NURSING CARE PLAN

ASSESSMENT INFERENCE DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Preeclampsia is a Decreased • After 8 hours Independent: • Comparison of • After 8 hours of
“Napansin ko na common problem cardiac output of nursing • Monitor blood pressures nursing
bigla na lang during pregnancy. related to interventions, pressure of the provides a more interventions,
bumigat ang The condition — decreased the patient will patient. Measure complete the patient was
timbang ko” (I sometimes referred venous return. participate in in both arms or picture of able to
noticed that I gained to as pregnancy activities that thighs three vascular participate in
a induced hypertension reduce blood times, 3-5 involvement or activities that
lot of weight) as — is defined by high pressure or minutes apart scope of the reduce blood
verbalized by the blood pressure and cardiac work while patient is at problem. pressure or
patient. excess protein in the load. rest, then sitting, • Presence of cardiac work
Objective: urine after 20 weeks then standing for pallor, cool, load
• Variations in of pregnancy. Often, initial evaluation. moist skin and
blood preeclampsia causes • Observe skin delayed
pressure. only modest color, moisture, capillary refill
• Edema increases in blood temperature and time may be
• V/S taken as pressure. Left capillary refill due to
follows: untreated, however, time. peripheral
T: 37.1 preeclampsia can • Note dependent vasoconstriction
P: 78 lead to serious — or general • May indicate
R: 20 even fatal — edema. heart failure,
BP: 140/90 complications for • Provide calm, renal or
both mother and restful vascular
baby. surroundings, impairment.
minimize • Help reduce
environmental sympathetic
activity or noise. stimulation,
• Maintain activity promotes
restrictions. relaxation.
• Instruct in • Reduces
relaxation physical stress
techniques, and and tension that
guided imagery. affect blood
Collaborative: pressure and
• Implement dietary course of
sodium, fat, and hypertension.
cholesterol • Can reduce
restrictions as stressful stimuli,
indicated. produce
calming effect,
NURSING CARE PLAN
thereby reduce
blood pressure.
• These
restrictions can
help manage
fluid retention
and with
associated
hypertensive
response,
which decrease
cardiac
workload.