a better prognosis and management of the disease. Lack of understanding of the disease is associated with reduced commitment to the treatment regime leading to unstable blood glucose levels.
Explore the patient’s practices in hypoglycemia management.	Hypoglycemia can lead to serious complications such as hypoglycemic coma if left untreated. It is recommended that it is treated with 10-20g of quick-acting carbohydrate followed by a long-acting carbohydrate drink or food.
Ask for any concerns regarding his/her medication regime, injection sites and techniques, and anything related to his/her condition.	Diabetes is a lifelong condition. Anxiety and stress are commonly associated with the disease. Discussing concerns with the patient can help identify the possible cause or causes of non-compliance to the treatment regime.
Assess the patient’s injection techniques, injection sites, and understanding of the signs and symptoms of hypoglycemia.	Hypoglycemia is caused by missed medications and improper insulin injection techniques, and injecting insulin on lipohypertrophy. Also, the inability to recognize the symptoms of hypoglycemia prevents proper treatment of the condition.
Discuss the importance of adhering to the prescribed treatment regime in maintaining a normal blood sugar level.	A discussion of the importance of the disease process and the compliance to the prescribed medication regime using easy-to-understand words can help the patient realize what he/she can do to improve his/her general control.

Nursing Care Plans for Unstable Blood Glucose Level: Nursing Care Plan 4- Diagnosis: Gestational Diabetes

Related to stress secondary to gestational diabetes mellitus

Desired Outcome

The patient will demonstrate understanding of the disease process and the importance of adhering to the treatment plan as evidenced by an increased frequency in blood sugar monitoring.

Intervention	Rationale
Assess the patient’s understanding of gestational diabetes. Also, include the assessment of whether the patient has a history of diabetes prior to pregnancy.	Gestational diabetes can occur in women without a history of diabetes pre-pregnancy. In these cases, the patients’ knowledge of the condition can be very little.
Discuss any concerns that the patient may have related to her condition.	Pregnancy can be different for everyone. Anxiety and stress are quite common, and pregnant women will usually have a lot of questions. Taking time to discuss these concerns can help identify the areas that need further teaching and discussion.
Assess the patient’s ability to test blood sugar levels.	For women without a history of diabetes, testing can be tricky and difficult. Also, some women are needle-phobic; hence they only rely on other people to do the testing for them. In the absence of their help, testing may not be possible for the patients to do on their own.
Discuss gestational diabetes with the patient in simple terms.	A thorough discussion of the patient’s condition can help improve her understanding of the disease and the importance of adhering to the treatment plan. Include possible complications of the disease to the patient and the unborn child.
Encourage the patient to record or diary her blood sugar readings, including the date and time the readings were taken.	A blood sugar diary is a helpful way of reminding women to regularly check their blood sugar levels. It also allows self-assessment of how well they are doing or what and when their blood sugar level tends to rise or fall.

Nursing Care Plans for Unstable Blood Glucose Level: Nursing Care Plan 5- Diagnosis: Pancreatic Cancer

Related to lack of knowledge on insulin management of pancreatic cancer

Desired Outcome

The patient will demonstrate proper use of a blood glucose monitoring machine.

Intervention	Rationale
Assess the patent’s understanding of the condition, including the normal blood sugar levels.	Unstable blood sugar levels may occur as a result of pancreatic disease. In pancreatic cancer, the body’s ability to regulate insulin and glucagon may be affected, leading to dysregulation of blood sugar. The patient may be unaware that this may occur as a complication. A thorough discussion of the disease using easy-to-understand words can help the patient make sense of what is happening in his/her body, further promoting compliance to the management regime. It is also important that the discussion includes the normal values of blood sugar to guide the patient in his/her management.
Assess the patient’s ability to use a blood sugar testing machine.	Glucose testing machines can be different depending on the manufacturer. However, their functions are mostly similar to one another. Demonstrate the proper use of blood sugar testing machine in case the patient is unable to correctly use it.
Discuss the importance of blood sugar testing, keeping a record, and adhering to the prescribed frequency of testing.	The care needs of a patient with pancreatic cancer can change over time. Having a record of the blood sugar readings can help plan the treatment in the future.
Allow time for discussion of concerns and questions related to the condition.	The patient may have plenty of questions related to the condition. Allowing time for questions and answers can improve understanding and compliance with treatment.

Related FAQs

1. Is unstable blood glucose level a nursing diagnosis?

Risk for unstable blood glucose level (00179) is a NANDA International, Inc.(NANDA-I) nursing diagnosis (ND), defined as “Vulnerable to variation in blood glucose/sugar levels from the normal range, which may compromise health” 1

2. What is unstable blood glucose related to?

Here are some factors or conditions that may lead put patients at risk for an unstable blood glucose: Lack of knowledge on diabetes management or blood glucose management. Developmental level. Imbalance of activity.

3. What is a nursing diagnosis for hypoglycemia?

Nursing Diagnosis: Unstable Blood Glucose Level related to insufﬁcient checking of blood sugar levels and lack of compliance to proper diabetes management secondary to hypoglycemia as evidenced by fatigue and tremors.

4. What are nursing interventions for hypoglycemia?

Severe hypoglycemia can be treated with intravenous (IV) dextrose followed by infusion of glucose. For conscious patients able to take oral (PO) medications, readily absorbable carbohydrate sources (such as fruit juice) should be given.

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May 10, 2022

4 Best Nursing Care Plans for Renal Failure

This article discusses Nursing Care Plans for Renal Failure plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Renal failure is a severe disorder that can cause the body to fill with fluid and cause additional life-threatening problems. Nursing diagnosis and care strategies for this potentially lethal condition must be up to date for medical practitioners.

Renal failure often called chronic kidney disease (CKD), is an irreversible long-term disorder marked by a gradual loss of kidney function.

It can eventually progress to end-stage renal failure (ESRF), which necessitates dialysis or a kidney transplant.

Roles of Kidney in the human body

They manage fluid balance, regulate electrolytes and pH levels, filter out and excrete waste and toxins, and help produce hormones.

Due to the kidneys’ many bodily functions, the signs and symptoms of RF can be varied and can progress as kidney function declines.

RF treatment aims to slow the disease progression by addressing the underlying cause.

Signs and Symptoms of Chronic Renal Failure

1. Oliguria — low urine output of fewer than 400 mL per day; anuria — no urine output.

2. Nausea and vomiting.

3. Loss of appetite.

4. Fatigue and weakness.

5. Decrease in mental sharpness.

6. Muscle twitching and cramping.

7. Swelling of feet and ankles.

8. Persistent itching.

9. Chest pain — occurs when the fluid builds up around the heart’s lining.

10. Shortness of breath if fluid builds up in the lungs.

11. Hypertension.

12. Sleep problems.

Causes Renal Failure

Some diseases can result in chronic renal failure. These include:

1. Type 1 or Type 2 Diabetes. Diabetes causes micro and macrovascular complications. Kidneys are often affected by the damage to the renal blood vessels, which will cause damage and reduction to the kidney functions. RF is quite common in patients with diabetes — with diabetes as the usual cause of their RF.

2. Hypertension. Hypertension can cause vascular issues, affecting the blood vessels in the kidneys, reducing function and causing damage.

3. Glomerulonephritis. Glomeruli are found in the nephrons in the kidneys. It is a network of blood vessels that filters the blood. Prolonged inflammation of these parts of the kidneys can lead to chronic renal failure.

4. Interstitial nephritis. Unresolved or prolonged interstitial nephritis can cause swelling between kidney tubules leading to RF.

5. Polycystic kidney disease. Clusters of cysts can sometimes build up in the kidneys. If unresolved, it can lead to RF as a complication.

6. Long-term obstruction of the urinary tract from conditions such as enlarged prostate, kidney stones, and some cancers.

7. Vesicoureteral reflux. Urine is the product of the filtration of fluids by the kidneys. It is excreted out of our body through the urethra. However, urine can go the other way, which can cause damage to the kidneys and related organs.

8. Pyelonephritis. If left untreated or prolonged, a kidney infection can cause permanent damage to the kidneys.

9. Cardiovascular Disease. Like in diabetes, cardiovascular problems can cause RF by affecting and damaging the blood vessels in the kidneys.

Risk Factors for Renal Failure

Smoking- can cause vascular damage that can affect kidney function

Obesity — obese patients require heightened metabolic demands causing the kidneys to be overworked, leading to RF if not addressed

Race — African American, Native American or Asian-American descent; RF is noted to be higher in races known to have a higher prevalence of hypertension and cardiovascular disease.

Family history of kidney disease

Abnormal kidney structure -anatomical issues can cause changes to kidney functions which can lead to RF.

Older age- organs decline and lose function as the human body ages.

Complications of Renal failure

1. Fluid retention. Kidneys play a role in regulating fluid volume; hence, reduction in its function can cause peripheral edema, pulmonary edema, and pericardial effusion.

2. Hyperkalemia. Extra Potassium in the body is excreted through the kidneys.

Impairment to this function can cause a build-up of Potassium in the bloodstream.

3. Cardiovascular disease. Kidneys help in the fluid regulation in the body. It also helps in the regulation of blood pressure thru hormone regulation. Changes in these processes can cause hypertension which is commonly related to cardiovascular problems.

4. Weak bones and an increased risk of bone fractures. RF causes reduced Vitamin D production and low phosphorous levels causing hypocalcemia. The body compensates by moving the calcium from the bones to the bloodstream causing weak bones.

5. Anemia. RF causes a reduction in the production of Erythropoietin — a hormone that triggers the bone marrow to produce red blood cells.

6. Decreased sex drive, erectile dysfunction, or reduced fertility. The causes of these complications in RF is multifactorial. RF can affect hormonal balance, cardiovascular function, and psychological health, which can cause changes in the patient’s sexual health.

7. Neurological complications. Regulation of waste in the body is one of the many essential roles of the kidneys. The build-up of the waste can cause neurological problems.

8. Decreased immune response. Reduction in immunity is commonly seen in patients with RF. This can lead to increased susceptibility to infections.

9. Pericarditis. Uremic pericarditis can happen because of the build-up of toxins in the human body.

10. Irreversible damage to the kidneys (end-stage kidney disease).

Diagnosis of Renal Failure

1. History taking and Physical exam — a detailed medical and family history will be taken by the health care provider when diagnosing the chronic renal failure. A physical examination will also be done to correlate with the results of diagnostic procedures.

2. Blood tests — creatinine and urea are blood markers that reflect kidney function; estimated glomerular filtration rate (eGFR) can help indicate the stage of kidney disease.

3. Urine tests — to give health care providers information about the patient’s kidney function

4. Imaging tests such as CT scan— to gather information about the current structure and size of the kidneys and other related organs.

5. Kidney biopsy — to collect a tissue sample that will be examined under the microscope, which can give a lot of information as to what is causing the kidney problem

Treatment for Chronic Renal Failure

Chronic renal failure is irreversible and often non-curable.

Measures can be taken to manage signs and symptoms, reduce complications, and slow the progression of the disease. If treatment options are unsuccessful, the damage can lead to end-stage kidney disease, requiring the need for dialysis or kidney transplant.

The treatment includes treating the underlying cause of RF. However, this is not always successful as the disease may persist and progress.

Addressing the complications and signs and symptoms is central to the treatment of RF.

Medications. The following medications can be used to manage RF:

1. Antihypertensive medications — drugs such as angiotensin-converting enzymes inhibitors (ACE inhibitors) or angiotensin II receptor blockers are prescribed to regulate blood pressure and preserve kidney function.

2. Anti-cholesterol drugs — cholesterol levels must be regulated to reduce the risks of cardiovascular problems.

3. Diuretics — relieve swelling; these can help address the fluid balance by excreting excess fluids in the body.

4. Medications to protect the bones — Calcium, Vitamin D, and phosphate supplements can be given to support the bones of RF patients.

5. Medications to treat anemia — erythropoietin is usually given to patients with RF to address anemia, reducing associated weakness and fatigue.

6. Low protein diet. A low protein diet is usually prescribed to patients with RF. The body’s protein processing causes the accumulation of wastes that are filtered by the kidneys. Reduction of dietary protein means reducing waste products, giving the kidneys rest and preventing further deterioration of renal perfusion and function.

7. Lifestyle changes. The patient should be encouraged to undergo a smoking cessation program to prevent further vascular damage. An exercise regimen as recommended by the physiotherapy team should also be considered. If the patient has diabetes, diabetes should be well-controlled as worsening of this condition can affect kidney function.

Nursing Care Plans for Renal Failure

Nursing Care Plan 1: Risk for Decreased Cardiac Output

Nursing Diagnosis: Risk for Decreased Cardiac Output

Risk factors

Fluid imbalances affect circulating volume, myocardial workload, and systemic vascular resistance (SVR).

Alterations in rate, rhythm, cardiac conduction (electrolyte imbalances, hypoxia)

Accumulation of toxins (urea), soft-tissue calcification (deposition of calcium phosphate)

Desired Outcomes

Maintain cardiac output as evidenced by BP and heart rate within patient’s normal range; peripheral pulses strong and equal with prompt capillary refill time.

Nursing Interventions	Rationale
Auscultate heart and lung sounds. Evaluate the presence of peripheral edema, vascular congestion and reports of dyspnea.	S3 and S4 heart sounds with muffled tones, tachycardia, irregular heart rate, tachypnea, dyspnea, crackles, wheezes, edema, and jugular distension suggest HF.
Assess presence and degree of hypertension: monitor BP; note postural changes (sitting, lying, standing).	Significant hypertension can occur because of disturbances in the renin-angiotensin-aldosterone system (caused by renal dysfunction). Although hypertension is common, orthostatic hypotension may occur because of intravascular fluid deficit, response to effects of antihypertensive medications, or uremic pericardial tamponade.
Investigate reports of chest pain, noting location, radiation, severity (0–10 scale), and whether or not it is intensified by deep inspiration and supine position.	Although hypertension and chronic HF may cause MI, approximately half of RF patients on dialysis develop pericarditis, potentiating the risk of pericardial effusion or tamponade.
Evaluate heart sounds (note friction rub), BP, peripheral pulses, capillary refill, vascular congestion, temperature, and sensorium or mentation.	The presence of sudden hypotension, paradoxic pulse, narrow pulse pressure, diminished or absent peripheral pulses, marked jugular distension, pallor, and a rapid mental deterioration indicate tamponade, which is a medical emergency.
Assess activity level, response to activity.	Weakness can be attributed to HF and anemia.
Monitor laboratory and diagnostic studies:
Electrolytes (potassium, sodium, calcium, magnesium), BUN and Cr;	Imbalances can alter electrical conduction and cardiac function.
Chest x-rays.	Helpful in identifying developing cardiac failure or soft-tissue calcification.
Administer antihypertensive drugs such as prazosin (Minipress), captopril (Capoten), clonidine (Catapres), hydralazine (Apresoline).	Reduces systemic vascular resistance and renin release to decrease myocardial workload and aid in preventing HF and MI.
Prepare for dialysis.	Reducing uremic toxins and correcting electrolyte imbalances and fluid overload may limit and prevent cardiac manifestations, including hypertension and pericardial effusion.
Assist with pericardiocentesis as indicated.	Accumulation of fluid within the pericardial sac can compromise cardiac filling and myocardial contractility, impairing cardiac output and potentiating the risk of cardiac arrest.

Nursing Care Plan 2: Disturbed Thought Process

Nursing Diagnosis: Disturbed Thought Process

It may be related to:

Physiological changes: accumulation of toxins (e.g., urea, ammonia), metabolic acidosis, hypoxia; electrolyte imbalances, calcifications in the brain

Possibly evidenced by:

Disorientation to person, place, time

Memory deficit; altered attention span, decreased ability to grasp ideas

Impaired ability to make decisions, problem-solve

Changes in sensorium: somnolence, stupor, coma

Changes in behaviour: irritability, withdrawal, depression, psychosis

Desired Outcomes

Regain/maintain an optimal level of mentation.
Identify ways to compensate for cognitive impairment/memory deficits.

Nursing Interventions	Rationale
Assess the extent of impairment in thinking ability, memory, and orientation. Note attention span.	Uremic syndrome’s effect can begin with minor confusion, irritability and progress to altered personality or inability to assimilate information and participate in care. Awareness of changes provides an opportunity for evaluation and intervention.
Ascertain from SO patient’s usual level of mentation.	Provides comparison to evaluate progression and resolution of impairment.
Provide SO with information about the patient’s status.	Some improvement in mentation may be expected with the restoration of more normal levels of BUN, electrolytes, and serum pH.
Provide a quiet or calm environment and judicious use of television, radio, and visitation.	Minimizes environmental stimuli to reduce sensory overload and confusion while preventing sensory deprivation.
Reorient to surroundings, person, and so forth. Provide calendars, clocks, outside windows.	Provides clues to aid in the recognition of reality.
Present reality concisely, briefly, and do not challenge illogical thinking.	Confrontation potentiates defensive reactions and may lead to patient mistrust and heightened denial of reality.
Communicate information and instructions in simple, short sentences. Ask direct, yes or no questions. Repeat explanations as necessary.	May aid in reducing confusion and increase the possibility that communications will be understood and remembered.
Establish a regular schedule for expected activities.	Aids in maintaining reality orientation and may reduce fear and confusion.
Promote adequate rest and undisturbed periods for sleep.	Sleep deprivation may further impair cognitive abilities.
Monitor laboratory studies such as BUN and Cr, serum electrolytes, glucose level, and ABGs (Po₂, pH).	Correction of elevations or imbalances can have profound effects on cognition or mentation.
Provide supplemental O₂ as indicated.	Correction of hypoxia alone can improve cognition.
Avoid the use of barbiturates and opiates.	Drugs typically detoxified in the kidneys will have increased half-life and cumulative effects, worsening confusion.
Prepare for dialysis.	Marked deterioration of thought processes may indicate worsening of azotemia and general condition, requiring prompt intervention to regain homeostasis.

Nursing Care Plan 3: Risk for Impaired Skin Integrity

Nursing Diagnosis: Risk for Impaired Skin Integrity

Risk factors may include:

Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy)
Alterations in skin turgor (edema/dehydration)
Reduced activity/immobility
Accumulation of toxins in the skin

Possibly evidenced by:

Not applicable. The existence of signs and symptoms establishes an actual nursing diagnosis.

Desired Outcomes

Maintain intact skin.

Demonstrate behaviours/techniques to prevent skin breakdown/injury.

Nursing Interventions	Rationale
Inspect the skin for changes in colour, turgor, vascularity. Note redness, excoriation. Observe for ecchymosis, purpura.	Indicates poor circulation or breakdown areas that may lead to decubitus formation and infection.
Monitor fluid intake and hydration of the skin and mucous membranes.	Detects the presence of dehydration or overhydration that affect circulation and tissue integrity at the cellular level.
Inspect dependent areas for edema. Elevate legs as indicated.	Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation.
Change position frequently; move patient carefully; pad bony prominences with sheepskin, elbow or heel protectors.	Decreases pressure on edematous, poorly perfused tissues to reduce ischemia.
Provide soothing skincare. Restrict use of soaps. Apply ointments or creams (lanolin, Aquaphor).	Baking soda, cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin.
Keep linens dry, wrinkle-free.	Reduces dermal irritation and risk of skin breakdown.
Investigate reports of itching.	Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products such as phosphate crystals (associated with hyperparathyroidism in ESRD).
Recommend patient use cool, moist compresses to apply pressure (rather than scratch) pruritic areas. Keep fingernails short; encourage the use of gloves during sleep if needed.	Alleviates discomfort and reduces the risk of dermal injury.
Suggest wearing loose-fitting cotton garments.	It prevents direct dermal irritation and promotes evaporation of moisture on the skin.
Provide foam or flotation mattress.	Reduces prolonged pressure on tissues, limiting cellular perfusion, potentiating ischemia and necrosis.

Nursing Care Plan 4: Risk for Impaired Oral Mucous Membrane

Nursing Diagnosis

Risk for Impaired Oral Mucous Membrane

Risk factors may include

Lack of/or decreased salivation, fluid restrictions
Chemical irritation, conversion of urea in saliva to ammonia

Possibly evidenced by

Not applicable. The existence of signs and symptoms establishes an actual nursing diagnosis.

Desired Outcomes

Maintain the integrity of mucous membranes.
Identify/initiate specific interventions to promote healthy oral mucosa.

Nursing Interventions	Rationale
Inspect oral cavity; note moistness, the character of saliva, presence of inflammation, ulcerations, leukoplakia.	Provides an opportunity for prompt intervention and prevention of infection.
Provide fluids throughout a 24-hr period within a prescribed limit.	Prevents excessive oral dryness from a prolonged period without oral intake.
Offer frequent mouth care and rinse with 0.25% acetic acid solution; provide gum, hard candy, breath mints between meals.	Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by the conversion of urea.
Encourage good dental hygiene after meals and at bedtime. Recommend avoidance of dental floss.	Reduces bacterial growth and potential for infection. Dental floss may cut gums, potentiating bleeding.
Recommend patient stop smoking and avoid lemon or glycerine products or mouthwash containing alcohol.	These substances are irritating to the mucosa and have a drying effect, potentiating discomfort.
Provide artificial saliva as needed (Ora-Lube).	It prevents dryness, buffers acids, and promotes comfort.
Administer medications as indicated, such as antihistamines: cyproheptadine (Periactin).	It may be given for relief of itching.

Summary

Finally, acute renal failure (ARF) is a common clinical condition that can be caused by various factors and must be treated utilizing various approaches. Nurses can be influential members of the healthcare team if they better understand the disease.

They can also provide appropriate nursing interventions to help patients suffering from acute renal failure. Nurses can provide vital information to patients who desire to learn more about the disease while delivering nursing care.

Other nursing diagnoses for patients with acute renal failure should be explored as well. Change in Health Status, Injury Risk, Disturbed Sleep patterns, Delayed Cough Reflex, Anxiety, Infection Risk, Impaired Skin Integrity, and Ineffective Coping are all on the list.

Related FAQs

1. What are the nursing care plan for renal failure?

Nursing goal of treating patients with acute renal failure is to correct or eliminate any reversible causes of kidney failure. Provide support by taking accurate measurements of intake and output, including all body fluids, monitor vital signs and maintain proper electrolyte balance

2. What is an appropriate nursing diagnosis for a client with chronic kidney disease CKD ?

Diagnosis. Based on the assessment data, the following nursing diagnoses for a patient with chronic renal failure were developed: Excess fluid volume related to decreased urine output, dietary excesses, and retention of sodium and water.

3. What are the main goals of nursing care of a client with CRF?

The nursing care planning goal for with chronic renal failure is to prevent further complications and supportive care. Client education is also critical as this is a chronic disease and thus requires long-term treatment.

4. How can nurses manage the symptoms of CKD?

Role of primary care nurses

Enhancing self-management can be achieved by: Educating patients on the importance of blood pressure control ensuring they are aware that reducing raised blood pressure is a key factor in preventing progression of CKD. Encourage home blood pressure monitoring where appropriate.

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May 9, 2022

5 Best Nursing Care Plans for Preeclampsia

This article discusses Nursing Care Plans for Preeclampsia plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Preeclampsia is a condition that can occur during pregnancy where there is a sudden rise in blood pressure. It can also lead to clotting issues that may affect organs, such as the liver and kidneys.

Preeclampsia is the most common complication to occur during pregnancy. It generally develops during the third trimester and affects about 1 in 25 pregnancies.

It can progress into eclampsia in some people, where they can experience seizures and enter a coma. It can also be fatal. Prenatal appointments are essential for managing health, preeclampsia, and potential conditions such as eclampsia.

Symptoms of Preeclampsia

Preeclampsia may present no initial symptoms, but common signs include:

Protein in the urine
High blood pressure
Blurry vision, sometimes seeing flashing lights
Headaches, often severe
Feeling ill
Shortness of breath
Pain just below the ribs on the right side
Rapid weight gain, caused by excess fluid
Nausea and vomiting during the second half of pregnancy
Urinating less often
Lower platelet count
Impaired liver function

Pregnant people should seek immediate medical attention if they experience any of these signs or symptoms.

Although some people may develop high blood pressure during pregnancy, it does not necessarily mean they have preeclampsia. The criteria for diagnosing preeclampsia include elevated blood pressure and at least one correlating sign from above.

Causes of preeclampsia

Experts are not sure why preeclampsia occurs. Most say there is a problem with the placenta’s development because the blood vessels that supply it respond differently to hormonal signals and are narrower than normal, limiting blood flow.

Experts also do not fully understand why the blood vessels develop differently, but several factors may play a role. These include:

Damage to the blood vessels
Insufficient blood flow to the uterus
Immune system problems
Genetic factors
Risk Factors of Preeclampsia
Risk factors associated with preeclampsia include:
First pregnancies: The chances of preeclampsia during a first pregnancy are considerably higher than subsequent ones.
Family history: A person whose parent or sibling had preeclampsia has a higher risk of developing it.
Personal history of preeclampsia: A person who had preeclampsia in their first pregnancy can have a much greater risk of having the same condition in subsequent pregnancies.
Certain conditions and illnesses: People with diabetes, chronic high blood pressure, autoimmune disorders, and kidney disease are more likely to develop preeclampsia.
Obesity: Preeclampsia rates are much higher among obese people.
Multiple pregnancies: If a person is expecting two or more babies, the risk is higher.

Diagnosis of Preeclampsia

For a doctor to diagnose preeclampsia, the pregnant person must have a diagnosis of high blood pressure and at least one additional associated sign, such as decreased blood platelets or impaired liver function.

Hypertension

A blood pressure reading of 140/90 mm Hg or higher is abnormal in pregnancy.

The doctor may also order diagnostic tests:

Blood tests: This checks kidney and liver function and whether the blood is clotting properly.

Fetal ultrasound: Doctors will closely monitor the baby’s progress to make sure they are growing correctly.

Non-stress test: The doctor checks how the baby’s heartbeat reacts when they move. If the heartbeat increases 15 beats or more a minute for at least 15 seconds twice every 20 minutes, it is an indication that everything is normal.

Prevention of Preeclampsia

Preeclampsia is not entirely preventable, but there are several steps a pregnant person can take to moderate some factors that contribute to high blood pressure.

These can include:

Drinking between 6 and 8 glasses of water every day
Avoiding fried or highly processed foods
Excluding added salt
Avoiding alcohol and caffeine
Taking regular exercise under their doctor’s guidance
Keeping feet elevated a few times per day
Resting

These steps can help maintain healthy blood pressure and may reduce the risk of preeclampsia. Pregnant people should follow their doctor’s advice on diet and exercise.

Complications of Preeclampsia

There is a risk of severe complications with untreated preeclampsia. Complications may be prevented if the signs of preeclampsia are detected sooner, which is possible by attending routine prenatal visits. However, if the condition is not diagnosed for some reason, the risks are considerably more significant.

The following complications may develop from preeclampsia:

Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome

HELLP can very quickly become life-threatening for both the pregnant person and the baby. It stands for hemolysis, elevated liver enzymes, and low platelet count. It is a combined liver and blood clotting disorder that most commonly occurs right after giving birth but can appear at any time after the 20th week of pregnancy. Very rarely, it may occur beforehand. The only way to treat HELLP syndrome effectively is to deliver the baby as soon as possible.

Poor blood flow to the placenta

If blood flow to the placenta is restricted, the baby might not be getting oxygen and nutrients, leading to slower growth, breathing difficulties, and premature birth.

Placental abruption

The placenta separates from the inner wall of the uterus. There may be heavy bleeding in severe cases, which can damage the placenta. Any damage to the placenta may place the baby’s and pregnant person’s life at risk.

Eclampsia

This is a combination of preeclampsia and seizures. The pregnant person may experience pain under the ribs on the right side of their body, intense headache, blurry vision, confusion, and decreased alertness. If left untreated, they are at risk of coma, permanent brain damage, and death. The condition is also life-threatening for the baby.

Preeclampsia can have some long-term consequences for the developing baby. Research shows that high blood pressure in pregnant people may affect the baby’s cognitive skills, which can carry through into later life.

Treatment of Preeclampsia

Preeclampsia is not cured until the baby is delivered.

Until the pregnant person’s blood pressure reduces, they are at a greater risk of stroke, severe bleeding, separation of the placenta from the uterus, and seizures. In some cases, mainly if preeclampsia develops earlier in pregnancy, early delivery may not be the best option for the baby.

People who have had preeclampsia in previous pregnancies are advised to attend prenatal visits more often. The doctor may recommend the following medications:

Antihypertensives

These help to lower blood pressure.

Anticonvulsants

Doctors may use these drugs to prevent a first seizure in severe cases. They may prescribe magnesium sulfate.

Corticosteroids

If the person has preeclampsia or HELLP syndrome – see below – these drugs can help induce fetal lung maturity to prepare for premature delivery. This can prolong the pregnancy.

Rest

If the person is far from the end of their pregnancy and has mild symptoms, the doctor may advise bed rest. Resting helps bring the blood pressure down, increasing blood flow to the placenta and benefiting the baby.

Doctors may advise some people to lie down in bed and only sit up or stand when needed. Others may be allowed to sit in an armchair or on the sofa or bed, but their physical activities will be strictly limited. There will be regular blood pressure and urine tests, and doctors will also monitor the baby closely.

The pregnant person may be hospitalized for continuous bed rest and monitored closely in severe cases.

Inducing labor

With a diagnosis of preeclampsia close to the end of pregnancy, doctors may advise delivering the baby early.

There may be no choice in very severe cases, and doctors will induce the labor or perform a cesarean delivery as soon as possible. The doctor may give the parent magnesium sulfate to improve uterine blood flow and prevent seizures during childbirth.

Nursing Care Plans for Preeclampsia Based on Diagnosis

Nursing Care Plan 1: Decreased Cardiac Output

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic demands of the body.

May be related to:

Hypovolemia/decreased venous return
Increased systemic vascular resistance

Possibly evidenced by:

Change in blood pressure/hemodynamic readings
Edema
Shortness of breath
Alteration in mental status

Desired Outcomes

The patient remains normotensive throughout the remainder of the pregnancy.
Patient reports absence and/or decreased episodes of dyspnea.
Patient alters activity level as condition warrants.

Nursing Interventions	Rationale
Record and graph vital signs, especially BP and pulse.	The patient with PIH does not display the normal cardiovascular response to pregnancy (left ventricular hypertrophy, increase in plasma volume, vascular relaxation with decreased peripheral resistance). Hypertension (the second manifestation of PIH after edema) occurs owing to increased sensitization to angiotensin II, which increases BP, promotes aldosterone release to increase sodium/water reabsorption from the renal tubules, and constricts blood vessels.
Assess MAP at 22 weeks gestation. A pressure of 90 mm Hg is considered predictive of PIH. Assess for crackles, wheezes, and dyspnea; note respiratory rate/effort.	Pulmonary edema may transpire with modification in peripheral vascular resistance and a drop in plasma colloid osmotic pressure.
Institute bedrest with a patient in lateral position.	Improves venous return, cardiac output, and renal/placental perfusion.
Check for invasive hemodynamic parameters.	Provides a precise picture of vascular changes and fluid volume. Prolonged vascular constriction, increased hemoconcentration, and fluid shifts decrease cardiac output.
Give antihypertensive drugs such as hydralazine (Apresoline) PO/IV so that diastolic readings are between 90 and 105 mm Hg. Begin maintenance therapy as needed, e.g., methyldopa (Aldomet) or nifedipine (Procardia).	If BP does not respond to conservative measures, short-term medication may be needed in conjunction with other therapies, e.g., fluid replacement and MgSO4. Antihypertensive drugs work directly on arterioles to promote relaxation of cardiovascular smooth muscle and help increase blood supply to the cerebrum, kidneys, uterus, and placenta. Hydralazine is the drug of choice because it does not produce effects on the fetus. Sodium nitroprusside is being used with some success to lower BP (especially in HELLP syndrome).
Check on BP and side effects of antihypertensive drugs. Administer propranolol (Inderal) as appropriate.	Side effects such as tachycardia, headache, nausea, and vomiting, and palpitations may be treated with propranolol.
Prepare for the birth of fetus by cesarean delivery, labor when severe PIH/eclamptic condition is stabilized, but vaginal delivery is not feasible.	If conservative treatment is ineffective and labor induction is ruled out, then surgical procedure is the only means of halting the hypertensive problems.

Nursing Care Plan 2: Altered Tissue Perfusion (Uteroplacental)

Impaired Tissue Perfusion: Decreased in oxygen resulting in the failure to nourish the tissues at the capillary level.

May be related to:

Maternal hypovolemia
Interruption of blood flow (progressive vasospasm of spiral arteries)

Possibly evidenced by:

Intrauterine growth retardation
Changes in fetal activity/heart rate
Premature delivery
Fetal demise

Desired Outcomes

The patient demonstrates normal CNS reactivity on nonstress test (NST)
The patient is free of late decelerations;
The patient has no decrease in FHR on the contraction stress test/oxytocin challenge test (CST/OCT).
The patient is full-term, AGA.

Nursing Interventions	Rationale
Present information to patient/couple concerning the home assessment or noting daily fetal movements and when to seek immediate medical attention.	Decrease in placental blood flow results in reduced gas exchange and impaired nutritional functioning of the placenta. Potential outcomes of poor placental perfusion include a malnourished, LBW infant and prematurity associated with early delivery, abruptio placentae, and fetal death. Reduced fetal activity means fetal compromise (occurs before detectable alteration in FHR and indicates demand for immediate evaluation/intervention.
Name factors affecting fetal activity.	Cigarette smoking, medication/drug use, serum glucose levels, environmental sounds, time of day, and a sleep-wake cycle of the fetus can increase or decrease fetal movement.
Report signs of abruptio placentae (i.e., vaginal bleeding, uterine tenderness, abdominal pain, and decreased fetal activity).	Immediate attention and intervention increase the likelihood of a positive outcome.
Present contact number for patient to direct questions, address changes in daily fetal movements, and so forth.	Provides a chance to address concerns/misconceptions and intervene in a timely manner, as indicated.
Evaluate fetal growth; measure progressive fundal accompany growth at each office visit or periodically during stress home visits, as appropriate.	Reduced placental functioning may accompany PIH, resulting in IUGR. Chronic intrauterine stress and uteroplacental insufficiency decrease the amount of fetal contribution to the amniotic fluid pool.
Note the fetal response to medications such as MgSO4, phenobarbital, and diazepam.	Depressant effects of medication reduce fetal respiratory and cardiac function and fetal activity level, even though placental circulation may be adequate.
Check FHR manually or electronically, as indicated.	Helps evaluate fetal well-being. An elevated FHR may show a compensatory response to hypoxia, prematurity, or abruptio placentae.
Assess fetal response to BPP criteria or CST, as maternal status indicates.	BPP helps evaluate fetus and fetal environment on five specific parameters to assess CNS function and fetal contribution to the amniotic fluid volume. CST assesses placental functioning and reserves.
Assist with assessing fetal maturity and well-being using L/S ratio, PG, estriol levels, FBM, and sequential sonography beginning at 20–26 weeks’ gestation.	In the event of declining maternal/fetal condition, risks of delivering a preterm infant are weighed against the risks of continuing the pregnancy, using results from evaluative studies of lung and kidney maturity, fetal growth, and placental functioning. IUGR is associated with reduced maternal volume and vascular changes.
Assist with assessment of maternal plasma volume at 24–26 weeks’ gestation using Evans’ blue dye when indicated.	Identifies fetus at risk for IUGR or intrauterine fetal demise associated with reduced plasma volume and reduced placental perfusion.
Utilizing ultrasonography, assist with the assessment of placental size.	Reduced placental function and size are associated with PIH.
Give corticosteroid (dexamethasone, betamethasone) IM for at least 24–48 hr, but not more than 7 days before delivery, when severe PIH necessitates premature delivery between 28 and 34 weeks gestation.	Corticosteroids are thought to induce fetal pulmonary maturity (surfactant production) and prevent respiratory distress syndrome, at least in a fetus delivered prematurely because of condition or inadequate placental functioning. Best results are obtained when the fetus is less than 34 weeks gestation and delivery occurs within a week of corticosteroid administration.

Nursing Care Plan 3: Risk for Maternal Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

May be related to:

Tissue edema/hypoxia
Tonic-clonic convulsions
Abnormal blood profile and/or clotting factors

Desired Outcomes

The patient participates in treatment and/or environmental modifications to protect themself and enhance safety.
The patient is free of signs of cerebral ischemia (visual disturbances, headache, changes in mentation).
The patient displays normal levels of clotting factors and liver enzymes.

Nursing Interventions	Rationale
Check for CNS involvement (i.e., headache, irritability, visual disturbances, or changes on funduscopic examination).	Cerebral edema and vasoconstriction can be evaluated in terms of symptoms, behaviors, or retinal changes.
Emphasize the importance of patient promptly reporting signs/symptoms of CNS involvement.	Delayed treatment or progressive onset of symptoms may result in tonic-clonic convulsions or eclampsia.
Check for alterations in level of consciousness.	In progressive PIH, vasoconstriction and vasospasms of cerebral blood vessels reduce oxygen consumption by 20% and result in cerebral ischemia.
Assess for signs of impending eclampsia: hyperactivity of deep tendon reflexes (3+ to 4+), ankle clonus, decreased pulse and respirations, epigastric pain, and oliguria (less than 50 ml/hr).	Generalized edema/vasoconstriction, manifested by severe CNS, kidney, liver, cardiovascular, and respiratory involvement, precedes the convulsive state.
Establish measures to lessen the likelihood of seizures; i.e., keep room quiet and dimly lit, limit visitors, plan and coordinate care, and promote rest.	Lessens environmental factors that may stimulate irritable cerebrum and cause a convulsive state.
Enforce seizure precautions per protocol.	If a seizure does occur, it reduces the risk of injury.
In the event of a seizure: Position patient on the side; insert airway/bite block only if the mouth is relaxed; suction nasopharynx, as indicated; administer oxygen; avoid restrictive clothing; do not restrict movement. Document motor involvement, duration of seizure, and post-seizure behavior.	Maintains the airway by reducing the risk of aspiration and preventing the tongue from occluding the airway. Maximizes oxygenation. Note: Be cautious with the use of airway/bite block because attempts to insert when jaws are set may result in injury.
Palpate for uterine tenderness or rigidity; check for vaginal bleeding. Review history of other medical problems.	These signs may indicate abruptio placentae, especially if there is a preexisting medical problem, such as diabetes mellitus or a renal or cardiac disorder causing vascular involvement.
Observe for signs and symptoms of labor or uterine contractions.	Convulsions increase uterine irritability; labor may ensue.
Assess fetal well-being, noting FHR.	During seizure activity, fetal bradycardia may occur.
Monitor for signs of DIC easy/spontaneous bruising, prolonged bleeding, epistaxis, GI bleeding.	Abruptio placentae with the release of thromboplastin predisposes the patient to DIC.
Hospitalize if CNS involvement is present.	Immediate introduction of therapy helps to ensure safety and limit complications.
Give MgSO 4 IM or IV using an infusion pump.	MgSO4, a CNS depressant, decreases acetylcholine release, blocks neuromuscular transmission, and prevents seizures. It has a transient effect of lowering BP and increasing urine output by altering vascular response to pressor substances. Although IV administration of MgSO4 is easier to regulate and reduces the risk of a toxic reaction, some facilities may still use the IM route if continuous surveillance is not possible and/or if appropriate infusion apparatus is unavailable. Note: Adding 1 ml of 2% lidocaine to the IM injection may reduce associated discomfort. (Current research suggests that the use of phenytoin infusion may be effective in treating PIH without the adverse side effects, such as respiratory depression and tocolytic effect on uterine smooth muscle, which can impede labor during intrapartum therapy.)
Monitor BP before, during, and after MgSO4 administration. Note serum magnesium levels in conjunction with respiratory rate, patellar/deep tendon reflex (DTRs), and urine output.	A therapeutic level of MgSO4is achieved with serum levels of 4.0–7.5 mEq/L or 6–8 mg/dL. Adverse/toxic reactions develop above 10–12 mg/dL, with loss of DTRs occurring first, respiratory paralysis between 15–17 mg/dL, or heart block occurring at 30–35 mg/dL.
Ready calcium gluconate. Give 10 ml (1 g/10 ml) over 3 min as indicated.	It serves as an antidote to counteract the adverse/toxic effects of MgSO4.
Administer amobarbital (Amytal) or diazepam (Valium), as indicated.	Depresses cerebral activity; has a sedative effect when MgSO4 does not control convulsions. Not recommended as first-line therapy because sedative effect also extends to the fetus.
Perform funduscopic examination regularly.	Helps to evaluate changes or severity of retinal involvement.
Review test results of clotting time, PT, PTT, fibrinogen levels, and FPS/FDP.	Such tests can indicate the depletion of coagulation factors and fibrinolysis, suggesting DIC.
Scan sequential platelet count. Avoid amniocentesis if the platelet count is less than 50,000/mm3. If thrombocytopenia is present during the operative procedure, use general anesthesia. As indicated, transfuse with platelets, packed red blood cells, fresh frozen plasma, or whole blood. Rule out HELLP syndrome.	Thrombocytopenia may arise because of platelet adherence to disrupted endothelium or reduced prostacyclin levels (a potent inhibitor of platelet aggregation). Invasive procedures or anesthesia requiring needle puncture (such as spinal/epidural) could result in excessive bleeding.
Monitor liver enzymes and bilirubin; note hemolysis and presence of Burr cells on peripheral smear.	An elevated liver enzyme (AST, ALT) and bilirubin levels, microangiopathic hemolytic anemia, and thrombocytopenia may indicate the presence of HELLP syndrome, signifying a need for immediate cesarean delivery if the condition of the cervix is unfavorable for induction of labor.
Prepare for cesarean birth if PIH is severe, placental functioning is compromised, and cervix is not ripe or is not responsive to induction.	When fetal oxygenation is severely reduced owing to vasoconstriction within the malfunctioning placenta, immediate delivery may be necessary to save the fetus.

Nursing Care Plan 4: Deficient Fluid Volume

Deficient Fluid Volume: Defined as decreased intravascular, interstitial, and intracellular fluid.

May be related to:

Osmotic pressure plasma protein loss
Decreasing plasma colloid
Allowing fluid shifts out of the vascular compartment

Possibly evidenced by:

Edema formation
Sudden weight gain
Decreased urine output
Hemoconcentration
Nausea/vomiting
Epigastric pain
Headaches
Visual changes

Desired Outcomes

The patient engages in therapeutic regimen and monitoring, as indicated.
The patient verbalizes understanding of the need for close monitoring of weight, BP, urine protein, and edema.
The patient is free of signs of generalized edema (i.e., epigastric pain, cerebral symptoms, dyspnea, nausea/vomiting)
The patient exhibits Hct WNL and physiological edema with no signs of pitting.

Nursing Interventions	Rationale
Weigh patient regularly. Tell patient to record weight at home in-between visits.	Abrupt, notable weight gain (e.g., more than 3.3 lb (1.5 kg)/month in the second trimester or more than 1 lb (0.5 kg)/wk in the third trimester) reflects fluid retention. Fluid moves from the vascular to the interstitial space, resulting in edema.
Differentiate physiological and pathological edema of pregnancy. Locate and determine the degree of pitting.	The presence of pitting edema (mild, 1+ to 2+; severe, 3+ to 4+) of face, hands, legs, sacral area, or abdominal wall, or edema that does not disappear after 12hr of bed rest is vital. Note: Significant edema may actually be present in non-pre-eclamptic patients and absent in patients with mild or moderated PIH.
Note signs of progressive or excessive edema, i.e., epigastric/RUQ pain, cerebral symptoms, nausea, vomiting). Assess for possible eclampsia.	Edema and intravascular fibrin deposition (in HELLP syndrome) within the encapsulated liver are manifested by RUQ pain; dyspnea, indicating pulmonary involvement; cerebral edema, possibly leading to seizures; and nausea, and vomiting, indicating GI edema.
Note alteration in Hct/Hb levels.	Identifies degree of hemoconcentration caused by fluid shift. If Hct is less than 3 times Hb level, hemoconcentration exists.
Check on dietary intake of proteins and calories. Give information as needed.	Proper nutrition decreases the incidence of prenatal hypovolemia and hypoperfusion; insufficient protein/calories increases the risk of edema formation and PIH. Intake of 80–100 g of protein may be required daily to replace losses.
Monitor intake and output. Note urine color, and measure specific gravity as indicated.	Urine output is a sensitive indicator of circulatory blood volume. Oliguria and specific gravity of 1.040 indicate severe hypovolemia and kidney involvement. Note: Administration of magnesium sulfate (MgSO4)may cause a transient increase in output.
Examine clean, voided urine for protein each visit, or daily/hourly as appropriate if hospitalized. Report readings of 2+, or greater.	Aids in identifying the degree of severity/progression of the condition. A 2+ reading implies glomerular edema or spasm. Proteinuria affects fluid shifts from the vascular tree. Note: Urine contaminated by vaginal secretions may test positive for protein, or dilution may result in a false-negative result. In addition, PIH may be present without significant proteinuria.
Assess lung sounds and respiratory rate/effort.	Dyspnea and crackles may mean pulmonary edema, which needs immediate treatment.
Check BP and pulse.	The rise in BP may happen in response to catecholamines, vasopressin, prostaglandins, and, as recent findings suggest, decreased levels of prostacyclin.
Respond to questions and review rationale for avoiding the use of diuretics to treat edema.	Diuretics further increase the chances of dehydration by decreasing intravascular volume and placental perfusion, and they may cause thrombocytopenia, hyperbilirubinemia, or alteration in carbohydrate metabolism in fetus/newborn. Note: It may be useful in treating pulmonary edema.
Schedule prenatal visit every 1–2 wk if PIH is mild; weekly if severe.	Important to monitor changes more closely for the well-being of the patient and fetus.
Review moderate sodium intake of up to 6 g/day. Tell patient to read food labels and avoid foods high in sodium (e.g., bacon, luncheon meats, hot dogs, canned soups, and potato chips).	Some sodium intake is necessary because levels below 2–4 g/day result in more significant dehydration in some patients. However, excess sodium may increase edema formation.
Collaborate with a dietitian as indicated.	The nutritional consult may be beneficial in determining individual needs/dietary plans.
Place patient on a strict regimen of bed rest; encourage lateral position.	Lateral recumbent position decreases pressure on the vena cava, increasing venous return and circulatory volume. This enhances placental and renal perfusion, reduces adrenal activity, and may lower BP as well as account for weight loss through diuresis of up to 4 lb in a 24-hr period.
As appropriate, educate patient and family members or significant others on home monitoring/day-care program.	Some mildly hypertensive patients without proteinuria may be managed on an outpatient basis if adequate surveillance and support is provided and the patient/family actively participates in the treatment regimen.
Substitute fluids either orally or parenterally via an infusion pump, as indicated.	Fluid replacement treats hypovolemia yet must be given cautiously to prevent overload, especially if interstitial fluid is drawn back into circulation when activity is reduced. With renal involvement, fluid intake is restricted; i.e., if the output is reduced (less than 700 ml/24 hr), total fluid intake is restricted to approximate output plus insensible loss. The use of an infusion pump allows more accurate control delivery of IV fluids.
When the fluid deficit is severe, and the patient is hospitalized:
Insert indwelling catheter if kidney output is reduced or is less than 50 ml/hr.	Allows more accurate monitoring of output/renal perfusion.
Help with insertion of lines and/or monitoring of invasive hemodynamic parameters, such as CVP and pulmonary artery wedge pressure (PAWP).	Gives a more precise measurement of fluid volume. In normal pregnancy, plasma volume increases by 30%–50%, yet this increase does not occur in the patient with PIH.
Monitor serum uric acid and creatinine levels and BUN.	Elevated levels, especially of uric acid, indicate impaired kidney function, worsening of the maternal condition, and poor fetal outcome.
Administer platelets as indicated.	Patients with HELLP syndrome awaiting delivery of the fetus may benefit from transfusion of platelets when the count is below 20,000.

Nursing Care Plan 5: Risk for Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.

It may be related to insufficient intake that can’t meet metabolic demands and replace losses.

Desired Outcomes

The patient verbalizes understanding of individual dietary needs.
Patient demonstrates knowledge of proper diet as evidenced by developing a dietary plan within their own financial resources.
The patient displays appropriate weight gain.

Nursing Interventions	Rationale
Determine patient’s nutritional status, condition of hair and nails, and height and pregravid weight.	Establishes guidelines for determining dietary needs and educating patients. Malnutrition may contribute to the onset of PIH, specifically when the client follows a low-protein diet, has insufficient caloric intake, and is overweight or underweight by 20% or more before conception.
Provide information about normal weight gain in pregnancy, modifying it to meet the client’s needs.	The underweight patient may need a higher-calorie diet; the obese patient should avoid dieting because it places the fetus at risk for ketosis.
Present oral/written information about the action and uses of protein and its role in PIH development.	Regular intake of 80–100 g/day (1.5 g/kg) is sufficient to replace proteins lost in the urine and allow for normal serum oncotic pressure.
Provide information regarding the effect of bed rest and reduced activity on protein requirements.	Decreasing metabolic rate through bed rest and limited activity reduces protein needs.
Collaborate with a dietitian, as indicated.	Helpful in creating individual dietary plans incorporating specific needs/restrictions.

Summary

Preeclampsia is a complication of pregnancy where there is a sudden rise in blood pressure. It usually develops during the third trimester.

Preeclampsia is not entirely preventable, but visiting a doctor for regular prenatal visits may lead to early detection. Limiting highly processed foods and choosing fruits and vegetables — frozen and canned are great options — can also help to keep people and their babies healthier during pregnancy.

It is advisable for pregnant people to speak with a healthcare professional about their risk of developing preeclampsia and its warning signs.

Related FAQs

1. What are some nursing interventions for preeclampsia?

Nursing Management

Monitor blood pressure.
Assess fetal heart rate.
Send blood and urine for testing.
Administer prescribed medications.
Monitor reflexes on patients on magnesium sulfate.
Neurologic checks regularly.
Seizure precautions if ordered.

2. What are some nursing diagnosis for preeclampsia?

Nursing Care Plan for Preeclampsia 4. Nursing Diagnosis: Risk for Injury related to Altered state of mind, hypoxia of the tissues, atypical blood profile and clotting factors, and episodes of tonic-clonic convulsions secondary to Pre-eclampsia.

3. What needs to be included in a plan of care for the woman experiencing preeclampsia?

Plan of Care

A thorough initial assessment of the woman with possible preeclampsia should include a complete history, a complete physical exam with close attention to preeclampsia symptoms including unremitting headaches, edema, visual changes, and epigastric pain, fetal activity, and vaginal bleeding.

4. What are interventions for preeclampsia?

Medications to treat severe preeclampsia usually include:

Antihypertensive drugs to lower blood pressure.
Anticonvulsant medication, such as magnesium sulfate, to prevent seizures.
Corticosteroids to promote development of your baby’s lungs before delivery.

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May 9, 2022

6 Best Nursing Care Plans for Postpartum Hemorrhage

This article discusses Nursing Care Plans for Postpartum Hemorrhage plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Postpartum hemorrhage is defined as any blood loss from the uterus of more than 500ml during or after delivery. It may occur either early (within the first 24 hours after delivery) or late (anytime after the 24 hours during the remaining days of the six-week puerperium).

It is important to note that vaginal bleeding called lochia is normally heavy from just after delivery until the next few hours and may not stop until the next few days.

The color of blood will usually change from bright red to brown over a couple of weeks. The full stoppage of lochia normally occurs no more than 12 weeks after delivery.

However, there is either heavy vaginal bleeding of at least 500 mL in the first 24 hours of delivery in postpartum hemorrhage or between 23 hours and 12 weeks of delivery.

Nursing Care Plans for Postpartum Hemorrhage – Types of Lochia

Postpartum hemorrhage may involve excessive bleeding and abnormality of lochia or postpartum vaginal discharge. It is especially important to take note of the duration of lochia rubra to help in the diagnosis of PPH. The following are the normal characteristics of the types or stages of lochia:

Lochia rubra – refers to the first vaginal discharge; Rubra means red; it usually happens from Day 1 to Day 5 after birth

Lochia serosa – the vaginal discharge appears either brownish or pinkish; typically occurs until Day 10 after birth

Lochia alba – the vaginal discharge appears whitish or yellowish; typically happens from the 2nd week to the 6th week after birth, but may also extend to 12 weeks postpartum.

Nursing Care Plans for Postpartum Hemorrhage – Types of Postpartum Hemorrhage

Primary PPH – occurs when the mother loses at least 500 mL or more of blood within the first 24 hours of delivering the baby.

Major Primary PPH – losing 500 mL to 1000 mL of blood

Minor Primary PPH – losing more than 1000 mL of blood

Secondary PPH – occurs when the mother has heavy or abnormal vaginal bleeding between 24 hours and 12 weeks of delivering the baby.

Nursing Care Plans for Postpartum Hemorrhage – Signs and Symptoms of Postpartum Hemorrhage

Uncontrolled bleeding
Hypotension – decreased blood pressure
Tachycardia – increased heart rate
Anemia – decrease in the red blood cell count or hemoglobin level
Edema or hematoma – swelling and pain in or around the vaginal area
Fatigue – extreme tiredness

The patient should also be educated on the following warning signs that would indicate the need to inform their healthcare provider either during a hospital stay or after discharge:

Excessive or increased vaginal bleeding – if the patient needs a new sanitary pad after an hour or if she passes large blood clots
Blurry vision or other visual disturbances
Light-headedness or dizziness
New or worsening stomach pain
Fatigue
Tachycardia

Nursing Care Plans for Postpartum Hemorrhage – Causes of Postpartum Hemorrhage

The 4 T’s is a mnemonic that can be used to remember the 4 common causes of postpartum hemorrhage:

Tone – uterine atony is the most common cause of PPH; overstretched uterus may cause a soft and boggy tone

Trauma – rupture, inversion, hematoma, and/or laceration

Tissue – retained or invasive placenta

Thrombin – coagulopathy; bleeding disorders or blood clotting problems

Nursing Care Plans for Postpartum Hemorrhage – Risk Factors of Postpartum Hemorrhage

Before Delivery

Placenta previa – a condition wherein the placenta is situated low near the neck of the uterus.
Abruptio placentae – a condition wherein the placenta separates from the uterus earlier than expected.
Multiple pregnancies – carrying twins or more
History of postpartum hemorrhage
Pre-eclampsia – high blood pressure
Obesity or having a BMI of greater than 35
Anemia
Thrombocytopenia or other blood clotting problems
On anticoagulant therapy
Fibroids

After Delivery

Delivery by Cesarean section
Forceps delivery
Induction of labor
Delayed delivery of the placenta or retained placenta – not passing the placenta within the hour after birth of the baby
Tear in the perineum (lacerations) or episiotomy
Fetal macrosomia – having a baby that weighs more than 9 lbs or 4 kg
Hyperthermia during labor
Having had long labor – more than 12 hours
Age of the mother – having the first baby at age 40 years or above
Use of general anesthetic during delivery

Nursing Care Plans for Postpartum Hemorrhage – Complications of Postpartum Hemorrhage

Hypovolemic shock
Failure of major organs, such as the lungs and kidneys
Anemia
Postpartum fatigue

Nursing Care Plans for Postpartum Hemorrhage – Diagnosis of Postpartum Hemorrhage

Measurement of blood loss – PPH is defined as blood loss of more than 500 mL in the first 24 hours post-delivery

Blood tests – include full blood count (particularly hemoglobin and hematocrit), clotting factors, and factor essays.

Pelvic exam – pregnant women who are at risk for PPH will undergo a pelvic exam, which checks the vagina, uterus, and cervix.

Imaging – ultrasound is the first imaging choice to visualize the baby and the pelvic organs.

Nursing Care Plans for Postpartum Hemorrhage – Prevention of Postpartum Hemorrhage

The following measures can be undertaken to prevent the likelihood of postpartum hemorrhage:

Active management of the third stage of labor

This includes the administration of oxytocin no earlier than the delivery of the anterior shoulder. It also involves controlled traction and a uterine massage after the delivery of the placenta.

Early recognition of the risk for PPH

Stopping or reducing anticoagulants, oral iron supplementation, coagulation tests, and regular antenatal check-ups help prevent PPH.

Nursing Care Plans for Postpartum Hemorrhage – Treatment for Postpartum Hemorrhage

Medications. Several medications may be prescribed to treat PPH:
Uterotonic agents – utilized to prevent or control PPH. Oxytocin is the first-line prevention and treatment for PPH. It is used to decrease the blood flow through the uterus after the baby’s delivery.
Adjuvant therapies – anti-bleeding drugs can be administered within the first 3 hours of the start of PPH.
Antibiotics – may be required if a bacterial infection has caused or contributed to PPH based on the culture results of the lochia.
Intravenous fluid replacement
Uterine massage
Transfusion – low hemoglobin /hematocrit level and excessive blood loss may require transfusion of blood and plasma products.
Application of pressure on labial or perineal lacerations
Episiotomy Repair – timely repair of lacerations and episiotomy is essential in controlling PPH
Reduction of uterine inversion – the Johnson method is a manual procedure wherein the protruding uterus is returned in the normal position by pushing it inside toward the direction of the umbilicus
Manual removal of retained placental tissues
Surgery– hysterectomy (removal of the uterus) or laparotomy may be needed if the other treatments are not effective in stopping PPH

Nursing Care Plans for Postpartum Hemorrhage Based on Diagnosis

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 1 – Diagnosis: Ineffective Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in oxygen resulting in the failure to nourish the tissues at the capillary level.

May be related to hypovolemia (a decreased volume of circulating blood in the body).

Possibly evidenced by:

Diminished arterial pulsations, cold extremities.

Decreased capillary refill.
Decreased milk production.
Changes in the vital signs.
Changes in the neurologic status.

Desired Outcomes

A patient will demonstrate blood pressure, pulse, arterial blood gasses (ABGs), and Hematocrit/hemoglobin level within the expected range.
A patient will demonstrate normal hormonal functioning by adequate milk supply for lactation (as appropriate) and resumption of normal menstruation.

Nursing Interventions	Rationale
Monitor vital signs closely; record the degree and duration of any hypovolemic episodes.	The extent of pituitary involvement may be related to the degree and duration of hypotension. A respiratory difficulty may indicate an effort to combat metabolic acidosis.
Observe the color of the nail beds, gums, tongue, and buccal mucosa; note the skin’s temperature.	With the vasoconstriction compensation and shunting to vital organs, circulation in the peripheral blood vessels is diminished, resulting in cyanosis and cold skin temperatures.
Evaluate the neurologic status and observe for any behavioral changes.	Changes in the mentation is an early sign of hypoxia. Cyanosis, on the other hand, is a late sign which may not appear until the PO2 levels drop below 50 mm Hg,
Check the breast at least daily; Inspect for changes in breast size and the presence or absence of lactation.	Sheehan’s syndrome, also known as postpartum hypopituitarism, reduces prolactin levels, resulting in agalactorrhea (absence of lactation) and a decrease in breast tissue.
Monitor Hemoglobin and hematocrit values before and after blood loss. Check for the height and weight; Assess the client’s nutritional status.	Such values indicate the severity of blood losses. Preexisting poor health status increases the extent of injury brought about by the oxygen deficits.
Monitor arterial blood gasses (ABGs) and PH levels.	To determine the degree of tissue hypoxia or acidosis, indicating lactic acid build-up resulting in anaerobic metabolism.
Administer sodium bicarbonate as indicated.	To correct metabolic acidosis.
Insert airway; suction as indicated.	Facilitates oxygen administration in the presence of retained secretions.
Provide supplemental oxygen as indicated.	Maximizes available oxygen for circulatory transport to tissues.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 2 – Diagnosis: Risk for Infection

Risk for Infection: At increased risk of being invaded by pathogenic organisms.

Risk factors

Decreased hemoglobin.
Invasive procedures.
Stasis of body fluids (lochia).
Traumatized tissues.

Desired Outcomes

A patient will state an understanding of individual causative/risk factors.
A patient will display white blood cell count and vital signs within expected ranges.
A patient will display a lochia-free odor.

Nursing Interventions	Rationale
Monitor rate of uterine involution and nature and the amount of lochial discharge.	Infection of the uterus delays involution and lengthens the flow of the lochia.
Observe for signs of fever, chills, body malaise, anorexia, pelvic pain, or uterine tenderness.	These symptoms reflect systemic involvement, possibly leading to bacteremia, shock, or even death if left untreated.
Check the episiotomy site and abdominal wound (for caesarian) for signs of edema, erythema, separation of wound edges, purulent drainage.	This indicates localized infection requiring immediate intervention to prevent systemic involvement.
Check for other possible sources of infection such as urinary tract infection(urinary frequency/pain, cloudy and odoriferous urine), mastitis (swelling, erythema, pain), or respiratory infection (productive cough, purulent sputum, fever).	Differential diagnosis is critical for effective management.
Teach and demonstrate proper hand-washing and self-care techniques. Review appropriate handling and disposal of contaminated materials (e.g., dressings, peripads, linens).	To prevent the spread of infectious organisms.
Review WBC count, hemoglobin, and hematocrit levels.	Increased white blood cell count indicates an infection. Anemia often accompanies infection, delays wound healing and weaken the immune system.
Administer iron supplement as indicated.	To correct anemia. And possibly improves wound healing.
Obtain a gram’s stain or culture and sensitivity if lochia is noted to have an odiferous smell, or purulent wound discharge is observed.	Gram stain identifies the type of infection while cultures and sensitivity identify the specific pathogen and can indicate which antibiotic is suitable to fight the organism.
Administer IV antibiotics as ordered.	Broad-spectrum antibiotics may be ordered until the results from culture and sensitivity are available, at which time organism-specific antibiotics may be started.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 3 – Diagnosis: Deficient Fluid Volume (isotonic)

Deficient Fluid Volume: It is defined as decreased intravascular, interstitial, and intracellular fluid.

May be related to excessive blood loss after birth.

Possibly evidenced by:

Changes in the mental status.
Concentrated urine.
Delayed capillary refill.
Decrease in the red blood cell count (hematocrit).
Decrease blood pressure (hypotension).
Dry skin/mucous membrane.
Increase heart rate (tachycardia).

Desired Outcomes

A patient will maintain a blood pressure of at least 100/60 mm Hg.
A patient will maintain a pulse rate between 70-90 beats per minute.
A patient will have a balanced 24-hour intake and output.
A patient will have a cognitive status within the expected range.
Patient will have a lochia flow of less than one saturated perineal pad per hour.
A patient will demonstrate improvement in the fluid balance as evidenced by a good capillary refill, adequate urine output, and skin turgor.

Nursing Interventions	Rationale
Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and, if possible, save blood clots to be evaluated by the physician.	The amount of blood loss and the presence of blood clots will help to determine the appropriate replacement need of the patient.
Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis.	The degree of uterus contractility will measure the status of the blood loss. Placing one hand just above the symphysis pubis will prevent possible uterine inversion during a massage.
Review the records and note certain conditions such as retained placental fragments, lacerations, abruptio placenta, etc.	This will help determine the management of the situation, thus preventing further complications.
Monitor vital signs, including systolic and diastolic blood pressure, pulse, and heart rate. Check for the capillary refill and observe nail beds and mucous membranes.	Increased heart rate, low blood pressure, cyanosis, delayed capillary refill indicate hypovolemia and impending shock. A decreased fluid volume of 30-50% will reflect changes in the blood pressure.
Note for the presence of vulvar hematoma and apply an ice pack if indicated.	An ice pack and rest can manage a small hematoma.
Measure a 24-hour intake and output. Observe for signs of voiding difficulty.	This will help in determining fluid loss. A 30-50 ml/hr or more urine output indicates an adequate circulating volume. Voiding difficulty may happen with hematomas in the upper portion of the vagina, causing pressure in the urethra.
Observe for reports of persistent perineal pain or feeling of vaginal fullness. Apply counterpressure on labial or perineal lacerations.	Hematomas often result from continued bleeding from lacerations of the birth canal.
Use caution when performing vaginal and rectal examinations.	May increase hemorrhage if cervical, vaginal, or perineal lacerations or hematomas are present. Note: Careful examination may be required to monitor the status of the hematoma.
Monitor clients with placenta accreta (a condition that occurs when blood vessels and other parts of the placenta grow too deeply into the uterine wall.), PIH or abruptio placenta for signs of Disseminated intravascular coagulation (DIC).	Thromboplastin released during attempts at manual removal of the placenta may result in coagulopathy as manifested by continued vaginal bleeding; epistaxis; oozing from incisions, mucous membranes, gums, IV site.
Measure hemodynamic parameters include central venous pressure (CVP) or pulmonary artery wedge pressure (PAWP) if available.	This will directly measure circulating volume, replacement needs, and response to therapy in case of life-threatening situations.
Maintain a nothing-by-mouth status (NPO) while assessing client status.	This will prevent aspiration of gastric contents if the mental status is impaired and if surgical management is required.
Maintain bed rest with an elevation of the legs by 20-30° and trunk horizontal.	The position increases venous return, ensuring greater availability of blood to the brain and other vital organs. Bleeding may be decreased with bed rest.
Start 1 or 2 IV infusion(s) of isotonic or electrolyte fluids with an 18-gauge catheter or via a central venous line. Administer fresh whole blood or other blood products (e.g., platelet concentrate, plasma, cryoprecipitate) as indicated	This is important for rapid or multiple infusions of fluids or blood products to increase circulating volume and enhance clotting. Note: Each unit of whole blood increases the hematocrit level by three percentage points.
Administer medications as ordered:
Oxytocin (Pitocin, Methylergonovinemaleate (Methergine), Prostaglandin F2a (Prostin 15M);	Increases contractility of the boggy uterus and myometrium closes off exposed venous sinuses and stops hemorrhage in the presence of atony.
Antibiotic therapy (based on culture and sensitivity of the lochia)	Antibiotics act as prophylaxis to prevent infection or may be needed for an infection that caused or contributed to uterine subinvolution or hemorrhage.
Insertion of indwelling Foley catheter (IFC).	This will provide an accurate measurement of the renal status and perfusion with regard to fluid volume. Note: Pressure on the urethra may obstruct urine flow/cause bladder distention if vaginal packs are inserted.
Insertion of a large indwelling catheter into the cervical canal.	Insertion of an indwelling catheter into the cervical canal and injecting the balloon with 60 ml of a saline solution that acts as a tamponade have some reports of success in limiting the hemorrhage caused by implantation of the placenta into a noncontractile cervical segment.
Monitor laboratory values as indicated, such as:
Hemoglobin and Hematocrit.	Hgb and Hct determine the amount of blood loss. Each milliliter of blood carries 0.5 mg of hemoglobin.
Platelet count, activated partial thromboplastin time (APTT), fibrinogen, and Fibrin degradation products (FDP).	Measures severity of Disseminated intravascular coagulation (DIC); determines replacement needs and effects of therapy.
Prepare for surgical intervention if indicated, e.g., evacuation of hematoma and ligation of a bleeding point, laceration or episiotomy extension, D & C, abdominal hysterectomy, or bilateral ligation of the hypogastric artery.	Surgical repair of lacerations/episiotomy, evacuation of hematoma, and removal of retained tissues will stop the bleeding; Immediate abdominal hysterectomy is indicated for the abnormally adherent placenta. Note: D & C may not be indicated if there is a concern that the procedure may traumatize the implantation site and increase bleeding.
Assist with procedures as indicated, such as manual separation and removal of placenta.	Hemorrhage stops once placental fragments are removed and uterus contracts, closing venous sinuses.
Uterine replacement or packing if inversion seems about to recur.	Replacement of the uterus allows it to contract, closing venous sinuses and controlling the bleeding.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 4 – Diagnosis: Risk for Excess Fluid Volume

Risk for Excess Fluid Volume: Defined as increased isotonic fluid retention.

Risk factor

Excessive/rapid replacement of fluid losses, intravascular fluid shifts (PIH).

Desired Outcome

Patient will demonstrate pulse, blood pressure, urine specific gravity, and neurologic signs within expected ranges and without any respiratory complications.

Nursing Interventions	Rationale
Assess neurologic status, observing for any behavioral changes and increasing irritable episodes.	Changes in the neurologic status or behavior may serve as early signs of cerebral edema caused by fluid retention.
Monitor for signs of hypertension and tachycardia; Observe for signs of dyspnea; Auscultate for signs of stridor, rhonchi, or moist crackles.	Symptoms of circulatory overload and respiratory difficulties may occur as a result of excessive fluid replacement.
Monitor for the intake/output, urine specific gravity if indicated. Check the infusion rate of the fluids manually or preferably through the use of infusion pumps.	With the stabilization of fluid levels, intake should approximate/equal the output; Urine specific gravity results change inversely to output. As kidney function improves, specific gravity readings decrease, and vice versa. Note: In the client with glomerular spasms caused by pregnancy-induced hypertension (PIH), the output may reduce until extracellular fluids return to the general circulation.
Monitor the hematocrit levels.	As plasma volume is restored, the hematocrit level decreases.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 5 – Diagnosis: Risk for Pain

Risk for Pain: Defined as an increased risk of having an unpleasant sensory and emotional experience arising from potential tissue damage.

Risk factor

Tissue damage.

Desired Outcomes

A patient will identify appropriate methods to provide relief from pain.
A patient will demonstrate the use of relaxation skills and diversional activities as indicated.
A patient will verbalize relief from pain and discomfort.

Nursing Interventions	Rationale
Assess psychological causes of pain and discomfort.	Emergency situations may precipitate fear and anxiety, raising the perception of pain and discomfort.
Perform pain assessment by identifying the type, location, characteristic, severity, and duration of the pain. Use a pain scale of 0-10;	This will help in differential diagnosis and in determining the applicable treatment method.
Encourage the use of relaxation techniques (e.g., deep breathing exercise) and diversional activities (e.g., watching TV).	To assist the client in exploring methods for the control of pain.
Provide comfort measures such as applying an ice pack into the perineum using a sitz bath or a heat lamp to episiotomy extension.	Ice compress decreases edema and minimizes hematoma and pain sensation while heat promotes vasodilation, which facilitates hematoma resorption.
Administer pain medication (analgesic, narcotic, or sedative) as prescribed.	Decreases pain and anxiety; Helps promote relaxation.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 6 – Diagnosis: Deficient Knowledge

Deficient Knowledge: Absence of cognitive information related to the specific topic.

May be related to:

Cognitive limitation.
Unfamiliarity with information resources.
Lack of exposure to information.

Possibly evidenced by:

Statement of misconceptions.
Request for information needed.
Inappropriate behaviors.

Desired Outcomes

A patient will participate in the learning process.
A patient will verbalize the pathophysiology, signs and symptoms, and implications of her disease condition in simple terms.
A patient will identify behaviors and lifestyle changes to enhance recovery.

Nursing Interventions	Rationale
Assess the client’s level of knowledgeability to learn. Talk and listen to the client in a calm demeanor. Provide time for questions and clarifications.	Provides information necessary to develop an individual plan of care and engage in problem-solving techniques. Reduces anxiety and stress, which can block learning, and provides clarification and repetition to enhance understanding.
Explain predisposing factors and treatment related to the cause of hemorrhage.	To provide information in helping the client cope with the situation.
Instruct the client to report inability to breastfeed, fatigue, amenorrhea, pubic/axillary hair loss, premature aging, and genital atrophy.	These are the signs of Sheehan’s syndrome, which is caused by the destruction of the anterior pituitary gland cells by oxygen starvation, usually at the time of childbirth. The condition may also result from septic shock or a massive hemorrhage. It often results in premature aging, irreversible fertility, decreased resistance to infection, or increased risk of shock.
Determine the availability of personal resources/support groups. Explain the importance of having adequate rest, healthy living, and pacing of activities.	Fatigue-related to hemorrhage will slow down the client’s resumption of normal activities, necessitating problem solving and dependence on others for a period of time.
Explain short-term implications of postpartum hemorrhage, such as an interruption in the process of mother-infant bonding and the inability to assume care of self and infant as soon as desired.	It can reduce anxiety and provides a realistic time frame for the resumption of bonding and infant/self-care activities.
Explain long-term implications of postpartum hemorrhage such as uterine atony, infertility if hysterectomy is done, or risk of having a postpartum hemorrhage in future pregnancies.	This will give the autonomy to the client to make informed decisions and to begin resolving feelings about current and past events.
Recommend that the client be seated when holding the infant and change position slowly when lying down or seated.	To prevent orthostatic hypotension because it puts the client at risk of falls.
Refer to a support group(s) as indicated.	Specific groups such as the hysterectomy support group may provide supplemental information regarding the situation they faced before and how they were able to manage it. This will facilitate positive adaptation of the client.

Related FAQs

1. What nursing interventions would you consider for a patient with postpartum hemorrhage?

Nursing Interventions

Save all perineal pads used during bleeding and weigh them to determine the amount of blood loss.
Place the woman in a side lying position to make sure that no blood is pooling underneath her.
Assess lochia frequently to determine if the amount discharged is still within the normal limits.

2. What is the nursing diagnosis of haemorrhage?

Risk for Bleeding is a NANDA nursing diagnosis that can be used for the care of patients with increased chances of bleeding, such as those diagnosed with reduced platelets, problems with clotting factors, or those in situations where the patient experiences a traumatic injury or an invasive procedure such as surgery.

3. How do you manage primary postpartum hemorrhage?

Treatment for primary PPH requires a multidisciplinary approach. Any measures and/or drug therapy taken as part of the initial treatment is considered first‐line therapy. In most cases, this includes resuscitation measures, exclusion of genital tract laceration, checking of the placenta and the use of uterotonics.

4. What are the nursing management of menorrhagia?

Medical therapy for menorrhagia may include: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).

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May 9, 2022

Nursing Care Plans for Pneumonia – Best Nursing Care Plans(2022)
This article discusses Nursing Care Plans for Pneumonia plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
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Introduction

Pneumonia is a lung infection that causes the air sacs in one or both lungs to become inflamed. Cough with phlegm or pus, fever, chills, and trouble breathing can occur when the air sacs fill with fluid or pus (purulent material). Pneumonia can be caused by various species, including bacteria, viruses, and fungus.

The severity of pneumonia can range from minor to life-threatening. Infants and young children, persons over the age of 65, and people with health problems or compromised immune systems are the most vulnerable.

Signs and Symptoms of Pneumonia

The following are some of the signs and symptoms of bacterial pneumonia:
1. Lips and fingernails are a bluish tint.
2. Delirium, or a confused mental state, is common in the elderly.
3. Mucus that is green, yellow, or red when coughed
4. Fever
5. Sweating profusely
6. Appetite loss.
7. Low energy and excessive exhaustion
8. Breathing quickly.
9. The heart beats quickly.
10. Chills shivering
11. Sharp or stinging chest pain that gets worse when you cough or breathe deeply
12. Shortness of breath that worsens as you go more active
The early signs of viral pneumonia are similar to those of bacterial pneumonia, and they can include:
- Headache
- Shortness of breath is getting worse.
- Muscle ache
- Weakness
- Coughing has gotten worse.
Causes of Pneumonia

Pneumonia has more than 30 different causes, which are categorised according to the cause. The following are the most common types of pneumonia:

Bacterial pneumonia. A variety of bacteria brings on this type. Streptococcus pneumoniae bacteria is the most frequent. It usually happens when the body is weakened in some way, such as by disease, inadequate nutrition, advanced age, or decreased immunity, allowing germs to enter the lungs. Bacterial pneumonia can afflict people of all ages. Still, those who abuse alcohol, smoke cigarettes, are disabled, have recently had surgery, have a respiratory ailment or viral infection, or have a weaker immune system are at higher risk.

Viral pneumonia. This type of pneumonia is caused by various viruses, including the flu (influenza), and accounts for roughly one-third of all instances of pneumonia. You may be more susceptible to bacterial pneumonia if you have viral pneumonia.

Mycoplasma pneumonia. Atypical pneumonia is a form of pneumonia with slightly distinct symptoms and physical characteristics. Mycoplasma pneumoniae is the bacteria that causes it. It creates moderate, widespread pneumonia that affects people of all ages.

Other types of pneumonia. Other infections, such as fungi, can cause other pneumonia that are less prevalent.

Risk factors of Pneumonia
1. Using a cigarette
2. A respiratory viral infection that occurred recently (common cold, laryngitis, influenza)
3. Stroke, dementia, Parkinson’s disease, or other neurological diseases can make swallowing difficult.
4. Chronic obstructive pulmonary disease (COPD) (COPD, bronchiectasis, cystic fibrosis)
5. Cerebral palsy is a condition that affects the brain.
6. Other significant ailments include heart disease, cirrhosis of the liver, and diabetes mellitus.
7. Being a resident of a nursing home
8. Consciousness impairment (loss of brain function due to dementia, stroke, or other neurologic conditions)
9. Trauma or recent surgery
10. An issue with the immune system.
Diagnosis of Pneumonia

Diagnosis is normally made primarily based totally on your latest fitness records (including surgery, a cold, or journey exposures) and the volume of the illness. Your healthcare company might also diagnose pneumonia clearly on an intensive record and bodily examination based on those factors.

The following exams can be used to verify the diagnosis:

Chest X-ray – This check takes photographs of inner tissues, bones, and organs, including the lungs.

Blood exams – This check can be used to look at whether or not contamination is a gift and if contamination has unfolded to the bloodstream (blood cultures). Arterial blood fuel online trying out assessments the quantity of oxygen in your bloodstream.

Sputum culture– This check is carried out at the cloth coughed up from the lungs and into the mouth. It’s regularly used to look if there’s contamination inside the lungs.

Pulse oximetry – An oximeter is a small device that measures the quantity of oxygen inside the blood. A small sensor is taped or clipped onto a finger. A small purple mild may be visible inside the sensor when the device is on. The check is painless, and the purple mild does now no longer get hot.

Chest CT test. This imaging technique uses a mixture of X-rays and computer technology to provide sharp, distinctive horizontal or axial photographs (regularly referred to as slices) of the body. A CT test suggests distinctive photographs of any part of the body, including the bones, muscles, fat, and organs. CT scans are greater distinctive than ordinary X-rays.

Bronchoscopy – This is a direct examination of the bronchi (the primary airlines of the lungs) by using a bendy tube (referred to as a bronchoscope). It enables to assess and diagnose lung problems, check blockages, and take out tissue and fluid testing samples.

Pleural fluid culture -In this check, a pattern of a fluid pattern is taken from the pleural space. This is the gap between the lungs and chest wall. A long, skinny needle is placed via the pores and skin among the ribs and into the pleural space. Fluid is pulled right into a syringe connected to the needle. It is despatched to the lab in which it’s examined to discover which microorganism is inflicting pneumonia.

Complications of Pneumonia

Although most patients with pneumonia react favourably to therapy, pneumonia can be extremely dangerous and even fatal.

If you’re an older adult, a very small child, have a weaker immune system or have a significant medical disease like diabetes or cirrhosis, you’re more likely to experience difficulties. Among the potential complications are:

Acute respiratory distress syndrome (ARDS) is a condition in which the body (ARDS). This is the most serious type of respiratory failure.

Abscesses in the lungs. These are pus-filled pockets that develop inside or around the lungs. They may need to be surgically drained.

Failure of the lungs. This necessitates the use of a ventilator or breathing equipment.

Sepsis. This is the point at which the pathogen enters the bloodstream. It has the potential to cause organ failure.

Treatment for pneumonia

The sort of pneumonia you have will determine your treatment options. Pneumonia is usually treated at home, but severe cases may require hospitalisation. Bacterial pneumonia is treated with antibiotics. Antibiotics can also help with mycoplasma pneumonia and other rare situations. The majority of viral pneumonia have no specific treatment. They typically improve on their own.

Other treatments could include proper nutrition, increased hydration intake, rest, oxygen therapy, pain medication, fever control, and possibly cough drugs if the cough is severe.

Prevention of Pneumonia

To help prevent pneumonia, do the following steps:

Get a vaccine. Some kinds of pneumonia and the flu can be prevented with vaccines. Make an appointment with your doctor to obtain these shots. Immunisation requirements have changed over time, so check with your doctor about your vaccination status, even if you recall receiving a pneumonia vaccine earlier.

Ascertain that your children are immunised. Children under the age of 2 and children aged 2 to 5 years who are at high risk of pneumococcal disease should receive a separate pneumonia vaccine. Vaccination is also recommended for children who attend a group child care centre. According to doctors, children above the age of six months should also get flu vaccines.

Maintain a healthy level of hygiene. Wash your hands frequently or use an alcohol-based hand sanitiser to protect yourself from respiratory infections that can lead to pneumonia.

Please don’t smoke. The natural defences of your lungs against respiratory infections are harmed by smoking.

Maintain a healthy immune system. Get plenty of rest, exercise regularly, and eat a nutritious diet.

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Nursing Care Plans for Pneumonia

Nursing Care Plans for Pneumonia Based on the Diagnosis

Nursing Diagnosis for Pneumonia
1. Ineffective Airway Clearance
2. Impaired Gas Exchange
3. Ineffective Breathing Pattern
Nursing Care Plan 1: Ineffective Airway Clearance

A common NANDA-I nursing diagnostic for pneumonia nursing care plans is ineffective airway clearance. Excessive secretions and ineffective or nonproductive coughing are associated with this diagnosis. Inflammation and excessive secretions make maintaining a patent airway challenging in pneumonia.

Desired Outcomes

To clear the airway, the patient will identify and show activities.

As indicated by preserving a patent airway and properly clearing secretions, the patient will display/maintain a patent airway with breath sounds clearing; absence of dyspnea and cyanosis.

Nursing Assessment and Rationales

1. Examine your breathing rate, rhythm, and depth, as well as your chest movement and auxiliary muscle use.

Because of the discomfort of moving the chest wall and fluid in the lung as a compensatory response to airway blockage, tachypnea, short respiration, and asymmetric chest movement are common. Breathing patterns may be altered in conjunction with auxiliary muscles to promote chest excursion and facilitate successful breathing.

2. Assess cough effectiveness and productivity

Coughing is the most efficient method of secretion removal. Pneumonia sufferers may have thick, sticky secretions.

3. Examine the lungs, noting areas of reduced or absent airflow, as well as unusual breath, sounds such as crackles and wheezes.

In regions where there is a buildup of fluid, airflow is reduced. These consolidated areas can also produce bronchial breath sounds. Fluid accumulation, thick secretions, and airway spasms and blockage cause crackles, rhonchi, and wheezes on inspiration and expiration.

4. Examine the colour, viscosity, and odour of the sputum. Changes should be reported.

Changes in the properties of sputum could suggest an infection. Discoloured, sticky, or odorous sputum may worsen airway resistance, necessitating further treatment.

5. Determine the patient’s hydration level.

Inadequate hydration and thickening of secretions obstruct airway clearance.

Nursing Interventions and Rationales

The ineffective airway clearance nursing procedures and activities for pneumonia and their rationales or scientific justifications are discussed in this section.
1. Raise the head of the bed and shift positions often.
The diaphragm would be lowered, allowing for chest expansion, aeration of lung segments, mobilisation, and secretory expectoration.
- Instruct and support the patient in deep-breathing exercises. Demonstrate correct chest splinting and successful coughing while standing upright. Encourage the patient to do so regularly.
- Deep breathing exercises boost cough productivity by allowing maximum expansion of the lungs and smaller airways.
- Coughing is a reflex and a natural self-cleaning process that helps the cilia keep the airways open and clear. It is the most effective method for removing most secretions.
- Splinting relieves chest discomfort, and standing upright encourages a deeper, more powerful cough, which is more effective.
- Suction as needed: frequent coughing, unusual breath sounds, and desaturation from airway secretions.
Stimulates cough or clears the airway manually in a patient who cannot do so due to an inefficient cough or a reduced degree of consciousness. Suctioning can induce increased hypoxemia, so make sure you get plenty of oxygen before, during, and after you suction.
- If necessary, assist with bronchoscopy and thoracentesis.
1. Bronchoscopy is used to remove mucous plugs, drain purulent secretions, and gather lavage samples for culture and sensitivity testing.
2. Thoracentesis is performed to drain pleural effusions and avoid atelectasis.
- If the patient’s health worsens, anticipate the need for supplemental oxygen or intubation.
To correct the hypoxemia, these measures are required. Intubation is required for deep suctioning and provides a source of oxygenation supplementation.
- Unless contraindicated, maintain appropriate hydration by forcing fluids to at least 3000 mL per day (e.g., heart failure). Warm fluids are preferred over cold fluids.
Fluids, particularly warm drinks, help mobilise and expectorate secretions. Fluids aid in hydration, improve ciliary activity to eliminate secretions and decrease secretion viscosity. Coughing up thinner secretions is easy.
- Assist with and monitor the effects of nebuliser therapy and another respiratory physiotherapy, such as incentive spirometers, IPPB, percussion, and postural drainage. Treatments should be done in between meals, and fluid intake should be limited as necessary.
1. Nebulisers thin secretions by humidifying the airway and facilitating liquefaction and expectoration.
1. Postural drainage may not be as efficient in interstitial pneumonia or those involving alveolar exudate or destruction.
2. Incentive spirometry can avoid atelectasis by improving deep breathing.
3. Chest percussion loosens and mobilises secretions that cannot be eliminated by coughing or suctioning in narrower airways.
4. The likelihood of vomiting with coughing and expectorations is reduced when therapies and oral intake are coordinated.
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Nursing Care Plan 2: Impaired Gas exchange

Desired Outcomes

ABGs will show increased ventilation and oxygenation of tissues within the patient’s tolerable range and the lack of respiratory distress signs.

The patient’s gas exchange will be maintained at an ideal level.

The patient will take part in activities that will improve oxygenation.

Nursing Assessment and Rationales
1. Evaluate breathing: take note of the quality, pace, rhythm, depth, usage of accessory muscles, ease, and adopted position for easy breathing.
As patients alter their breathing patterns to support effective gas exchange, symptoms of respiratory distress are dependent on/indicative of the degree of lung involvement and underlying general health state. Gas exchange is directly influenced by rapid, shallow breathing patterns and hypoventilation. Signs of increased respiratory effort are linked to hypoxia. The use of a tripod indicates significant dyspnea.
- Look at the colour of your skin, mucous membranes, and nail beds to see if you have peripheral cyanosis (nail beds) or central cyanosis (skin, mucous membranes, and nail beds) (circumoral).
Peripheral tissues become cyanotic as oxygenation and perfusion are compromised. Cyanosis of the nail beds may indicate vasoconstriction or the body’s reaction to a fever or chills; however, cyanosis of the earlobes, mucous membranes, and skin around the mouth (“warm membranes”) indicates systemic hypoxemia.
- Evaluate mental health, restlessness, and changes in consciousness.
Hypoxemia and reduced brain oxygenation can cause restlessness, irritability, disorientation, and drowsiness, which need further treatment. In older persons, check pulse oximetry readings if their mental status changes.
- Keep an eye on your body temperature as directed. Assist with fever and chill relief by adding or removing bedcovers, maintaining a comfortable room temperature, and taking a tepid or cool water sponge bath.
Fever (which is frequent in bacterial pneumonia and influenza) raises metabolic demands and oxygen consumption and alters cellular oxygenation.
- Keep an eye out for signs of worsening, such as hypotension, bloody sputum, pallor, cyanosis, LOC changes, severe dyspnea, and restlessness.
The most prevalent causes of death in pneumonia are shock and pulmonary oedema, both of which require prompt medical attention.
- Check ABGs and pulse oximetry.
It monitors the progression of the disease and allows for changes in pulmonary therapy. Changes in oxygenation are detected by pulse oximetry. O2 saturation levels should be at least 90%.
- Evaluate your anxiety level and encourage you to verbally express your feelings and concerns.
Anxiety is a symptom of psychological distress and physiological responses to hypoxia. The psychological component can be reduced by providing reassurance and increasing a sense of security, lowering oxygen consumption and unpleasant physiological responses.
- Keep an eye on your heart rate and rhythm, as well as your blood pressure.
Tachycardia is commonly caused by fever and dehydration, but it can also respond to hypoxia—initial hypoxia and hypercapnia raise blood pressure and heart rate. With dysrhythmias, BP may drop as hypoxia becomes more severe, whereas HR tends to be fast.

Nursing Interventions and Rationales
1. Maintain bed rest by carefully scheduling activity and rest hours to save energy. Encourage the use of relaxation techniques and activities that provide a change of pace.
It minimises overexertion and lowers oxygen needs, making infection resolution easier. Relaxation techniques help you save energy to focus on breathing and coughing more effectively.
- Encourage frequent position changes, deep breathing, and productive coughing by elevating the head of the bed.
These techniques encourage maximum chest expansion, secretion mobilisation, and improved ventilation.
- Use nasal prongs, a mask, or a Venturi mask to administer oxygen therapy.
The goal of oxygen treatment is to keep PaO2 levels above 60 mmHg. Oxygen is provided using a mechanism that ensures proper delivery while staying within the patient’s tolerance. Note: Oxygen should be provided with caution to patients with underlying chronic lung disorders.

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Nursing Care Plan 3: Ineffective Breathing Pattern

The nursing diagnostic of Ineffective Breathing Pattern, in this case, is linked to compensatory tachypnea as a result of a failure to meet metabolic needs. Many pneumonia patients have this problem. Because of chest pain and elevated body warmth, damaged alveoli cannot adequately exchange oxygen and carbon dioxide, resulting in changes in breathing patterns.

Desired Outcomes

As shown by calm breathing at a normal rate and depth and the absence of dyspnea, the patient maintains an effective breathing pattern.

The patient’s respiration rate is within normal norms.

Nursing Assessment and Rationales

The following are nurse assessments for pneumonia nursing care plans that target inefficient breathing patterns.
1. Measure and record your breathing rate and depth at least once every four hours.
Adults breathe at a pace of 10 to 20 breaths per minute on average. When there is a change in breathing patterns, it is critical to act quickly to recognise early indicators of respiratory compromise.
- Determine ABG levels in accordance with facility policies.
This device keeps track of your oxygenation and ventilation levels.
- Keep an eye on the patient’s breathing habits.
Breathing patterns that are unusual could indicate an underlying sickness or dysfunction. Cheyne-Stokes respiration is a symptom of bilateral brain damage or metabolic disorders in the deep cerebral or diencephalon. The failure of the respiratory centres in the pons and medulla is linked to apneusis and ataxic breathing.
- Listen to your breath for at least four (4) hours.
This is to identify abnormal or diminished breath sounds.
- Determine whether or not auxiliary muscle is being used.
As lung compliance declines, the amount of work required to breathe climbs dramatically.
- Keep an eye out for diaphragmatic muscle weakness or tiredness (paradoxical motion).
The inward versus outward displacement of the belly during inspiration is symptomatic of respiratory muscle exhaustion and weakening.

Nursing Interventions and Rationales
1. Align the patient’s body properly for the best breathing rhythm.
Sitting allows for the most lung excursion and chest expansion.
- Encourage long, deep breaths by doing the following:
1. Demonstration: gradual inhalation, holding end inspiration for a few seconds, and quiet exhalation are all highlighted.
2. Using a spirometer with an incentive
3. Insisting on the patient yawning
Deep inspiration is encouraged by these procedures, which enhances oxygenation and prevent atelectasis. Controlled breathing techniques may also help tachypneic patients breathe more slowly. Air trapping is avoided by exhaling slowly.
- Encourage diaphragmatic breathing in chronic illness patients.
This approach relaxes muscles while also increasing oxygen levels in the patient.
- Encourage the patient to cough successfully to mobilise their own secretions and maintain a clear airway.
This allows for proper secretion clearance.
- Teach the following to the patient:
1. Breathing with a pursed-lip
2. Breathing from the abdomen
3. Using relaxing methods
4. Taking Prescription Drugs (ensuring the accuracy of dose and frequency and monitoring adverse effects)
5. Planning activities to avoid exhaustion and allow for rest times
6. Ambulate the patient three times daily, as tolerated by the patient and as directed by the doctor.
Secretions that have clogged the airways can be broken up and moved by ambulation.
- Encourage the patient to take regular breaks and teach them how to pace themselves.
Shortness of breath might be exacerbated by increased activity. Ensure that the patient gets plenty of rest in between heavy activity.
- Encourage regular little meals.
This keeps the diaphragm from getting too crowded.
- Make sure there’s a fan in the room.
Feelings of air hunger can be alleviated by moving air.

Related FAQs

1. What are nursing plan of pneumonia?

Nursing interventions for pneumonia and care plan goals for patients with pneumonia include measures to assist in effective coughing, maintain a patent airway, decreasing viscosity and tenaciousness of secretions, and assist in suctioning.

2. What are the 4 main parts of a nursing care plan?

Nursing care plan formats are usually categorized or organized into four columns: (1) nursing diagnoses, (2) desired outcomes and goals, (3) nursing interventions, and (4) evaluation.

3. What is interprofessional care for pneumonia?

Interprofessional care is a collaborative practice approach for a harmonious process of patient care. Teamwork produces better patient outcomes and efficient healthcare delivery. Managing pneumonia is challenging, especially COVID-19 pneumonia.

4. How do you position a patient with pneumonia?

Lateral decubitus positioning with “the good side down” can significantly improve oxygenation in many adult patients with unilateral parenchymal lung disease (e.g., lobar pneumonia). In the intensive care unit, continuous rotational therapy has been reported to reduce pulmonary complications.

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