6. Encourage
verbalization of
feelings 7. To protect
regarding client from
movement injury.
limitations.
8. To familiarize
7. Promote comfort self of
measures. adequate
energy
reserves
required for
8. Assess nutritional activity.
status.
9. To increase
patients self-
confidence and self-
esteem.
9. Involve the patient
and significant others
in goal setting and care
planning.
Diagnosis Interventions
Subjective: Decreased After 2 days of nursing Independent: Independent: After 2 days of nursing
Predisposin Predisposin
cardiac interventions, the interventions, the client
Taas ang BP niya g Factors: g Factors: 1. Monitor and check 1. To serve as baseline data
output client will be able to: was able to:
halin kagab-e related to vital signs
Female Low
wala ganubo sa decreased 1. Identify her acordingly. 1. Goal met.
socioeconmic
160 as venous Aged 36 current health
status 2. Regulate IVF and 2. To avoid circulatory She reflects on her
verbalized by return level status.
check for overload current health status by
patients as Multiparity Low
signigicant other patency. verbalizing nagtaas akon
evidenced educational 3. To determine fluid shifts or
With 5 BP, tani manubo na
by BP of attainment 3. Assess urine signs of urinary
children
160/130 output; monitor incontinence.
Objective: mmHg how often the
4. To assist patient in 2. Goal met.
Maternal Constitutional Factors: patient urinates.
UA Result: 2. Engage in identifying and acquiring
behaviors or 4. Explain drug knowledge regarding Engaged in behaviors or
Client is hypertensive and has
(+) Definition: history of Eclampsia activities to regimen, prescribed drug. actions to improve her
Proteinuria improve her purpose, dose current health status such
Patient with seventh pregnancy (28 current health and side effects. as maintaining bed rest in
Dizziness 2/7 AOG) status. order to facilitate early
The state in
recovery.
Oxygen at 2 which an
individual Collaborative: Collaborative:
cpm via nasal Abnormal Development or Poor
cannula experiences Placentation
1. Maintain optimal 1. To help evaluate client's
a reduction
fluid balance. fluid and electrolyte
Slight edema in the Oxidative Stress
balance
in both hands amount of 2. Maintain adequate
blood Defective invasion of the spiral
ventilation and 2. To prevent for signs of
Decreased pumped by arteries by cytotrophoblast cells
perfusion, as in poor ventricular
urine output the heart,
Endothelial Activation/Dysfunction the following: function, poor organ
resulting in functions and in the
Anxiety,
compromise Spasm of veins Place patient in event of impending
Restlessness
d cardiac semi- to high- cardiac failure
Tachypnea function. Abnormal Placental Development Fowlers
and Reduced Perfusion to organs position.
Increased
Diffusion of blood from bloodstream Place patient in
uric acid
into interstitial tissue supine position
Increased Source: Edema Administer
Lactate
dehydrogena humidified
Decreased cardiac output related to
se oxygen as
decreased venous return level as
Nurses ordered
evidenced by BP of 160/130 mmHg
Pocket Guide
3. Maintain physical
Diagnoses,
and emotional 3. To helps lessen
Prioritized
rest and sympathetic
Intervention
Vital signs: emotional rest, stimulation physical
s, and
as in the stress/tension;
BP=160/130 Rationales;
following: promotes relaxation
mmHg 13th edition
by Marilynn Provide quiet,
PR= 88 bpm E. Doenges, relaxed
Mary environment
RR= 27 cpm Frances
Moorhouse, Organize
Temp= 36.7 C Alice C. Murr nursing and
medical care.
Capillary refill =