Nursing Care Plan
Patient’s Code: Mrs. Olie Age: 45y.o. Sex: F
Attending Physician: Dr. Adrian Higup
Nursing Diagnosis (PES): Decreased cardiac output related to decreased venous return.
Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body
Assessment/ Cues
(Subjective/ Objective)
Subjective:
On the day of admission patient
stated, “Dili ko kasabot sa akong
kundisyon, wala pud koy gibati
karon, natingala lang gyud ko kay
pag homan nila ug kuha sa akong
pressure health center, ingon sa
midwife magpa checkup daw ko sa
hospital kay taas daw akong BP.”
On the 2nd day of admission
patient experienced severe
headache, persistent vomiting and
epigastric pain.
Patient also complained of double
vision, scotoma, and sometimes
rainbow-colored rings around the
light
Patient states “Pagmata nako
ganina, sakit kaayo akong ulo ug
na lipong ko; lain kayo akong
gibati, dili ko kasabot ky mura kog
kasuka-on hangtud naka suka
Civil Status: Married
Chief Complaints: Presents with increased blood pressure.
Planning
(Goals and Objectives)
After 2 days of nursing
interventions, the patient will
participate in activities that
reduce blood pressure or
cardiac work load.
Religion: Iglesia ni Cristo
Interventions
Day 1:
• Monitor blood pressure of the patient.
Measure in both arms or thighs three times, 3-
5 minutes apart while patient is at rest, then
sitting, then standing for initial evaluation.
• Observe skin color, moisture,temperature
and capillary refill time.
• Note dependent or general edema.
• Provide calm, restful surroundings,
minimize environmental activity or noise.
• Maintain activity restrictions.
• Instruct in relaxation techniques, and
guided imagery.
Collaborative:
• Implement dietary sodium, fat, and
cholesterol restrictions as indicated.
Dependent:
Administer antihypertensive drugs as
ordered.
Date & Time of Admission: January 15, 2021, 9 am Room:
Rationale Evaluation
Day 1
After 2 days of nursing
• Comparison of pressures provides a more interventions, the patient was
complete picture of vascular involvement or able to participate in activities
scope of the problem. that reduce blood
pressure or cardiac work
• Presence of pallor, cool, moist skin and
delayed capillary refill time may be due to
peripheral vasoconstriction.
• May indicate heart failure,
renal or vascular impairment.
• Help reduce sympathetic
stimulation, promotes relaxation.
• Reduces physical stress and tension that
affect blood pressure and course of
hypertension.
• Can reduce stressful stimuli, produce
calming effect, thereby reduce blood pressure.
• These restrictions can help manage fluid
retention and with associated hypertensive
response, which decrease cardiac workload.
 seeks to prevent the complications
of high blood pressure, such as
stroke and myocardial infarction.
Day 2:
gyud ko. Ug lain kayo akong
panan-aw ky mura kog malibat ug
ga kipat-kipat akong mata nga
silaw kaayo. Nabantayan pud nako
nga gamay lang akong gina ihi ug
balason pa.”
Objective:
BP: 140/90 mmHg
Temp: 36.2 degrees Celsius
PR: 90 bpm
RR: 20 bpm
Weight: 203 lbs
Height: 5 ft. and 3 in.
Blood type: AB (+)
Fundic height: 23 cm
FHT: 150 bpm
(+) excessive weight gain on the
2nd trimester
On the second day of admission
while the patient is talking to you,
suddenly patient
 Ceases to talk
 Face becomes fixed
 Eyes jerk from side to side
and the roll upward
 Mouth twitches
 Convulsion becomes general
 Hyperactive reflexes were
noted
 Pt's tongue was caught in
between the teeth
 All the muscles including the
diaphragm becomes rigid
which cause cessation of
Day 2:
Independent:
During seizure:
Enforce precautions per protocol
Position patient on side; insert
airway/bite block only if mouth is
relaxed; suction nasopharynx, as
indicated; administer oxygen; avoid
restrictive clothing; do not restrict
movement. Document motor
involvement, duration of seizure, and
post seizure behavior.
After seizure:
Check for alterations in level of
consciousness.
Assess fetal well-being, noting FHR.
Dependent:
Administer Magnesium Sulfate as
ordered by the physician.
Administer medications as ordered by
the physician:
 Metoclopramide 10 mg/amp
IVTT STAT
 Hydralazine 5 mg IVTT
 Betamethasone 12 mg
Collaborative:
Send laboratory sample for proteinuria
test.
Independent:
During:
Reduces risk of injury
Maintains airway by reducing risk of
aspiration and preventing tongue from
occluding airway. Maximizes
oxygenation. Note: Be cautious with
use of airway/bite block, because
attempts to insert when jaws are set
may result in injury.
After seizure:
In progressive PIH, vasoconstriction
and vasospasms of cerebral blood
vessels reduce oxygen consumption by
20% and result in cerebral ischemia.
During seizure activity, fetal
bradycardia may occur.
Dependent:
Decreases acetylcholine release, blocks
neuromuscular transmission, and
prevents seizures. It has a transient
effect of lowering BP and increasing
urine output by altering vascular
response to pressor substances.
 Metoclopramide is given to
counter vomiting.
 Hydralazine is used to treat high
blood pressure.
 Betamethasone is used for
inflammation and blurred vision
 breathing ang marked Collaborative:
cyanosis Emergency C-Section This helps determine pre-eclampsia
 Pulse become very rapid Call for anesthetics and pediatric care among pregnant patients.
 Arm and legs began to jerk Emergency C-Section
 Tongue was bitter Monitor platelet count post-op. Call for anesthetics and pediatric care.
 Bloody forth appears in the
mouth To ensure patient safety.
 Pt began breathing again
but is stertorous and
labored. After a few mins,
breathing becomes deeper
and easier and the cyanosis
disappears
 Muscles ceased jerking

Reference : ACOG Committee on Obstetric Practice. ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. No. 33, January 2002. American College of Obstetricians and
Gynecologists. Obstet Gynecol.

Name of Student: Illaizah T. Edicto Yr/Crs/Sec: BSN 2D RLE Group: Group 3 CI: Neda Joy Espina