GOLEZ, Steffi Gabrielle R.

September 05,2017
2NUR-1.1 RLE 1 Maam Lisette Navarro

Assessment Nursing Diagnosis Scientific Analysis Goals / Objectives Interventions Rationale Evaluation

Subjective: Decreased cardiac output Preeclampsia is a common After the nursing Independent:
Hindi ako makahinga. related to decreased problem during pregnancy. The interventions, the Monitor blood pressure of Comparison of pressures
Masakit ang dibdib at venous return condition referred to as patient will be able to the patient. Measure in both provides a more complete After the nursing
batok ko. as verbalized pregnancy-induced manifest increased arms or thighs three times, picture of vascular interventions, the patient was
by the patient. hypertension defined by high tissue perfusion 3-5minutes apart while patient involvement or scope of the able to participate in
blood pressure and excess protein evidenced by: is at rest, then sitting, then problem. activities that reduce blood
Objective: in the urine. Preeclampsia refers standing for initial evaluation. pressure or cardiac
Variations in to a set of symptoms rather than Blood workload.
blood pressure any causative factor, and there are pressure in Observe skin color, Presence of pallor, cool,
Edema many different causes of the normal range moisture, temperature and moist skin and delayed
T - 36.0C condition. It appears likely that Absence of capillary refill time. capillary refill time may be
PR 94/min there are substances from the edema due to peripheral
RR 21/min placental that can cause vasoconstriction.
BUBBLE SHE endothelial dysfunction in the
ASSESSMENT maternal blood vessels of the Note dependent or general May indicate heart failure,
Breast: Lactating, not susceptible women. While blood edema. renal or vascular
engorged pressure elevation is the most impairment.
Uterus: Firm, contracted visible sign of the disease, it
Bladder: Urinated involves generalized damage to Provide calm, restful Help reduce sympathetic
Bowel: Defecated the maternal endothelium, surroundings, minimize stimulation, promotes
Lochia: alba kidneys and liver, with the release environmental activity or relaxation.
Episiotomy: none of vasoconstrictive factors noise.
Skin: with linea nigra, no being secondary to the Maintain activity Reduces physical stress
lesions original damage. restrictions. and tension that affect blood
Homans sign: negative pressure and course of
Emotional State: Letting hypertension.
go
Instruct in relaxation Can reduce stressful
techniques, and guided stimuli, produce calming
imagery. effect, thereby reduce blood
pressure.

Collaborative:
Implement dietary sodium, These restrictions can
fat, and cholesterol help manage fluid retention
restrictions as indicated. and with associated
hypertensive response,
which decrease cardiac
workload.