Nursing

Needs/Problems/Cues Scientific Basis Objectives of Care Nursing Actions Rationale

Diagnosis
I. Physiologic Ineffective The blood pressure, or the force of blood against the Goal: Measures to
Overload tissue walls of your arteries, becomes high enough to After 5 days of improve circulation
perfusion: damage your arteries and other blood vessels. holistic nursing and maintain the
A. Ineffective tissue Edema Damage to your arteries may restrict blood flow. It can care, the client will normal range of
perfusion related to produce swelling in the blood vessels in your brain, be able to blood pressure:
elevated extremities and to your growing baby. If this abnormal demonstrate 1. Encourage  To lessen in
Subjective Cues: blood blood flow through vessels interferes with your brain’s behaviors and client to limit contributing
 Verbalization pressure. ability to function, seizures may occur. lifestyle changes salt intake and to edema.
of worry over Source: to improve protein intake.
the obvious https://www.healthline.com/health/eclampsia#causes circulation and 2. Instruct in  To facilitate
sign of maintain the blood pressure management
swelling. normal range of monitoring at of
blood pressure. home. hypertension,
Objective Cues: which is a
 Blood pressure Objectives: major risk
of 140/110 After 8 hours of factor for
mmHg nurse-client damage to
 Presence of interaction, the blood vessel
protein in client will be to: organ
urine function.
 Pitting and 1. decrease 3. Collaborate in  To maximize
general edema blood treatment of systemic
at the upper pressure hypertension. circulation
and lower from and organ
extremities 140/110 perfusion
and face mmHg to 4. Administer  To improve
120/90 medications tissue
mmHg such as perfusion or
below. antiplatelets organ
2. Improve agents or function.
tissue thrombolytics.
perfusion
as
evidenced
by
absence of
edema.
5. Administer  To promote
 fluids, optimal
electrolytes, blood flow,
nutrients, and organ
oxygen, as perfusion,
indicated and function.
0

MANAGEMENT OF ECLAMPSIA

Nursing Management Medical Management Pharmacologic Management Surgical Management

1. To prevent aspiration, turn her 1. Administer oxygen by face mask 1. Magnesium sulfate or diazepam 1. If fetus appears to be in
onto her side to allow secretions as needed to protect fetal (Valium) may be administered imminent danger, cesarean birth
to drain from her mouth. oxygenation. intravenously as emergency becomes birth of choice.
measures.
2. Assess oxygen saturation via 2. Preferred method of birth is
pulse oximeter. vaginal because of the minimal
use of anesthesia.
3. Apply an external fetal heart
monitor if one is not already in
place to assess the FHR.
4. Check for vaginal bleeding to
detect placental separation,
although evidence placental
separation has occurred will
probably appear first on the
fetal heart record; vaginal
bleeding will strengthen
presumption.
5. Be certain to
assess for uterine
contractions
during the
postictal stage
because if labor
begins during
this period, the
woman will be
unable to report
 the sensation of
contractions.
Pain stimulus can
initiate seizures.
6. Give her nothing
to eat.
7. Conversation is
limited to those
things you would
say if she were
awake.