NAME:
AGE:
GENDER:
ASSESSMENT NURSING DIAGNOSIS
SUBJECTIVE:
 Deficient knowledge
”16 years old palang
ako wala pa akong alam
sa condition ko” as
verbalized by the
patient.
OBJECTIVE:
Mild pedal edema
BP: 150/90mmHg
RR: 20breaths/min
PR: 82beats/min
Temperature: 97.9
degrees Fahrenheit
OBJECTIVES NURSING RATIONALE EVALUATION
INTERVENTION
General Independent: Independent:
 To recognize the 1. Establish rapport 1. To gain the patient trust to  Goal met; after 8
related to Insufficient physiological responses 2. Provide information about be cooperative. hours of nursing
information possibly of the body to disease signs/symptoms indicating intervention the
evidence by condition. worsening of the condition, 2. Helps ensure that the Patient identifies
Development of and instruct the client when client seeks timely signs/symptoms
preventable to notify the healthcare treatment and may requiring medical
complications. Specific provider. prevent worsening of evaluation.
 After 8 hours of nursing 3. Educate the client with preeclamptic state or  The client
intervention the Patient possible or mild additional complications. maintains BP
identifies preeclampsia and ensure within
signs/symptoms enough protein in the diet. 3. Loss of protein through individually
requiring medical 4. Identify modifiable risk the urine is common acceptable
evaluation. factors like diet high in among clients with parameters.
 The client maintains BP sodium, saturated fats and preeclampsia because of  The client
within individually cholesterol. glomerular damage, performs the
acceptable parameters. 5. Suggest frequent position leading to excessive necessary
 The client performs the changes such as turning to protein excretion. Protein procedures
necessary procedures sides, passive leg exercises is essential for correctly.
correctly. when lying down. intravascular and
extravascular fluid
regulation.
Dependent: 4. These risk factors have
1. Magnesium sulfate 4gm been shown to contribute
loading dose to followed by 2g/hr to hypertension.
5. Suggest frequent position
changes such as turning to
sides, passive leg
exercises when lying
down.

Dependent:
1. Blocks neuromuscular
transmission, amount
of acetylcholine to halt
convulsions