NURSING CARE PLAN

ASSESSMENT DIAGNOSIS
INFERENCE
PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:“Napansin ko nabigla na langbumigat angtimbang ko” (
Inoticed that I gained alot of weight 
) asverbalized by thepatient.Objective:
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 Variations inbloodpressure.
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 Edema
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 V/S taken asfollows:T: 37.1P: 78R: 20BP: 140/90Decreasedcardiac outputrelated todecreasedvenous
return.Preeclampsia is acommon problemduring pregnancy.The condition —sometimes referredto as
pregnancy-induced hypertension — is defined by highblood pressure andexcess protein in theurine after 20
weeksof pregnancy. Often,preeclampsia causesonly modestincreases in bloodpressure. Leftuntreated,
however,preeclampsia canlead to serious —even fatal —complications forboth mother andbaby.
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 After 8 hoursof nursinginterventions,the patient willparticipate inactivities thatreduce bloodpressure orcardiac
workload.
Independent:
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 Monitor bloodpressure of thepatient. Measurein both arms orthighs threetimes, 3-5minutes apartwhile patient
is atrest, then sitting,then standing forinitial evaluation.
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 Observe skincolor, moisture,temperature andcapillary refilltime.
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 Note dependentor generaledema.
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 Provide calm,restfulsurroundings,minimizeenvironmentalactivity or noise.
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 Maintain activityrestrictions.
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 Comparison ofpressuresprovides a morecompletepicture ofvascularinvolvement orscope of theproblem.
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 Presence ofpallor, cool,moist skin anddelayedcapillary refilltime may bedue
toperipheralvasoconstriction
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 May indicateheart failure,renal orvascularimpairment.
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 Help reducesympatheticstimulation,promotesrelaxation.
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 Reducesphysical stressand tension thataffect bloodpressure andcourse of
•
 After 8 hours ofnursinginterventions,the patient wasable toparticipate inactivities thatreduce
bloodpressure orcardiac workload.