ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

KNOWLEDGE

Subjective: Decreased cardiac Eclampsia an After 8 hours of *Monitor blood *Comparison of *After 8 hours of
output related to acute and life nursing pressure every 5 blood pressure nursing
“Minsan hirap pa deacreased threatening intervention the minutes. and provide more intervention the
din akong venous return. complication of patient will complete picture patient was able
huminga”,as pregnancy,is decrease blood of vascular to decreased her
verbalized by the characterized by pressure of involvementor blood pressure of
client. the appearance of 160/100 to scope of the 160/100 to
tonic chronic 120/80. *Observe skin problem. 120/80.
Objective: seizures usually in color, moisture,
a patient who had temperature and *Presence of *Goal Met.
*Pallor developed pre- capillary refilltime. pallor, cool moist
*Edema eclampsia. skin and delayed
V/S: capillary refill time
BP:160/100 *Note dependent may.
RR:30 and general
PR:64 edema. *May indicate
heart failure renal
or vascular
*Provide calm imparement.
restful sorroudings
and minimize *Help reduce
environmental sympathetic
activity and noise. stimulation,
promote
*Maintain activity relaxiation.
restriction.

*reduces physical
 stress and tension
that affect blood
*Implement pressureand
dietary sodium fat cause of
and cholesterol hypertension
restriction as
indicated. *These restriction
can help mamage
fluid restriction
and with
associated
response which
decreased heart’s
workload.