Problem 1 (PE Format): Impaired peripheral tissue perfusion related to decreased blood flow

Level of Prioritization: High Priority

Cause Analysis: Perfusion is the passage of fluid through the circulatory system or lymphatic
system to an organ. With hypertension or high blood, it alters the perfusion of the fluid as it
causes the blood vessels to narrow as the muscles adapt to the high pressure of the fluid. The
narrowing of the blood vessels will then lead the fluids to the less effective perfusion of the fluid
to the organs of the body.

Goals: The patient will demonstrate normal tissue perfusion, indicated by stable vital signs,
within-normal-range laboratory values, and the absence of lower extremity edema, signifying
adequate blood flow and oxygenation.

CUES DESIRED INTERVENTIONS RATIONALE EVALUATIO

OUTCOMES N

SUBJECTIVE SHORT INDEPENDENT SHORT

TERM ● Elevating TERM:
The patient After 4 hrs of ● Elevate lower the legs Goal met. After
complained of nursing extremities 4 hours of
above the
dizziness and lower intervention nursing
extremity edema the client will level of the intervention the
be able to heart can client
verbalize help participated in
OBJECTIVE understanding improve activities that
Vital signs as follows: of risk factors venous reduced blood
● BP: 160/110 or condition, return and pressure
mmHg therapy (<130/90mmHg
reduce
● PR: 125 bpm regimens, side ).
● RR: 30 cpm effects of edema,
● O2 medications. thereby
saturation: enhancing
95% LONG ● Monitor vital signs peripheral LONG TERM
TERM regularly circulation. Goal met. After
● Lethargic After ● Vital sign completing
completing course of
● Weak monitoring
course of treatment/
peripheral helps
treatment/ nursing
pulses nursing identify interventions,
interventions, trends or the client will
● Decreased the client will sudden be able to
capillary be able to deviations manifest normal
refill manifest from tissue
● Edema on normal tissue perfusion as
baseline,
lower perfusion as evidence by
evidence by indicating vital signs
extremities worsening
● Mild vital signs laboratory
laboratory or values, capillary
Proteinuria
values, improving refill, and
(5.2 grams) capillary refill, ● Encourage mobility tissue peripheral
and peripheral and position perfusion. pulses
pulses within normal
changes ● Movement
within normal range
range helps
facilitate
venous
return and
prevents
blood
pooling,
which can
contribute
to impaired
tissue
perfusion
and the
formation
● Provide education of blood
on signs and clots.
symptoms of ● Educating
complications the patient
about
warning
signs, such
as severe
headaches,
visual
disturbance
s, or
epigastric
pain,
empowers
 them to
seek
prompt
● Monitor fluid medical
intake and output attention if
necessary.
● Monitoring
fluid intake
and output
ensures that
the patient's
fluid status
is within
normal
DEPENDENT/COLLAB limits
ORATIVE

● Administer
Isoxsuprine
Hydrochloride 10g ● Relaxes
1 tab BID P.O veins and
arteries,
which
makes them
wider and
allows
● Administer blood to
Amlodipine pass easily
besylate 5g 1tab
OD P.O ● Amlodipine
- To lower
● Administer blood
Magnesium sulfate pressure
5g IM Q6 hours per ● Relaxes
buttocks as ordered blood
vessels,
calming
nerves,
blocking
calcium,
 and
stabilizing
the heart.
increase of
blood
pressure.

Problem 3: Decreased Cardiac Output related to pre-eclampsia, evidenced by hypertension,

proteinuria, and peripheral edema.
Level of Prioritization: high
Cause Analysis: Pre-eclampsia, characterized by hypertension and proteinuria, can lead to
decreased cardiac output due to increased systemic vascular resistance and decreased blood
volume secondary to fluid redistribution. This decreased cardiac output can further compromise
perfusion to vital organs, resulting in symptoms such as decreased urine output, altered mental
status, and visual disturbances.
Goals: The client demonstrates adequate cardiac output as evidenced by blood pressure and
pulse rate and rhythm within normal parameters for the client; strong peripheral pulses; normal
urine output

CUES DESIRED OUTCOMES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE SHORT TERM INDEPENDENT SHORT TERM
● After 4 hours of ● Maintain fluid ● A fluid Goal met. After 4
The patient reports nursing interventions, restriction and/or and/or hours of nursing
of anxiety and the patient will exhibit sodium interventions, the
fatigue with restriction
recurring episodes hemodynamic stability, sodium may be patient will exhibit
of dizziness and as evidenced by blood restriction. necessary to hemodynamic
blurred vision. pressure within her minimize stability, as evidenced
normal range fluid by blood pressure
OBJECTIVE retention. within her normal
● Initiate bedrest ● This
range
intervention
Vital signs as during the acute
involves
follows: phase and
LONG TERM bedrest
● BP: gradually initially to
160/110 progress activity reduce
mmHg After completing course of as tolerated to cardiac
● PR: 125 treatment the patient will, improve stamina workload,
bpm ● Patient will be able and functional followed by
● RR: 30 to return to baseline capacity as the gradual
cpm activity level. patient's activity
● O2 ● Patient will be able condition increase to
saturation to verbalize future improve LONG TERM
: 95% self-care activities cardiovascu
to improve cardiac lar function
health. during Goal met.After
● Non- recovery. completing course of
pitting treatment the patient
● Education
edema on ● Provide patient will,
will assist
lower education on patients in ● Patient will be
extremities home self-care understandi able to return
● Decreased measures. ng to baseline
urine measures activity level.
output they can ● Patient will be
take at able to
home to verbalize
improve future
their self-care
cardiac activities to
health and improve
prevent cardiac health.
further
deterioratio
n.
● Monitor fetal ● Early
well-being detection of
closely fetal
distress,
which may
be caused
by maternal
 cardiac
compromis
e.
● Encourage bed ● Bed rest
rest reduces
myocardial
oxygen
demand and
cardiac
workload
by
minimizing
physical
exertion.
● Position the ● This
patient in a left position
lateral position also helps
relieve
pressure on
the inferior
vena cava,
improving
blood flow
and cardiac
function.
DEPENDENT/COL
LABORATIVE

● Administer
Amlodipine
besylate 5g
1tab OD P.O

● By
lowering
vascular
resistance,
amlodipine
decreases
the
workload
on the
heart,
which can
help
improve
cardiac
output.