1. Assessment
A. Medical history
A. Medical history
- Common identity mothers
- Mother's age, whether primi gravida
- Is hypertension in the family
- Nutritional status of mothers
- History of chronic kidney disease
- Complaints head disease, visual impairment, uluhati pain, nausea and vomiting
B. Obstetric
history
- Has twin
- Is there a history hiydramnion
- Is there a history molahidatidosa
C. Physical
examination
- Is there edema
- an increase in overweight
- paleness of skin color lembat
- whether blurred vision, headache, heartburn
- decrease in urine output
- checking vital signs
- Uriah protein
- serum total protein and albumin decreased
- hematorik rise, low nemuglobin
- increased uric acid
- increased creatinine, urea miningkat
- SOGT and lactic dehydrogenase increased
- Decreased blood clotting time
2. Nursing
Diagnosis
1. Excess fluid volume related to decreased osmotic pressure, changes in vascular permeability, as well as sodium and water retention.
2. Decrease in cardiac output associated with hypovolemia / decrease in venous return.
3. High risk of injury to the fetus associated with inadequate perfusion of blood to the placenta.
3. Intervention
Diagnosis 1: Excess caiarn associated with a decrease in the osmotic pressure, changes in vascular permeability, fiber and sodium retention nair.
a. Monitor and record intake and output every day.
Rational:
By monitoring intake and output is expected to note the existence of fluid and can diramalkankeadaan keseimbanngan and kerusakanglomerulus.
b. Monitoring TTV
Rational:
With memanatu TTV and capillary refill can be used as guidelines for fluid replacement or assess the response of the cardiovascular.
c. Monitor or weigh the mother.
Rational:
By monitoring the weight of the mother can know that weight is an indicator to determine the proper fluid balance.
d. Observation circumstances edema
Rational:
The state is an indicator of the state of edema fluid in the body.
e. Provide low-salt diet based on the results of collaboration with a nutritionist.
Rational:
Low-salt diet will reduce the excess fluid.
f. Collaboration to diuretic therapy.
Rational:
Kegagaln overloaded or circulation can lead to pulmonary edema requiring aggressive integral. Rather, it is contraindicated indicated when it may cause dehydration.
Diagnosis 2. The decrease in cardiac output associated with hypovolemic or decrease venous return.
a. Pemanataun pulse and blood pressure.
Rational:
Denagn monitor blood pressure and pulse dpat seen an increase in plasma volume, relaxation vaskriferular with decreased peripheral custody
b. Make bed rest in women with left position.
Rational:
Increasing venous return, cardiac output and renal perfusion.
c. Monitoring invasive or hemodynamic parameters (collaboration)
Rational:
Give an accurate picture of changes in vascular volume and vascular cairan.Konstruksi time, improvement and hemoconcentration, and fluid shifts menurunnkan cardiac output.
d. Give antihypertensive medications as needed based on collaboration with Doctors
Rational:
Antihypertensive medications work directly on arteriolar smooth muscle relaxation to improve cardiovascular and helps improve blood supply.
e. Pemanatauan blood pressure and antihypertensive medication.
Rational:
Knowing the side effects occur such as tachycardia, headache, nausea, vomiting, and palpitations.
Diagnosis 3: High risk of injury to the fetus associated with inadequate perfusion of blood to the placenta
a. Rest your mother.
Rational:
With mother menistirahatkan expected decrease metabolism and blood circulation to the placenta so inadequate, so the need of oxygen to the fetus can be met.
b. Encourage the mother to tilt to the left.
Rational:
With the left side sleeping expected vena cava to the right is not depressed by the enlarging uterus, so that blood flow to the placenta so smoothly.
c. Monitor the mother's blood pressure.
Rational:
With memanatau maternal blood pressure can know the state of the blood flow to the placenta such as high blood pressure, blood flow to the placenta is reduced, so that the oxygen supply to the fetus is reduced.
d. Monitor maternal heart sounds
Rational:
By monitoring the fetal heart rate can know the state of the fetal heart is weak or declining indicating reduced oxygen supply to the placenta, which can direncankan further action.
e. Give hypertension medications after collaborating with physicians
Rational:
With antihypertensive drugs will lower the tone of the arteries and causes heart afterload by vasodilation of blood vessels, so blood pressure turun.Dengan decrease in blood pressure, the blood flow to the placenta to be adequate.
4. Implementation of Nursing
Once the plan is composed of nursing, then applied to real action to achieve the desired results in the form of reduction or loss of maternal problems. At the implementation stage consists of several actions the nursing plan validation, writing or document a plan of nursing, And continue collecting data.
In the implementation of nursing, measures should be detailed and clear cukkup that all nursing personnel to run it well within the stipulated time. Nurses can melaksanakn directly or in collaboration with other executive personnel.
5. Evaluation
Evaluation of nursing is the final activity of the nursing process, in which nurses assess the expected outcomes to changes in maternal self and assess the extent of the problem can be solved mother. In addition, nurses also provide feedback or reassessment, if the goals set have not been achieved, so in this case the nursing process can be modified.
1. Excess fluid volume related to decreased osmotic pressure, changes in vascular permeability, as well as sodium and water retention.
2. Decrease in cardiac output associated with hypovolemia / decrease in venous return.
3. High risk of injury to the fetus associated with inadequate perfusion of blood to the placenta.
3. Intervention
Diagnosis 1: Excess caiarn associated with a decrease in the osmotic pressure, changes in vascular permeability, fiber and sodium retention nair.
a. Monitor and record intake and output every day.
Rational:
By monitoring intake and output is expected to note the existence of fluid and can diramalkankeadaan keseimbanngan and kerusakanglomerulus.
b. Monitoring TTV
Rational:
With memanatu TTV and capillary refill can be used as guidelines for fluid replacement or assess the response of the cardiovascular.
c. Monitor or weigh the mother.
Rational:
By monitoring the weight of the mother can know that weight is an indicator to determine the proper fluid balance.
d. Observation circumstances edema
Rational:
The state is an indicator of the state of edema fluid in the body.
e. Provide low-salt diet based on the results of collaboration with a nutritionist.
Rational:
Low-salt diet will reduce the excess fluid.
f. Collaboration to diuretic therapy.
Rational:
Kegagaln overloaded or circulation can lead to pulmonary edema requiring aggressive integral. Rather, it is contraindicated indicated when it may cause dehydration.
Diagnosis 2. The decrease in cardiac output associated with hypovolemic or decrease venous return.
a. Pemanataun pulse and blood pressure.
Rational:
Denagn monitor blood pressure and pulse dpat seen an increase in plasma volume, relaxation vaskriferular with decreased peripheral custody
b. Make bed rest in women with left position.
Rational:
Increasing venous return, cardiac output and renal perfusion.
c. Monitoring invasive or hemodynamic parameters (collaboration)
Rational:
Give an accurate picture of changes in vascular volume and vascular cairan.Konstruksi time, improvement and hemoconcentration, and fluid shifts menurunnkan cardiac output.
d. Give antihypertensive medications as needed based on collaboration with Doctors
Rational:
Antihypertensive medications work directly on arteriolar smooth muscle relaxation to improve cardiovascular and helps improve blood supply.
e. Pemanatauan blood pressure and antihypertensive medication.
Rational:
Knowing the side effects occur such as tachycardia, headache, nausea, vomiting, and palpitations.
Diagnosis 3: High risk of injury to the fetus associated with inadequate perfusion of blood to the placenta
a. Rest your mother.
Rational:
With mother menistirahatkan expected decrease metabolism and blood circulation to the placenta so inadequate, so the need of oxygen to the fetus can be met.
b. Encourage the mother to tilt to the left.
Rational:
With the left side sleeping expected vena cava to the right is not depressed by the enlarging uterus, so that blood flow to the placenta so smoothly.
c. Monitor the mother's blood pressure.
Rational:
With memanatau maternal blood pressure can know the state of the blood flow to the placenta such as high blood pressure, blood flow to the placenta is reduced, so that the oxygen supply to the fetus is reduced.
d. Monitor maternal heart sounds
Rational:
By monitoring the fetal heart rate can know the state of the fetal heart is weak or declining indicating reduced oxygen supply to the placenta, which can direncankan further action.
e. Give hypertension medications after collaborating with physicians
Rational:
With antihypertensive drugs will lower the tone of the arteries and causes heart afterload by vasodilation of blood vessels, so blood pressure turun.Dengan decrease in blood pressure, the blood flow to the placenta to be adequate.
4. Implementation of Nursing
Once the plan is composed of nursing, then applied to real action to achieve the desired results in the form of reduction or loss of maternal problems. At the implementation stage consists of several actions the nursing plan validation, writing or document a plan of nursing, And continue collecting data.
In the implementation of nursing, measures should be detailed and clear cukkup that all nursing personnel to run it well within the stipulated time. Nurses can melaksanakn directly or in collaboration with other executive personnel.
5. Evaluation
Evaluation of nursing is the final activity of the nursing process, in which nurses assess the expected outcomes to changes in maternal self and assess the extent of the problem can be solved mother. In addition, nurses also provide feedback or reassessment, if the goals set have not been achieved, so in this case the nursing process can be modified.
