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C.

NURSING CARE PLAN

ASSESSMENT
Objectives:
T-36.7oC
PR-95bpm
RR-20bpm
BP170/100mmHg

DIAGNOSIS
Decreased
Cardiac Output
related to
vasoconstriction
secondary to
preeclampsia

PLANNING
At the end of the
shift the patient
will be display
hemodynamic
stability as
evidenced of BP

INTERVENTION
RATIONALE
Monitor vital
Baseline Data
signs especially
BP
Elevate the
To provide
head of the bed
circulation
venous return
Provide diet
To maintain
restriction and
adequate
increase
nutrition and
frequent small
fluid balance
feeding
Provide bed
To prevent fatigue
rest
To avoid further
Provide calm
increase BP
and restful
surroundings
and minimize
environmental
activity/ noise.
Help reduced
Limit the
sympathetic
number of
stimulation/
visitors and
promote
length of stay.
relaxation
To help the
Administer

EVALUATION
The patient is
expected to
manifest the
following:
Maintain
BP within
individually
acceptable
range
BP=
160/100mm
HG

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medication

ASSESSMENT
Objectives:
Edema
Distention of the
pelvis and ureters
Decrease output
BP=
170/100mmHg

DIAGNOSIS
Fluid volume
excess related to
decrease
glomerular
filtration
secondary to
preeclampsia

cardiac output
decrease

PLANNING
INTERVENTION
RATIONALE
At the end of the Assess skin,
Edema occurs
shift the patient
face, and
primarily in
will be able to
dependent area
dependent
manifest increase
for edema.
tissues of the
urine output at
body
least 100cc/hr

EVALUATION
The patient is
expected to
manifest the
following:
Absence of
distended
pelvis
Baseline Data
Vital signs
Monitor vital
within
signs especially
normal
BP
Place in semi- Facilitate
range
Absence of
fowlers position
movement of
edema
diaphragm

Increase
improving
urine output
respiratory effort
Baseline data
Evaluate
edematous
extremities,
change position
frequently
Provide bed
To prevent fatigue
rest
To maintain cell
Administer
integrity and
medication
improve GFR
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Help reduced
sympathetic
stimulation/
promote
relaxation
To help the
cardiac output
decrease
ASSESSMENT
Objectives:
Grimace
Irritable
Restlessness
Pain scale= 7/10
Subjective:
Patient may
complaint pain in
the right upper
quadrant of the
abdomen.

DIAGNOSIS
Altered comfort;
Acute pain related
to reduce supply
of blood in the
pancreas
secondary to
preeclampsia

PLANNING
At the end of the
shift the patient
will be alleviated
of pain

INTERVENTION
RATIONALE
Determine pain Baseline Data
history,
location,
frequency,
intensity using
pain scale
Promote proper To promote
relaxation
positioning
such as semi
To promote
fowler
relaxation
Instruct patient
doing a deep
breathing
To relieve the
exercise
pain and
Encourage

EVALUATION
The patient is
expected to
manifest the
following:
Decrease
pain scale=
4/10
Maintain bed
rest
Maintain
relaxation
technique

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ASSESSMENT

DIAGNOSIS

PLANNING

client to
anxiety
express her
feelings
Instruct to
To alleviate the
adequate rest
fatigue
and sleep
period of time.
Limit the
To have an
number of
adequate rest
visitors
INTERVENTION
RATIONALE

EVALUATION

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Objectives:
Slightly pitting
edema-+1
Oliguria
Subjective:
Patient may
complaint
tightness of the
hands, swelling of
the lower
extremities

Fluid volume
deficit related to
fluid loss
secondary to
capillary
permeability

At the end of the


shift the patient
will be able to
verbalize

understanding the
need for close

monitoring of BP,
urine protein and
edema

Monitor the
Baseline Data
intake and
output
Baseline Data
Monitor the
weight
Helps body to
Change
increase tissue
position every
oxygen demand
2hours
and increase
venous return
To help the
Instruct to
venous return
increase

The patient is
expected to
manifest the
following:
Reduced
edema
Absence of
swelling,
tightness of
the lower
extremities

activity level
Instruct to fluid To reduced
edema
restriction and
diet
Review sodium
intake

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