NAME OF PATIENT: ROOM NO.

AGE: CC:
NURSING CARE PLAN

CUES BACKGROUND NURSING PLANNING IMPLEMEN- RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS TATION

OBJECTIVE: Pre-eclampsia is Ineffective tissue After 8 hours of INDEPENDENT: GOAL PARTIALLY

“Nahihilo ako. a medical condition in perfusion related duty, client will - Monitor vital signs To identify physical MET
Masakit ang batok which hypertension arises to be able to paticularly responses associated
ko.” as verbalized. in pregnancy (pregnancy- vasoconstriction manifest blood with medical - Blood pressure is
induced hypertension) in of blood vessels increased tissue pressure. conditions. slightly above
association with perfusion as normal range:
significant amounts evidenced by: - Perform assistive ROM promotes 130/90
of protein in the urine.  blood passive range of improved blood
Pre-eclampsia refers to a pressure motion. circulation. - Skin is warm to
set of symptoms rather within touch.
than any causative factor, normal range - Provide quiet and It conserves
SUBJECTIVE: and there are many  warm and dry restful environment. energy/lowers tissue - Capillary refill
- Edema different causes for the skin oxygen demand. within 4 seconds.
noted on condition. It appears  capillary
lower likely that there are refill within - Edema is still
extremities (grade substances from normal range DEPENDENT present (from grade
2) the placenta that can (3- 5 - Administer Antihypertensives 2 to grade 1)
cause endothelial seconds) antihypertensive drugs help decrease and
- cold, dysfunction in the  absence of as ordered. control blood
clammy skin maternal blood vessels of edema pressure.
noted. susceptible women. - Administer
While blood Magnesium sulfate as Magnesium sulfate
- capillary refill pressure elevation is the ordered. prevents or controls
within 6 seconds most visible sign of the seizures in pre-
disease, it involves eclampsia brought
- BP: generalized damage to the about by vasospasm
140/100 maternal endothelium, ki secondary to
dneys, and liver, with the vasoconstriction of
release blood vessels.
of vasoconstrictive factor
s being secondary to the
original damage.
-
http://en.wikipedia.org/wi
ki/Pre-eclampsia