ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: STG: IND:

Client’s blood pressure Decrease physical Physical activity and Client’s blood pressure
“Nurse, my head aches will be alleviated. activity and stress. stress can make blood was lowered.
so bad.” pressure elevate above
normal.
IND:
Objective Data: Modify client’s diet. Avoiding fatty foods and Client’s diet was
high and cholesterol can improved, and blood
 Temp – 37.2 C Preeclampsia, related alleviate the effects of pressure is alleviated.
(98.96 F) to high blood pressure hypertension.
 RR – 10 rpm as evidence by swelling
 PR – 105 bpm on both feet, dizziness DEPENDENT:
 BP – 140/90 mm Hg for more than 10 mins, Administer 100 mg PO This reduces the risk of Client’s blood pressure
 Pain scale of 9 out of a pain scale of 9, RR of labetalol as prescribed severe hypertension alleviated and close to
10 10/min, PR of 110, BP by the physician. during the times of normal values.
 Noted swelling on of 140/90 mm Hg, and pregnancy.
both feet. a temperature of 38 C
 Dizziness for more (100.4 F). LTG: IND:
than 10 mins. Client will recover from Monitor vital signs for To ensure the ability to Reduced the risk for
 Noted weight gain in preeclampsia every 4 hours. identify and intervene more clinical
2 days. for those at risk for deterioration and
clinical deterioration prevented death.
and preventable death.
IND:
Monitor protein in High protein in urine Risk for kidney failure is
urine. may indicate kidney reduced.
failure.
IND:
Advice the client to be in May reduce systolic BP Client’s systolic BP was
a prone position. in women with reduced.
preeclampsia without
obvious adverse effects.
DEPENDENT:
Administer 0.5-1 To induce labor or help Uterine contractions
mUnit/min of oxytocin strengthen uterine were increased and
through IV as contractions to facilitate strengthen, and delivery
prescribed by the delivery. as facilitated well.
physician.
LAMBINO, DIAMOND M. Prof. Jennie L. Corpuz RN, MAN, FRiN
BSN 1- B University of Luzon

NS103 LEC
FUNDAMENTALS OF NURSING PRACTICE ASSIGNEMENT
FDAR CHART AND NURSING CARE PLAN FOR OXYTOCIN

DATE – TIME – SHIFT FOCUS DATA ACTION RESPONSE

06/24/22
3-11 Shift
PRE-ECLAMPSIA
5:00 PM
DATA: “Nurse, my head aches so bad” as verbalized. With swelling on both
feet, noted weight gain in 2 days, temperature of 37.2 C (98.96 F), a respiration
rate of 10 breaths per minute, a pulse rate of 105 beats per minute and a
blood pressure of 140/90.
5:10 PM
ACTION: Administered 100 mg per os labetalol under a physician's
supervision to lower the blood pressure of the client, also administered 0.5-1
mUnit/min of oxytocin through Intravenously, under a physician's
supervision to induce labor or help strengthen uterine contractions to facilitate
delivery, decreased physical activities and stress, and client was placed in a
5:20 PM prone position.

RESPONSE: Patient verbalized that pain was alleviated. A pain scale of 3 out
of 10 was given, a blood pressure of 120/90, a respiration rate of 12 breaths
per minute, a pulse rate of 90 beats per minute, a temperature of 37.2 C
(98.96 F) and the client verbalize that she is not dizzy anymore.