NURSING CARE PLAN

Assessment Diagnosis Planning Goal Implementation Rationale Evaluation Goal Met

Nursing Intervention
Pertinent Data: Patient will: Nurse will: Why: What happened: Yes or no
Subjective:

“I was in bed rest Deficient Diversional After 4 hours of nursing

for a long time.” as Activity related to intervention, the Provide calm, restful Increase stimulation The patient engaged in Goal was met
verbalized by the prescribed bed rest patient will engage in surroundings and and promotes satisfying activities within
patient as evidenced by satisfying activities minimized relaxation personal limitation
patient’s within personal environmental activity
“Not seeing verbalization. limitation or noise
daylight was so
hard” as verbalized
Reduces physical
by the patient Maintain activity
stress and tension
restrictions

Provides information
Assess the type of
about the type of
activities allowed and
activities to suggest
amount of activity
needed

Ask the patient’s usual This allows to explore

support systems and for activities that
the significant other may be appropriate
about the patient’s for the health care
interests setting
 Assist the patient to To help the patient
engage with the feel relaxed and
surroundings by going reduce stress
out on a wheelchair

Encourage the patient

To divert the
to read some books or
patient’s attention
watch her favorite
from serious
movie
concerns and reduce
boredom

Measure blood To monitor that the

pressure of the patient patient’s blood
“My blood pressure 10-15 minutes apart pressure remains
was elevated” as Increased blood After 8 hours of nursing manageable and to The patient was able to Goal was met
verbalized by the pressure related to interventions the see whether there’s participate in activities
patient possible pre- patient will participate instability that reduce blood
eclampsia in activities that reduce pressure
blood pressure
Instruct relaxation Reduces stress and
techniques tension that affect
blood pressure
To determine what
Assess underlying
else triggers elevated
condition if there’s
 anything else that blood pressure
triggers increase of
blood pressure aside
from pre-eclampsia

instruct the patient to To promote

participate in activities relaxation and relief
that will promote
movement such as light
exercise, elevation, and
massaging

Identify client’s
“My stress level To know the
perception of the
would go up and I Severe anxiety as After 4 hours the appropriate The patient’s stress level Goal was met
threat presented by
couldn’t handle it evidenced by the patient will be able to teachings for the and anxiety were
situation
mentally” as verbalization of the reduce stress and client reduced to a more
verbalized by the patient’s experience anxiety to a more manageable level
patient manageable level
Provide accurate
Helps patient to
information about the
“I lost it and I’m in identify what is
situation
total shock” as reality-based
verbalized by the
patient
Communicate with
May serve to reduce
patient, instruct
level of anxiety by
Objective Data: relaxation, and
 BP: 181/108 encourage to have a relieving tension
Presence of tears positive thought

Administer anti-
Relieves symptoms
depressants as
of anxiety
prescribed by physician

Summary

The patient mentioned that she is doing this documentation story to raise some awareness for anyone who’s going through a similar
situation. She stated that “honestly like in my mind I thought, that fertility is over and this was the hard part and after that its now rainbows
and butterflies like I thought everything was just gonna go perfectly as plan but no, and I didn’t understand it because literally I am eating
healthy foods I cut all my carbs out of my diet and walking three miles a day.” Preeclampsia is a pregnancy complication characterized by
high blood pressure and many more, and it always starts after 20 weeks of pregnancy in women whose blood pressure has been normal.
She stated that preeclampsia is a very serious thing. I didn’t even think anything of it. I thought I was going to the hospital and they would
just put me on blood pressure meds, and things turned bad very quickly. It didn't take long for us to find out that things were not good. The
doctor came back and told me that I’m not leaving this hospital until I gave birth. I blacked out. I was in total shock and I felt like the world
stopped.
 Reflection
History of previous preeclampsia is a known risk factor for a new event in a future pregnancy. It is always challenging to a woman with a
previous history of preeclampsia. As nurses we should provide the utmost care and make sure that the interventions formulated by us will
effectively help the patient. We need to apply what we have and will learn in our course in order to truly help people in need

Video: https://www.youtube.com/watch?v=f78deE-FjIk&ab_channel=Austin%26AlexMcGee
Aprn Bc, M. D. E., Crrn, M. M. R. M. F., & Bsn Rn, A. M. C. (2019). Nurse's Pocket Guide: Diagnosis, Prioritized Interventions and Rationales (Fifteenth ed.). F.A. Davis Company

Members :
Esleigue, J
Gonzales, R
Nolasco, K