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Medical Diagnosis: Pre-Eclampsia

Problem: Decreased Cardiac Output RT Decreased Venous Return

Assessment Nursing Diagnosis Scientific Planning Interventions Rationale Evaluation


Explanation
Subjective: Patient may Decreased Cardiac Inadequate blood is Short Term: 1. Establish rapport 1. To gain pt’s trust Short Term:
verbalize output r/t decreased pumped by the heart After 3 hrs of nursing 2. Monitor and assess and cooperation The pt shall have
 Palpitations venous return to meet the interventions, the pt VS 2. To obtain baseline displayed
 Fatigue secondary to severe metabolic demands will display 3. Assess the pt’s 3. To determine hemodynamic
general physical presence of
 Shortness of preeclampsia AEB of the body. It hemodynamic stability (blood
condition abnormality
breath/dyspnea altered BP and resulted from a stability AEB blood pressure within
 anxiety edema systemic vaso pressure within her 4. Determine baseline 4. Provides
closer range)
constriction in the body normal range vital opportunities to
Objective: caused by signs/hemodynami track changes Long Term:
Patient manifested: preeclampsia. Long Term: c parameters The pt shall have
Vasoconstriction is the After 3 days of demonstrated
 Weight gain including
decrease in the nursing peripheral pulses. activities that reduce
 Edema diameter of the blood interventions, the pt the workload of the
 Variations in BP vessels which occur in will demonstrate 5. Review signs of 5. To prevent heart (stress
reading diseases like impending failure hypovolemic shock
activities that reduce management,
 Restlessness pregnancy-induced /shock.
hypertension.
the workload of the therapeutic
Decreased blood supply heart (stress medication regimen
Patient’s fetus may 6. Position with HOB 6. To increase venous
leads to a decrease in management, program, balanced
manifest: flat or keep trunk return
venous return, thus therapeutic activity/ rest plan)
 Jugular vein horizontal while
there is a relatively medication regimen raising legs 20 to
distention smaller amount of program, balanced 30 degrees
 Cold clammy skin blood expelled by the activity/ rest plan) (contraindicated in
 Arrhythmaia ventricles of the heart. congestive state in
 crackles which semi-
 Prolonged fowler’s position is
capillary refill preferred)

7. Promote adequate 7. To maximize sleep


rest, by decreasing periods
stimuli, providing
quiet environment

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8. Maintain patency 8. To prevent air
of invasive embolus and/or
intravascular exsanguination.
monitoring and
infusion lines. Tape
connections.

9. Avoid activities 9. May stimulate a


such as isometric valsalva response
exercises, rectal
stimulation,
vomiting, and
spasmodic
coughing.
Administer stool
softener as
indicated.

10. Encourage pt to 10. This prevents


breathe deeply exertion of too
in/out during much workload to
activities that the heart.
increase risk for
valsalva effect.

11. Provide 11. Honesty can be


psychological reassuring when so
support. Maintain much activity and
calm attitude “worry” are
butadmit concerns apparent to the
if questioned by patient.
the client.

12. Encourage 12. To reduce anxiety


relaxation
techniques.

13. Elevate edematous 13. To promote


extremities and comfort
avoid restrictive

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clothing.

14. Provide for diet 14. To enhance pt’s


restrictions. therapeutic
regimen

15. Monitor intake and 15. To determine fluid


output. balance

16. Discuss significant 16. May be sign of


signs and drug toxicity
symptoms that and/or mineral loss
need to be , especially
reported to the potassium.
healthcare
provider ( e.g.
muscle cramps,
d/a, dizziness, skin
rashes). 17. To reduce risk of
orthostatic
17. Encourage hypotension
changing positions
slowly, dangling
legs before
standing.

18. Give information 18. To provide


about positive encouragement.
signs of
improvement such
as decreased
edema, improved
vital signs /
circulation). 19. To increase oxygen
19. Administer available to tissues
supplemental
oxygen as
indicated.

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20. Administer due
meds.

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