Assessment Nursing Diagnosis Planning Intervention Rationale Evaluaton

Cues: Independent
 Subjective Decreased Cardiac Short Term: Short Term:
“Pagod na output r/t decreased After 3 hrs of 1)Establish rapport 1.To gain pt’s trust The pt shall have
pagod na ako venous return nursing and cooperation displayed
at nahihirapan secondary to interventions, the 2.Monitor and assess VS 2.To obtain baseline hemodynamic
na ako eclampsia, altered pt will display stability (blood
huminga!” as BP and edema blood pressure 3.Assess the pt’s general 3.To determine pressure within
verbalized by within her normal physical condition presence of closer range)
the patient. range abnormality
4.Determine baseline 4.Provides
Long Term: vital signs/hemodynamic opportunities to Long Term:
 Objective After 3 days of Parameters including track changes The pt shall have
nursing peripheral pulses. demonstrated
Edema interventions, the activities that
pt will demonstrate 5. Review signs of 5.To prevent reduce the workload
Variations in activities that impending failure /shock. hypovolemic shock of the heart (stress
BP reading reduce the management,
Restlessness workload of the 6.Position with flat or 6.To increase therapeutic
heart. keep trunk horizontal venous return medication regimen
V/S while raising legs 20 to program, balanced
BP: 30 degrees activity/rest plan
175/80mmHg (contraindicated in
Temp: 37.0 C congestive state in which
RR: 25 cpm semi-fowler’s position is
Pulse: 115 bpm preferred)

7. Promote adequate rest 7.To maximize

by decreasing stimuli. sleep periods
NAME OF DRUG MECHANISM ADMINISTRATIO INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING
OF ACTION N RESPONSIBILITIES
Dosage
GENERIC NAME: Cofactor of IV or IM: pre Contraindicated with SLE: syndrome Assess possibility
Magnesium many enzyme 2.5 g eclampsia or allergy to magnesium joint swelling, for interactions w/
Sulfate systems eclampsia products; heart fever) reaction, other drugs or
involved in 5g block, myocardial anemia, herbal products
neuro chemical damage; fecal agranulocytosis, the patient may be
transmission Route To correct o r impaction, intestinal hepatitis, taking especially
and muscular prevent and biliary tract glomerulo anything that may
excitability; 2.5g IV hypomagnesemia obstruction nephritis, acute impact blood
prevents or in patients or renal failure. pressure before
controls 5g IM parenteral Do not give during 2 start treatment.
seizures by nutrition hours preceding
blocking neuro delivery because of Monitor patients
Frequency
muscular risk of magnesium closely during and
transmission; toxicity to the following infusions.
5g IV through
attracts and neonate Observe
IM at each
retains water orthostatic
buttocks q6
in the intestinal precautions.
lumen and
distends bowel
to promote
mass
movement and
relieve
constipation