Notre Dame of Midsayap

College
COLLEGE OF NURSING
NURSING MANAGEMENT

NURSING CARE PLAN

Patient’s Name: V.O.A

Birthday: March 18, 1990

Age: 34 years old

Address: Purok Acharon, Labangal, General Santos City, South Cotabato

Physician: Dr. Veliganio

Diagnosis: G5P4 (4004) Pregnancy Uterine 34 6/7 weeks age of gestation by last menstrual period, not in
labor, preeclampsia with some features – controlled.

1. Actual Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Excess After 8 hours Independent Goal partially
data: Fluid of nursing Nursing met.
“Hubag man Volume interventions, Interventions:
kaayo akong related to the patient - Established - Building trust After 8 hours
tiil unya decreased will rapport. enhances of nursing
sakit pa cardiac demonstrate patient interventions,
gyud functioning a reduction in cooperation, the client
ilakaw.” as fluid volume improves demonstrated
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
evidenced as evidenced communication slight
Objective by pitting by decreased , and reduces decrease in
data: edema in edema, stable anxiety. pitting edema
- (+1) lower blood - Provides critical in the lower
Pitting extremities pressure - Obtained vital data on the extremities,
edema in and within target signs. patient’s intake and
lower elevated range, and hemodynamic output
extremities blood balanced status and measurements
noted. pressure. intake and early detection showed a
- Decreased output within of trend towards
blood 8 hours. abnormalities. balance, and
platelet - Helps assess blood pressure
count. - Obtained kidney remained
- VS taken Intake and function, fluid slightly
as follows: Output retention, and elevated
T – 36.1°C measurement. effectiveness of above the
P – 61 bpm diuretics or target range.
R – 17 cpm fluid restriction
BP – 140/70 protocols.
mmHg - Provides
O2Sat – - Evaluated the insights into
99% location, the severity of
severity, and fluid overload,
extent of effectiveness of
edema in the treatment, and
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
extremities. risk for
complications
like skin
breakdown.
- Monitoring for
- Assess for symptoms such
signs and as dyspnea,
symptoms of fatigue, weight
worsening gain, and
cardiac peripheral
function. edema is
crucial for
timely
intervention.
- Helps reduce
- Educate the fluid retention
patient about and manage
the conditions like
importance of hypertension
a low-sodium and heart
diet. failure,
preventing
complications.
- Improve
- Encouraged circulation,
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
the need for prevent
mobility and dependent
frequent edema, and
position reduce the risk
change. of
complications
such as deep
vein thrombosis
(DVT) and
pressure ulcers.
- Allows for
timely
intervention,
- Teach the preventing
patient about severe
the signs and complications.
symptoms of
fluid overload
and when to - Providing
report them. information
- Explained the empowers the
condition, patient and
treatment family,
plan, and ensuring
potential informed
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
complications decision-
to the patient making and
and family. adherence to
the treatment
regimen.
- Increases early
detection of
- Instructed the worsening
patient on conditions,
signs and allowing for
symptoms to prompt medical
report. intervention.

Dependent Nursing - Magnesium

Interventions: Sulfate is
- Administered prescribed to
Magnesium manage
Sulfate, as conditions such
ordered. as
preeclampsia,
cardiac
arrhythmias, or
electrolyte
imbalances.
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
Nurses ensure
proper
administration
and monitor for
side effects.
- Ensures
adequate
- Regulate IVF, hydration while
as ordered. preventing fluid
overload, which
can lead to
complications.

Collaborative
Nursing - Conditions like
Interventions: heart failure,
- Noted kidney disease,
presence of and liver
medical disease can
condition that exacerbate
can contribute fluid retention.
to fluid Identifying
retention. these factors
guides
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College
COLLEGE OF NURSING
appropriate
management.
- Allows for early
detection of
- Documented deterioration,
trends and guiding timely
reported interventions
significant and preventing
changes complications.
immediately.

2. Actual Nursing Care Plan

Assessmen Diagnosis Planning Intervention Rationale Evaluation

t
Subjective: Deficient After 8 hours Independent Nursing Goal
-"Murag knowledge of nursing Interventions: partially
nitaas ra na related to lack of intervention, - Establish - to build trust met. After 8
akong BP understanding of patient will rapport and and hours of
kay pre-eclampsia, be able to therapeutic encourage the nursing
ginakulbaa its verbalize communicatio patient to intervention
n ko. complications, understandin n. express , patient
Pwede na and g of the concerns was able to
man guro management as effects of about her verbalize
ko makauli? evidenced by elevated some
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
" as uncooperativene blood condition. effects of
verbalized ss and pressure - Use simple - to explain pre- elevated
by the verbalization of during language and eclampsia and blood
patient. always wanting pregnancy. analogies its risks to pressure
to go home and ensure better during
Objective: go against comprehensio pregnany as
-Hesitant to medical advice. n. evidenced
have her - Helps to by nodding
vital signs - Provide reduce stress head and
checked - relaxation and anxiety, asking
Rarely techniques which may questions
interacts (e.g., deep contribute to and
-Frequent breathing resistance. clarification
verbalizatio exercises) s.
n of - Encourage
wanting to - Encourage the the patient to
go home patient to ask ask questions
questions and and express
express concerns
concerns.
- Helps the
- Explain the patient make
risks of leaving an informed
against decision
medical advice about her
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
(e.g., care.
eclampsia,
stroke, fetal
distress).

Dependent Nursing
Interventions:
- Administer - Helps control
prescribed blood
antihypertensi pressure.
ve
medications as
ordered
- Helps to
- Monitor assess
laboratory disease
values (e.g., progression.
liver enzymes,
platelet count)
as requested
by the
physician
- To reduce
- Implement bed blood
rest or activity pressure
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
restrictions as fluctuations.
prescribed

- Prepare the - To assess

patient for maternal and
further fetal well-
diagnostic being.
tests (e.g.,
fetal
monitoring,
ultrasound) as
ordered.
- Assist in the - This prevents
administration seizures in
of magnesium severe pre-
sulfate if eclampsia.
prescribed.

Collaborative
Nursing
Interventions:
- Consult with a - For blood
dietitian to pressure
provide an management.
appropriate
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
diet plan.

- Refer to a - For additional

health education on
educator or pregnancy
prenatal complications
counselor. and self-care.
 Notre Dame of Midsayap
College
COLLEGE OF NURSING

3. Actual Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

S: Ineffective After 8 hours Independent Goal Partially
Patient Health of nursing Nursing Met
repeatedly Maintenance intervention, Interventions After the end
states, “gusto related to patient will  Establish - Building trust of the 8hr
ko na umuwi” hesitation and express at rapport and helps the shift the
lack of least one show patient feel patient was
O: cooperation in health empathy heard and able to show
V/S health concern and supported, some
T-36.1 interventions show which may openness by
RR 17 as evidenced openness to encourage engaging in
PR 61 by inadequate learning participation in brief
O2-99 interest in about the healthcare discussions
Bp- 140/90 improving importance of - Acknowledg - may help but still
health. health e the reduce expressed
Displays maintenance Patient’s resistance and hesitation.
reluctance to through Feelings encourage
participate in guided communicatio
health-related discussions. n
discussions.
- Provide - Providing
basic Health accurate
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
Minimal Education in information
engagement a non- can address
in personal Judgmental concerns.
health Manner
maintenance - Use - This
activities. Motivational encourages
Interviewing the patient to
Techniques take an active
role in their
health
decisions.

Dependent
Nursing
Intervention: - can help
- Encourage clarify doubts
Discussion and reduce
with the mistrust.
Healthcare
Team
- Understanding
- Assist in the role of
Medication medication in
Teaching. improving
Help explain health may
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
medication increase
benefits in a adherence
way that
relates to
patient’s
concerns

Collaborative
Nursing
Intervention:
- Involve - Family support
Family or a can reinforce
Support positive health
Person behaviors.

1. Potential Nursing Care Plan

 Notre Dame of Midsayap
College
COLLEGE OF NURSING
Assessment Diagnosis Planning Intervention Rationale Evaluation
O:
 Restlessness Risk for After 8 hours Independent
 Hyperreflexi convulsion of nursing Nursing
a related to intervention
 Muscle central the patient Interventions
 twitching nervous and caregiver  Establish  To facilitate
system will verbalize rapport cooperation
irritability understanding and to gain
of seizure trust
precautions  Monitor vital  To obtain
and sign baseline data
emergency
intervention  Monitor early  Early
signs of recognition of
convulsion warning sign
allows for
immediate
intervention
and
prevention
 Ensure safe
environment  A safe
environment
helps prevent
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
injury from
falls or
seizures

 Educate the  To helps them

family about know how to
seizure keep the
precautions patient safe
and when to during a
seek help seizure and
when to get
medical help
quickly

 Encourage  Getting
adequate rest enough rest
helps lower
blood
pressure and
reduces
stress.

Dependent
 Anticonvulsan
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
 Administer t medication
prescribed helps prevent
anticonvulsan or control
t medication seizure
as ordered
 Balanced
 Monitor and electrolytes
correct help the
electrolyte nerves and
imbalance ls muscles work
as per properly
physician's
order

Collaborative
 A neurologist
 Coordinate can check for
with a brain or nerve
neurologist for problems and
further help prevent
evaluation seizures or
other
complications

 A psychologist
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
 Collaborate can help the
with a patient cope
psychologist with stress
to address and anxiety,
emotional and which can
psychological affect their
well-being health and
recovery

2. Potential Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

O:
 Restlessness related to After 8 hours Independent
 Hyperreflexi central of nursing Nursing
a nervous intervention
 Muscle system the patient Interventions
 twitching irritability and caregiver  Establish  To facilitate
will verbalize cooperation
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
understanding rapport and to gain
of seizure trust
precautions  To obtain
and  Monitor vital baseline data
emergency sign
intervention  Early
 Monitor early recognition of
signs of warning sign
convulsion allows for
immediate
intervention
and
prevention

 Ensure safe  A safe

environment environment
helps prevent
injury from
falls or
seizures

 Educate the  To helps them

family about know how to
seizure keep the
precautions patient safe
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
and when to during a
seek help seizure and
when to get
medical help
quickly

 Encourage  Getting
adequate rest enough rest
helps lower
blood
pressure and
reduces
stress.

Dependent
 Anticonvulsan
 Administer t medication
prescribed helps prevent
anticonvulsan or control
t medication seizure
as ordered
 Balanced
 Monitor and electrolytes
correct help the
 Notre Dame of Midsayap
College
COLLEGE OF NURSING
electrolyte nerves and
imbalance ls muscles work
as per properly
physician's
order

Collaborative
 A neurologist
 Coordinate can check for
with a brain or nerve
neurologist for problems and
further help prevent
evaluation seizures or
other
complications

 A psychologist
 Collaborate can help the
with a patient cope
psychologist with stress
to address and anxiety,
emotional and which can
psychological affect their
well-being health and
recovery
 Notre Dame of Midsayap
College
COLLEGE OF NURSING