Assessment Nursing (Rationale) Desired Nursing Intervention Justification Evaluation

Cues Diagnosis Pathophysiologic / Outcome

Name of Student: Mary Claire Joy Pescadero Schematic Diagram
Subjective: Risk for injury r/t Predisposing Factors: NURSING CAREIndependent
After 8 hours of Nursing PLANIntervention: After 8 hours of
“gulpi nalang nag seizure activity or Age: 38 years old Intervention, the Nursing
turong mata ya convulsion of the Gender: Family patient and 1. Monitor vital signs of the 1. This serve as a baseline Intervention, the
Section and Group
tapos nanig’a syanumber: 4C G5
patient significant other will be patient especially the blood data for assessment. patient and
Precipitating Factors: able to: pressure.
kag gin kurog.” As significant other was
Name of CI: Ma. Karen Lechoncito RN, MN
verbalized by the Lifestyle be able to:
husband of the History of hypertension 2. Raise side rails of the 2. For patient safety since
Area of Exposure: TDHI OB Ward
Definition: she is experiencing
patient patient.
A. Demonstrate stable convulsion.
A state in which a Defective spiral artery A. Demonstrate vital
vital signs.
Objective: person has the remodeling during pregnancy signs such as for
Facial grimace potential for 3. Discuss seizure warning 3. Enables the patient & SO temperature 36.2 C,
Weakness being physically Insufficient trophoblast cell signs and usual seizure to protect the patient from pulse rate of 90
Convulsions harmed due to invasion, which causes the pattern to patient & SO. injury. bpm, respiratory
Restlessness environmental spiral arteries to remain rate of 19 cpm and a
hazards and/or narrow and leads to placental 4. Explore with the patient 4. This could help in blood pressure of
Edema present in
impairments in hypoperfusion. possible factors that could preventing seizure activity.
feet 130/80. Goal Met.
his adaptive and B. Demonstrate contribute to seizure.
Latest Vital Signs: defensive Diseased placenta releases behaviors to reduce B. Demonstrated
5. Instruct the patient to 5. To help in lowering blood
T: 36.7 C resources. proinflammatory proteins risk factors and behaviours that
have a complete bed rest pressure levels, improve
P: 101 bpm protect self from could reduce risk
Proteinuria and avoid environmental cardiac rate and enhance
R: 21 cpm injury. factors such as
stressors. renal-placental perfusion.
BP: 150/100 mmHg Source/ raising the side rails
Reference Systemic vasoconstriction and observing safety
Nurse’s Pocket and endothelial dysfunction 6. Provide a calm and 6. Helps reduce sympathetic
precautions. Goal
Guide. Edition 11 peaceful surroundings and stimulation and promotes
Strength : Met.
by Marilynn Hypertension C. Modify the minimize environmental relaxation.
Good family
Doenges, Mary environment as activity or noise.
support C. Modified the
Frances Preeclampsia indicated to enhance
Willing to adhere environment of the
Moorhouse and safety.
to the treatment Alice Murr patient such as the
Eclampsia
Patient complies to Dependent Interventions: light was not that
Dependent Interventions:
her medications 1. To lower blood pressure bright and raising
Oxidative stress 1. Administer prescribed
levels and prevent side rails of the bed
medications such as
Weakness: occurrence of seizure and positioned as
S/S: Antihypertensive,
Lack of knowledge activity. low as possible.
 elevated blood corticosteroid and
regarding Goal Met.
 pressure swelling in your anticonvulsant.
eclampsia and face or hands
seizure  headaches Long Term Goals:
 excessive weight gain D. Adhere to