ASSESSMENT

PLANNING AND IMPLEMENTATION

Data Collection and

Organization

Nursing Diagnosis

Expected
Outcome

Subjective Data:
Patient stated,
I have this
headache that wont
go away and I feel
lightheaded at times
Im anxious
something wrong
will happen

Ineffective tissue
perfusion related to
changes in
circulating blood
volume as evidenced
by admitting BP of
143/95 and headache
secondary to the
diagnosis of
pregnancy induced
hypertension

STG:
Patient and fetus
will experience
adequate tissue
perfusion as
evidenced by
mother denying
headache, visual
disturbances and
epigastric pain
and maintaining
FHR to 110-160
without late
decelerations
within shift

My blood pressure
usually runs around
120/80
Objective Data:
Patient is currently
under observation
status
Admitting blood
pressure of
0200:143/95 and
0300:155/105
Anxiety level 8/10
+2 pitting bilateral
lower leg edema
Current medical
condition:
GDM
Age: 32
Allergies:NKA
Blood Type: B+
Rubella: Immune
RPR: Non Reactive
HBSAg: Negative
HIV test: Done,
results still pending

Planning Nursing
Interventions

1. Assess BP, PR, RR

and FHR q2hr

2. Assess for signs of

worsening condition
(headache, N/V,visual
disturbances epigastric
pain)
(Luxner, p.49)
3.Assess LOC and
severe headaches and
hyperreflexia q2hr

1. Assessment
provide ongoing
information about
physiologic changes
(Luxner, p.51)
2. Provides
information on
cerebral irritability.
(Luxner, p.49)
3. assessment
provides information
about neurologic
perfusion and
irritation(Luxner,
p.51)

4.Assess intake and

output monitor for
proteinuria, serum BUN
and CREA, 24 hr urine

4.provides
information on renal
perfusion Luxner,
p.51

5. Monitor for HELLP

5. HELLP syndrome
may be associated to
preeclampsia
Luxner, p.51

LTG:

Patient will
verbalize
knowledge
regarding PIH
treatment to be
done and
demonstrate
ways to
improve fetal
and maternal
perfusion
during the
course of

Rationale

6.Keep physician and

other health care
providers informed of
the patient and fetus
condition
(Luxner, p.50)
7.Provide emotional
support to client and
family. Explain
procedures and

6. Informing ensures
continuity of care
and allows team
approach to ensure
maternal and fetal
well-being.
(Luxner, p.50)
7. Knowledge
decreases anxiety
related to unfamiliar

EVALUATION
Evaluation of
Interventions
1. 2. 3. Goal met:

0800 BP128/83,
PR76, temp 98.2
with 5/10 headache
refused pain
medication
FHR via external
fetal monitor: 144
with accelerations
12x60 mins with
moderate variability
with no
decelerations
10-11am BP136/86,
PR72, temp 98.2,
headache 5/10
refused pain
medication
FHR via external
fetal monitor: 146
with accelerations
11x30 mins with
moderate variability
mins with no
decelerations
1100-1200
BP148/87, PR94,
temp 98.0, 5/10 pain
refused pain
medication
FHR via external
fetal monitor: 143
with accelerations
14x30 mins with
moderate variability
mins with no
decelerations

Evaluation of Short
Term Goal

STG:
Goal met.
Patient was able to
verbalize relief from
headache, denies
epigastric pain and
visual disturbance.
FHR was maintained
110-160

LTG:
Goal met: Patient
was able to verbalize
that PIH will be
resolved after the
delivery of her baby
as per doctors
teaching and patient
was able to perform
proper positioning
and monitoring of
fetal contractions and
movements

Gravida/Para: 1/0
Pain Scale: 1/10
Fetal data:
Gestational age:
37+3
Breech Presentation
FR 135

pregnancy or
until delivery

equipments. Arrange
healthcare provider to
meet with client and
family to discuss plans

events and
equipment.
(Luxner, p.51

8.Reinforce teaching
regarding delivery.
Assist with delivery

8.Treatment for PIH

is delivery
Luxner, p.124

9.teach clients on how

to count kicks and
abdominal contractions
10.teach patient to rest
on left lateral position
or semifowlers with
wedge on right hip

9.provides
information on fetal
oxygenation
Luxner, p.46
10.rest and
positioning helps in
placental perfusion
Luxner, p.46

1200-1pm
BP136/86, PR87,
temp 98.1. denies
episodes of NV,
epigastric pain,
headache 5/10
refused pain
medication
FHR via external
fetal monitor: 149
with accelerations
1x30 mins with
moderate variability
mins with no
decelerations
1pm-1400
BP137/74, PR79,
temp 98.2
FHR via external
fetal monitor: 141
with accelerations
25x60 mins with
moderate variability
mins with no
decelerations
1500: patient was
prepped for CS
delivery
1543:Baby was born
1612: patient was
sent to
PACU:BP100/64
PR77, Temp 97.6.
Denies pain and
relief from
headache.
4. goal not met: CS
was done prior to the

collection of 24 hr
urine
6. 7. 1100: Dr.
Rivera visited
mother and
explained her
condition and agreed
to have cesarian
delivery at 1500
8,9,10. 0900:
enforced teaching on
how the monitor
works,
1000: Teaching on
how to count
contractions done
how to do kick
counts and proper
positioning done
1200: Reinforcement
teaching was done
regarding what to
expect with the
surgery, what to
expect after surgery,
proper way on how
to stand up and how
to ambulate after
surgery.

Delmar's Maternal-infant Nursing Care Plans, Volume 1, 2nd edition By Karla L. Luxner

Luxner, Karla L., Delmars Maternal-Infant Nursing Care Plans (Second Edition), Published 2004