NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

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

Collaborative:
• Implement dietary • These
sodium, fat, and restrictions can
cholesterol help manage
restrictions as fluid retention
indicated. and with
associated
hypertensive
response,
which decrease
cardiac
workload.