NURSING CARE PLAN

CUES BACKGROUND NURSING PLANNING IMPLEMEN- RATIONALE EVALUATION

KNOWLEDGE DIAGNOSI TATION
S

SUBJECTIVE: Pre-eclampsia is a medical Ineffective After 8 hours of INDEPENDENT: GOAL PARTIALLY

“Nahihilo ako. condition in Tissue duty, client will MET
Masakit ang batok which hypertension arises Perfusion RT be able to - Monitor vital signs To identify physical
ko.” as verbalized. in pregnancy (pregnancy- Vasoconstrictio manifest particularly blood responses associated - Blood pressure is
induced hypertension) in n of Blood increased tissue pressure. with medical slightly above
association with significant Vessels perfusion as conditions. normal range:
OBJECTIVE: amounts of protein in the Secondary to evidenced by: 130/90
- Edema urine. Pre-eclampsia refers Pre-eclampsia  blood - Perform assistive ROM promotes
noted on to a set of symptoms rather pressure passive range of improved blood - Skin is warm to
lower than any causative factor, within motion. circulation. touch.
extremities (grade and there are many normal range
2) different causes for the  warm and dry - Provide quiet and It conserves - Capillary refill
condition. It appears likely skin restful environment. energy/lowers tissue within 4 seconds.
- cold, that there are substances  capillary oxygen demand.
clammy skin from the placenta that can refill within - Edema is still
noted. cause endothelial normal range DEPENDENT present (from grade
dysfunction in the maternal (3- 5 2 to grade 1)
- capillary refill blood vessels of seconds) - Administer Antihypertensives
within 6 seconds susceptible women.  absence of antihypertensive drugs help decrease and
While blood edema as ordered. control blood
- BP: pressure elevation is the pressure.
140/100 most visible sign of the - Administer
disease, it involves Magnesium sulfate as Magnesium sulfate
generalized damage to the ordered. prevents or controls
maternal endothelium, kidn seizures in pre-
eys, and liver, with the eclampsia brought
release about by vasospasm
of vasoconstrictive factors secondary to
being secondary to the vasoconstriction of
original damage. blood vessels.