NURSING CARE PLAN

ASSESSMEN NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATIO VALUE

T DIAGNOSIS ANALYSIS N INTEGRATIO
N

Objective Deficient A woman is General: 1. Assessed 1. To evaluate After 6 hours Time and
cues: fluid volume said to be After 6 patient’s vital degree of fluid of nursing effort of the
- edema related to preeclampti hours of signs (BP, deficit. interventions nurse to
formation on protein loss c when her nursing temperature, PR, , patient was listen.
the as BP rises, intervention and RR) and able to attain
extremities evidenced taken on s, patient noted strength of normal Patience of
by edema, two will: peripheral pulses. conditioning, the nurse
- visual visual occasions at -Independent participated because
changes changes, least 6 hours a.) be able nursing in the actions objective is
and dry apart. The to know the intervention which not easily
- dry mouth mouth with diastolic causative 2. To more improved met.
and cracked cracked lips. value of BP factors that 2. Observed accurately body’s
lips is extremely affects the urinary output, determine normal fluid Willingness of
important to sudden color, and replacement volume, and the patient to
document increase of measured needs. was able to reduce
because it is BP during amount and know the uneasiness.
this pressure pregnancy. specific gravity. causative
that best Measured or factors that Willingness of
indicates the b.) estimated other affect high the nurse to
degree of demonstrate fluid losses. BP. help the
peripheral a positive -Inependent patient.
arterial attitude nursing
spasm toward the intervention
present. In nurse’s 3. To evaluate
addition to teachings. 3. Reviewed degree of fluid
the laboratory data. deficit.
hypertensio -Collaborative
n a woman nursing
has Specific: intervention
proteinuria Within 6
(1+ or 2+ hours of 4. To assess
on a reagent nursing 4. Evaluated causative/precipita
test strip on intervention nutritional status, ting factors.
a random s, patient noted current
sample). will: intake, weight
Many changes, and
women a.) maintain problems with
show a trace fluid volume oral intake.
of protein at a -Independent
during functional nursing
pregnancy. level. intervention 5. To correct or
Actual replace fluid losses
proteinuria b.) attain 5. Provided to reverse
is said to stable vital nutritious diet via pathophysiological
exist when it signs. appropriate mechanisms.
registers as route; gave
at least 1+ c.) have adequate free
or more (this moist water with
represents a mucous enteral feedings.
loss of 1g/L). membranes. -Dependent 6. To maintain skin
Edema nursing integrity and
develops intervention prevent excessive
because of dryness.
the protein 6. Bathed less
loss, sodium frequently using
retention, mild
and lowered cleanser/soap,
glomerular and provided
filtration optimal skin care
rate. Edema with suitable
begins to emollients. 7. To prevent
accumulate -Independent injury from
in the upper nursing dryness.
part of the intervention
body, rather
than just the 7. Provided
typical ankle frequent oral 8. Early
edema of care. identification of
pregnancy. -Independent risk factor can
nursing decrease
Source: intervention occurrence and
Maternal severity of
and Child 8. Discussed complications
Health factors related to associated with
Nursing (5th occurrence of hypovolemia.
edition, p. deficit, as
427) individually
-Adelle appropriate.
Pillitteri -Independent 9. Alcohol or
nursing caffeinated
intervention beverage tends to
exert a diuretic
 effect.
9. Instructed to
limit intake of
alcoholic/caffeina
ted beverages.
-Independent
nursing
intervention 10. To promote
comfort and safety.

10. Changed
position
frequently.
-Independent
nursing
intervention
ASSESSMEN NURSING SCIENTIFIC OBJECTIVE INTERVENTIO RATIONALE EVALUATION VALUE
T DIAGNOSIS ANALYSIS N INTEGRATIO
N
Subjective Decreased With General: 1. Monitored 1. After 6 hours Willingness of
cue: cardiac hypertension, After 6 hours blood pressure Comparison of of nursing the patient to
“Nabantayan output the cardiac of nursing of the patient. pressures interventions, attain normal
nako nga related to system can interventions, Measured in provides a patient was conditioning.
murag nikalit decreased become the patient will both arms or more able reduce
lang ug dako venous overwhelmed reduce blood thighs three complete blood pressure Determination
akong return. because the pressure or times, 3-5 picture of or cardiac of the nurse to
timbang” as heart is forced cardiac minutes apart vascular workload and help the
verbalized by to pump workload. while patient involvement was able to patient
the patient. against rising was at rest, or scope of identify the improve and
peripheral Specific: then seated, the problem. signs of achieve
Objective resistance. After 6 hours then stood for cardiac optimal level
cues: This reduces of nursing initial decompensati of health.
- variations in the blood interventions, evaluation. on.
blood supply to the patient will -Independent Patience
pressure organs, most be able to nursing because
markedly the identify the intervention objective is
- edema on kidney, signs of not easily
the pancreas, liver, cardiac 2. Observed met.
extremities brain, and decompensati skin color, 2. Presence
placenta. Poor on. moisture, of pallor, cool,
- vital signs placental temperature, skin moist,
taken as perfusion may and capillary and delayed
follows: reduce the refill time. capillary refill
BP= 150/120 fetal nutrient -Independent time may be
mmHg and oxygen nursing due to
supply. intervention peripheral
PR= 96 bpm Another effect vasoconstricti
is that arterial on.
RR= 24 cpm spasm causes 3. Noted
the bulk of the dependent or
T= 36.6 C blood volume general edema. 3. May
in the maternal -Independent indicate heart
circulation to nursing failure, renal
be pooled in intervention or vascular
the venous impairment.
circulation, so a 4.
woman has a Implemented
deceptively low dietary sodium,
arterial fat, and 4. These
intravascular cholesterol restrictions
volume. In restrictions as can help
addition, indicated. manage fluid
thrombocytope -Collaborative retention and
nia or a nursing with
lowered intervention associated
platelet count hypertensive
occurs as response,
platelets 5. Avoided the which
cluster at the use of decrease
sites of restraints. May cardiac
endothelial increase workload.
damage. agitation and
increase the 5. To
Source: cardiac minimize/corr
Maternal and workload. ect causative
Child Health -Independent factors,
Nursing (5th nursing maximize
edition, p. 426) intervention cardiac
-Adelle Pillitteri output.

6. Maintained
activity
restrictions.
-Independent
nursing 6. Reduces
intervention physical stress
and tension
that affect
7. Instructed in blood
relaxation pressure and
techniques, course of
and guided hypertension.
imagery.
-Independent 7. Can reduce
nursing stressful
intervention stimuli,
produce
8. Provided calming effect
calm, restful thereby
surroundings, reduce blood
minimized pressure.
environmental
noise.
-Independent 8. Help
nursing reduce
intervention sympathetic
stimulation,
9. Provided for promotes
adequate rest, relaxation.
positioned
patient for
maximum
comfort.
-Independent
nursing 9. To promote
intervention venous return.

10. Gave
information
about positive
signs of
improvement,
such as
decreased 10. Provides
edema, encourageme
improved vital nt and
signs/circulatio promotes
n. wellness.
-Independent
nursing
intervention
ASSESSMEN NURSING SCIENTIFIC OBJECTIVE INTERVENTIO RATIONALE EVALUATIO VALUE
T DIAGNOSIS ANALYSIS N N INTEGRATIO
N

Vital signs Ineffective Increased cardiac General: 1. Monitored 1. For After 6 hours Time and
taken as tissue out put that injures After 6 hours blood pressure baseline of nursing effort of the
follows: perfusion those endothelial of nursing every 2 hours. information. interventions nurse.
related to cells of the arteries interventions -Independent , patient was
BP= 150/120 vasoconstricti and the action of , the patient nursing able to know Eagerness of
mmHg on of blood prostaglandins. will be able intervention the factors the patient to
vessels. Vasoconstriction to know the that affect achieve
PR= 96 bpm occurs and blood factors 2. Determined 2. To note her normal state.
pressure increases. affecting her presence of degree of condition,
RR= 24 cpm condition. visual, impairment verbalized Willingness of
Source: sensory/motor or organ understandin the nurse to
T= 36.6 C http://nursingcrib.co Specific: changes, involvement. g of impart
m/ vasoconstriction- After 6 hours headache, condition, knowledge
of-blood-vessels/ of nursing dizziness, and and being
interventions altered mental demonstrate certain in the
, the patient status, d behaviors interventions.
will be able personality that
to verbalize changes. improved
understandi -Independent circulation.
ng of nursing
condition intervention
and 3. Sodium
demonstrate 3. Instructed tends to be
behaviors to to eat low and excreted at
improve salt low fat a faster rate.
circulation. diet.
- Independent
nursing
intervention 4. To
control the
4. blood
Administered pressure and
anti- to avoid
hypertensive other
drug complication
prescribed by s.
the physician.
-Dependent
nursing
intervention
5. To note
degree of
5. Noted impairment.
reports of
nausea/vomitin
g.
-Independent
nursing 6. To
intervention promote
wellness.
6. Encouraged
discussion of
feelings
regarding
prognosis/long-
term effects of
the condition.
-Independent
nursing 7. Promotes
intervention wellness.

7. Referred to
specific
support
groups,
counseling, as
appropriate.
-Collaborative 8. To know
nursing whether
intervention patient’s
condition
8. Evaluated has changed
vital signs, or not.
noted changes
in BP, heart
rate, and
respirations. 9. To assess
-Independent causative or
nursing contributing
intervention factors.

9. Evaluated
for signs of
infection,
especially
when immune 10.
system is Enhances
compromised. venous
-Independent return.
nursing
intervention

10.
Encouraged
ambulation
when possible.
-Independent
nursing
intervention