ASSESSMENT

BACKGROUND KNOWLEDGE

DIAGNOSIS

PLANNING

NURSING STRATEGIES / INTERVENTION
Independent: Position the client into dorsal recumbent or side lying position for bed rest Provide Emotional Support to the client

RATIONALE

EVALUATION

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After 3 days of nursing Helps in aiding for the evacuation of sodium and to diuresis Client are vague in their condition and must be supported by the nurse to help the client understand the intervention, the maternal blood pressure was alleviated from mild hypertension to normal as evidenced by: >BP- 120/80 mmHg >R- 20 cpm >P- 74 bpm >(-) edema of hands and face >(-) proteinuria

Subjective: -³Mataas po ang presyon ko kapag nagbubuntis ako´ as verbalized by the mother Objective: >G4P3 Pu 39 wks >BP- 140/80 mmHg >R- 18 >P- 87 >(-) edema of hands and face >(+) proteinuria

Vasospasm of the veins and arteries

Ineffective Tissue Perfusion related to vasoconstriction of blood vessels as manifested by a blood pressure of 140/80 mmHg

Within 3 days of nursing intervention, the maternal blood pressure will be alleviated from mild hypertension to normal

vasoconstriction

Poor organ perfusion esp. in the renal tubules Monitor VS q30

seriousness of the symptoms To check for the possibility of progress from mild preeclampsia to severe

Initiation of RAAS Assess for Upper extremities and face for presence of edema Water Retention Provide a calm environment to the patient Increased Blood Pressure Dependent: Administer Magnesium Sulfate as ordered by the physician Collaborative: Refer to a nutritionist to ensure that the client has a balanced diet meal planlike bland or low salt diet

preeclampsia To know if the client has moved from mild to severe preeclampsia To alleviate stress and to prevent severe pre-eclampsia

To prevent seizures

A balanced diet has low salt that helps alleviate the problem of BP resulting from activation of RAAS system

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