Nursing Care Plans For Chronic Confusion

Nursing Diagnosis: Chronic Confusion

Nursing Care Plans For Chronic Confusion
NANDA Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by a decreased ability to interpret environmental stimuli and a decreased capacity for intellectual thought processes, which manifest as disturbances of memory, orientation, and behavior

Defining Characteristics: Altered interpretation/response to stimuli; clinical evidence of organic impairment; altered personality; impaired memory (short and long term); impaired socialization; no change in level of consciousness
Related Factors: Multi-infarct dementia; Korsakoff's psychosis; head injury; Alzheimer's disease; cerebrovascular accident

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Cognitive Orientation
• Information Processing
• Memory
• Neurological Status: Consciousness

Client Outcomes
• Remains content and free from harm
• Functions at maximal cognitive level
• Participates in activities of daily living at the maximum of functional ability

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Dementia Management
• Environmental Management
• Reality Orientation
• Surveillance: Safety

Nursing Interventions and Rationales

• Determine client's cognitive level using a screening tool such as the Mini Mental State Exam (MMSE). Using a standard evaluation tool such as the MMSE can help determine the client's abilities and assist with planning appropriate nursing interventions.
• Gather information about client pre-dementia functioning, including social situation, physical condition, and psychological functioning. Knowing the client's background can help the nurse identify agenda behavior and use validation therapy, which will provide guidance for reminiscence. Background information may help the nurse to understand client’s behavior if client becomes delusional and hallucinates.
• Assess the client for signs of depression: insomnia, poor appetite, flat affect, and withdrawn behavior. As much as 50% of clients with dementia have depressive symptoms.
• Ensure that client is in a safe environment by removing potential hazards such as sharp objects and harmful liquids. Clients with dementia lose the ability to make good judgments and can easily harm self or others.
• Place an identification bracelet on client. Clients with dementia wander and can become lost; identification bracelets increase client safety.
• Avoid exposing client to unfamiliar situations and people as much as possible. Maintain continuity of caregivers. Maintain routines of care through established mealtimes, bathing, and sleeping schedules. Send familiar person with client when client goes for diagnostic testing or into unfamiliar environments. Situational anxiety associated with environmental, interpersonal, or structural change can escalate into agitated behavior.
• Keep environment quiet and nonstimulating; avoid using buzzers and alarms if possible. Minimize sights and sounds that have a high potential for misinterpretation such as buzzers, alarms, and overhead paging systems. Sensory overload can result in agitated behavior in a client with dementia. Misinterpretation of the environment can also contribute to agitation.
• Begin each interaction with client by identifying self and calling client by name. Approach client with a caring, loving, and accepting attitude and speak calmly and slowly. Dementia clients can sense feelings of compassion. A calm, slow manner projects a feeling of comfort to the client.
• Touch client gently, stroking hand or arm in a soothing fashion if acceptable in client's culture.
• Give one simple direction at a time and repeat as necessary. Use verbal and physical prompts, and model the desired action if needed and possible. People with dementia need time to assimilate and interpret your directions. If you rephrase your question, you give them something new to process, increasing their confusion.
• Break down self-care tasks into simple steps. Dementia clients are unable to follow complex commands; breaking down an activity into simple steps makes completing the activity more feasible.
• Keep questions simple; yes or no questions are often preferable to open-ended questions. Use positive statements and actions and avoid negative communication. Negative feedback leads to increased confusion and agitation. It is more effective to go along with the client and then redirect as necessary.
• If eating in the dining room causes increased agitation, let client leave and eat in a quieter environment with a smaller number of people. The noise and confusion in a large dining room can be overwhelming for a dementia client and can result in agitated behavior. It is preferable to have dementia clients eat in small groups.
• Provide finger food if patient has difficulty using eating utensils or if unable to sit to eat. Feeding oneself is a complex task and may prove challenging for someone with significant dementia.
• Provide boundaries by placing red or yellow tape on the floor or by using a stop sign. Boundaries help the client identify safe areas; older clients can more easily see red and yellow than other colors.
• Assess the etiology of wandering before or rather than attempting to control the wandering. Wandering indicates a problem and need for intervention; therefore the reason for the wandering behavior needs to be determined.
• Write client's name in large block letters in the room and on client's clothing and possessions. Use symbols rather than words to identify areas such as the bathroom or kitchen.
• Limit visitors to two and provide them with guidelines on appropriate topics to discuss and how to best communicate with client. 
• Set up scheduled quiet periods in a recliner or room. Use blankets and other environmental cues to define rest periods. Quiet times allow the client's anxiety and building tension levels to decrease. Fatigue has been associated with the onset of increased confusion and agitation.
• Provide quiet activities, such as listening to classical or religious music, or other cues that promote relaxation in the afternoon or early evening. An increase in confusion and agitation, referred to as sundowning syndrome, may occur in the late afternoon and early evening. Quiet activities can provide a calming environment.
• Provide simple activities for the client, such as folding washcloths and sorting or stacking activities. Avoid misleading and frightening stimuli, which may include television, mirrors, and pictures of people or animals. Repetitive activities give the client with dementia a positive outlet for behavior. Dementia clients see, hear, and perceive a different world than other people. They may not recognize themselves in the mirror and be afraid of the stranger they see so close to them.
• Consider using doll therapy. Ask family members to bring a large, safe doll or stuffed animal such as a teddy bear. Doll therapy can be soothing to some dementia clients.
• If client becomes increasingly confused and agitated, perform the following steps:

1. Monitor client for physiological causes, including acute hypoxia, pain, medication effects, malnutrition, infections such as urinary tract infection, fatigue, electrolyte disturbances, and constipation. An acute change in behavior is a medical emergency and should be evaluated. Many physiological factors can result in increased agitation of clients with dementia.
2. Monitor for psychological causes, including changes in environment, caregiver, and routine; demands to perform beyond capacity; and multiple competing stimuli. It is important for the nurse to recognize precipitating events and subsequent behavior to prevent furthers incidents of agitation.
3. Avoid confrontations with the client; allow client to dissipate energy by performing repetitive tasks or by pacing.

• If client is delusional or hallucinating , do not confront him or her with reality. Use validation therapy to verbally reflect back the emotions that the client appears to be experiencing. Use statements such as, "It must be frightening to see a fire at the end of your bed," "I can see that you are afraid," "I will stay with you," or "Can you tell me more about what is going on right now?" Orienting the client to reality can increase agitation; validation therapy conveys empathy and understanding and can help determine the internal stimulus that is creating the change in behavior. In one study, training in validation therapy for staff resulted in decreased doses of psychotherapeutic medications and incidences of behavior problems.
• Decrease stimuli in the environment (turn off Radio, take client to a quiet place). Institute activities associated with pleasant emotions, such as playing soft music the client likes, looking through a photo album, providing favorite food, or using simulated presence therapy. Decreasing stimuli can decrease agitation. Reassuring activities, such as simulated presence therapy wherein client listens to a tape of a loved one's phone conversation, can help bring about pleasant emotions that soothe the client.
• Avoid using restraints if at all possible. Restraints are not benign interventions and should be used sparingly and judiciously only when alternatives to manage the behaviors have been tried and been unsuccessful. Side effects include falls, increased confusion , deconditioning, and incontinence.
• Use prn or low dose regular dosing of psychotropic or antianxiety drugs only as a last resort. They are effective in managing symptoms of psychosis and aggressive behavior. Start with the lowest possible dose. Psychotropic drugs such as haloperidol (Haldol) and resperidone (Risperdol) may decrease client function and have side effects that need to be monitored.
• Avoid use of anticholinergic medications such as Benadryl. Anticholinergic medications have a high side effect profile that includes disorientation, urinary retention, and excessive drowsiness (Nurses Drug Hand book). The anticholinergic side effects outweigh the antihistaminic effects.
• For predictable difficult times, such as during bathing and grooming, try the following:

1. Massage the client's hands lovingly or use therapeutic touch to relax the client. Hand massage and therapeutic touch have been shown to induce relaxation that may allow care activities to take place without difficulty.
2. Use positive behavioral reinforcement for each of the small steps involved in bathing, such as praising client for walking toward the shower, sitting in the shower chair, and removing items of clothing. Positive behavioral reinforcement for desired behavior is effective for clients with dementia. Consider a towel bath if shower or tub bathing is too stressful for client.
3. Treat the client with the utmost respect and give individualized care. Treating confused clients with respect and individualizing care can decrease aggression and increase nursing staff satisfaction.

• For early dementia clients with primarily symptoms of memory loss, see care plan for Impaired Memory. For clients with self-care deficits, see appropriate care plan (Feeding Self-care deficit, Dressing/grooming Self-care deficit, Toileting Self-care deficit).
  

Geriatric
• Most of the preceding interventions apply to the geriatric client.
• Use reminiscence and life review therapeutic interventions; ask questions about client's work, child rearing,

Multicultural

• Assess for the influence of cultural beliefs, norms, and values on the family or caregiver understanding of chronic confusion or dementia. What the family considers normal and abnormal health behavior may be based on cultural perceptions.
• Inform client family or caregiver of the meaning of and reasons for common behavior observed in clients with dementia . An understanding of dementia behavior will enable the client family/caregiver to provide the client with a safe environment.
• Refer family to social services or other supportive services to assist with meeting the demands of caregiving for the client with dementia. Black caregivers of dementia clients may evidence less desire than others to institutionalize their family members and are more likely to report unmet service needs . Families of dementia clients may report restricted social activity.
• Encourage family to make use of support groups or other service programs. Studies indicate that some minority families of clients with dementia may use few support programs even though these programs could have a positive impact on caregiver well-being.
• Validate the family members’ feelings with regard to the impact of client behavior on family lifestyle. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship.

Home Care Interventions

• Keeping the client as independent as possible is important. However, because community-based care is usually less structured than institutional care, in the home setting, the goal of maintaining safety for the client takes on primary importance.
• Provide support to family of client with chronic and disabling condition.
• If client will require extensive supervision on an ongoing basis, evaluate client for day care programs. Refer family to medical social services to assist with this process if necessary. Day care programs provide safe, structured care for the client and respite for the family. Respite care for caregivers is an essential part of successful long-term care for a confused client.
• Encourage family to include client in family activities when possible. Reinforce use of therapeutic communication guidelines and sensitivity to the number of people present. These steps help the client maintain dignity and lead to familiar socialization of the client.
• Assess family caregivers for caregiver burden. Caring for a loved one with a dementing process is highly stressful. Respite care is a necessary component to the overall care plan.

Client/Family Teaching

• Recommend that the family develop a memory aid wallet or booklet for client that contains pictures and text that chronicle the client's life. Using memory aids such as wallets or booklets helps dementia clients make more factual statements and stay on topic, and it decreases the number of confused, erroneous, and repetitive statements.
• Teach family how to converse with a memory-impaired person. Guidelines include the following:

1. Ask client to have a conversation with you.
2. Guide conversation to specific, nonthreatening topics and redirect the conversation back on topic when client begins to ramble.
3. Reassure and help out when the client gets stuck or cannot find the right words.
4. Smile and act interested in what client is saying even if unsure what it means.
5. Thank client for talking.
6. Avoid quizzing client or asking a lot of specific questions.
7. Avoid correcting or contradicting something that was stated even if it is wrong.

• Teach family how to set up environment and use care techniques/interventions listed so that client will experience a progressively lowered stress threshold. Alzheimer's clients are unable to deal with stress; decreasing stress can decrease confusion and changes in behavior.
• Discuss with the family what to expect as the dementia progresses .
• Counsel the family about resources available with regard to end-of-life decisions and legal concerns.
• Inform family that as dementia progresses, hospice care may be available in the terminal stages in the home to help the caregiver. Hospice services in the late stages of dementia can help support the family with nursing services and visitation by primary care provider, home health aides, social services, volunteer visitors, and a spiritual counselor if desired as the client is dying.

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Nursing Care Plans For Bowel incontinence

Nursing Diagnosis: Bowel incontinence
Nursing Care Plans For Bowel incontinence


NANDA Definition: Change in normal bowel habits characterized by involuntary passage of stool.

Defining Characteristics: Constant dribbling of soft stool, fecal odor; inability to delay defecation; rectal urgency; self-report of inability to feel rectal fullness or presence of stool in bowel; fecal staining of underclothing; recognizes rectal fullness but reports inability to expel formed stool; inattention to urge to defecate; inability to recognize urge to defecate, red perianal skin

Related Factors: Change in stool consistency (diarrhea, constipation, fecal impaction); abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance); defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele); sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles); neurological disorders impacting gastrointestinal motility, rectal vault function and sphincter function (cerebrovascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural tube defects, gastroparesis of diabetes mellitus, heavy metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, myasthenia gravis)

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
• Bowel Continence
• Bowel Elimination

Client Outcomes
• Regular, complete evacuation of fecal contents from the rectal vault
• Defecates soft-formed stool
• Decreased or absence of bowel incontinence incidences
• Intact skin in the perianal/perineal area
• Demonstrates the ability to isolate, contract, and relax pelvic muscles , Increases pelvic muscle strength .

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Bowel Incontinence Care
• Bowel Training
• Bowel Incontinence Care: Encopresis

Nursing Interventions and Rationales

• In a reasonably private setting, directly question any client at risk about the presence of fecal incontinence. If the client reports altered bowel elimination patterns, problems with bowel control or "uncontrollable diarrhea," complete a focused nursing history including previous and present bowel elimination routines, dietary history, frequency and volume of uncontrolled stool loss, and aggravating and alleviating factors. Unless questioned directly, patients are unlikely to report the presence of fecal incontinence. The nursing history determines the patterns of stool elimination to characterize involuntary stool loss and the likely etiology of the incontinence .
• Complete a focused physical assessment including inspection of perineal skin, pelvic muscle strength assessment, digital examination of the rectum for presence of impaction and anal sphincter strength, and evaluation of functional status (mobility, dexterity, visual acuity). A focused physical examination helps determine the severity of fecal leakage and its likely etiology. A functional assessment provides information concerning the impact of functional status on stool elimination patterns and incontinence.
• Complete an assessment of cognitive function. Dementia, acute confusion, and mental retardation are risk factors for fecal incontinence.
• Document patterns of stool elimination and incontinent episodes via a bowel record, including frequency of bowel movements, stool consistency, frequency and severity of incontinent episodes, precipitating factors, and dietary and fluid intake. This document is used to confirm the verbal history and to assist in determining the likely etiology of stool incontinence. It also serves as a baseline to evaluate treatment efficacy.
• Identify the probable causes of fecal incontinence. Fecal incontinence is frequently multifactorial; therefore identification of the probable etiology of fecal incontinence is necessary to select a treatment plan likely to control or eliminate the condition.
• Improve access to toileting:

o Identify usual toileting patterns among persons in the acute care or long term care facility and plan opportunities for toileting accordingly.
o Provide assistance with toileting for patients with limited access or impaired functional status.
o Institute a prompted toileting program for persons with impaired cognitive status.
o Provide adequate privacy for toileting.
o Respond promptly to requests for assistance with toileting.

• For the client with intermittent episodes of fecal incontinence related to acute changes in stool consistency, begin a bowel reeducation program consisting of:
o Cleansing the bowel of impacted stool if indicated.
o Normalizing stool consistency by adequate intake of fluids and dietary or supplemental fiber.
o Establishing a regular routine of fecal elimination based on established patterns of bowel elimination

• Begin a prompted defecation program for the adult with dementia, mental retardation, or related learning disabilities. Prompted urine and fecal elimination programs have been shown to reduce or eliminate incontinence in the long term care facility and community settings.
• Begin a scheduled stimulation defecation program, including the following steps, for persons with neurological conditions causing fecal incontinence:

o Before beginning the program, cleanse the bowel of impacted fecal material.
o Implement strategies to normalize stool consistency, including adequate intake of fluid and fiber and avoidance of foods associated with diarrhea.
o Whenever feasible, determine a regular schedule for bowel elimination  based on previous patterns of bowel elimination.
o Provide a stimulus before assisting the patient to a position on the toilet. Digital stimulation, stimulating suppository, "mini-enema," or pulsed evacuation enema may be used.
The scheduled, stimulated defecation program relies on consistency of stool and a mechanical or chemical stimulus to produce a bolus contraction of the rectum with evacuation of fecal material.

• Begin a pelvic floor reeducation or muscle exercise program for persons with sphincter incompetence or pseudodyssynergia of the pelvic muscles, or refer persons with fecal incontinence related to sphincter dysfunction to a nurse specialist or other therapist with clinical expertise in these techniques of care. Pelvic muscle reeducation, including biofeedback, pelvic muscle exercise, and/or pelvic muscle relaxation techniques, is a safe and effective treatment for selected persons with fecal incontinence related to sphincter or pelvic floor muscle dysfunction.
• Begin a pelvic muscle biofeedback program among patients with urgency to defecate and fecal incontinence related to recurrent diarrhea. Pelvic muscle reeducation, including biofeedback, can reduce uncontrolled loss of stool among persons who experience urgency and diarrhea as provacative factors for fecal incontinence. Reducing the incidence of diarrhea can help to reduce bowel incontinence.
• Cleanse the perineal and perianal skin following each episode of fecal incontinence. When incontinence is frequent, use an incontinence cleansing product specifically designed for this purpose. Frequent cleaning with soap and water may compromise perianal skin integrity and enhance the irritation produced by fecal leakage.
• Apply mineral oil or a petroleum based ointment to the perianal skin when frequent episodes of fecal incontinence occur. These products form a moisture and chemical barrier to the perianal skin that may prevent or reduce the severity of compromised skin integrity with severe fecal incontinence.
• Assist the patient to select and apply a containment device for occasional episodes of fecal incontinence. A fecal containment device will prevent soiling of clothing and reduce odors in the patient with uncontrolled stool loss.
• Teach the caregivers of the patient with frequent episodes of fecal incontinence and limited mobility to regularly monitor the sacrum and perineal area for pressure ulcerations. Limited mobility, particularly when combined with fecal incontinence, increases the risk of pressure ulceration. Routine cleansing, pressure reduction techniques, and management of fecal and urinary incontinence reduces this risk.
• Consult the physician concerning the use of an anal continence plug for the patient with frequent stool loss. The anal continence plug is a device that can reduce or eliminate persistent liquid or solid stool incontinence in selected patients.
• Apply a fecal pouch to the patient with frequent stool loss, particularly when fecal incontinence produces altered perianal skin integrity. Fecal pouches contain stool loss, reduce odor, and protect the perianal skin from chemical irritation resulting from contact with stool. 
• Consult the physician concerning the use of a rectal tube for the patient with severe fecal incontinence. A large-sized French indwelling catheter has been used for fecal containment when incontinence is severe and perianal skin integrity significantly compromised. The safety of this technique remains unknown.

Geriatric

• Evaluate elderly client for established or acute fecal incontinence when client enters the acute or long term care facility; intervene as indicated. The rate of fecal incontinence among patients in acute care facilities is as high as 3%; in long term care facilities the rate is as high as 50%.
• To evaluate cognitive status in the elderly person, use a NEECHAM confusion scale to identify acute cognitive changes, a Folstein Mini-Mental Status Examination, or other tool as indicated. Acute or established dementia increases the risk of fecal incontinence among elderly persons.

Home Care Interventions

• Assess and teach a bowel management program to support continence.
• Provide clothing that is nonrestrictive, can be manipulated easily for toileting, and can be changed with ease. Avoidance of complicated maneuvers increases the chance of success in toileting programs and decreases the client's risk for embarrassing incontinent episodes.
• Assist the family in arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. Careful planning can both help client retain dignity and maintain integrity of family patterns.
• If the client is limited to bed (or bed and chair), provide a commode or bedpan that can be easily accessed. If necessary, refer the client to physical therapy services to learn side transfers and to build strength for transfers.
• If the client is frequently incontinent, refer for home health aide services to assist with hygiene and skin care.

Client and Family Teaching

• Teach the client and family to perform a bowel reeducation program; scheduled, stimulated program; or other strategies to manage fecal incontinence.
• Teach the client and family about common dietary sources of fiber, as well as supplemental fiber or bulking agents as indicated.
• Teach nursing colleagues and nonprofessional care providers the importance of providing toileting opportunities and adequate privacy for the patient in an acute or long term care facility.
• Refer to nursing diagnoses Diarrhea and Constipation for detailed management of these related conditions.

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Nursing Care Plan For Pregnancy Induced Hypertension (PIH) Preeclampsia and Eclampsia

Pregnancy-induced hypertension (PIH) is a potentially life-threatening disorder that usually develops after the 20th week of pregnancy. It typically occurs in nulliparous women and may be nonconvulsive or convulsive. Preeclampsia, the nonconvulsive form of the disorder, is marked by the onset of hypertension after 20 weeks of gestation. It develops in about 7% of pregnancies and may be mild or severe. The incidence is significantly higher in low socioeconomic groups.

Eclampsia, the convulsive form, occurs between 24 weeks' gestation and the end of the first postpartum week. The incidence increases among women who are pregnant for the first time, have multiple fetuses, and have a history of vascular disease. About 5% of women with preeclampsia develop eclampsia; of these, about 15% die of eclampsia or its complications. Fetal mortality is high because of the increased incidence of premature delivery PIH and its complications are the most common cause of maternal death in developed countries.

Cause of Preeclampsia 
The cause of preeclampsia is unknown, it is often called the “DISEASE OF THEORIES” because many causes have been proposed, yet none has been well established. than how does preeclampsia occur Experts believe that decreased levels of prostaglandins and a decreased resistance to angiotensin II lead to a generalized arterial vasospasm that then causes endothelial damage. The brain, liver, kidney, and blood are particularly susceptible to multiple dysfunctions. Several risk factors have been identified that may predispose a woman to developing preeclampsia: nulliparity; familial history; multiple gestation; patient history of diabetes mellitus, chronic hypertension, renal disease, trophoblastic disease, and malnutrition.

Complications
Generalized arteriolar vasoconstriction is thought to produce decreased blood flow through the placenta and maternal organs. This decrease can result in intrauterine growth retardation, placental infarcts, and abruptio placentae. Hemolysis, elevated liver enzyme levels, and a low platelet count characterize severe eclampsia. A unique form of coagulopathy is also associated with this disorder. Other possible complications include stillbirth of the neonate, seizures, coma, premature labor, renal failure, and hepatic damage in the mother.

Assessment Nursing care Plans For Pregnancy Induced Hypertension
A patient with mild preeclampsia typically reports a sudden weight gain of more than 3 lb (1.4 kg) per week during the second trimester or more than 1 lb (0.5 kg) per week during the third trimester.
The patient's history reveals hypertension, as evidenced by elevated blood pressure readings: 140 mm Hg or more systolic, or an increase of 30 mm Hg or more above the patient's normal systolic pressure, measured on two occasions, 6 hours apart; and 90 mm Hg or more diastolic, or an increase of 15 mm Hg or more above the patient's normal diastolic pressure, measured on two occasions, 6 hours apart.
Inspection reveals generalized edema, especially of the face. Palpation may reveal pitting edema of the legs and feet. Deep tendon reflexes may indicate hyperreflexia.
As preeclampsia worsens, the patient may demonstrate oliguria (urine output of 400 ml/day or less), blurred vision caused by retinal arteriolar spasms, epigastric pain or heartburn, irritability, and emotional tension. She may complain of a severe frontal headache.
In a patient with severe preeclampsia, blood pressure readings increase to 160/110 mm Hg or higher on two occasions, 6 hours apart, during bed rest. Also, ophthalmoscopic examination may reveal vascular spasm, papilledema, retinal edema or detachment, and arteriovenous nicking or hemorrhage.
Preeclampsia can suddenly progress to eclampsia with the onset of seizures. The patient with eclampsia may appear to cease breathing, then suddenly take a deep, stertorous breath and resume breathing. The patient may then lapse into a coma, lasting a few minutes to several hours. Awakening from the coma, the patient may have no memory of the seizure. Mild eclampsia may involve more than one seizure; severe eclampsia, up to 20 seizures.
Physical examination findings in a patient with eclampsia are similar to those of a patient with preeclampsia but more severe. Systolic blood pressure may increase to 180 mm Hg and even to 200 mm Hg. Inspection may reveal marked edema, but some patients exhibit no visible edema.

Diagnostic tests
Blood Hematocrit
Renal Function
Serum uric acid
Creatinine
Creatinine clearance
BUN
Coagulation Platelets
Fibrin degradation products

Nursing diagnoses Nursing Care Plan For Pregnancy Induced Hypertension

• Activity intolerance
  
• Anxiety
  
• Disturbed sensory perception (visual)
  
• Disturbed thought processes
  
• Excess fluid volume
  
• Fear
  
• Impaired urinary elimination
  
• Ineffective coping
  
• Ineffective tissue perfusion: Cerebral, peripheral
  
• Risk for injury
  

Key outcomes

• The patient will be able to perform activities of daily living without excessive fatigue.
  
• The patient will identify strategies to reduce anxiety.
  
• The patient will maintain optimal functioning within the confines of the visual impairment.
  
• The patient will maintain orientation to environment.
  
• The patient's fluid volume will remain within normal parameters.
  
• The patient will verbalize fears and concerns.
  
• The patient's urine output will remain within normal limits.
  
• The patient will demonstrate adaptive coping behaviors.
  
• The patient will exhibit signs of adequate cerebral and peripheral perfusion.
  
• The patient will avoid complications
  

Nursing interventions, Rationales  And Patient teaching
Related to nursing diagnosis

Nursing Management Of Preeclampsia

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Nursing Care Plans For Bathing hygiene Self care deficit

Nursing Diagnosis: Bathing hygiene Self care deficit

NANDA Definition: Impaired ability to perform or complete bathing/hygiene activities for oneself

Defining Characteristics: Inability to: wash body or body parts; obtain or get to water source; regulate temperature or flow of bath water; get bath supplies; dry body; get in and out of bathroom

Impaired physical mobility-functional level classification:

1. Completely independent
   
2. Requires use of equipment or device
   
3. Requires help from another person for assistance, supervision, or teaching
   
4. Requires help from another person and equipment or device
   
5. Dependent does not participate in activity

Related Factors: Decreased or lack of motivation; weakness and tiredness; severe anxiety; inability to perceive body part or spatial relationship; perceptual or cognitive impairment; pain; neuromuscular impairment; musculoskeletal impairment; environmental barriers

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Self-Care: Activities of Daily Living (ADLs)

• Self-Care: Bathing

• Self-Care: Hygiene

Client Outcomes

• Remains free of body odor and maintains intact skin

• States satisfaction with ability to use adaptive devices to bathe

• Bathes with assistance of caregiver as needed without anxiety

• Explains and uses methods to bathe safely and with minimal difficulty

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Bathing

• Self-Care Assistance: Bathing/Hygiene

Nursing Interventions and Rationales

• Assess client's ability to bathe self through direct observation (in usual bathing setting only) and from client/caregiver report, noting specific deficits and their causes. Use of observation of function and report of function provide complementary assessment data for goal and intervention planning .
• If in a typical bathing setting for the client, assess via direct observation using physical performance tests for ADLs. Observation of bathing performed in an atypical bathing setting may result in false data for which use of a physical performance test compensates to provide more accurate ability data .
• Ask client for input on bathing habits and cultural bathing preferences. Creating opportunities for guiding personal care honors long-standing routines, increases control, prevents learned helplessness, and preserves self-esteem. Cultural preferences are respected.
• Develop a bathing care plan based on client's own history of bathing practices that addresses skin needs, self-care needs, client response to bathing and equipment needs. Bathing is a healing rite and should not be routinely scheduled with a task focus. It should be a comforting experience for the client that enhances health..
• Individualize bathing by identifying function of bath , frequency required to achieve function, and best bathing form  to meet client preferences, preserve client dignity, make bathing a soothing experience, and reduce client aggression. Individualized bathing produces a more positive bathing experience and preserves client dignity. Client aggression is increased with shower and tub bathing. Towel bathing increases privacy and eliminates need to move client to central bathing area; therefore it is a more soothing experience than either showering or tub bathing.
•  Request referrals for occupational and physical therapy. Collaboration and correlation of activities with interdisciplinary team members increases the client's mastery of self-care tasks.
• Plan activities to prevent fatigue during bathing and seat client with feet supported. Energy conservation increases activity tolerance and promotes self-care.
• Provide medication for pain 45 minutes before bathing if needed. Pain relief promotes participation in self-care.
• Consider environmental and human factors that may limit bathing ability, such as bending to get into tub, reaching required for bathing items, grasping force needed for faucets, and lifting of self. Adapt environment by placing items within easy reach, lowering faucets, and using a handheld shower. Environmental factors affect task performance. Function can be improved based on engineering principles that adapt environmental factors to the meet the client's capabilities.
• Use any necessary adaptive bathing equipment. Adaptive devices extend the client's reach, increase speed and safety, and decrease exertion.
• Provide privacy: have only one caregiver providing bathing assistance, encourage a traffic-free bathing area, and post privacy signs. The client perceives less privacy if more than one caregiver participates or if bathing takes place in a central bathing area in a high-traffic location that allows staff to enter freely during care .
• Keep client warmly covered. Clients, especially elderly clients, who are prone to hypothermia may experience evaporative cooling during and after bathing, which produces an unpleasant cold sensation .
• Allow client to participate as able in bathing. Smile and provide praise for accomplishments in a relaxed manner. The client's expenditure of energy provides the caregiver the opportunity to convey respect for a well-done task, which increases the client's self-esteem. Smiling and being relaxed are associated with a calm, functional client response.
• Inspect skin condition during bathing. Observation of skin allows detection of skin problems.
• Use or encourage caregiver to use an unhurried, caring touch. The basic human need of touch offers reassurance and comfort.
• If client is bathing alone, place assistance call light within reach. A readily available signaling device promotes safety and provides reassurance for the client.

Geriatric

• Provide same type of bathrobe and bathing articles, such as scented dusting powder and bath oil, that client used previously. Use of sensory channels to stimulate memory may help foster understanding of bathing and self-care.
• Assess for grieving resulting from loss of function. Grief resulting from loss of function can inhibit relearning of self-care.
• Arrange bathing environment to promote sensory comfort: reduce noise of voices and water and decrease glare from tiles, white walls, and artificial lights. Noise discomfort can result from high-echo tiled walls, loud voices, and running water. Glare can cause visual discomfort, especially in clients with visual changes or cataracts.
• When bathing a cognitively impaired client, have all bathing items ready for client's needs before bathing begins. Injury often occurs when cognitively impaired client is left alone to obtain forgotten items 
• Bathe elderly clients before bedtime to improve sleep. An evening bath helps elderly clients sleep better
• Bathe cognitively impaired clients before bedtime. Bathing a cognitively impaired client in the evening helps improve symptoms of dementia.
• Limit bathing to once or twice a week; provide a partial bath at other times. Frequent bathing promotes skin dryness. Reducing frequency of bathing decreases aggressive behavior in cognitively impaired clients.
• Allow client or caregiver adequate time to complete the bathing activity. Significant aging increases the time required to complete a task; therefore elderly individuals with a self-care deficit require more time to complete a task.
• Avoid soap or use only mild soap on genital and axillary areas; rinse well. Soap can alter skin pH and thus skin defenses, and it may increase skin dryness that results from decreased oil and perspiration production in the elderly.
• Use tepid water: test water temperature before use with a thermometer. Hot water promotes skin dryness and may burn a client with decreased sensation.
• Use a gentle touch when bathing; avoid vigorous scrubbing motions. Aging skin is thinner, more fragile, and less able to withstand mechanical friction than younger skin.
• Add hydrating bath oils to tub bath water 15 minutes after client immerses in water. Client's skin is coated with oil rather than being hydrated if bath oil is placed in water before client's skin is moistened with water

Home Care Interventions

• Based on functional assessment and rehabilitation capacity, refer for home health aide services to assist with bathing and hygiene. Support by home health aides preserves the energy of the client and provides respite for caregivers.
• Cue cognitively impaired clients in steps of hygiene. Cognitively impaired clients can successfully participate in many activities with cueing, and participation in self-care can enhance their self-esteem.
• Respect the preference of terminally ill clients to refuse or limit hygiene care. Maintaining hygiene, even with assistance, may require excessive energy demands from terminally ill clients. Pain on touch or movement may be intractable and not resolved by medication.
• If a terminally ill client requests hygiene care, make an extra effort to meet request and provide care when client and family will most benefit. When desired, improved hygiene greatly boosts the morale of terminally ill clients.
• Maintain temperature of home at a comfortable level when providing hygiene care to terminally ill clients. Terminally ill clients may have difficulty with thermoregulation, which will add to the energy demand or decrease comfort during hygiene care.

Client And Family Teaching

• Teach client and family how to use adaptive devices for bathing, and teach bathing techniques that promote safety . Adaptive devices can provide independence, safety, and speed.
• Teach client and family an individualized bathing routine that includes a schedule, privacy, skin inspection, soap or lubricant, and chill prevention. Teaching methods to meet client's needs increases the client's satisfaction with the bathing experience.

Source Nursing Diagnosis : A Guide To Planning Care

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