NAME OF PATIENT:

ROOM NO.:

AGE:

CC:

NURSING CARE PLAN

CUES

BACKGROUND
KNOWLEDGE

NURSING
DIAGNOSIS

PLANNING

OBJECTIVE:
Nahihilo ako.
Masakit ang batok
ko. as verbalized.

Pre-eclampsia is
a medical condition in
which hypertension arises
in pregnancy (pregnancyinduced hypertension) in
association with
significant amounts
of protein in the urine.
Pre-eclampsia refers to a
set of symptoms rather
than any causative factor,
and there are many
different causes for the
condition. It appears
likely that there are
substances from
the placenta that can
cause endothelial
dysfunction in the
maternal blood vessels of
susceptible women.
While blood
pressure elevation is the
most visible sign of the
disease, it involves
generalized damage to the
maternal endothelium, ki
dneys, and liver, with the
release

Ineffective tissue
perfusion related
to
vasoconstriction
of blood vessels

After 8 hours of
duty, client will
be able to
manifest
increased tissue
perfusion as
evidenced by:
blood
pressure
within
normal range
warm and dry
skin
capillary
refill within
normal range
(3- 5
seconds)
absence of
edema

SUBJECTIVE:
- Edema
noted on
lower
extremities (grade
2)
- cold,
clammy skin
noted.
- capillary refill
within 6 seconds
- BP:
140/100

IMPLEMENTATION

RATIONALE

INDEPENDENT:
- Monitor vital signs
paticularly
blood
pressure.

To identify physical
responses associated
with medical
conditions.

- Perform assistive
passive range of
motion.

ROM promotes
improved blood
circulation.

- Provide quiet and

restful environment.

It conserves
energy/lowers tissue
oxygen demand.

DEPENDENT
- Administer
antihypertensive drugs
as ordered.
- Administer
Magnesium sulfate as
ordered.

Antihypertensives
help decrease and
control blood
pressure.
Magnesium sulfate
prevents or controls
seizures in preeclampsia brought
about by vasospasm
secondary to
vasoconstriction of
blood vessels.

EVALUATION

GOAL PARTIALLY
MET
- Blood pressure is
slightly above
normal range:
130/90
- Skin is warm to
touch.
- Capillary refill
within 4 seconds.
- Edema is still
present (from grade
2 to grade 1)

of vasoconstrictive factor
s being secondary to the
original damage.
http://en.wikipedia.org/wi
ki/Pre-eclampsia