Nursing Care of a Family Experiencing a Pregnancy Complication From a Pre Existing or

Newly Acquired Illness

(Capunitan & Galutan)

CASE INTRODUCTION:

Case Scenario : Paula Taylor is a 38 year old, G1P0 seen during her 12th week of pregnancy .
She was diagnosed as having sickle cell anemia as a child. She had no previous pregnancies ,
present pregnancy was not planned but is wanted. The couple was planning on waiting 3 more
months and then starting a family. She is prescribed digoxin and bed rest.

Objectives:
This case presentation aims to help students acquire related learning experience on various
health situations of Nursing Care of a Family Experiencing a Pregnancy Complication From a
Pre Existing or Newly Acquired Illness in online distance learning through analysis of a given
scenario.

Specific Objectives:
1. Define the high risk of pregnancy , including pre existing factors that contribute to its
development.
2. Apply nursing theory in formulating nursing care plan and discharge plan of patient in
association with the present concern.
3. Assess a woman with an illness during pregnancy for changes occuring in the illness ,
because of the pregnancy or in the pregnancy because of the illness.
4. Formulate comprehensive nursing care plan in accordance to the patients need
and evaluate nursing management.
5. Accurately present the assessment of the client includes personal health history,
physical assessment, laboratory results, and family history taking.
6. Identify expected outcomes that will contribute to a safe pregnancy outcome when
illness occurs with pregnancy as well as help families manage seamless transitions
across differing health care settings.
7. Implement nursing care for a woman when illness complicates pregnancy , such as
teaching her how to measure blood glucose.
8. Provide a comprehensive discharge plan of the patient to ensure the continuation of the
management for the patient’s case at home.
9. Evaluate expected outcomes for achievement and effectiveness of care.

Definition of cases :
1. Sickle Cell Anemia is an inherited red blood cell disorder in which there aren't
enough healthy red blood cells to carry oxygen throughout your body. Normally,
the flexible, round red blood cells move easily through blood vessels. In sickle
cell anemia, the red blood cells are shaped like sickles or crescent moons.
2. Iron-deficiency anemia is a common type of anemia — a condition in which
blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the
 body's tissues. As the name implies, iron deficiency anemia is due to insufficient
iron.
3. Congestive Heart Failure (also called heart failure) is a serious condition in
which the heart doesn't pump blood as efficiently as it should. Despite its name,
heart failure doesn't mean that the heart has literally failed or is about to stop
working.
4. Orthopnea is the sensation of breathlessness in the recumbent position, relieved
by sitting or standing. It means you find it harder to breathe when you lie down
because of fluid in your lungs. It usually comes on over time, but in some cases,
it can happen suddenly.
5. High risk of pregnancy is one in which a concurrent disorder, pregnancy related
complication or external factor jeopardizes the health of the woman , the fetus or both. It
is important that women with such pregnancies be identified because illness during
pregnancy can complicate but only the pregnancy , but also a woman’s entire lifestyle
and that for her family. In most instances , more than one factor contributes to the
classification of a pregnancy as a high risk. Some pregnancies become high risk as they
progress , while some women are at increased risk for complications even before they
get pregnant for a variety of reasons.
Early and regular prenatal care helps many women have healthy pregnancies and
deliveries without complications.

Current Trends and Update related to topic :

A number of 2020 National Health Goals speak to the care necessary because of physiologic
and psychological changes or pregnancy complications from a pre-existing or newly acquired
illness.

- Iron deficiency anemia , sickle cell anemia and folic acid deficiency anemia are
examples of various forms of anemia that can also cause complications of pregnancy.
- When women with a pre existing disease become pregnant , it is crucial to obtain a
thorough history and physical examination at the first prenatal visit to establish a
baseline information in the condition .
- Documentation by a medication reconciliation form of any medication being taken is
important to protect against adverse drug interactions and the possibility of teratogenic
effects of the fetus.
- Reduce the rate of fetal deaths of 5.6 per 1,000 live births from a baseline of 6. 2 per
1, 000 live births.
- Reduce the rate of maternal deaths to 11. 4 per 100, 00 live births from a baseline of
12.7 per 100, 000 live births.
- Reduce the rate of maternal illness and complications of during pregnancy to 28 per
100 births from a baseline of 31.1 per 100 births. (U.S Department of Health and Human
Services, 2010)
 Nurses can help the nation to reach these goals by educating women about the importance
of entering a pregnancy in the best state of health possible . It focuses on women who enter
pregnancy with a chronic condition such as sickle cell anemia, iron deficiency , folic acid
deficiency and those who experience unintentional injury or develop a chronic illness during
pregnancy. Both the woman and the fetus can be at risk for complications, either the pregnancy
can complicate the disease or the disease can complicate the pregnancy, affecting the fetus or
leaving the woman less equipped to function in the future or undergo a future pregnancy.

ASSESSMENT
(Aspacio & Enera)

Nursing Related Theory

Theory: Adaptational Model
Theorist: Callista Roy

The Adaptational Model is a prominent nursing theory aiming to explain or define the provision
of nursing science. In her theory, Sister Callista Roy’s model sees the individual as a set of
interrelated systems that maintain a balance between various stimuli.

Major concept of Adaptational Model:

1. Person
2. Environment
3. Health - is not a freedom from the inevitability of death, disease, unhappiness, and
stress, but the ability to cope with them in a competent way.
4. Nursing
5. Adaptation

Concept of Theory of Adaptational Model:

Patient Paula with a present chief complaint is unable to sleep at night and has a shortness of
breath. Paula has a history of chief concern and she has been extremely fatigued and cannot
sleep at night without four pillows. Paula is diagnosed with iron-deficiency anemia and
congestive heart failure. She is prescribed digoxin and bed rest.

Paula is diagnosed with iron-deficiency anemia and congestive heart failure. She is prescribed
digoxin and bed rest. - Health

Goal: To make humans realize that illness is a part of life, health results from a process where
health and illness can coexist. If they can adapt properly, they will maintain health to reach
completeness and unity within themselves. If they cannot adapt accordingly, the integrity of the
person can be affected negatively.
Biographical Data:
Name: Paula Taylor
Age: 38 years old
Gender: Female

Reasons for Seeking Health Care:

“I can’t sleep at night, I am so short of breath”

History of Present Health Concern Using COLDSPA:

Characteristic
- extremely fatigue
Onset
- 2 weeks ago
Location
- mild constant swelling in her ankle
Duration
- not stated
Severity
- inability to walk upstairs without becoming breathless and orthopnea
Pattern
- she cannot sleep at night without four pillows
Associated Factors
- persistent cough

Personal Health History:

She developed scoliosis as an early adolescent. She has retainer rods inserted to support her
spine.

Family History:
One aunt has breast cancer; an uncle has asteriosclerotic heart diseaee. Her sister has
recurrent absence seizures. A cousin has type 1 diabetes mellitus.

Lifestyle and Health Practices:

She does not smoke and has no alcohol ingestion since pregnant.

Physical Exam Findings:

Skin, hair and nails -

Ears and eyes - negative

Mouth, nose, throat and sinuses - negative

Thorax and lungs - prominent grade 2 diastolic murmur heard at left sternal margin; apical first
heart sound is accentuated; second sound is split; cardiac enlargement suggested by
percussion; heart rate: 96 beats/min; rhonchi heard on lung auscultation; respiratory rate: 22
breaths per minute.

Abdomen- fundal height: 28cm; linea nigra and striae present on abdomen; FHR: 158 beats per
minute

Rectum - Two 1-cm hemorrhoids present; no bleeding

Neurologic - deep tendon reflexes 2+

Coarse in the ward – In chronological order/Event timeline

a) Assessment
b) Diagnostic/Laboratory
c) Medical/Surgical Intervention
d) Medications/Treatment
e) Referral

GUIDED ACTIVITY:
a) Anatomy/Physiology of related case (CZERNA AND ANA PETH)
BLOOD ANATOMY:
● Blood The circulating fluid including plasma and different cells such as red blood cells, white
blood cells and platelets in the vascular system of humans and other Vertebrates.
● Functions of blood
○ Supplies essential nutrients in cells such as glucose, fatty acid and amino acids.
○ Transport oxygen O2 and carbon dioxide CO2, and hormones in the body.
○ Protects from pathogens, blood loss and diseases.
○ Helps regulate body temperature.
● Physical characteristics
○ More viscous(thick) than water.
○ 100.4 degree F temperature.
○ 8% of total body weight.
○ Average blood volume in males is 5-6 liters.
○ And 4-5 liters for the average female.
● Components of blood Blood are made up of two main components.
○ Blood cells (45%)
○ Plasma (55%
● Three types of blood cells are
○ Red blood cells (erythrocytes)
○ White blood cells (leucocytes)
○ Platelets (thrombocytes)

​Red blood cells

● Also called erythrocytes
 ● Biconcave shape
● Elastic cell membrane
● No nucleus
● 95% of the RBC consist of hemoglobin(red pigment)
● Remaining 5% consist of enzymes, salts and other protein
• Formed in red bone marrow
• Average life's four months
• About 2-10 million red blood cells are formed and destroyed every second.
• The main function of the RBC is to transport oxygen and carbon dioxide.
• Blood of male contains 5-5.5 million RBC per cubic millimeter. • Blood of female contains 4-4.5
million RBC per cubic millimeter.

White blood cells

● Also called as leukocytes
● They are colorless
● Much larger than red blood cells
● One cubic millimeter of blood contains 7000 to 8000 WBC
● Formed in bone marrow
● Their life span depends on the body need so they have life span of months or even years
• white blood cells are about 1% in healthy people.
• Only 2% of total WBC population circulating in blood at a time - Rest is in the skin, lungs and
spleen. Main function These are the cells of the immune system that are involved in protecting the
body against both infectious disease and foreign invaders.
Types of WBC
• Granulocytes These WBC have granules in their cytoplasm. -Granulocytes include neutrophils,
eosinophils and basophils.
• Agranulocytes These are without granules in their cytoplasm -These include monocytes and
lymphocytes.

platelets
• Platelets are also called Thrombocytes.
• Platelets are not cells. They are fragments of large cells .
• Nucleus are absent
• Random shaped
• 2-4 micron size
• Normal platelet count is 150,000-400,000/ drop of blood
• Platelets have a lifespan of only 5 to 9 days
• Platelets are formed in Bone marrow Function
• Stoppage of bleeding in a quick way when blood vessels are damaged this process is also called
Hemostasis
• Prevent hemorrhage(loss of large amount of blood)
• Normaly 55% of our blood is made up of plasma
• Composed of approximately 90% water. • plasma is the liquid portion of the blood
• Plasma is primarily water in which proteins, salts, nutrients and waste are dissolved. Plasma can
be divided into six components.
• Inorganic ions or Mineral ions.
• The plasma proteins
• Organic nutrients in the blood
• Nitrogenous waste products
• Hormones
• Gasses

Function of plasma
• Plasma helps maintain blood pressure .
• Regulates body temperature
• It contain minerals, salts, hormones and proteins that perform important function in the body

HEART ANATOMY

The human heart is muscular organ that pumps blood throughout the body via the vessels of the
circulatory system

● Functions
○ Generating blood pressure.
○ Routing Blood
○ Ensuring one-way blood flow
○ Regulating blood supply

● Size, Form, and Location

○ The heart is approximately the size of a closed fist and is located in the
pericardial cavity.

● Pericardium
○ It is a sac consisting of fibrous and serous pericardia. The fibrous pericardium is
lined by the parietal pericardium.
○ Outer surface of the heart is lined by the visceral pericardium (epicardium).
○ Between the visceral and parietal pericardia is the pericardial cavity, which is field
with pericardial fluid.

● External Anatomy
○ The atria are separated externally from the ventricles by the coronary sulcus. The
right and left ventricles are separated externally by the interventricular sulci.
○ The inferior and superior vena cavae enter the right atrium. The four pulmonary
veins enter the left atrium.
○ The pulmonary trunk exits the right ventricle, and the aorta exits the left ventricle.
● Heart Chambers and Internal Anatomy
○ There are four chambers in the heart. The left and right atria receive blood from
veins and function mainly as reservoirs. Contraction of the atria completes
ventricular filling.
 ○ The atria are separated internally from each other by the interatrial septum.
○ The ventricles are the main pumping chambers of the heart. The right ventricle
pumps blood into the pulmonary trunk, and the left ventricle, which has a thicker
wall, pumps blood into the aorta.
○ The ventricles are separated internally by the interventricular septum.

● Heart Valves
○ The heart valves ensure one-way flow of blood.
○ The tricuspid valve (three cusps) separates the right atrium and the right
ventricle, and the bicuspid valve (two cusps) separates the left atrium and the left
ventricle.
○ The papillary muscles attach by the chordae tendineae to the cusps of the
tricuspid and bicuspid valves and adjust tension on the valves.
○ The aorta and pulmonary trunk are separated from the ventricles by the
semilunar valves.
○ The skeleton of the heart is a plate of fibrous connective tissue that separates the
atria from the ventricles, acts as an electrical barrier between the atria and
ventricles, and supports the heart valves.

● Blood Supply to the Heart

○ The left and right coronary arteries originate from the base of the aorta and
supply the heart.
○ The left coronary artery has three major branches: the anterior interventricular,
the circumflex, and the left marginal arteries.
○ The right coronary artery has two major branches: the posterior interventricular
and the right marginal arteries.
○ Blood returns from heart tissue through cardiac veins to the coronary sinus and
into the right atrium. Small cardiac veins also return blood directly to the right
atrium.

Iron Deficiency Anemia (patho by: melody doria)

Causes of increased prevalence of anemia in pregnancy - Iron deficiency anemia is most

prevalent in the tropics amongst women of childbearing age, especially in the underprivileged
sector. - There is an increase in the daily requirement of iron.

During pregnancy: Increased demands of iron. Diminished intake of iron – low socio-economic
group, faulty diet, loss of appetite, vomiting. Diminished absorption – antacids,
hypochlorohydria. Disturbed metabolism – presence of infection. Pre-pregnant health status –
pre-existing anemic state. Excess demand

– a. Multiple pregnancies.
b. Rapidly recurring pregnancy.

c. Young age of pregnant lady.

Iron Deficiency Anemia (Pathophysiology)

STAGE 1: is characterized by decreased bone marrow iron stores; Hb and serum iron remain
normal, but serum ferritin level falls. There is compensatory increase in iron absorption and
increase in TIBC (transferrin level)

STAGE 2: Erythropoiesis is impaired. Although TIBC increases, the serum iron level decreases;
transferring saturation decreases.

STAGE 3: anemia with normal-appearing RBCs and indices develops.

STAGE 4: microcytosis and then hypochromia develop

STAGE 5: iron deficiency affects tissues, resulting in symptoms and signs.

CLINICAL FEATURES SYMPTOMS:

1. Lassitude and feeling of weakness.

2. Easy fatigability, dyspnea on exertion.

3. Anorexia, indigestion, palpitations.

SIGNS:

1. Pallor of varying degrees, koilonychia, atrophic glossitis, angular stomatitis.

2. Edema of leg if associated pre-eclampsia present.

3. Soft systolic murmur due to physiological mitral incompetence.

Congestive Heart Failure (Pathophysiology)

- In order to maintain normal cardiac output, several compensatory mechanisms play a role as
under: Compensatory enlargement in the form of cardiac hypertrophy, cardiac dilation, or both

- Tachycardia - increased heart rate due to activation of neurohumoral system e.g. release of
norepinephrine and atrial natrouretic peptide, activation of renin-angiotensin aldosterone
mechanism

- STARLINGS LAW, Within limits, the force of ventricular contraction is a function of the
end-diastolic length of the cardiac muscle, which in turn is closely related to the ventricular
end-diastolic volume
- This is achieved by increasing length of sarcomeres in dilated heart

- Increases the myocardial contractility and thereby attempts to maintain stroke volume

- Heart failure results in depression of the ventricular function curve

- Compensation in the form of stretching of myocardial fiber results

- Stretching leads to cardiac dilatation which occurs when the left ventricle fails to eject its
normal end-diastolic volume.

COMPENSATORY MECHANISM

• Sympathetic nervous system stimulation

• Myocardial hypertrophy

• Renin-angiotensin system activation

• Altered cardiac rhythm

SIGNS AND SYMPTOMS OF CHF:

- Shortness of breath often with activities or while lying flat

- Weakness and fatigue - Awakening short of breath at night

- Need for increased pillows at night

- helps lungs drain of excess fluid

- Coughing or wheezing

- Swelling of feet and legs or other "dependent" areas

- Anorexia/loss of appetite

- Weight gain

SYMPTOMS OF HEART FAILURE:

- Fatigue - Activity decrease

- Cough (especially supine)

- Edema - Shortness of breath

COMPLICATIONS:
- Cardiac arrythmia

- Hypotension

- N/V

- Amrinone Thrombocytopenia, liver enzyme

- Milirinone Bone marrow suppression. liver toxicity GI

-N/V, Diarrhea, abdominal pain. constipation Neurologic

-headache, fatigue, insomnia, vertigo Visual

-color vision (green or yellow), colored halos around the subject Miscellaneous

-allergic, thrombocytopenia, necrosis Heart

-SA and AV node suppression

-AV block

-Atrial arrhythmia

-Ventricular arrhythmia

DRUG STUDY:
Action
DIGOXIN
● belongs to a class of medications called cardiac glycosides.
● Cardiac glycosides are a class of organic compounds that increase the output
force of the heart and decrease its rate of contractions by acting on the cellular
sodium-potassium ATPase pump.
● used to treat heart failure, usually along with other medications. It is also used to
treat certain types of irregular heartbeat (such as chronic atrial fibrillation).
● Helps your heart pump more efficiently by inhibiting normal function of Na+/K+
pump.
● It works by affecting certain minerals (sodium and potassium) inside heart cells.
This reduces strain on the heart and helps it maintain a normal, steady, and
strong heartbeat.
ACTION
➢ Digoxin inhibits the Na-K-ATPase membrane pump, resulting in an increase in
intracellular sodium.
 ➢ The sodium calcium exchanger (NCX)in turn tries to extrude the sodium and in
so doing, pumps in more calcium.
➢ Increased intracellular concentrations of calcium may promote activation of
contractile proteins (e.g., actin, myosin).
➢ Digoxin also acts on the electrical activity of the heart, increasing the slope of
phase 4 depolarization, shortening the action potential duration, and decreasing
the maximal diastolic potential.

Indication /Contraindication

Indication: Treatment of cardiovascular conditions such as heart failure and atrial

fibrillation.
Contraindication: Digitalis toxicity, ventricular tachycardia/fibrillation, obstructive
cardiomyopathy.

Side effect/Adverse reaction

● Dizziness or lightheadedness
● Drowsiness
● Vision changes (blurred or yellow)

● Irregular heartbeat
● Upset stomach
● Vomiting
● Diarrhea in elderly
● Loss of appetite
● Swelling of the feet or hands
● Unusual weight gain
● Difficulty breathing

Nursing considerations
➢ Check dosage and preparation carefully.
➢ Avoid IM injections, which may be very painful.
➢ Follow diluting instructions carefully, and use diluted solution promptly.
➢ Avoid giving with meals; this will delay absorption.
➢ Have emergency equipment ready; have K+ salts, lidocaine, phenytoin, atropine,
and cardiac monitor readily available in case toxicity develops.

Discharge Planning/Health Teaching for Patient and Family

Medications
Environmental management
Treatment
Health Education, personal care, activity, rest, exercise, spiritual and emotional care
Out-patient referral and follow-up appointments
Diet/Nutrition

Medications

MegaFood Blood Builder

● This multivitamin and iron supplement from Mega Food is gentle on the stomach and
should not cause constipation. Containing 26 mg of iron, it also has vitamin C to help
iron absorption and vitamin B12 and folates for pregnancy health.

Pure Encapsulations Liquid Iron

● Flavored with blueberries, this liquid supplement from Pure Encapsulations is suitable for
vegans and vegetarians, and good for expectant moms. The recommended daily dosage
of 15 milliliters will supply 25 mg of iron.

Garden of Life Iron Complex

● This product is certified vegan, non-GMO, gluten-free, and is made from natural plant
products. It is delivered in a single capsule, which measures just less than 1 inch.
Although this is fairly large, it will slide down quite easily with a glass of juice or water.

beta-blockers

● Beta blockers, also spelled β-blockers, are a class of medications that are predominantly
used to manage abnormal heart rhythms, and to protect the heart from a second heart
attack after a first heart attack.

Furosemide

● Furosemide is a loop diuretic medication used to treat fluid build-up due to heart failure,
liver scarring, or kidney disease. It may also be used for the treatment of high blood
pressure. It can be taken by injection into a vein or by mouth.

Digoxin

● Digoxin, sold under the brand name Lanoxin among others, is a medication used to treat
various heart conditions. Most frequently it is used for atrial fibrillation, atrial flutter, and
heart failure. Digoxin is one of the oldest medications used in the field of cardiology.

Environmental management

● Environmental conditions, such as temperature, noise, light, bed comfort and electronic
distractions, play a significant role in one's ability to get proper sleep.
● Encourage the pregnant woman to talk and ask her questions during the prenatal visit.
● Encourage the pregnant woman for the regularly follow up check up.
Treatment

● You may need to start taking an iron supplement and/or folic acid supplement in addition
to your prenatal vitamins.

ALTERNATIVE TREATMENT

● Massage
● Relaxation
● Meditation
● Breathing pattern
● Family support

Health Education

● Keep your prenatal appointments. Visit your health care provider regularly throughout
your pregnancy.
● Take your medication as prescribed.
● Know what's off-limits. Avoid smoking, alcohol, caffeine, and illegal drugs

Personal care

FOR EDEMA
● Lying on the left side, which moves the uterus off the large vein that returns blood to the
heart (inferior vena cava)
● Resting frequently with the legs elevated
● Wearing elastic support stockings
● Wearing loose clothing that does not restrict blood flow, particularly in the legs (for
example, not wearing socks or stockings that have tight bands around the ankles or
calves)

Activity and Rest

● Bed rest or limited activity.

● Get plenty of rest. Take a daily nap, if you can, and avoid strenuous physical activities.

Exercise

● Some women should not exercise during pregnancy. If you have a medical condition
such as asthma, heart disease, or diabetes, you should consult your doctor before
exercising. Exercise might not be advisable for you.
● Kegel exercises, also called pelvic floor exercises, help strengthen the muscles that
support the bladder, uterus, and bowels.
● Tailor exercises strengthen the pelvic, hip, and thigh muscles, and can help relieve low
back pain.
 Spiritual Care and Emotional Care

● During pregnancy, women intensify their prayers to God for protection, safe delivery and
blessings. Some women panic at the mention of a caesarian section for fear of death
during surgery and others who undergo a caesarian section are stigmatized. This stigma
transcends their generations. Therefore, pregnant women would explore all spiritual and
traditional options to ensure that they deliver spontaneously. Women commune with their
God either individually or in a group. The prayer offered by pregnant women increases
their faith and hope in God and it affords them the confidence of going through a safe
delivery.
● Pregnancy is usually a time of excitement. But sometimes, pregnant women and their
partners may feel like they're expecting a bundle of anxiety along with the joy. They have
to cope with the changes and unknowns that come with pregnancy and birth. When both
partners support each other, they strengthen their bond and their sense of teamwork. A
partner's support is especially important for the mom and baby during this busy time.
○ A woman who feels supported by her partner during and after pregnancy may
feel happier and less stressed.
○ Lower stress in moms during pregnancy may help infants too.

Out-patient referral and follow-up appointments

● Consult the cardio-obstetrics team if the condition worsens.

Diet/Nutrition

● Eat iron-rich foods such as meat, chicken, fish, eggs, dried beans and fortified grains.
The form of iron in meat products, called heme, is more easily absorbed than the iron in
vegetables. If you are anemic and you ordinarily eat meat, increasing the amount of
meat you consume is the easiest way to increase the iron your body receives.
● Eat foods high in folic acids, such as dried beans, dark green leafy vegetables, wheat
germ, and orange juice.
● Eat foods high in vitamin C, such as citrus fruits and fresh, raw vegetables.
● Take your prenatal multivitamin and mineral pill which contains extra folate.

NCP

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Ineffective tissue - After 4 hours of - Evaluate patient’s - Patient demonstrates

perfusion related providing nursing tolerance to activity, limit an improved
- “I can’t sleep to altered intervention, the activities within patient’s ventilation/oxygenation
at night, I am oxygen-carrying patient will tolerance. Assist with as evidenced by
demonstrate ADLs and mobility as respiratory rate within
capacity of blood improved needed. Reducing the normal limits and use of
 so short of caused by the ventilation/oxyge metabolic accessory muscles
breath.” sickle-like nation as requirements of the
structure of the evidenced by body would reduce - Patient participates in
respiratory rate the oxygen ADLs without weakness
red blood cell
within normal requirements. and fatigue
- She has been limits and use of
accessory - Teach and
extremely
muscles demonstrate the use of
fatigued relaxation techniques:
- After 4 hours of guided imagery, deep
providing nursing breathing exercises,
intervention, the and visualization.
patient will Relaxation decreases
participate in muscle tension and
ADLs (activities anxiety and hence the
of daily living) metabolic demand for
without oxygen.
weakness and
fatigue. - Review
oxygen-conserving
techniques (e.g., sitting
instead of standing to
perform tasks; eating
small meals; performing
slower, purposeful
movements).

- Give blood
components (commonly
packed RBCs) via an
intravenous catheter as
prescribed. This
method will increase
the number of RBCs
circulating in the
blood, which
eventually increases
the blood’s
oxygen-carrying
capacity.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Disturbed Sleep - After 3 days of - Elevate the head of - Patient reports of
Pattern related to providing nursing the bed and position the improved sleep.
- Orthopnea is patient intervention, the client appropriately.
so severe at patient will report Elevation or upright - Patient reports of
 night that she experiencing improved sleep. position facilitates increased sense of
cannot sleep orthopnea respiratory function well-being and feeling
without four caused by the - After 3 days of by gravity; however, rested.
providing nursing clients in severe
pillows. sickle cell and
intervention, the distress will seek a
possible fluid in patient will report position of comfort.
Objective the lungs an increased
sense of - Encourage deep
- rhon­chi heard well-being and breathing techniques
on lung feeling rested. and administer oxygen
auscultation as prescribed before
sleeping. These
methods boost
oxygen delivery to the
tissue.

- Give blood
components (commonly
packed RBCs) via an
intravenous catheter as
prescribed. This
method will increase
the number of RBCs
circulating in the
blood, which
eventually increases
the blood’s
oxygen-carrying
capacity.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Readiness for - After 1 week of - Discuss any - Patient demonstrates a

Enhanced providing nursing medications that may healthy pregnancy free of
- “I can’t sleep Childbearing intervention, the be needed to control or preventable
at night, I am Process related patient will treat medical complications.
so short of to demonstrate a conditions. Helpful in
patient healthy pregnancy choosing treatment - Patient verbalizes
breath.” expresses desire understanding of care
free of options because
to have an preventable need must be requirements to promote
complications. weighed against health of self and infant.
possible harmful
 - Tries to sleep adequate effects on the fetus.
8 hours at amount of sleep
night but - After 1 hour of - Encourage light
providing nursing exercise such as
receives only 3
intervention, the walking, or non-weight
to 4 hours patient will bearing activities in
because of verbalize accordance with
constant understanding of client’s physical
waking with care requirements condition and cultural
shortness of to promote health beliefs. Tends to
breath of self and infant. shorten labor,
increases likelihood
of a spontaneous
vaginal delivery, and
decreases need for
oxytocin
augmentation.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Risk for Activity

Subjective Intolerance - Two hours after - Assist client with - Patient identifies
related to patient the intervention, planning for changes alternative ways to
- “I can’t sleep having difficulty patient will identify
that may become maintain desired activity
at night, I am performing alternative ways to necessary, such as level.
an maintain desired use of supplemental
so short of activity
activity level oxygen to improve
breath.”
client’s ability to
- Two hours after participate in desired - Patient identifies
the intervention, activities. conditions or symptoms
the patient will that require medical
- she has been identify conditions - Identify and discuss reevaluation.
extremely or symptoms that symptoms for which
fatigued require medical client needs to seek
reevaluation. medical
assistance/evaluation,
providing for timely
- inability to walk intervention.
upstairs
- Instruct the client in
without proper performance of
becoming unfamiliar activities
breathless and in alternate ways
of doing familiar
activities to conserve
 energy and promote
safety.

ASSESSMENT DIAGNOSI PLANNING INTERVENTION EVALUATION

S

Subjective Decrease At the end of 8 hours of

- “I can’t sleep cardiac nursing intervention, the - Perform periodic At the end of 8-hour
at night, I am output client will be able to: hemodynamic nursing interventions,
- Demonstrate measurements, as the goal was partially
so short of related to
hemodynamic indicated (e.g., arterial, met as evidenced by:
breath.” Impaired stability (blood CVP, pulmonary, and left
contractility pressure and atrial pressures and - Hemolytic
- Has been cardiac output) by cardiac output). stability
extremely 20%-30% as - Maintain
fatigued revealed in the - Keep client on the bed adequate
cardiac monitor in a semi fowler. cardiac output
orthopnea so
- Maintain Decreases oxygen - Stable vital
severe at consumption and risk signs and
adequate cardiac
night. output as of decompensation. normal level of
evidenced by consciousness
Objective stable vital signs - Administer high-flow
- respiratory and normal level oxygen via mask or
rate: 22 of consciousness ventilator, as indicated,
to increase oxygen
breaths/min
available for cardiac
function/ tissue
- cardiac perfusion
enlargement
suggested by - Monitor cardiac rhythm
percussion continuously to note
effectiveness of
medications and/or
assistive devices, such
as implanted
pacemaker or
defibrillator.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Fatigue r/t - After 3 days of

patient having intervention, - Provide supplemental Patient report improved
patient will report oxygen, as indicated. sense of energy.
improved sense of Presence of sickle
 - she has been inadequate energy. cell anemia reduces Patient performs
extremely amount of sleep oxygen available for activities of daily living
fatigued - After 3 days of cellular uptake and and participate in desired
intervention, contributes to activities at level of
- “I can’t sleep
patient will fatigue. ability.
at night” perform activities
of daily living and - Elevate the head of
Objective participate in the bed and position
- tired appearing desired activities the client appropriately.
pregnant at level of ability. Elevation or upright
position facilitates
female
respiratory function
by gravity; however,
clients in severe
distress will seek a
position of comfort.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Excess fluid - After 3 days of

- has mild volume as providing nursing - Compare current - The patient has a
constant evidenced by the intervention, the weight with admission stabilize fluid volume as
patient will have a and/or previously evidenced by balanced
swelling in her swelling of ankle
stabilize fluid stated weight. Weigh input and output (I&O),
ankle and legs volume as daily or on a regular vital signs within client’s
evidenced by schedule, as indicated. normal limits, stable
- orthopnea so balanced input weight, and free of signs
severe at night and output (I&O), - Measure and record of edema.
she cannot vital signs within I&O accurately. Include
client’s normal “hidden” fluids (e.g., IV - Patient demonstrates
sleep without
limits, stable antibiotic additives, behaviors to monitor fluid
four pillows liquid medications, ice status and reduce
weight, and free of
signs of edema. chips). Calculate recurrence of fluid
Objective 24-hour fluid balance excess.
- After 3 days of (plus or minus). Note
- Edema 2+ providing nursing patterns, times, and
present on intervention, the amount of urination
patient will (e.g., nocturia,
both legs demonstrate oliguria).
extending from behaviors to
monitor fluid - Elevate edematous
feet to mid-calf status and reduce extremities, change
recurrence of fluid position frequently to
excess. reduce tissue
pressure and risk of
- rhon­chi heard skin breakdown.
on lung
- Place in
auscultation semi-Fowler’s position,
as appropriate, to
facilitate movement of
diaphragm, thus
improving respiratory
effort.

- Discuss importance
of fluid restrictions and
“hidden sources” of
intake (such as foods
high in water content).

- Instruct client/family
in the use of voiding
record, I&O.