Pre-eclampsia Leading to Fetal Death in Utero| 29

Date ASSESSMENT (Problem Statement/Nursing Diagnosis NURSING CARE PLAN (Objective/Goal)

ST: Within the shift client will demonstrate stable cardiac rhythm
and rate within patient’s normal range.
March 8, Elevated Blood Pressure related to Preeclampsia
LT: After 3 days of nurse learner-client interaction, client will
maintain a BP within individually acceptable range

Individual Problems (CUES) IMPLEMENTATION

APPORACHES
- Note presence, quality of central and peripheral pulses,
Subjective: andnote for dependent and general edema.
“Kanayun met
ngaNangatokanuitimaalala da nga -Closely monitor BP and cardiac rate and record
blood pressure ko.” accordingly. For initial evaluation, measure in both arms
and thighs three times, 3–5 min apart while patient is at
rest, then sitting, then standing using the correct cuff size
and accurate technique.
- Evaluate client reports or evidence of extreme fatigue,
intolerance for activity, sudden or progressive weight gain,
Objective: swelling of extremities, and progressive shortness of breath.
BP of 160/100 mmHg - Provide calm, restful surroundings, minimize
CR of 86 bpm environmental activity and noise. Limit the number of
visitors and length of stay.
- Maintain activity restrictions (bed rest or chair rest);
schedule periods of uninterrupted rest; assist patient with
self-care activities as needed.
- Emphasize the importance of compliance to medication
regimen.
- Implement dietary sodium, fat, and cholesterol
restrictions.
RATIONALE
Pulses in the legs and feet may be diminished, reflecting
effects of vasoconstriction and venous congestion. Edema
may indicate heart failure, renal or vascular impairment.
- To check for symptoms that may need prompt nursing
interventions. Comparison of pressures provides a more
complete picture of vascular involvement or scope of
problem.
- To assess for signs of poor ventricular function or
impending cardiac failure.
- Helps lessen sympathetic stimulation; promotes
relaxation.
- Lessens physical stress and tension that affect blood
pressure and the course of hypertension.
- Strict compliance to medication regimen maintains a
blood pressure at an acceptable range and helps in
prevention of possible complications
- These restrictions can help manage fluid retention and,
with associated hypertensive response, decrease
myocardial workload.

Actual Outcome Date & Time Resolved

After 8 hours of nursing interventions, blood pressure decreased from 160/100 mmHG March 08, 2016
to 140/80 mmHG 11:00 pm
 Pre-eclampsia Leading to Fetal Death in Utero| 30

Date ASSESSMENT (Problem Statement/Nursing Diagnosis NURSING CARE PLAN (Objective/Goal)

ST: Within 8 hours of nursing interventions, client will
participate in necessary measures needed to compensate for
March 8, Impaired Urinary Elimination present condition.
LT: After 3 days of nurse-patient interaction, client will
achieve a normal elimination pattern.

Individual Problems (CUES) IMPLEMENTATION

Subjective:
“Marigatanakmettenngamakaisbo.
Basitbasitlaengitiisbokisusangainkabil
da daytoy. Ngemidi met ketmayat met
itipanagisbok.”
Objective:
With urinary retention
Urine output of at least 10mL/hour
With intact and patent IFC
With tea-colored urine
APPORACHES
- Assess frequently for bladder distention
- Strictly monitor input and output and record accordingly
- Promote adequate oral fluid intake of up to 3 liters per
day by offering sips of water
- Teach significant others on how to closely monitor I and
O and to record by providing and I and O monitoring sheet
and to drain urine bag to a graduated, used IVF bottle.
- Emphasize the importance of keeping the perineum clean
and dry.
- Discuss on possible dietary restrictions on food with high
sodium content such as canned and processed food and
reiterate the importance of compliance to intervention.
RATIONALE
- To reduce the risk for urinary tract infection
- To assess for improvement of urinary elimination
- To help in renal function
- To facilitate strict monitoring of client’s input and output
- To prevent skin breakdown
- High amounts of sodium in the body leads to fluid
retention in the cells. Sodium restriction is to help reduce
fluid shift in the cells therefore fluid is excreted from the
body.

Actual Outcome Date & Time Resolved

Within 8 hours of nursing interventions, client was able to participate in necessary actions
needed to manage present condition and also demonstrated behaviors towards preventing March 08, 0000
urinary infection. 11:00 pm
 Pre-eclampsia Leading to Fetal Death in Utero| 31

Date ASSESSMENT (Problem Statement/Nursing Diagnosis NURSING CARE PLAN (Objective/Goal)

Pain related to elevated blood pressure secondary to pregnancy as
evidence by difficulty of urination ST: after nursing intervention patients pain will be in mild level
March 8,
and urine output will be in normal range

Individual Problems (CUES) IMPLEMENTATION

APPROACHES RATIONALE
Subjective: Assess for referred pain - To too help determine underlying condition
“ nagsakit nu umis-isboak “
Note when pain occurs ( dysuria) - To medicate as appropriately
Provide comfort measures such as hot packs and reposition To provide none pharmacological pain
Objective:
Promote a calm environment conducive to rest management
Rated pain 6 out of 10
Urine output of 10ml / hour Instruct client to do deep breathing when in pain - To reduce tension and relieve pain
Guarding behavior
Encourage to verbalize feelings and concerns - To address concerns properly

Actual Outcome Date and Time Resolved

Within 8 hours of nursing interventions, client rated pain as 5 out of 10 and still with urine March 08, 0000
output of 15 ml per hour 11:00 pm
 Pre-eclampsia Leading to Fetal Death in Utero| 32

Date ASSESSMENT (Problem Statement/Nursing Diagnosis NURSING CARE PLAN (Objective/Goal)

March 08 ST: after nursing intervention patients vital sign will be within
normal limits
Excess body fluid LT: after nursing intervention patient will have stabilize fluid
volume as evidence by balance input and output and free from
signs of edema

Individual Problems (CUES) IMPLEMENTATION

APPORACHES RATIONALE
Subjective: - Monitor vital signs and input, output and record - To assess extent of the condition
“ sobraitimanasko , dinmakkeldagitoyima appropriately
Ken sakak”
- Limit Intake of sodium - To reduce water retention
Objective:
- generalize edema - Teach client to : - Prevent stasis and risk for skin breakdown
-proteinuria Elevate edematous extremities
-elevated blood pressure (BP of Change position frequently
160/100 mmHg) Promote ambulation
-urine output of 10ml / hour
- Encourage patient to avoid diet rich in protein - To lessen protein level in the body

Actual Outcome Date & Time Resolved

After 8 hours of nursing intervention blood pressure has decreased to 140/ 80mmHg and March 08, ____
still with generalized edema and urine output of 15 ml per hour 11pm
 Pre-eclampsia Leading to Fetal Death in Utero| 33

Date ASSESSMENT (Problem Statement/Nursing Diagnosis NURSING CARE PLAN (Objective/Goal)

ST: Within 8 hours of nursing interventions, client will be free
of injury.
March 8, LT: After 3 days of nursing interaction, client will be free of
Risk for Injury related to Seizure Episodes
injury and will demonstrate behaviours to reduce risk factors
and protect self from injury.

Individual Problems (CUES) IMPLEMENTATION

APPORACHES RATIONALE
Subjective: - Closely monitor vital signs and record accordingly. - To check for symptoms that may need prompt nursing
interventions.
“Kaslamariknakmettenngamaululawak. - Maintain O2 inhalation at prescribed rate. - To ensure adequate oxygenation.
Kasla - Use and pad side rails with bed in lowest position, or - Prevents or minimizes injury when seizures occur.
kayatko pay ngaagsarwa. Nagsakitmetlaeng
place bed up against wall and pad floor.
daytoyulok ken patibagbagik.” - Provide adequate rest periods by promoting a calm and - To reduce stimuli and stress that may trigger seizure
quiet environment and by clustering nursing interventions. episodes that may result to injury from falls.
Objective: - Do not leave the patient during and after seizure. - To promote safety.
BP of 160/100 mmHg - Teach SO to determine and familiarize warning signs and - Enables patient to protect self from injury and recognize
CR of 88 bpm how to care for patient during and after seizure attack. changes that require notification of physician and further
Temperature of 36.7 Celsius intervention. Knowing what to do when seizure occurs can
SPO2 at 98% ; With O2 inhalation prevent injury or complications and decreases SO’s
per nasal cannula at 1-2 LPM feelings of helplessness

Actual Outcome Date & Time Resolved

March 3,____
Within 8 hours of nursing interventions, patient was free of injury.
11:00 PM