NURSING CARE PLAN

Patient’s Initials:
Age:
Gender: F
Date Admitted: Student Nurse:

CC: for
NURSING SCIENTIFIC
ASSESSMENT DIAGNOSIS ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Pregnancy- Pre-eclampsia is Goal: Independent: -Goal is

cues:”Minsan Induced diagnosed when a Short-term: -Monitor blood -Comparison of completely met
nahihilo ako” as Hypertenstion pregnant woman After 1 day of pressure of the pressures provides as evidenced by
verbalized by (Preeclampsia) develops high blood nursing patient. Measure a more complete the patient was
the client. related to pressure (two separate intervention the in both arms three picture of vascular able to
decreased readings taken at least 6 patient will times, 3-5 involvement or participate in
minutes apart
cardiac output hours apart of 140/90 or participate in scope of the the activities
while patient is at
Objective cues: more) and 300 mg of activities that will problem. that reduces
rest, then sitting,
-presence of protein in a 24-hour urine reduce blood then standing for blood pressure.
edema sample (proteinuria). pre- pressure from initial evaluation.
eclampsia it is thought 140/90 to 120/80
Vital Signs that the mother lacks the -Observe skin -Presence of pallor,
-T:36.8*C receptors for the proteins color, moisture, cool, moist skin and
-RR:19 bpm the placenta is using to temperature and delayed capillary
-PR:78 bpm downregulate the capillary refill refill time may be
-BP:140/90 maternal immune time. due to peripheral
system's response to it. vasoconstriction.
This view is also
consistent with evidence -Note dependent or -May indicate heart
showing many general edema. failure, renal or
miscarriages to be an vascular
immunological disorder impairment.
where the mother's
immune system -Maintain activity -Reduces physical
"unleashes a destructive restrictions such as stress and tension
attack on the tissues of advising bed rest in that affect blood
the developing fetus. left lateral recumbent pressure and course
position. of hypertension.

Dependent
-Administer -Magnesium sulfate
Magnesium sulfate as helps prevent the
prescribed by the occurrence of
physician seizures in women
with preeclampsia.

Collaborative
-Refer to a dietician -These restrictions
in giving a proper can help manage
nutritional diet and fluid retention and
restrictions to foods with associated
that has high sodium, hypertensive
fat, and cholesterol response.
content.