[Type text]
Name : Mrs. I.B.B
Age/Sex : 24 years old/ F
Medical Diagnosis : Eclampsia
Nursing Diagnosis : Ineffective (Utero -placental) tissue perfusion related to vasoconstriction of blood vessels.
Short Term Goal : Within the shift, patient’s blood pressure will decrease and will be able to have an adequate rest
and sleep.
Long Term Goal : At the end of the patient’s hospitalization, she will be able to understand the condition, prognosis,
therapeutic/medical regimen and safety measures.
Cues Problem Scientific Rationale Nursing Interventions Rationale Evaluation
SUBJECTIVE: Increased Inability of the kidneys Goal Partially Met
blood to excrete sodium, Monitor vital signs. This serves
“Sumasakit ang ulo ko pressure Natriuretic Factor being as the Patient
pag kagising ko at nung secreted to promote salt baseline data verbalized,
kinuhaan ako ng BP excretion with the side- of the “Hindi na
mataas pala.”, as effect of raising total Establish rapport. patient. sumasakit ang
verbalized by the peripheral resistance. To gain trust ulo ko”.
patient. and
An overactive renin cooperation. Patient’s blood
Pain Scale: 8/10 system leads to Provide rest pressure
vasoconstriction and periods. To facilitate, decreased from
OBJECTIVES: retention of sodium and comfort, 140/90 to 130/80.
water. The increase in sleep and
Variations in Blood blood volume leads to relaxation.
pressure reading. hypertension. Encourage patient
↑(140/90) to elevate head or To promote
place pillow under blood
6am-2pm shift the head circulation
>↓(130/80)
Encourage To enhance
adequate intake of well – being
fluids/ nutritious and
foods maximizes
energy
production
[Type text]
Name : Mrs. I.B.B
Age/ Sex : 24 years old/ F
Medical Diagnosis : Eclampsia
Nursing Diagnosis : Impaired physical mobility related to prescribed bed rest and body pain.
Short Term Goal : Within the shift, the patient will feel comfortable and can do such activities.
Long Term Goal : At the end of patient’s hospitalization, she will be able to perform ADL’s
Cues Problem Scientific Rationale Nursing Interventions Rationale Evaluation
SUBJECTIVE: Impaired Hysterectomy Monitor vital signs. To have a baseline Goal Partially Met
physical ↓ data of the patient.
“Hindi pa rin ako mobility To note any Patient
masyadong makakilos Breaking in the Observe movement incongruence with increased body
ngayon.” as verbalized continuity of the skin when client reports of abilities mobility
by the patient. unawake of and to assess
↓ observation functional ability. Patient
OBJECTIVES: Inflammation process To promote maintain body
wellness (teaching function
Conscious and coherent triggered Assist patient to discharge
Afebrile learn ways of considerations).
↓
Cooperative managing problems Enhances
Limited range of motion Nerve ending of immobility commitment to
Weak plan, optimizing
compression outcomes
6am-2pm shift ↓ To promote
>↓(130/80) optimal level of
Pain function and
↓ Instruct in use of prevent
side rails, overhead complications
Limited range of motion, trapeze, toilet pads
slowed movements and for position changes
reluctance to attempt and transfer
movement.
To enhance well –
↓ being and
Impaired physical Encourage adequate maximizes energy
[Type text]
intake of fluids/ production
Mobility nutritious foods
References:
[Link]
[Type text]
Name : Mrs. I.B.B
Age/Sex : 24 years old/ F
Medical Diagnosis : Eclampsia
Nursing Diagnosis : Anxiety related to threat of change in health status or death.
Short Term Goal : Within the shift, the patient will be able to show appropriate range of
feelings and lessened fear.
Long Term Goal : At the end of hospitalization, the patient will be able to demonstrate understanding through use of
effective coping behaviors.
Cues Problem Scientific Rationale Nursing Interventions Rationale Evaluation
SUBJECTIVE: Anxiety Avague Monitor vital To have a baseline Goal Partially Met
uneasy signs. data of the patient
“Dahil sa nangyari feelingof The patient was
sa akin parang discomfort Identify It enhance sense of able to cope up
natatakot na tuloy ordread patient’s control with the present
ako mag-anak pa accompanie responsibility situation.
ulet.” as verbalized dbyan for the solution.
by the patient automatic Patient’s
response; Speak in simple To facilitate decreased
OBJECTIVES: thesource sentence in understanding and feeling of
often providing retention of anxiety.
Conscious and nonspecific information information
coherent orunknown
Afebrile tothe Stay with the To diminished
Cooperative individual; patient to have feeling of fear.
Restless afeelingof someone to be
apprehensi there.
6am-2pm shift oncaused
>↓(130/80) by Educate patient It helps the patient to
anticipation to cope up with relieve stress.
ofdanger. the situation
Itisan
altering
signalthat
warnsof
impending
[Type text]
dangerand
enablesthe
individual
totake
measures
todealwith
threat.
