Athena Irish D.

Lastimosa BSN 2Y1-1 RLE 217 13A DR

NURSING CARE PLAN
Client: Dolly Cama Age: 30
Medical Diagnosis: Eclampsia Gender: Female
Priority #1 Decreased Cardiac Output
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Decreased Cardiac Short-term: Dependent: Short-term:
The patient said in verbatim, output related to After 4 hours of nursing  Give antihypertensive drug  If BP does not respond to conservative After 4 hours of nursing
“Tuwing buntis lang ako nagiging decreased venous intervention, the patient such as hydralazine measures, short-term medication may be intervention, the patient:
highblood, after 3 days return secondary to will: (Apresoline) PO/IV, so that needed in conjunction with other  Able to report absence of
pagkapanganak ko normal naman Eclampsia as  Report absence diastolic readings are therapies. Antihypertensive drugs work dyspnea.
na ulit.” “Okay lang naman yung evidenced by change and/or decreased between 90 and 105 mm Hg. directly on arterioles to promote  Had a lower blood pressure
pakiramdam ko, nahihilo lang at in blood pressure episodes of dyspnea. Begin maintenance therapy relaxation of cardiovascular smooth than her consistent 160-
nauuhaw.”  Have a lower blood as needed, e.g., methyldopa muscle and help increase blood supply to 140/100 range.
pressure than her (Aldomet) or nifedipine cerebrum, kidneys, uterus, and placenta.
Objective: consistent 160- (Procardia). Hydralazine is the drug of choice Long-term:
 Shortness of breath 140/100 range. because it does not produce effects on After 2 days of Nursing
 Consistent 160-140/100- the fetus. Sodium nitroprusside is being intervention, the patient:
90 BP range Long-term: used with some success to lower BP  Became normotensive with
 G4P4(3102) After 2 days of Nursing (especially in HELLP syndrome). a BP of 120/80 throughout
intervention, the patient  Administer propranolol  Side effects such as tachycardia, remainder of postpartum
 V/S taken as follows: will: (Inderal), as appropriate. headache, nausea, and vomiting, and recovery.
T- 36.7  Become palpitations may be treated with
P - 80 normotensive Independent: propranolol.
RR - 16 throughout remainder  Record and graph vital signs  The patient with PIH does not display
BP – 140/90 of postpartum especially BP and pulse. the normal cardiovascular response to
SP02 – 86% recovery. pregnancy. Hypertension occurs owing
to increased sensitization to angiotensin
II, which increases BP, promotes
aldosterone release to increase
sodium/water reabsorption from the
renal tubules, and constricts blood
vessels.
 Improves venous return, cardiac output,
 Institute bedrest with patient and renal/placental perfusion.
in lateral position.  Side effects such as tachycardia,
 Check on BP and side effects headache, nausea, and vomiting, and
of antihypertensive drugs. palpitations may be treated with
propranolol.
Collaborative:  Strengthens importance of patient’s
 Review techniques for stress responsibility in treatment.
management and diet
restriction with help of other
health care practitioners.