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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
Assessment Nursing Goal Intervention Rationale Evaluation
Diagnosis
Subjective: Ineffective tissue After 8 hours of duty, Independent: GOAL PARTIALLY MET
perfusion related client will be able to - Monitor vital signs -To identify physical
to manifest increased
“Nahihilo ako. Masakit vasoconstriction particularly blood pressure. responses associated with - Blood pressure is slightly
tissue perfusion as medical conditions.
ang batok ko.” as of blood vessels above normal range: 130/90
evidenced by:
verbalized by the patient.
blood pressure
within normal -ROM promotes improved - Skin is warm to touch.
range - Perform assistive passive
Objective: blood circulation.
warm and dry range of motion.
skin - Capillary refill within 4
Edema noted on capillary refill -It conserves energy/lowers seconds.
within normal - Provide quiet and restful
lower extremities tissue oxygen demand.
range (3- 5 environment.
(grade 2)
cold, clammy skin seconds) - Edema is still present (from
noted. absence of grade 2 to grade 1)
edema Dependent:
capillary refill
- Antihypertensives help
within 6 seconds - Administer
decrease and control blood
Vital signs taken antihypertensive drugs as
pressure.
as follows: ordered.
BP= 150/110mmHg
PR= 80bpm - Administer Magnesium - Magnesium sulfate prevents
RR= 18cpm sulfate as ordered. or controls seizures in pre-
Temperature= 35.6⁰
eclampsia brought about by
vasospasm secondary to
vasoconstriction of blood
vessels.
Name: Samantha Maureen Vera Age: 30 years old Sex: Female
Assessment Nursing Goal Intervention Rationale Evaluation
Diagnosis
Subjective: Decreased After 8 hours of Independent: After 8 hours of nursing
cardiac output nursing interventions, the patient
Monitor blood - Comparison of
related to interventions, the was able to participate in
pressure of the pressures provides a
“Napansin ko na bigla na decreased patient will activities that reduce blood
patient. Measure in more complete
lang bumigat ang timbang venous return. participate in pressure or cardiac work
either arms or picture of vascular
ko,” as verbalized by the activities that reduce load.
thighs three times, involvement or scope
patient. blood pressure or 3-5 minutes apart of the problem.
cardiac work load. while patient is at
rest, then sitting,
Objective:
then standing for
initial evaluation.
Variations in
blood pressure.
Observe skin color,
Edema - Presence of pallor,
moisture,
Vital signs taken temperature and
cool, moist skin and
as follows: delayed capillary
capillary refill time.
BP= 140/90 mmHg refill time may be
PR= 78 bpm due to peripheral
RR= 20 cpm vasoconstriction.
Temperature= 37.1⁰
Note dependent or - May indicate heart
general edema. 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
Assessment Nursing Goal Intervention Rationale Evaluation
Diagnosis
Subjective: Fluid volume After 2-3hours of Independent: Goal was met after 2-3
excess related to nursing interventions -To evaluate degree of fluid hours of nursing
1. Assess vital signs.
compromised patient will be able to excess. interventions patient was
“Ang sakit po ng ulo ko regulatory verbalize able verbalized
saka po parang tumataba mechanism as understanding of understanding of individual
po ako nang sobra,” as evidenced by individual dietary/fluid restriction.
verbalized by the patient. tissue edema. dietary/fluid 2. Change position -To promote comfort and
restrictions frequently. safety.
3. Evaluate mentation. - For confusion or personality
Objective: changes.
Restlessness
Weight: 145lbs 4. Restrict Sodium and fluid -To emphasize dietary/fluid
Vital Signs taken intake. restriction.
as follows:
BP= 170/120 mmHg
PR= 84 bpm
RR= 21 cpm 5. Advised to elevate the -To reduce tissue pressure
Temperature= 36.7⁰ edematous extremities, and risk for skin breakdown
change position frequently
6. Stress the need for - To prevent stasis and risk of
mobility and frequent tissue injury
position changes
7. Identify signs requiring -To ensure timely
notification of healthcare evaluation/intervention
provider
8. Provide safety measures -To promote safety.
when client is confused.
Dependent:
1. Administer -Antihypertensives help
antihypertensive decrease and control blood
medications as indicated. pressure.
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 at After 3 hours of 1. Establish rapport - To gain patient’s The patient have displayed
r/t decreased
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: general physical condition. presence of The patient have
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 by - To maximize sleep
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 pinipisil effective nursing causative factors cause facilitates nursing intervention the
vasoconstriction
yung paa.” as verbalized intervention the related to impaired effective treatment. client had a blood pressure
as manifested by
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 - To decrease anxiety
on normal tissue level
perfusion and
possible causes for
impairment.
Instruct in blood - To facilitate
pressure monitoring management of
at home hypertension, which
is a major risk factor
for damage to blood
vessel organ
function.
Demonstrate or - To decrease tension
encourage use of level and enhances
relaxation activities, relaxation.
exercises
techniques
Encourage the client - To lessen in
to limit salt and contributing to
protein intake edema.
Suggest limiting - It is contraindicated
intake of coffee and with the diuretic
tea. effect and impact on
voiding pattern.
Dependent:
1. Administer medication as - To treat underlying
ordered by the physician. condition.
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 systemic below 140/90mmHg, urine
uteroplacental
the patient. adequate perfusion, and note capillary refill, perfusion, fluid/ output of above 30ml/hour,
perfusion
as evidenced by assess urinary output, weigh blood, needs, and fetal heart rate is between
evidenced by
stable vital signs, client daily and evaluate developing 120-160 beats per min,
Objective: decreased
palpable pulses, and changes in mentation. complications. absence of seizure episodes,
hematocrit and
alert and oriented, decrease in presence of
haemoglobin
absence of seizure edema.
Pallor episodes, balanced 2. Place client on left - This is to avoid
Variations in intake and output, recumbent position. uterine pressure on
blood pressure decrease in presence Monitor maternal well- the vena cava and Long Term:
Edema of edema and good being periodically. prevent supine Client verbalizes plans upon
Vital Signs taken as fetal status hypotension discharge, participates
follows: evaluation within a syndrome. during lecture- discussion
BP= 180/120 mmHg week. sessions, and demonstrates
PR= 103 bpm 3. Administer oxygen as - Woman’s BP should willingness to perform
Long Term:
RR= 25 cpm prescribed. be taken at least monitoring measures.
Temperature= 37.6⁰ Client will every 4 hours to
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.
signs for toxicity.
7. Administer fluids as - This drug is usually
prescribed. given to control the
blood pressure of
client’s with
pregnancy induced
hypertension.
8. Assist in the delivery of - Replacement of
the baby. fluids maintains
circulating volume
and tissue perfusion.
Delivery of the baby
is considered the
only cure for
Eclampsia.
