NURSING CARE PLAN

Assessment Nursing Goals and Nursing Intervention Rationale Evaluation

Diagnosis Objectives
Subjective Data: -Decreased cardiac Short term Independent: •Edema, headaches, visual •After the nursing
“Masaki tang ulo ko at output related to • The client will be •Assess vital signs, conduct disturbances, and epigastric interventions, the
nahihilo ako” decreased venous able to display physical examination, and pain are associated with patient wasable to
return as manifested hemodynamic commence daily weight patient’s high blood pressure participate inactivities
as verbalized by the by headache, dizziness stabliity monitoring level. Weight gain is an that reduce blood
patient and BP of important symptom of pressure or
OBJECTIVE DATA: 150/100mmHg Long term preeclampsia. Fluid cardiacworkload
•UTI • Participate in retentention may evident if
• Skin lesions activities that reduce the mother has a weight gain
• Abdominal striae the workload of the of more than 1.5kg/month
gravidarum heart (e,g., stress during the 2nd trimester, or
management or more than 0.5kg/week during
therapeutic the 3rd trimester
Vital signs taken as ,medication regimen
follow: program, weight • Intsruct the patient to have •To lower blood pressure
T: 37.3 C reduction, balanced bedrest and avoid levels, improve cardiac rate,
PR: 120 bpm activity/restplan, environmental stressors enhance renal-placental
RR: 23 cpm proper use of perfusion,
BP: 150/100 mmHg supplemental
oxygen, cessation of
smoking). Dependent: •To lower blood pressure
•Administer hypertensive as levels. Common
prescribed. antihypertensives for
preeclampsia include
hydralazine, MgSO4, and
nifedipine.
 Collaborative:
•

Develop a nursing care plan based on the following scenario:

This is a case of a 39y/o G3P1 pregnant patient who was admitted with chief complaint of headache and dizziness. The client
weighs 73 kg and has a height of 148cm.
Patient claim to have complete childhood immunization. The patient has no known history of HPN, Asthma, DM, PTB, Thyroid
Disease, and malignancy. No known allergy to food and medications. No history of blood transfusions and previous surgeries.
Past Medical History: (-)HPN, (-)Asthma, (-)DM, (-)PTB, (-)Thyroid Disease, and (-)malignancy
Allergies: No known allergy to food; No known allergy to medications
Patient had her menarche at 13 years old occurring at regular interval, lasting for 3-5 days, consuming 2-3 pads per day,
moderately soaked with occasional dysmenorrhea. Subsequent menses came in regularly with the same amount, flow and
duration.
Patient had her first child in 2010 and delivered full term via normal spontaneous delivery. Her second pregnancy was a missed
miscarriage at 12 weeks AOG in 2012. Dilation and curettage were done in a provincial hospital. Her current pregnancy is on
her 28 weeks gestation. She had been on antibiotic(prescribed) a month ago due to urinary tract infection.
The patient has 2 siblings and she is the eldest. She is a high school graduate, unemployed, single and currently living in with
her partner who works as construction worker. Patient is a non-smoker, occasional alcohol beverage drinker. ASSESSMENT:
• • Vital signs: T: 37.3C, PR: 120bpm, RR:23cpm, BP 150/100mmHg
• • Cardiovascular: (-) orthopnea, (+) fatigability, (-) Palpitations, (-) Chest pain
• • Respiratory: (-) cough, (-) shortness of breathing
• • GI: (-) nausea and vomiting (-) Diarrhea, (-) constipation, (-) melena
• • GU: (-) UTI, no discharges
• • Extremities: (+) pedal non pitting edema, (+) edema on upper extremities (Grade 1)
• • Skin: fair complexion, good skin turgor, warm to touch, (+) abdominal striae gravidarum, (-) skin lesions
• • Neurological: (-) tingling sensations, (-) tremors, (-) numbness
• • IVF: D5Lr 1 liter x 8 hours
• • Meds: Hydralazine 5mg, Methyldopa 250mg, Spironolactone 50mg, Furosemide 40mg
• • Labs: CBC with BT, Urinalysis (with proteinuria), HbSAG, HVDRL, CTG
• • Radiology: BPS, UTZ
ASSESSMENT:
• • Vital signs: T: 37.3C, PR: 120bpm, RR:23cpm, BP 150/100mmHg
• • Cardiovascular: (-) orthopnea, (+) fatigability, (-) Palpitations, (-) Chest pain
• • Respiratory: (-) cough, (-) shortness of breathing
• • GI: (-) nausea and vomiting (-) Diarrhea, (-) constipation, (-) melena
• • GU: (-) UTI, no discharges
• • Extremities: (+) pedal non pitting edema, (+) edema on upper extremities (Grade 1)
• • Skin: fair complexion, good skin turgor, warm to touch, (+) abdominal striae gravidarum, (-) skin lesions
• • Neurological: (-) tingling sensations, (-) tremors, (-) numbness
• • IVF: D5Lr 1 liter x 8 hours
• • Meds: Hydralazine 5mg, Methyldopa 250mg, Spironolactone 50mg, Furosemide 40mg
• • Labs: CBC with BT, Urinalysis (with proteinuria), HbSAG, HVDRL, CTG
• • Radiology: BPS, UTZ