Assessment Cues: Subjective Pagod na pagod na ako at nahihirapan na ako huminga! as verbalized by the patient.

. Objective Edema Variations in BP reading Restlessness V/S BP: 175/80mmHg Temp: 37.0 C RR: 25 cpm Pulse: 115 bpm

Nursing Diagnosis

Planning

Intervention Independent

Rationale

Evaluaton

Decreased Cardiac output r/t decreased venous return secondary to eclampsia, altered BP and edema

Short Term: After 3 hrs of nursing interventions, the pt will display blood pressure within her normal range Long Term: After 3 days of nursing interventions, the pt will demonstrate activities that reduce the workload of the heart.

1)Establish rapport 2.Monitor and assess VS 3.Assess the pts general physical condition 4.Determine baseline vital signs/hemodynamic Parameters including peripheral pulses. 5. Review signs of impending failure /shock. 6.Position with flat or keep trunk horizontal while raising legs 20 to 30 degrees (contraindicated in congestive state in which semi-fowlers position is preferred) 7. Promote adequate rest by decreasing stimuli.

1.To gain pts trust and cooperation 2.To obtain baseline 3.To determine presence of abnormality 4.Provides opportunities to track changes

Short Term: The pt shall have displayed hemodynamic stability (blood pressure within closer range)

5.To prevent hypovolemic shock 6.To increase venous return

Long Term: The pt shall have demonstrated activities that reduce the workload of the heart (stress management, therapeutic medication regimen program, balanced activity/rest plan

7.To maximize sleep periods

NAME OF DRUG

MECHANISM OF ACTION Cofactor of many enzyme systems involved in neuro chemical transmission and muscular excitability; prevents or controls seizures by blocking neuro muscular transmission; attracts and retains water in the intestinal lumen and distends bowel to promote mass movement and relieve constipation

ADMINISTRATIO N Dosage 2.5 g 5g Route 2.5g IV 5g IM Frequency 5g IV through IM at each buttocks q6

INDICATION

CONTRAINDICATION

ADVERSE EFFECT

NURSING RESPONSIBILITIES Assess possibility for interactions w/ other drugs or herbal products the patient may be taking especially anything that may impact blood pressure before start treatment. Monitor patients closely during and following infusions. Observe orthostatic precautions.

GENERIC NAME: Magnesium Sulfate

IV or IM: pre eclampsia or eclampsia

To correct o r prevent hypomagnesemia in patients or parenteral nutrition

Contraindicated with allergy to magnesium products; heart block, myocardial damage; fecal impaction, intestinal and biliary tract obstruction Do not give during 2 hours preceding delivery because of risk of magnesium toxicity to the neonate

SLE: syndrome joint swelling, fever) reaction, anemia, agranulocytosis, hepatitis, glomerulo nephritis, acute renal failure.