ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING RATIONALE EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS

Subjective Data: According to NOC NIC Goal was met as
Decreased NANDA, manifested by:
Subjective Cues: Cardiac Output Decrease Cardiac Cardiac Pump Hemodynamic
related to Output define as Effectiveness Regulations
• Mrs. SC, Altered preload: inadequate blood Short term goal
35 years old, decreased pumped by the Short term goal Check for any Decreased cerebral
multigravida venous return as heart to meet the alterations in level perfusion and After 7 hours of
evidenced by metabolic After 7 hours of of consciousness. hypoxia are nursing intervention
• During elevated BP of demands of the nursing intervention reflected in the client was able
the first trimester, 180/90 mmhg body  the client will be able irritability, to:
spotting was and presence of to: restlessness, and
noted. edema difficulty
concentrating. a. Determine and
• In the a. Verbalize verbalized
second trimester, knowledge of Monitor blood disease process,
she didn’t the disease pressure of the Comparison of risk factors to
experience any process and patient. Measure in pressures provides avoid severity,
individual risk both arms or thighs a more complete and participate
discomfort
factors. three times,3- picture of vascular in activities that
related to 5minutes apart while involvement or reduce blood
pregnancy except Long term goal: patient is at rest, scope of the pressure.
that she felt like After 1-2 days of then sitting, then problem
her diet was nursing intervention standing for initial Long term goal:
uncontrolled. She the client will be able evaluation After 1-2 days of
was fond of to: nursing intervention
the client was able
eating chocolates,
to:
fruit shakes, and a. Display Review clients at Acute or chronic
ice cream. hemodynamic risk as noted in conditions (e.g.,
stability Related Factors and multiple trauma, a. Display
• On her
Defining renal failure, hemodynamic
third trimester,
she was surprised Characteristics, as brainstem trauma, stability as
upon knowing well as individuals spinal cord injuries evidenced by
some deviations with conditions that at T8 or above, reduce blood
from her vital stress the heart. alcohol or other pressure or
drug abuse/ cardiac
signs. She was
overdose, and workload,
troubled about pregnancy with management
some discomforts hypertensive state) of edema and
in certain areas of may compromise proteinuria
her body. circulation and
place excessive
•According to her demands on the
she was troubled heart.
about the edema Note age and ethnic-
that she related When in the supine
experienced in cardiovascular position, pregnant
considerations. women incur
both feet and
decreased vascular
hands. return during the
second and third
trimesters,
Objective Data: potentially
compromising
OB Score: cardiac output.
G2T1P0A0L1 

Vital Signs upon

admission:  
T: 37.4  Encourage Help reduce
RR: 17  relaxation sympathetic
P: 80  techniques, provide stimulation,
BP: 180/90  calm, restful promotes
UTZ surroundings, relaxation, reduce
result: Abnormal minimize anxiety and
cord coiling  environmental conserve energy.
   activity or noise.
Urinalysis
Result: 
Sugar (-) 
Protein (++++)  Maintain activity Reduces physical
Ketones (-)  restrictions stress and tension
Blood (-)  that affect blood
Bilirubin (-)  pressure and course
WBC (0-2)  of hypertension.
Bacteria – none 

Elevate edematous Elevation increases

Laboratory extremities, and venous return to the
Report  handle with care. heart and, in turn,
Examination: 75 decreases edema.
grams OGTT  Edematous skin is
more susceptible to
injury.
  
Test Result Unit
Normal Value 
   Improve nutritional sodium-restricted
FBS 5.34 Intake diet should be
2nd Hour BS  5.99 maintained while a
patient is
edematous and
until proteinuria
remits; during
severe edema,
careful and modest
fluid restriction
 may be appropriate,
but the patient must
be monitored
closely for
excessive
intravascular
volume depletion.

Administer diuretics Diuretics promote

such as Thiazide excretion of water
diuretics such as and electrolytes by
hydrochlorothiazide the kidneys; these
(Microzide) and agents are used to
evaluate patient's treat heart failure or
response. hepatic, renal, or
pulmonary disease
when sodium and
water retention has
resulted in edema
or ascites.

Administer This agent is used

Immunosuppressive to supplement
agents such as diuresis in patients
prednisone and with edema; it
evaluate patient’s increases oncotic
response pressure and
thereby promotes a
fluid shift from
interstitial tissues.