Nursing Care Plan for Keratoplasty

Keratoplasty is the surgical removal of a scared cornea and transplantation of a donor cornea to treat corneal degeneration and dystrophies, opacities, scarring, injuries. Types of corneal grafts include penetrating, lamellar, keyhole lamellar.

Nursing diagnosis for keratoplasty: Anxiety related to threat to health status caused by possible loss of vision or transplant injection.

Expected Outcomes: Anxiety within manageable levels of evidenced by verbalizations that anxiety and fear reduced and feeling relaxed.

Nursing intervention with rationale:
I. Assess for:
1. Level of anxiety, feelings about expectations of effect of graft.
Rationale: Anxiety ranges from mild to severe with moderate levels of expected with any surgery.

II. Perform or Provide:
1. Answers to any questions honestly and clearly
Rationale: Reduces anxiety and fear of unknown.

2. Quiet, supportive environment.
Rationale: Reduces anxiety and promotes relaxation.

Nursing diagnosis: Pain related to physical injuring agent caused by surgical graft procedure

Expected Outcomes: Absence of pain or discomfort evidenced by verbalizations that pain relieved by analgesic.

Nursing intervention with rationale:
I. Assess for:
1. Pain, scratchiness in eye, severity, and if increasing.
Rationale: Pain descriptors reveal need for analgesic and potential complications of surgery such as hemorrhage or glaucoma.

II. Administer
1. Mydriatic (atropine 1% eye drops).
Rationale: Decreases spasms of ciliary body to reduce pain.

2. Analgesic (aspirin, acetaminophen, codeine)
Rationale: Acts to relieve pain by interrupting CNS pathways.

III. Perform or Provide
1. Warm or cool compress to eye.
Rationale: Reduces lid and conjunctival edema and removes secretions.

2. Eye shield
Rationale: Prevents accidental rubbing or bumping of eye.

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Nursing Care Plan for Precipitous Labor

Rapid progression of labor, lasting less than 3 hr from onset to delivery, and out-of-hospital delivery are
emergency situations that place the client/fetus at increased risk for complications and/or untoward outcomes. The attending nurse may have primary responsibility for the safety of the mother and fetus.

NURSING PRIORITIES
1. Promote maternal and fetal/newborn well-being.
2. Provide a physiologically and psychologically safe experience for client and newborn.
3. Prevent complications.

Nursing diagnosis of precipitous labor: Anxiety may be related to situational crisis, threat to self/fetus, interpersonal transmission possibly evidenced by increased tension; scared, fearful, restless/jittery; sympathetic stimulation.

Desired Outcomes
1. Use breathing and relaxation techniques effectively.
2. Cooperate with necessary preparations for a rapid delivery.
3. Follow directions and/or actively participate in delivery process.

Nursing intervention with rationale
1. Maintain calm, deliberate manner. Offer clear, concise instructions and explanations.
Rationale: An emergency or extremely rapid delivery occurring out of the hospital or in a hospital setting without the presence of a clinician (physician or nurse midwife) can be extremely anxiety-provoking for the client/couple, who had anticipated an orderly progression through labor and delivery. When the actual birth event is not in keeping with their expectations, reactions may include hostility, fear, and disappointment. Composure of nurse reassures client and prevents transmission of undue concern and anxiety.

2. Provide a quiet environment and privacy within parameters of the situation. Position client for optimal comfort.
Rationale: Reduces distractions/discomfort, allowing client to focus attention. May reduce “contagious” anxiety of onlookers in out-of-hospital delivery and support modesty.

3. Encourage partner/support person to remain with client, provide support, and assist as needed.
Rationale: Allowing full participation by a support person enhances self-esteem, furthers cohesion of family unit, reduces anxiety, and provides assistance for the professional.

4. Remain with client. Provide ongoing information regarding labor progress and anticipated delivery.
Rationale: Reduces anxiety, fosters positive coping and cooperation, and reduces fear associated with the unknown.

5. Support appropriate coping/relaxation techniques.
Rationale: Enhances sense of control; optimizes participation in the birth process.

6. Arrange for services of medical/nursing staff as soon as possible. Inform client that help has been requested.
Rationale: The arrival of assistance helps the client/couple to feel less anxious and more secure.

7. Conduct delivery in a calm manner; provide ongoing explanations.
Rationale: Helps client/couple remain calm and cooperate with instructions.

8. Place newborn on maternal abdomen once newborn respirations are established. Allow partner to hold infant.
Rationale: Helps promote bonding and establishes a positive feeling about the experience.

9. Administer sedation as appropriate.
Rationale: May help slow labor progress and allow client to regain control.

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Nursing Care Plan for Premature Dilation of the Cervix (Incompetent/Dysfunctional Cervix)

Premature dilation of the cervix often occurs in the 4th or 5th mo and is associated with repeated second-trimester spontaneous abortions accounting for 15%–20% of second-trimester pregnancy losses.

NURSING PRIORITIES
1. Evaluate client/fetal status.
2. Assist with efforts to maintain the pregnancy, if possible.
3. Provide emotional support.
4. Provide appropriate instruction/information.

DISCHARGE GOALS
1. Client/fetal condition stable following procedure
2. Uterine contractions absent
3. Therapeutic needs and concerns understood

Nursing diagnosis of incompetent cervix: Anxiety may be related to situational crisis, threat of death/fetal loss possibly evidenced by increased tension, apprehension, feelings of inadequacy, sympathetic stimulation, and repetitive questioning.

Desired Outcomes
1. Verbalize fears and concerns.
2. Report anxiety is reduced to a manageable level. Use individually appropriate coping mechanisms to deal with the short- and long-term outcomes of the situation.

Nursing intervention with rationale:
1. Provide primary nurse, if possible.
Rationale: Facilitates continuity of care and increases client’s/couple’s confidence in care providers.

2. Review obstetric history.
Rationale: The degree of anxiety depends on the nature of the situation, the history of fetal loss, the client’s understanding of the events and proposed interventions, and the client’s coping behaviors, both past and present.

3. Identify client’s perception of the threat represented by this occurrence.
Rationale: The ambiguity of the outcome can aggravate anxiety.

4. Determine availability of support systems and psychological response to event.
Rationale: Establishes data base and plan of care. Degree of negative response and lack of/inadequate support contributes to heightened levels of anxiety, possibly to the point of affecting overall outcome.

5. Assess physiological indicators of anxiety: BP, pulse, respiratory rate, and diaphoresis.
Rationale: Physiological changes in vital signs may have psychological origin.

6. Remain with couple. Explain what is happening and what can be expected. Provide factual information about causes, implications, and proposed treatment.
Rationale: May reduce anxiety by increasing awareness of the circumstance.

7. Provide information on an ongoing basis.
Rationale: Can allay anxiety.

8. Refer to other sources for support or counseling if anxiety is excessive or support systems are inadequate.
Rationale: May aid in long-term adjustment to situation.

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Nursing Care Plan for Cesarean Delivery

Cesarean birth is an alternative to vaginal birth only when the safety of the mother and/or fetus is compromised.


NURSING PRIORITIES
1. Promote maternal/fetal well-being.
2. Provide client/couple with necessary information.
3. Support client’s/couple’s desires to participate actively in birth experience.
4. Prepare client for surgical procedure.
5. Prevent complications.

Nursing Diagnosis: Anxiety may be related to situational crisis, threat to self-concept, perceived/actual threat of maternal and fetal well-being, interpersonal transmission possibly evidenced by increased tension, distress, apprehension, feelings of inadequacy, sympathetic stimulation, restlessness

Desired Outcomes:
1. Verbalize fears for the safety of client and infant.
2. Discuss feelings about cesarean birth.
3. Appear appropriately relaxed.

Nursing interventions and rationale
1. Assess psychological response to event and availability of support system(s).
Rationale: The greater the client perceives the threat, the greater the level of her anxiety.

2. Note cultural influences/expectations.
Rationale: Some cultures (e.g., Latin, Mexican/Arab-American) may view surgical intervention as detrimental to the client’s well-being or may believe client will be stigmatized as a “weak woman” (e.g., Puerto Rican).

3. Ascertain whether procedure is planned or unplanned.
Rationale: With unplanned cesarean birth, the client/couple usually has no time for physiological or psychological preparation. Even when planned, cesarean birth can create apprehension in the client/couple owing to an actual or perceived physical threat to the mother and infant related to the condition necessitating the procedure and to the surgery itself.

4. Stay with client, and remain calm. Speak slowly. Convey empathy.
Rationale: Helps to limit interpersonal transmission of anxiety, and demonstrates caring for the client/couple.

5. Reinforce positive aspects of maternal and fetal condition.
Rationale: Focuses on likelihood of successful outcome and helps to bring perceived/actual threat into perspective.

6. Encourage client/couple to verbalize and/or express feelings (cry).
Rationale: Helps to identify negative feelings/concerns and provides opportunity to cope with ambivalent or unresolved feelings/grief. The client may also feel an emotional threat to her self-esteem, owing to her feelings that she has failed, that she is weak as a woman, and that her expectations have not been met. Partner may question own abilities in assisting client and providing needed support.

7. Support/redirect expressed coping mechanisms.
Rationale: Enhances basic and automatic coping mechanisms, increases self-confidence and acceptance, and reduces anxiety. Note: Some client actions may be viewed as ineffective (e.g., screaming and throwing things) and need to be redirected to enhance client’s sense of control.

8. Discuss past childbirth experience/expectations, as appropriate.
Rationale: Client may have distorted memories of past delivery or unrealistic perceptions of abnormality of cesarean birth that will increase anxiety.

9. Provide period of privacy, if possible. Reduce environmental stimuli, such as the number of people present, as indicated by client’s desires.
Rationale: Allows client/couple opportunity to internalize information, marshal resources, and cope effectively.

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Nursing Care Plan for Prenatal Hemorrhage

Prenatal Hemorrhage may occur early or late in pregnancy, owing to certain physiological problems, each with its own signs and symptoms, which help in establishing a differential diagnosis and in creating the plan of care. This general guide for care is meant to treat hemorrhage in the antepartal client. Where appropriate, interventions specific to each physiological problem are identified.

NURSING PRIORITIES
1. Determine client/fetal status.
2. Maintain circulating fluid volume.
3. Assist with efforts to sustain the pregnancy, if possible.
4. Prevent complications.
5. Provide emotional support to the client/couple.
6. Provide information about possible short- and long-term implications of the hemorrhage.

DISCHARGE GOALS
1. Homeostasis achieved
2. Pregnancy maintained
3. Free of complications
4. Client/couple dealing constructively with situation
5. Condition, prognosis, and treatment needs understood

Nursing diagnosis of Prenatal Hemorrhage: Fluid Volume deficit may be related to excessive vascular loss possibly evidenced by hypotension, increased pulse rate, decreased pulse pressure, decreased/concentrated urine, decreased venous filling, change in mentation.

Nursing intervention with rationale:
1. Evaluate, report, and record amount and nature of blood loss. Initiate pad count; weigh pads/underpad.
Rationale: Estimation of blood loss helps in differential diagnosis. Each gram of increased pad weight is equal to approximately 1 ml of blood loss.

2. Institute bedrest. Instruct client to avoid maneuver and intercourse or any sexual activity that could lead to orgasm.
Rationale: Valsalva’s Bleeding may stop with a reduction in activity.Increased abdominal pressure or orgasm (which increases uterine activity) may stimulate bleeding.

3. Position client appropriately, either supine with hips elevated or in semi-Fowler’s position for placenta previa. Avoid Trendelenburg position.
Rationale: Ensures adequate blood available to the brain.Elevating hips avoids compression of the vena cava, while semi-Fowler’s position allows the fetus to act as a tampon, controlling bleeding in placenta previa. Trendelenburg position may compromise maternal respiratory status.

4. Note vital signs, capillary refill of nailbeds, color of mucous membranes/skin, and temperature. Measure CVP, if available.
Rationale: Helps determine severity of blood loss, although cyanosis and changes in BP and pulse are late signs of circulatory loss and/or developing shock. Also monitors adequacy of fluid replacement.

5.Monitor uterine activity, fetal status, and any abdominal tenderness.
Rationale: Helps determine nature of the hemorrhage and possible outcome of hemorrhagic episode. Tenderness is usually present in ruptured ectopic pregnancy or abruptio placentae.

6. Ascertain religious practices and preferences.
Rationale: May prohibit use of blood products and establish need for alternative therapy.

7. Avoid rectal or vaginal examination.
Rationale: May increase hemorrhage, especially if marginal or total placenta previa is present.

8. Record intake/output. Obtain hourly urine samples; measure specific gravity.
Rationale: Determines extent of fluid losses and reflects adequacy of renal perfusion.

9. Obtain/review stat blood work: CBC, type and crossmatch, Rh titer, fibrinogen levels, platelet count, APTT, PT, and HCG levels.
Rationale: Determines amount of blood loss and may provide information regarding cause. Hct should be maintained above 30% to support oxygen and nutrient transport.

10. Prepare for cesarean delivery if any of the following are diagnosed: severe abruptio placentae, DIC; or placenta previa when fetus is mature, vaginal delivery is not feasible, and bleeding is excessive or unresolved by bedrest.
Rationale: Hemorrhage stops once the placenta is removed and venous sinuses are closed.

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Nursing Care Plan for Prenatal Substance Dependence/Abuse

Substance Dependence/Abuse is a continuum of phases incorporating a cluster of cognitive, behavioral, and physiological symptoms that include loss of control over use of the substance and continued use of the substance, despite adverse maternal/fetal consequences (e.g., poor nutrition/weight gain, anemia, predisposition to infection, PIH, fetal defects/IUGR, fetal alcohol syndrome [FAS]). The drugs most often abused are alcohol, cocaine (crack), heroin, methamphetamine, barbiturates, marijuana, and phencyclidine (PCP). Care depends on the degree of abuse and whether the client is intoxicated or is in the withdrawal phase. The client who is addicted may not seek care during the prenatal period, compounding any existing or developing problems. In addition, negative attitudes on the part of society and often from caregivers affect the pregnant woman and her care.

A return to health consists of gaining a mastery and control over self and environment, and pleasure seeking that does not require the use of drugs.


NURSING PRIORITIES
1. Promote physiological stability and well-being of client and fetus.
2. Support client’s acceptance of reality of situation.
3. Facilitate learning of new ways to reduce anxiety; strengthen individual coping skills.
4. Incorporate client into supportive community environment.
5. Promote family involvement in treatment process.
6. Provide information about condition, prognosis, and treatment needs.


DISCHARGE GOALS
1. Free of injury/complications to self and fetus/newborn.
2. Engaged in treatment modalities by identifying and using support systems.
3. Responsibility for own life and behavior assumed.
4. Abstinence from drug(s) maintained on a day-to-day basis.
5. Dependence condition and its impact on pregnancy, prognosis, and therapeutic regimen verbalized.
6. Participation in follow-up care by making and keeping all appointments, managing therapeutic regimen.

Nursing diagnosis of Prenatal Substance Dependence/Abuse: Nutrition: altered, less than body requirements may be related to insufficient dietary intake to meet metabolic needs for psychological, physiological, or economic reasons possibly evidenced by low-weight gain, prepregnant weight below norm for height/body build, decreased subcutaneous fat/muscle mass, poor muscle tone, reported altered taste sensation, lack of interest in food; sore, inflamed buccal cavity; laboratory evidence of protein/vitamin deficiencies.

Desired Outcomes:
1. Verbalize understanding of effects of substance abuse and reduced dietary intake on nutritional status and pregnancy.
2. Demonstrate behaviors and lifestyle changes to regain/maintain appropriate weight for pregnancy.

Nursing intervention with rationale:
1. Determine age, height/weight, body build, strength, and activity/rest pattern. Note condition of oral cavity.
Rationale: Provides information on which to base caloric needs/dietary plan. Type of diet/foods may be affected by condition of mucous membranes and teeth.

2. Obtain anthropometric measurements, e.g., triceps skinfold.
Rationale: Calculates subcutaneous fat and muscle mass to aid in determining dietary needs.

3. Note total daily calorie intake. Encourage client to maintain a diary of intake, times, and patterns of eating.
Rationale: Information about patient’s dietary pattern will identify nutritional strengths, needs, and deficiencies.

4. Discuss prenatal nutritional needs and develop dietary plan. Assist with developing a grocery budget and provide opportunity to choose foods or snacks to meet dietary plan.
Rationale: Enhances participation/sense of control and may promote resolution of nutritional deficiencies.

5. Evaluate energy expenditure (e.g., pregnancy needs, pacing or sedentary activities), and establish an individualized exercise program.
Rationale: Pregnant state and activity level affect nutritional needs. Exercise enhances muscle tone, may stimulate appetite, and promotes sense of well-being.

6. Weigh client weekly and record.
Rationale: Provides information regarding current status/effectiveness of dietary plan.

7. Consult with dietitian.
Rationale: Useful in establishing individual dietary needs/plan. Provides additional resource for learning about the importance of nutrition in nonpregnant and pregnant states.

8. Review laboratory work as indicated; e.g., glucose, serum albumin, and electrolytes.
Rationale: Identifies anemias, electrolyte imbalances, and other abnormalities that may be present, requiring specific therapy. Note: Toxic vapor abuse of toluenebased solvents (such as spray paint or glue) may cause a distal renal tubular acidosis with resultant hypokalemia, hypophosphatemia, hypomagnesemia, and hypocalcemia as well as rhabdomyolysis.

9. Refer for dental consultation as necessary.
Rationale: Teeth are essential to good nutritional intake, and dental hygiene/care is often neglected in this population.

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