NCP B

ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE EVALUATION

Subjective: Risk for Decreased  Establish rapport  To earn client’s The goal was met as
- Client reported that
Cardiac Output related and therapeutic trust and build a evidenced by:
she is fond of to increased vascular communication good relationship.
eating chocolates,
resistance secondary to with the client.
fruit shakes, and ice
Preeclampsia with severe Short Term: Short Term:
cream. features as manifested by After 2 hours of nursing After 2 hours of nursing
- Client reported that
client reported that she is intervention, the client  Provide client with  To promote intervention, the client
her diet is
fond of eating chocolates, will be able to: a quite adequate rest to was able to:
uncontrolled. fruit shakes, and ice environment. the client.
cream, her diet was Alter, clean, and
Objective: uncontrolled, and her BP organize client’s
- BP: 180/100 mmHg is 180/100 mmHg.  Have a normal environment or
 Have a normal
- T: 37.4 Blood Pressure bed linens.
Blood Pressure
- P: 80 level  Resting will level for a
- R: 17  Encourage the
reduce cardiac pregnant woman:
 Feel comfortable client to acquire
workload, and BP=130/90
and relaxed adequate rest
through doing bed since the client is
pregnant, the left-  Feel comfortable
 Be coordinated or chair rest in a
side lying position and relaxed as she
and referred to comfort position,
is recommended, it verbalized, “Mas
other health care like left-side lying.
helps blood flow to maganda sa
providers for the the placenta that pakiramdam pag
concerns with will prevent maayos ang
regard to their placenta ischemia. paligid.”
field of expertise.
 Be coordinated
 Encourage client  Relaxation and referred to
 to do relaxation techniques helps other health care
techniques (deep to prevent or providers for the
breathing, reduce stress, concerns with
massage, pain, anxiety, and regard to their
meditation, etc.). anger, and it will field of expertise.
increase calmness.

 Administer  To lower client’s

antihypertensive blood pressure
as ordered. level.

 Monitor client’s  These will serve as

vital signs while a baseline data if
patient is at rest. the activities and
intervention are
effective and if
there is a need for
some
modifications.
 Consult with the  To develop a
dietitian for the dietary plan with
diet plan of the the client where
client. she can still
acquire the
nutrients that she
needs for her
pregnancy.
Long Term:
After 3 days of nursing  Instruct client to
adhere to the diet  Eating more food
intervention, the client that has good
will be able to: plan re: cutting
amount of
 out or reducing nutrients will
the amount of food make sure that the
 Control the that is not good mother is in good
amount of food for her and the health and the
intake and adhere baby’s health and baby will receive Long Term:
to the diet plan. eat more the right amount After 3 days of nursing
nutritious and of nutrients for intervention, the client
unprocessed food growth and will be able to:
that can development.
contribute to her
 Control the
and the child’s  Pregnant women
amount of food
good health need to increase
intake and adhere
the amount of
to the diet plan.
 Encourage the nutrient intake,
client to do some but binge eating is
other activities not highly
(walking, having a recommended
conversation with because it can
friends and family, increase cardiac
watching movies, workload.
etc.) that will
redirect client’s
attention rather
than eating more
food.
 If there is a great
 Instruct client to amount of sugar in
reduce the amount the body, it will be
of eating sweets. converted into
fats, and too much
fat in the body can
cause
atherosclerosis (fat
and cholesterol
build up in the
walls of arteries.