TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

NURSING CARE PLAN

Name: Patient DTI
Age: 27 y/o
Medical Diagnosis: Preeclampsia
NURSING CARE PLAN
ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EXPECTED
DIAGNOSIS OUTCOME

S: Deficient After 30 minutes of Independent:

“Hindi ko po sinasabi sa OB ko ang knowledge appropriate nursing
aking pagmamanas dahil ang sabi ng related to intervention, the  Assess the client`s understanding  To provide information After 1 hour of
coworker ko ay normal lang na inadequate client will verbalize of the disease process by about areas in which appropriate nursing
ganito kapag buntis, unang exposure and understanding of providing a thorough explanation learning is needed. Taking intervention, the client
pagbubuntis ko rin ito kaya hindi ko unawareness condition process. about the disease, etiology, signs information can improve will verbalize
na rin masyadong binigyang pansin” and symptoms, and the understanding and reduce understanding of
as client verbalized. Patient also consequences for both the fear, helping to facilitate condition process and
stated that she feels the following: mother and the fetus if not the treatment plan for the therapeutic options
 Blurry vision treated/controlled. client
 Headache

O:  Inform the client to report  Helps ensure that patient

 (+) Pitting edema on both legs immediately any signs and seeks timely treatment
Gr. 2 symptoms that indicate a and may prevent
  BP: 150/100 mmHg worsening of the condition.
 PR: 115 bpm
 RR: 26 bpm  Have patient informed of health
 Temp: 37 C status, results of when tests, and
 GTPAL: fetal well-being.
 G1T0P0A0L0
 Educate the client on how to keep
track of her weight at home and
how to use and monitor blood
pressure at home
 Instruct the client to follow the
recommended dietary plan, which
is low sodium and low fat and
emphasize diet restrictions
Note: Highlighted parts were the revisions
worsening of preeclamptic
state or additional
complications.
 To reduce fears and
anxieties that can be
compounded if client does
not have adequate
information about the state
of the disease process or
its impact on client and
fetus.
 Encourages cooperation in
treatment regimen, allows
immediate intervention as
needed, and may provide
reassurance that efforts
are beneficial.
 Strengthens importance of
patient’s responsibility in
treatment.