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NURSING CARE PLAN

PREECLAMPSIA AND
ECLAMPSIA

NCM 109 RLE CLINICAL

Saturday 7:00 AM – 12:00 PM

Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3
PREECLAMPSIA
Name: Louisse Natasha Valeria Age: 28 years old
Sex: Female
 Name: Samantha Maureen Vera Age: 30 years old

sment Nursing Goal Intervention Rationale Evalua

Diagnosis

Ineffective tissue After 8 hours of duty, Independent: GOAL PARTIALL

perfusion related client will be able to - Monitor vital signs -To identify physical
to manifest increased
ko. Masakit vasoconstriction particularly blood pressure. responses associated with - Blood pressu
tissue perfusion as medical conditions.
ko.” as of blood vessels above norm
evidenced by:
the patient. 130/90
 blood pressure
within normal -ROM promotes improved
range - Perform assistive passive
blood circulation. - Skin is warm t
 warm and dry range of motion.
skin
ma noted on  capillary refill -It conserves energy/lowers - Capillary refi
within normal - Provide quiet and restful
r extremities tissue oxygen demand. seconds.
range (3- 5 environment.
de 2)
clammy skin seconds)
d.  absence of - Edema is
edema Dependent: (from grade 2 to
lary refill
- Antihypertensives help
n 6 seconds - Administer
decrease and control blood
signs taken antihypertensive drugs as
llows: pressure.
ordered.
0/110mmHg
bpm - Administer Magnesium -
cpm Magnesium sulfate
sulfate as ordered. prevents or controls seizures
rature= 35.6⁰
in pre-eclampsia brought
about by vasospasm
secondary to
vasoconstriction of blood
vessels.
Sex: Female
 sment Nursing Goal Intervention Rationale Evalua
Diagnosis

Decreased After 8 hours of Independent: After 8 hours

cardiac output nursing interventions,
 Monitor blood - Comparison of
related to interventions, the was able to p
pressure of the pressures provides a
o na bigla na decreased patient will activities that r
patient. Measure in more complete
migat ang venous return. participate in pressure or c
either arms or picture of vascular
ko,” as activities that reduce load.
thighs three times, involvement or
by the blood pressure or 3-5 minutes apart scope of the
cardiac work load. while patient is at problem.
rest, then sitting,
then standing for
initial evaluation.

tions in
 Observe skin color,
d pressure.
moisture,
ma - Presence of pallor,
temperature and
signs taken cool, moist skin and
capillary refill time.
llows: delayed capillary
0/90 mmHg refill time may be
bpm due to peripheral
cpm vasoconstriction.
rature= 37.1⁰
 Note dependent or
general edema. - May indicate heart
failure, renal or
vascular impairment.

 Provide calm,
restful - Help reduce
surroundings, sympathetic
minimize stimulation,
environmental promotes relaxation.
activity or noise.

 Maintain activity - Reduces physical

restrictions. stress and tension
that affect blood
pressure and course
of hypertension.

 Instruct in - Can reduce stressful

relaxation stimuli, produce
techniques, and calming effect, and
guided imagery. thereby reduce
blood pressure.

Collaborative:
 Implement dietary - These restrictions
sodium, fat, and can help manage
cholesterol fluid retention and
restrictions as with associated
indicated. hypertensive
response, which
decrease cardiac
workload.
Name: Ashianna Kim Fernandez Age: 30 years old
Sex: Female
sment Nursing Goal Intervention Rationale Evalua
Diagnosis

Fluid volume After 2-3hours of Independent: Goal was me

excess related to nursing interventions -To evaluate degree of fluid hours of
1. Assess vital signs.
compromised patient will be able to excess. interventions
po ng ulo ko regulatory verbalize able
ang tumataba mechanism as understanding of understanding
g sobra,” as evidenced by individual dietary/fluid res
the patient. tissue edema. dietary/fluid 2. Change position -To promote comfort and
restrictions frequently. safety.

3. Evaluate mentation. - For confusion or

personality changes.

essness
ht: 145lbs 4. Restrict Sodium and fluid -To emphasize dietary/fluid
Signs taken intake. restriction.
llows:
0/120 mmHg
bpm
cpm 5. Advised to elevate the -To reduce tissue pressure
rature= 36.7⁰ edematous extremities, and risk for skin breakdown
change position frequently

- To prevent stasis and risk of

6. Stress the need for tissue injury
mobility and frequent
position changes

-To ensure timely

7. Identify signs requiring evaluation/intervention
notification of healthcare
provider

-To promote safety.

8. Provide safety measures
when client is confused.

Dependent:
-Antihypertensives help
1. Administer decrease and control blood
antihypertensive pressure.
medications as indicated.
ECLAMPSIA
Name: Avianna Rye Diaz Age: 28 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis
: Subjective: Decreased Short Term: Independent: Short Term:
Cardiac output
“Pagod na pagod na ako After 3 hours of 1. Establish rapport - To gain patient’s The patient have displayed
r/t decreased
at nahihirapan na ako nursing trust and hemodynamic stability
venous return
huminga!” as verbalized interventions, the cooperation. (blood pressure within
secondary to
by the patient. patient will display closer range).
eclampsia,
blood pressure 2. Monitor and assess Vital - To obtain baseline.
altered BP and
within her normal signs.
Objective: edema
range
Long Term:
3. Assess the patient’s - To determine
 Variations in BP Long Term: presence of The patient have
general physical condition.
reading abnormality. demonstrated activities that
After 3 days of
 Restlessness reduce the workload of the
nursing
 Vital Signs taken as 4. Determine baseline vital - Provides heart (stress management,
interventions, the
follows:
patient will signs/hemodynamic opportunities to therapeutic medication
BP= 175/80 mmHg Parameters including track changes. regimen program, balanced
demonstrate
PR= 115 bpm peripheral pulses. activity/rest plan.
activities that reduce
RR= 25 cpm
the workload of the
Temperature= 37⁰
heart.
5. Review signs of - To prevent
impending failure /shock. hypovolemic shock.

6. Position with flat or keep - To increase venous

trunk horizontal while return.
raising legs 20 to 30 degrees
(contraindicated in
congestive state in which
semi-fowler’s position is
preferred).

7. Promote adequate rest - To maximize sleep

by decreasing stimuli. periods.
Name: Kierra Valeria Ynares Age: 27 years old Sex: Female
 Assessment Nursing Goal Intervention Rationale Evaluation
Diagnosis

Subjective: Ineffective tissue Short Term: Independent: Short Term:

Perfusion related
“Wala akong After 8 hours of  Assess for possible - Early detection of Goal met. After 8 hours of
to
maramdaman pag effective nursing causative factors cause facilitates nursing intervention the
vasoconstriction
pinipisil yung paa.” as intervention the related to impaired effective treatment. client had a blood pressure
as manifested by
verbalized by the patient. client will able to blood flow. of 140/110.
elevated blood
decrease blood
pressure
pressure from  Monitor and record - To provide
Objective: 170/150 to 140/110. vital signs for every comparisons with Long Term:
hour. current findings. Goal partially met because
after 16 hours of nursing
 (+3) pitting and Long Term:
intervention the client was
generalized
After 16 hours of  Assess visual - Leads to vasospasm not able to demonstrate
edema at the disturbances. and alerts for an behaviors
effective nursing or lifestyle
lower and upper indication of changes
intervention the to improve
extremities and probable convulsion circulation and maintain the
client will able to
face .
demonstrate normal range of blood
 400ml/24 hrs of  Provides quiet - To reduce stress, pressure she needs further
behaviors or lifestyle
urine. environment promotes rest and teachings and time to adapt
changes to improve
 Vital Signs taken sleep.
circulation and the change.
as follows:
maintain the normal  Do passive range of - Exercise prevents
BP= 170/150 mmHg motion (ROM) venous strains
range of blood
PR= 78 bpm exercise
pressure.
RR= 18 cpm
Temperature= 37.8⁰
 Administer - To decrease blood
medication as order pressure and drug
response, half-life,
toxic level may by
decrease tissue
perfusion
 Provide information
on normal tissue
- To decrease anxiety
perfusion and
level
possible causes for
impairment.

 Instruct in blood
pressure - To facilitate
monitoring at home management of
Name: Amora Elyse Ledezma Age: 26 years old Sex: Female
 Assessment Nursing Goal Intervention Rationale Evaluation
Diagnosis

Subjective: Altered tissue Short Term: Independent: Short Term:

perfusion related
“Hindi ako makahinga ng Client will 1. Monitor vital signs, - Indicators of Client’s blood pressure is
to decreased
maayos,” as verbalized by demonstrate palpate peripheral pulses adequacy of below 140/90mmHg, urine
uteroplacental
the patient. adequate perfusion, and note capillary refill, systemic perfusion, output of above 30ml/hour,
perfusion
as evidenced by assess urinary output, fluid/ blood, needs, fetal heart rate is between
evidenced by
stable vital signs, weigh client daily and and developing 120-160 beats per min,
Objective: decreased
palpable pulses, and evaluate changes in complications. absence of seizure
hematocrit and
alert and oriented, mentation. episodes, decrease in
haemoglobin
absence of seizure presence of edema.
 Pallor episodes, balanced - This is to avoid
 Variations in intake and output, 2. Place client on left uterine pressure on
blood pressure decrease in presence recumbent position. the vena cava and Long Term:
 Edema of edema and good Monitor maternal well- prevent supine Client verbalizes plans upon
 Vital Signs taken as fetal status being periodically. hypotension discharge, participates
follows: evaluation within a syndrome. during lecture- discussion
BP= 180/120 mmHg week. sessions, and
PR= 103 bpm - Woman’s BP should demonstrates willingness to
Long Term:
RR= 25 cpm 3. Administer oxygen as be taken at least perform monitoring
Temperature= 37.6⁰ Client will prescribed. every 4 hours to measures.
demonstrate detect for increase
readiness during the which is a warning of
postpartal period in worsening; if
monitoring one’s fluctuating, it should
health and involving be done hourly.
oneself to dietary
restrictions and
medical follow up
checkups and 4. Ensure safety by putting - To ensure supply of
intervention. the side rails always up and oxygen to both the
monitor client for tonic- mother and the
clonic convulsions. fetus.

5. Insert Foley catheter as - Convulsions are

indicated by the physician evident in Eclampsia
and monitor urine output. so it should be
watched out and
monitored.

6. Administer Magnesium - Urine output should

Sulfate as ordered by the be in congruence
physician and monitor for with fluid intake.