NCP: Pregnancy Induced Hypertension Patient Name: Sam AOG – 2nd Trimester

Assessment Diagnosis Planning Intervention Rationale Nursing Core Evaluation

Theory Values
Subjective Data: Independent: Independent:
Jean Watson: ● Compas
“Nabudlayan ako Decreased After 12 - 24 a) Position the patient a) Elevation of the leg decreases Theory of Goal met.
cardiac comfortably with feet venous stasis and may reduce Human Caring: sionate
mag-ginhawa hours of nursing
incidence of thrombus and “Nursing Service
ma’am nurse. Kit output related interventions, the slightly elevated. Provide is
an ko sa ispiho, to increased patient will have: frequent rest periods with embolus formation. Bed rest concerned with
nagapalanghubag systemic bed rest. Restrict and restriction of activity help promoting “Medyo nag-ayo
akon mga tiil. Kis- vascular 1. Normotension activities and give improve venous return, cardiac health, ● Social naman akon
a gablur akon resistance 2. Normal assistance to patient’s output, and renal-placental preventing Commit pamatyag. Wala na
panan-awan ,” as breathing and needs. perfusion and reduce stress illness, caring ment ko nabudlayan mag-
verbalized by the heart rate and tension that may affect for the sick, and ginhawa”, as
patient. 3. Decreased blood pressure restoring verbalized by the
patient.
edema health.” ● Co-
4. Overall responsi
b) Monitor blood b) Provides comparison of After 12 - 24 hours
improvement bility
Objective Data: pressure of the patient in pressures that gives complete of nursing
both arms three times and interventions, the
idea about vascular respect
● Edema on with 3-5 minutes interval involvement. patient was able to:
upper and lower while patient is at rest, Faye Abdellah’s for
extremities then sitting, then 21 Nursing human 1. Cooperate with
standing for initial Problems: “The dignity the interventions.
● Diminished evaluation. 21 nursing 2. Bring back blood
peripheral problems fall pressure within
pulses into three normal value
c) Continuous categories: 3. Gain overall
● Confusion monitoring/assessment c) To monitor changes that may physical, improvements.
of: signal worsening of the sociological,
● Dyspnea
condition. and emotional
 Blood pressure,
needs of
pulse rate, heart
patients; types
rate and rhythm
of interpersonal
 Crackles, wheezes,
relationships
and dyspnea
between the
 Neurological status
patient and
 Visual disturbances
nurse; and
 Intake and output
common
 Patients’ 24-hour
elements of
 urine for proteinuria patient care.” Objective Data:
 Indications for
Vital signs: earlier delivery ● Patient has
d) To monitor the presence of palpable pulses
T: 36.5°C
pallor, cool, moist skin and
d) Observe skin color, delayed capillary refill that may ● Have still slight
PR: 115 bpm
moisture, temperature indicate vasoconstriction edema on upper
CR: 117 bpm and capillary refill. and lower
extremities.
RR: 22 bpm e) To make patient aware of what
e) Educate patient about is happening on her body and
BP:150/100 the condition and good how to help manage it.
mmHg nutrition.

Vital signs:
f) Monitor the fetus by f) To check the health status of
Urine Output: the fetus
cheking Fetal Heart T: 36.7°C
Decreases
Tone, Fetal Movement
Counting, Nonstress PR: 98 bpm
Testing, Biophysical
Profile, etc. CR: 100 bpm

RR: 21 bpm
g) Provide calm, restful g) Help reduce sympathetic
stimulation and stressful stimuli. BP:130/80 mmHg
environment and
encourage relaxation Promotes relaxation.
techniques such as
watching T.V., or Urine Output:
mobile phones. Slightly, increased
h) Delivery of the fetus is the cure
for the hypertension. Fetal
h) Prepare for Cesarean
death may occur if not
Delivery if indicated by
executed immediately while the
the severity of
condition is worsening because
hypertension.
of lack of oxygen and nutritional
supply.
Dependent: Dependent:

a) Administer Methyldopa a) Works as an antihypertensive

(Aldomet) 250 mg, 1 drug that works by relaxing the
tablet, BID as ordered. blood vessels making the
blood flow more easily.

b) Administer Magnesium b) Works as a Central Nervous

sulfate 4 g IV bolus over
20 minutes followed by 1
g/hr infusion for 24 hours
as ordered.
System depressant that acts
to block neuromuscular
transmission of acetylcholine
to halt convulsions. It also
halts premature labor, as it
relaxes smooth muscle.

c) Administer c) Works as a corticosteroid drug

Betamethasone that can cross the placenta
(Celestone) 2 mL IM and help fetal lung and brain
every 24 hours times 2 to mature.
doses PRN for
anticipated preterm
delivery as ordered.

d) Implement dietary d) It can help manage fluid

sodium, fat and retention and decrease
cholesterol restriction as cardiac workload.
ordered.