Name of Patient: M. R.

Date Admitted: May 7, 2022 Chief Complaint: Preeclampsia Case Number: 1

Age: 35 years old Gender: Female Civil Status: Married Address: Los Banos Laoang AP: Jonathan Mercado Raul Sy
 NURSING GOALS AND NURSING
ASSESSMENT RATIONALE RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTION
Subjective Data: Decreased cardiac Blood flow from Short Term Goals and Independent: Independent: Short term Goal and
output related to various organs Objectives: 1. Monitor blood 1. A spike in blood Objectives:
“Yes, I keep seeing increased systemic increases during pressure hourly or pressure would
vascular resistance pregnancy to meet the Within 5 hours of providing indicate Within 5 hours of patient
floaters and have even as needed
nursing care, the patient will progression of
thrown up from it. I do secondary to increased metabolic care, desired outcomes are
be able to:
have some swelling and preeclampsia as needs of tissues. In preeclampsia to a met and patient is:
 Achieve normal
my upper abdomen has evidenced by increased preeclamptic patients, cardiac output much severe case,  Able to achieve
really been hurting. My blood pressure, vasospasm is prevalent. through well eclampsia. normal cardiac
head is really hurting.” swellings, and hepatic Due to controlled blood 2. Note presence and 2. Diminished output and well
ischemia evident in vasoconstriction, there pressure levels quality of peripheral pulse in controlled blood
“I have been experiencing severe epigastric pain. is an increase in  Demonstrate normal peripheral pulse legs reflects effects pressure levels
systemic vascular respiratory rate of vasoconstriction
shortness of breath lately”  Able to demonstrate
observed by absence and venous
resistance normal respiratory
of dyspnea
Objective Data: congestion rate
 Decrease progression
3. Auscultate breath 3. Development of  Able to stop
of preeclampsia to
eclampsia, a much and heart sounds abnormal breath progression of
 BP: 156/98
severe case of and heart sounds preeclampsia to
mmhg
hypertension in may indicate eclampsia
 RR: 32
pregnancy ventricular
breaths/minute
hypertrophy, Long Term Goals and
Long Term Goals and impaired
Objectives: Objectives:
functioning,
development of Within 3 days of patient care,
Within 3 days of nursing
intervention, the patient will: pulmonary the desired goals are now met
 Demonstrate normal congestion and and the patient:
ranges of blood chronic heart  Is able to
pressure and normal failure. demonstrate normal
breathing patterns 4. Presence of pallor,
4. Observe skin color, ranges of blood
 Have reduced edema moist skin, or
temperature, pressure and normal
 Be able to verbalize delayed capillary
measures in order to moisture and breathing pattern
capillary refill time refill time may be
reduce progression of  Have reduced
due to peripheral
edema and reduction edema
of water retention vasoconstriction
 Is able to verbalize
 Be able to verbalize and reflects cardiac
measures in order to
measures to reduce decompensation.
reduce progression
stress induced by 5. Assess urine output 5. Elevated protein in
of edema and reduce
environmental urine and
and protein water retention
stimuli. decreased urine
 Verbalize knowledge  Is able to verbalize
output may
towards different measure to reduce
indicate
breathing techniques stress induced by
and relaxation progression of
environmental
techniques to aid preeclampsia to
stimuli.
respiration and eclampsia
 Verbalize
relaxation 6. Encourage bed rest 6. Bed rest in lateral
knowledge towards
position (left-side)