ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Decreased Preeclampsia is a • After 8 hours Independent: • After 8 hours

“Napansin ko na cardiac output common problem of nursing • Monitor blood • Comparison of of
bigla na lang related to during pregnancy. interventions, pressure of the pressures nursing
bumigat ang decreased The condition — the patient will patient. Measure provides a more interventions,
timbang ko” (I venous return sometimes participate in in both arms or complete the patient was
noticed that I referred activities that thighs three picture of able to
suddenly gained a to as reduce blood times, 3-5 vascular participate in
lot of weight) as
pregnancyinduced pressure or minutes apart involvement or activities that
verbalized by the hypertension cardiac work while patient is at scope of the reduce blood
patient. — is defined by load. rest, then sitting, problem. pressure or
high then standing for cardiac work
blood pressure initial evaluation. load.
and
Objective: excess protein in • Observe skin • Presence of
the color, moisture,
• Variations in pallor, cool,
urine after 20 temperature and
blood moist skin and
weeks capillary refill
pressure. delayed
of pregnancy. time. capillary refill
Often,
time may be
• Edema preeclampsia
due to
causes
peripheral
only modest
vasoconstriction
increases in blood
pressure. Left
untreated, • Note dependent • May indicate
however, or general heart failure,
preeclampsia can edema. renal or
lead to serious — vascular
even fatal — impairment.
complications for
both mother and • Provide calm, • Help reduce
baby. restful sympathetic
stimulation,
surroundings, promotes
minimize relaxation.
environmental
activity or noise.
• Reduces
• Maintain activity physical stress
restrictions. and tension that
affect blood
pressure and
course of
hypertension.

• Can reduce
stressful stimuli,
• Instruct in produce
relaxation calming effect,
techniques, and thereby reduce
guided imagery. blood pressure.

• These
Collaborative: restrictions can
• Implement help manage
dietary fluid retention
sodium, fat, and and with
cholesterol associated
restrictions as hypertensive
indicated. response,
which decrease
cardiac
workload.