NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING

INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • After 8
hours • Monitor blood • Comparison of • After 8 hours of
Decreased of nursing
pressure of the pressures nursing
Preeclampsia is a
“Napansin ko na cardiac output
interventions, patient. Measure provides a more
interventions,
bigla na lang related to common problem the patient
will in both arms or complete the patient was
bumigat ang decreased during pregnancy. participate
in thighs three picture of able to
timbang ko” (I venous return. The condition — activities
that times, 3-5 vascular participate in
noticed that I gained a reduce blood
minutes apart involvement or activities that
sometimes referred
lot of weight) as pressure or
while patient is at scope of the reduce blood
verbalized by the to as pregnancy-
cardiac work
rest, then sitting, problem. pressure or
patient. induced hypertension
load.
then standing for cardiac work
— is defined by high
initial evaluation. load.
Objective: blood pressure and
• Observe skin • Presence of
excess protein in the
color, moisture, pallor, cool,
• Variations in
temperature and moist skin and
urine after 20 weeks
blood
capillary refill delayed
pressure. of pregnancy. Often,

time. capillary refill

preeclampsia causes
time may be
• Edema only modest
due to
increases in blood
peripheral
• V/S taken as pressure. Left
vasoconstriction
follows:
untreated, however,
• Note dependent • May indicate

or general heart failure,

T: 37.1 preeclampsia can
edema. renal or
P: 78 lead to serious —
vascular
R: 20 even fatal —
impairment.
BP: 140/90 complications for
• Provide calm, • Help reduce
both mother and
restful sympathetic
baby.
surroundings, stimulation,

minimize promotes

environmental relaxation.

activity or noise.

• Maintain activity • Reduces

restrictions. physical stress

and tension that

affect blood

pressure and

course of
 hypertension.
• Instruct in • Can reduce
relaxation stressful stimuli,
techniques, and produce
guided imagery. calming effect,
thereby reduce
blood pressure.

Collaborative:
• Implement dietary • These
sodium, fat, and restrictions can
cholesterol help manage
restrictions as fluid retention
indicated. and with
associated
hypertensive
response,
which decrease
cardiac
workload.