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PRESENTATION
ON
PREECLAMPSIA
CONTENTS
1 Objectives
2 Introduction
3 Statistics
4 Patients Profile
5 Nursing Health History
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CONTENTS
6 Gordons
7 Physical Assessment
8 Laboratory Result
9 Course in the Ward
10 Anatomy and Physiology
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CONTENTS
11 Pathophysiology
12 Nursing Care Plan
13 Drug Study
14 Discharge Plan
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GENERAL OBJECTIVE
This case presentation was
conducted for us to be able to
gain improved depth of insight
and perspective on patients with
regard to their affliction for the
purpose of gaining functional and
applicable and proper nursing
interventions.
SPECIFIC OBJECTIVES
At the end of the case presentation, the
students will be able to:
hypertension
proteinuria
edema
CLASSIFICATIONS OF
PRE ECLAMPSIA
1.Gestational Hypertension
Manifestations:
BP of 140/90 mmHg
No proteinuria
No edema
2. Mild Preeclampsia
Manifestations:
BP of 140/90 mmHg
1+ to 2+ proteinuria on a
random sample or reagent
strip test
weight gain of more
than 2 lbs/week in the
2nd trimester and 1 lb/
week in the 3rd trimester
Slight edema in upper
extremities and face
Nursing Interventions:
Monitor blood
pressure.
Promote bed rest (left
lateral recumbent
position)
Promote good nutrition
moderate to high protein
and low to moderate
sodium)
Provide emotional
support.
Administer magnesium
sulfate.
3. Severe Preeclampsia
Manifestations:
BP of 160/110 mmHg higher on
2 occasions at least 6 hours
apart
3+ or 4+ proteinuria on random
urine sample or more than 5g
in a 24- hour sample.
Oliguria (approximately 400-
600 ml/24 hrs)
Cerebral or visual disturbances
Severe headaches
Epigastric pain
Nausea and vomiting
Pulmonary edema
Hepatic dysfunction
Thrombocytopenia
Intrauterine growth restriction
Nursing interventions:
Complete bed rest
Support a nutritious diet.
(high protein and low to
moderate sodium)
Monitor maternal well-
being.
Administration of sulfate,
fluid and electrolyte
replacements and
sedative hypertensive
such as diazepam or
Phenobarbital or an
anticonvulsant such as
phenytoin.
If severe, preeclampsia
progresses to fulminant pre-
eclampsia, with headaches, visual
disturbances, and epigastric pain,
and further to HELLP syndrome
and eclampsia.
Placental abruption is
associated with hypertensive
pregnancies. These are life-
threatening conditions for both the
developing baby and the mother.
Ophthalmoscopic
examination may reveal
vascular spasm,
papilledema, retinal
edema or detachment,
and arteriovenous
nicking or hemorrhage.
D. Eclampsia
It causes seizures. These seizures
usually happen in women who have
severe preeclampsia. However, they
can occur with mild preeclampsia.
The fetal prognosis is poor.
Manifestations:
loss of consciousness.
jerking movements of the arms and
legs.
loss of control of bladder or bowels.
CLINICAL
MANIFESTATIONS
Severe headaches
Vomiting blood
Excessive swelling of the feet and
hands (edema)
Oliguria
Hematuria
Rapid heartbeat
Dizziness
Excessive nausea and
vomiting
Ringing or buzzing sound in
ears
Drowsiness
Fever
Double vision
Blurred vision
Sudden blindness
Risk factors:
Family history of
preeclampsia
Nulliparity
African- American
descent
Chronic hypertension
(high blood pressure
before becoming
Urinary tract infection
Renal disease
Diabetes
Multiple gestation
Primiparas younger than
20 of age or age more than
40.
Preeclampsia in a previous
pregnancy
Obesity: Body weight is strongly
correlated with progressively
increased risk, ranging from 4.3%
for women with a BMI <20 kg/m to
13.3% in those with a BMI >35 kg/m
Low socioeconomic backgrounds
Complications of
Preeclampsia
Intrauterine growth restriction
(IUGR)
Oligohydramnios
Risk of placental abruption
Risk of preterm delivery (often
iatrogenic)
Coagulopathy/ DIC
(disseminated intravascular
coagulation)
Stillbirth
Seizures and coma
Pulmonary and cerebral edema
Renal failure
Maternal hepatic damage
Hemolysis
HELLP syndrome
Thrombocytopenia
Medical Management
Monitor BP, proteinuria and edema.
Assess for placental separation, headache and
visual disturbance, epigastric pain, and altered
level of consciousness.
Ausculted lungs for crackles or diminished
lungs sounds that might indicate pulmonary
edema
Signs of impending seizure. Institute seizure
precautions. Seizures may occur up to 72 hours
after delivery.
Protecting the patient is key- side rails up
and padded, suction accessible, O2
available.
Monitor vital signs and FHR.
Minimize external stimuli; promote rest
and relaxation
Measure and record urine output, protein
level, and specific gravity.
Assess for edema of face, arms, hands,
legs, ankles, and feet. Also assess for
pulmonary edema.
Weigh the client daily.
Assess deep tendon
reflexes every 4 hours.
Administer Magnesium
sulfate.
Address emotional and
psychosocial needs
Diagnostic Tests
A. Blood pressure test
The blood pressure is monitored at least every 4
hours.
Nursing Responsibility
Explain the procedure.
Discuss the purpose of test.
Assist woman to the same position for each reading,
preferably she should be in sitting position, if the
pressure is greater than 140/90 mmHg, reposition the
woman to her left side, wait 5 minutes and repeat the
reading. If the pressure is continues to be elevated,
Determine if the woman is experiencing headache,
blurred vision or epigastric pain.
Reposition the woman comfortably on her left side
supported by pillows.
Record the blood pressure per agency protocol. If the
pressure was taken twice, record each reading, noting
the time of each and maternal position.
B. Urine Protein test
A.k.a 24-Hour Urine Protein; Urine Total
Protein; Urine Protein to Creatinine
Ratio; UPCR.
It is used to detect protein in the urine,
to help evaluate and monitor kidney
function, and to help detect and
diagnose early kidney damage and
disease.
Dipstick a strip of cellulose chemically
impregnated to render its sensitivity to
protein, glucose, or other substances in
the urine.
The concentration of urinary
protein in random samples is
highly variable, and urinary
dipstick readings have correlated
poorly in recent studies with the
amount of proteinuria found in 24-
hour readings in women with
gestational hypertension.
Nursing Responsibility
Explain to the patient that the urine protein test
detects the proteins in the urine.
Tell the patient that the test usually requires
urine protection over a 24-hr period; random
collection can be done.
Instruct the patient not to eat foods that can
color the urine, before the test.
Inform the patient not to exercise strenuously
before the test. Ask the patient if she is
menstruating or close to starting your menstrual
period.
Instruct the patient to stop taking certain
C. Blood urea nitrogen (BUN) and
serum creatinine
Measures the amount of nitrogen in
your blood that comes from the waste
product urea.
A BUN test is done to see how well your
kidneys are working. If your kidneys are
not able to remove urea from the blood
normally, your BUN level rises.
Nursing Responsibility
1. Explain the procedure.
2. Discuss the purpose.
3. Instruct the patient not to eat a lot of meat
or other protein in 24 hours before having
blood urea nitrogen (BUN) test.
4. Ask the patient if she is taking any
medications (antibiotics) that can affect
BUN results.
D. Liver function tests: Liver
enzymes (AST, ALT, LDH,
Bilirubin)
1. Liver function tests (LFTs or LFs),
which include liver enzymes, are
groups of clinical biochemistry
laboratory blood assays designed
to give information about the state
of a patient's liver.
1. Alanine transaminase (ALT) - ALT is raised in
acute liver damage. When hepatocytes (liver
cells) are damaged, this enzyme is leaked into
the blood. It is also known as serum glutamic
pyruvate transaminase (SGPT) or alanine
aminotransferase (ALAT).
2. Aspartate transaminase (AST) - AST is raised
in conditions of acute liver damage, however it
is not liver-specific. AST to ALT ratio is at
times used to differentiate the underlying
cause of liver damage. It is also known as
serum glutamic oxaloacetic transaminase
(SGOT) or aspartate aminotransferase
(ASAT)
1. Bilirubin is a breakdown product of heme.
The liver is responsible for clearing the blood
of bilirubin. It does this by the following
mechanism: bilirubin is taken up into
hepatocytes, conjugated (modified to make it
water-soluble), and secreted into the bile,
which is excreted into the intestine.
2. Lactate dehydrogenase (LDH Lactate
dehydrogenase is an enzyme found in many
body tissues, including the liver. Elevated
levels of LDH may indicate liver damage.
Nursing Responsibility
Explain to the patient that this test is used
to assess liver function.
Tell the patient that the test requires a blood
sample.
Explain who will perform the venipuncture
and when.
Explain to the patient that he may
experience slight discomfort from the
tourniquet and needle puncture. Inform the
patient that she need not restrict food and
fluids.
Notify the laboratory and physician of
medications the patient is taking that may
E. Hematology (blood cell counts)
It is a common blood test that evaluates the three major
types of cells in the blood: red blood cells, white blood
cells, and platelets including hematocrit and hemoglobin..
It is a series of tests used to evaluate the composition and
concentration of the cellular components of blood.
Nursing Responsibility
Explain and instruct the patient that this test is to
detect abnormal blood conditions.
Tell the patient that the test requires a blood
sample.
Explain who will perform the venipuncture and
when.
Explain to the patient that he may experience slight
discomfort from the tourniquet and needle puncture.
F. Coagulation studies
Hemolysis, elevated liver
enzyme levels, and a low platelet
count (HELLP syndrome)
characterize severe eclampsia. A
unique form of coagulopathy is
also associated with this disorder.
Thrombin time
This test is used to screen for
abnormalities in the conversion of
fibrinogen to fibrin.
Prothrombin time (PT)
The PT measures the function of the
extrinsic and common pathways of the
coagulation cascade.
Activated partial thromboplastin time (aPTT)
The aPTT measures the function of the
intrinsic and common pathways of the
coagulation cascade.When the aPTT test is
being used to monitor the effect of
heparin, the test is done before the first
Nursing Responsibility
1. Explain and instruct patient about the
procedure.
2. Informed the patient about the
importance of the test/ studies.
3. Before administering the test, ask the
patient to list the medications she is
taking.
4. Ask the patient whether or not he or
she has recently experienced active
bleeding, acute infection or illness, or
undergone a blood transfusion., as
these factors could adversely affect
Medical Management
Monitor BP, proteinuria and edema.
Assess for placental separation, headache and
visual disturbance, epigastric pain, and altered
level of consciousness.
Ausculted lungs for crackles or diminished
lungs sounds that might indicate pulmonary
edema
Signs of impending seizure. Institute seizure
precautions. Seizures may occur up to 72 hours
after delivery.
Protecting the patient is key- side rails up and
padded, suction accessible, O2 available.
Monitor vital signs and FHR.
Minimize external stimuli; promote rest and
relaxation
Measure and record urine output, protein level,
and specific gravity.
Assess for edema of face, arms, hands, legs,
ankles, and feet. Also assess for pulmonary
edema.
Weigh the client daily.
Assess deep tendon reflexes every 4 hours.
Administer Magnesium sulfate to promote
diuresis, reduce blood pressure, and prevent
seizures.
Treatment:
1. Anti-Hypertensive Therapy
Antihypertensives may reduce maternal and
fetal mortality among pregnancy patients with
hypertension as compared to placebo
according to a randomized controlled trial .
2. Magnesium sulfate
In some cases, women with preeclampsia or
eclampsia can be stabilized temporarily with
magnesium sulfate intravenously to forestall
seizures while steroid injections are
administered to promote fetal lung maturation.
3. Dietary and Nutritional Factors
Adequate nutrition is important to
promote fetal growth and maternal
well- being.
4. Exercise
Improves muscle tone, circulation and
sense of well- being.
5. Avoid ACE inhibitors - possible fetal
effects
6. Avoid Angiotensin II (AII) receptor
antagonists
7. Bed rest - in mild cases
8. Induced labor - once the condition is
stable.
8. Caesarian section - once the condition is
stable.
9. Normal delivery - some babies are born
vaginally; in other cases caesarian is
STATISTICS
International
statistics
Country Region Incidence rate Population Estimated Used
INTERNATIONAL
Preeclampsia in North America
Preeclampsia in Europe
Preeclampsia in Asia
Preeclampsia in Africa
January 0 2 1 1
February 0 2 0 0
March 0 2 0 1
April 0 0 0 1
May 1 4 0 2
June 0 2 0 2
July 0 3
August 0 1
September 1 2
October 1 2
November 0 1
December 0 1
Total 3 22 1 7
Interpretation:
The above data for local statistics of
preeclampsia from CVMC shows that patients
under 20-44 y/o is greater than that of 15-19
y/o. On the year 2009, 22 out of 25 patients
who was diagnosed of preeclampsia were
under 22-44 y/o, same is through on the year
2010 (from January to June) where in 7 out of
8 patients is also under 20-44 y/o. This only
mean that AGE is one of the risk factors of
developing such disease where in <20 to >44
y/o is the age bracket for those who are at risk.
Patients profile
Name: R.R
Address : Baggao, Cagayan
Birthday: September 18, 1992
Age: 17 years old
Birthplace: Baggao, Cagayan
Religion: Roman Catholic
Occupation: None
Fathers Name: M.R.
Mothers Name: R.P.
Date of Admission: August 2,
2010
Time of Admission: 5:10 pm
Attending Physician: Dr. Divina Gracia
Arellano
Chief Complaint: Elevated BP, labor
pains
Admitting Diagnosis: Pregnancy
Uterine 39 1/7 weeks of gestation
Cephalic in beginning labor, G1P0,
Pre-eclampsia primigravida
Principal Diagnosis: Pregnancy
uterine 39 1/7 wks AOG, cephalic
delivered operatively to live full
term baby girl
BW = 3175 g
APGAR Score = 8/9
= 38- 39 wks G1P1 (1001)
Principal Operative procedure:
Preeclampsia severe
Transient Uterine Atony
Young Primigravida
Other Operation: Emergency primary
low segment caesarean section
NURSING
HEALTH HISTORY
PRESENT HISTORY
According to Mrs. R.R, she had an
abdominal pain that was started on the
day she was admitted at CVMC. She
noted that the intensity of the pain was
best felt every time she had a
contraction. When we asked her about
the rate of the pain from 0- 10, she
responded immediately and rated it as
8/10. When we asked about other
unusual feelings is she suffering, she
answered dizziness, fatigue and
headache. The patient also had pitting
edema on her lower extremities; the
patient had a pitting edema of +2 upon
PAST HISTORY
Mrs. R.R verbalized that it was her first
time to be confined in a hospital however
she has a previous check-up in their
barangay clinic due to her pregnancy. The
patient said that she only had fever, cough
and colds as her childhood illness.
According to her, she takes OTC drugs such
as paracetamol for fever, neozep for cough
and colds and alaxan for body pain. She
also completed all her childhood
vaccinations and has no noted allergies on
foods and drugs. She also said that she
never got involved in any accident. She
never underwent any surgeries before apart
from her present surgery which is CS due to
FAMILY HISTORY
The patient stated she is living with
her husband. She said that their
current state of health was okay
except her because she was admitted
at CVMC due to labor and suffering
from pre eclampsia with the BP of
140/100 mmHg. The patient stated
that they have no history of
hypertension, DM, asthma, TB and
cancer. She also said that she was
the first member of the family who
suffered from pre eclampsia.
SOCIAL HISTORY
Mrs. R.R. is the youngest in the family. She
stated that she is in good term with them.
According to her she is a shy type person
however she can still mingle and socialize with
her friend. She said that she has no vices. The
patient stated that she finished 2nd year high
school while her husband finished grade 6.
When asked about her familys financial status,
she said that they dont belong in middle class
instead she emphasized that financial aspect is
causing a problem in providing their needs.
Farming is the primary source of their income
but they are just a tenant. Lastly, she said they
have no practices and beliefs that could affect
their health.
OB HISTORY
HEALTH The patient defines health as The patient declares that health
the absence of any disease or is very important to an
PERCEPTION- illness. According to the patient, individual. She is worrying on
HEALTH she is taking ferrous sulfate her condition because she may
twice a day during her not take care of her baby well
MANAGEMENT pregnancy and whenever she due to her condition. She follows
PATTER got sick, she managed it by properly the entire doctors
taking OTC drugs such as order because she wants to
paracetamol for fever, neozep recover as soon as possible for
for cough and colds, and alaxan her baby.
for body pain.
NUTRITIONAL- The patient verbalized that her The patient was on NPO. The
favorite meals during her IVF of the patient are D5LRS 1L
METABOLIC pregnancy were mango, junk x 30 gtts/min @ the level of 50ml
PATTERN foods, santol and pritong isda. hooked @ the right arm, PNSS
According to the patient, she 1L x KVO @ the level of 550cc +
eats a large amount of rice and second line of 250cc of Blood
drinks 7 glasses of water a day. transfusion hooked @ the left
She is not drinking coke, milk arm.
and cold water and not eating
halo-halo. She also takes snack
in between meals.
Gordons 11 Functional
Pattern Before Hospitalization During Hospitalization
COPING STRESS She verbalized that whenever The patient verbalized that she
she has a problem, she is is sharing her feelings with her
PATTERN sharing it with her parents and mother and husband. She just
her husband. Sometimes, if she thinks her baby to ease the pain
is stress she managed it by she feels. She doesnt think that
watching tv and by socializing she is problem to her family.
with their neighbors.
SEXUALITY- The patient had her menarche The patient is very happy in
when she was 10 years old. She giving birth of their first child
REPRODUCTIVE has no problem with her which is a baby girl.
PATTERN menstruation and dont
experience dysmenorrhea
during menstruation. She had
her coitarche last November 2,
2009. They are not using any
contraceptive method.
The patient is a Roman According to the patient, she
Catholic and she attends the always prays at night to recover
VALUE- BELIEF mass 3x a month. She often from her condition and for the
PATTERN prays at night. She verbalized wellness of her baby. She always
that she do believe in quack asks guidance and a good health
doctor but never consulted to from God.
them.
PHYSICAL
ASSESSMENT
Date assessed: August 4, 2010
Time assessed: 5:30 am
General Appearance:
Received patient lying on bed with IFC at 100 cc level
with ongoing IVF of D5LRS 1L + 10 U oxytocin x 30
gtts/min @ the level of 50 ml hooked @ the right arm, and
PNSS 1L x KVO + second line of 250cc of Blood transfusion
hooked @ the left arm, patent and infusing well. The age of
the patient appeared appropriate with the weather, time, &
situation.
Latest vital signs:
BP: 110/ 80 mmHg
BT: 36.7 0C
RR: 23 cpm
CR: 91 bpm
Weight: 52 kg
Height: 153 cm
BMI: 20.5 (normal)
AREA METHOD NORMAL ACTUAL REMARKS
ASSESSED USED FINDINGS FINDINGS
SKIN
Inspection Light to deep Varies from Normal
brown deep to brown
COLOR to light
of
lesions
Inspection Uniform except Uniform except Normal
areas exposed areas exposed
to to
sun; areas of sun
Uniformity Lighter
pigmentation
(palm,
lips, nail beds)
in
dark skinned
people
Palpation Dry, skin folds Dry, skin folds Normal
are are
Moisture normally moist normally moist
FACE
Symmetry Inspection Symmetrica Symmetrica Normal
l l
EYEBROWS
Distributio Inspection Equally Equally Normal
n distributed distributed
EYELASHES
Evenness Inspection Equally Equally Normal
distributed distributed
EYES
Color Inspection White sclera White sclera Normal
CORNEA
Appearanc Inspection Shiny Shiny Normal
e (clarity)
PUPILS
Color Inspection Black, no Black, no Normal
cloudiness cloudiness
NECK
Position Inspection Centrally Centrally Normal
located located
between the between the
shoulders. shoulders.
Mobility Inspection Can move Can move Normal
spontaneously spontaneously
in all directions. in all directions.
Lymph nodes Palpation no tenderness no tenderness Normal
or inflammation or inflammation
present, no pain present, no pain
THORAX AND LUNGS
Symmetry Inspection Chest Chest Normal
expands expands
symmetrically symmetrically
during during
respiration; respiration;
effortless. effortless.
Chest wall Inspection Intact; no Intact; no Normal
and Palpation tenderness, tenderness,
no mass. no mass.
I & O q shift and record To monitor fluid and Ensured accurate I &
electrolyte balance O measurement.
August 07, IVF: D5LRS 1L x KVO Route for Checked IVF line
patency and
2010 emergency drugs
regulated.
7:55am Checked for signs of
BP: 130/90 phlebitis and
(-) cough infiltration
With febrile
episodes Full diet For adequate Emphasized diet
(+)breast nutrition of the patient.
pain
(+)phlebitis Continue To decrease Continued
hydralazinne drip elevated blood Hydralazine drip.
pressure Checked IVF line
patency and
regulated.
Checked for signs
of phlebitis and
infiltration.
PATHOPHYSIOLOGY
PRE-ECLAMPSIA
PREDISPOSING
PRECIPITATING
FACTORS FACTORS
*Family history trophobla *Diet*Lifestyle
and
*Age(<20->40 y/o)
Nutrition stic
*Pre-existing hypertension
*Primiparity cells to
maternal
arteries
Release of placental factor (factor X)
PATHOPHYSIOLOGY
A B
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PATHOPHYSIOLOGY
C
hypertension
D E hyperreflexia seizure
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PATHOPHYSIOLOGY
D E
fetal distress
decrease increase
GFR reabsorption active labor
in tubules
decrease Emergency
urine increase sodium caesarian
output and water section
retention
increase
creatinine edema
increase
level glumerular
permeability
proteinuria
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NURSING
CARE PLAN
Assessment Diagnosis Planning Interventions Rationale Evaluation
Provided To promote
comfort nonpharmalo
measures such gical pain
as
repositioning
management 1
Assessment Diagnosis Planning Interventions Rationale Evaluation
Instructed in To distract
use of attention and
relaxation reduce
techniques tension
such as
focused
breathing
Encouraged To distract
diversional attention
activities by
initiating
conversation
to the patient
Administere For
d medication collaborative
as ordered function
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Activity After 3- 4 Monitored For baseline Goal met.
Hindi ko intolerance hours of vital signs and data and to note After the
masyadong nursing recorded progress. nursing
r/t edema intervention
maigalaw ang interventions, Positioned the To promote
on the s, the patient
paa ko as the patient patient comfort had used/
lower
verbalized by will be able to comfortably identified
the patient. extremities use /identify
techniques
Objective: techniques to Encouraged To know what to enhance
Body enhance verbalization of nursing activity
feeling interventions are intolerance
weakness activity
needed
Inability to intolerance
perform Assisted Ensures safety
activity patient during and additional
(+) edema moving or on support for client
on the feet going in the
comfort room
Adjusted To prevent
activities overexertion
Provided Helps to
positive minimize
atmosphere frustration
Promoted To enhance
comfort ability to
measures participate in
activities
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Impaired After 1-2 Monitored vital For baseline Goal met
Masakit skin hours of the signs and data and to After the
ang sugat integrity nursing recorded note progress. nursing
Positioned the To promote
ko as r/t interventions intervention
patient comfort
verbalized surgical , the patient s, the
comfortably
by the incision will assessed Wound patient
patient. participate in wound for dehiscence participated
Objective: prevention intactness occurs with in
(+) measures excessive prevention
surgical and stress on a measures
incision treatment new incision and
Encouraged To know
Warm program treatment
verbalization of what nursing
program
feelings interventions
will be
performed
assessed for Purulent
signs of infection drainage is an
indication of
Stressed the infection
importance of To control
hand washing the spread of 3
Encouraged To aid in
the patient to tissue repair
eat foods rich
in protein.
Applied To help in
appropriate wound
dressing. healing
Instructed To prevent
the patient in infection
proper care of
area
Assessmen Diagnosis Planning Interventions Rationale Evaluation
t
Subjective Ineffectiv After 3 Monitored For Goal met.
: e tissue hours of vital signs baseline After 3
namam perfusion the nursing and data and hours of
anas ang r/t interventio recorded to note the
paa ko as vasocons ns, the progress. nursing
verbalized triction of patient will To interventi
by the blood be able to Positioned promote ons, the
patient vessels demonstrat the patient comfort patient
Objective: 2T e behaviors comfortably To know had
Edema edema to improve Encourage what demonstr-
noted on circulation d nursing ated
lower verbalization interventi behaviors
extremities of feelings ons will to
Cold, be improve
clammy perform circulatio
skin This n
Checked may
for calf indicate
tenderness thrombus
(homans formation 4
Assessme Diagnosis Planning Interventions Rationale Evaluation
nt
Reinforced Contractin Goal met.
leg exercises g the leg After 3
taught muscle hours of the
preoperativel decreases nursing
y venous intervention
stasis and s, the
encourages patient had
good demonstrat
venous ed
return behaviors
Encourage To reduce to improve
d used of tension circulation
relaxation
techniques
Encourage Enhances
d early venous
ambulation return
Elevated For
feet on bed venous
return
Assessmen Diagnosi Planning Interventions Rationale Evaluation
t s
Subjective: Impaired After 2 hours Monitored For Goal met
hinde physical of the vital signs baseline After 2 hours
ako mobility nursing and recorded data and to of the
masyadong r/t interventions note nursing
makagalaw surgical , the patient Positioned progress. interventions
as incision will be able the patient To , the patient
verbalized to verbalize comfortably promote verbalized
by the understandin on bed comfort understandin
patient g of situation Encourage g of situation
Objective: and d and
Difficulty individual verbalization To know individual
moving treatment of feelings what treatment
Body regimen and nursing regimen and
weakness safety intervention safety
measures. Scheduled s will be measures
activities performed
with To reduce
adequate fatigue
rest periods
during the
day
Encourage Enhances 5
Assessmen Diagnosis Planning Interventions Rationale Evaluatio
t n
Encouraged Maximizes
adequate energy
intake of production
nutritious
foods
Mobility
Facilitated aids can
transfer increase level
training by of mobility
using
appropriate
assistance of
persons or
devices Patients
may be
Provided reluctant to
positive move due to
reinforcement fear of falling
during activit
To promote
Kept side a safe
rails up and environment
bed in low
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Deficient After 2 Monitored For Goal met
di ko alam knowledge hours of the vital signs and baseline After 2 hours
kung ano ang r/t lack of nursing recorded data and to of t he
dapat gawin informatio interventions Positioned note nursing
sa sakit ko n about , the patient the patient progress. interventions
as verbalized the current will verbalize comfortably on To , he patient
by the patient condition understandi bed promote verbalized
Objective: ng of current Encouraged comfort understandin
Primigravid condition verbalization of g of current
a and feelings To know condition
OB score: treatment what and
G1P0 Instructed in nursing treatment
use of intervention
relaxation s are
techniques needed
such as To
focused promote
breathing comfort
Determined
clients ability
/readiness and
barriers to The client
learning may not e 6
Assessmen Diagnosis Planning Interventions Rationale Evaluatio
t n
Assessed the May need to
level of the help SO(s) or
clients caregivers to
capabilities and learn
the possibilities
of the situation
Provided To prevent
information overload
relevant only to
the situation
Provided
active role for Promotes
client in sense of
learning control over
process situation
DRUG STUDY
NAME OF CLASSIFICA ACTION INDICATION ADVERSE NURSING
DRUG TION REACTION RESPONSIBILITIES