V.

NURSING MANAGEMENT

NURSING CARE PLAN

Cardiac Output, decreased r/t altered stroke volume

36
 NURSING SCIENTIFIC
NURSING EXPECTED
CUES DIAGNOSI EXPLANATIO PLANNING RATIONALE
INTERVENTION OUTCOME
S N

S: Ø Cardiac Increased After 8 hours of After 8 hours

O: Output, blood nursing >Monitor and > The client of nursing
Variation decreased pressure interventions, record BP and with PIH does interventions,
s in r/t altered client will be able pulse. not manifest client will be
blood stroke to verbalize the able to
pressure volume Vasospasm knowledge of the normal verbalize
, disease process, cardiovascular knowledge of
edema, individual risk response to the disease
shortnes Increased factors and pregnancy process,
s of vascular treatment regimen. (left individual risk
breath. resistance ventricular factors and
hypertrophy, treatment
increase in regimen
plasma .
Difficulty of volume,).
the heart to Hypertension
pump blood (the second
manifestation
of PIH after
Increased edema) occurs
cardiac
workload to increased
sensitization
to angiotensin
II,
which
Decreased increases BP,
cardiac output promotes
aldosterone
release
to increase
sodium/water
reabsorption
from
the renal
tubules, and
constricts
blood vessels.
> Institute
bedrest with 37
client in lateral
position.
> Increases
Ineffective Tissue Perfusion r/t impaired transport of oxygen

NURSING SCIENTIFIC
NURSING EXPECTED
CUES DIAGNOSI EXPLANATIO PLANNING RATIONALE
INTERVENTION OUTCOME
S N

S: Ø Ineffective increased Short Term: >Evaluate vital >Vital signs Short Term:
O: Altered Tissue blood After 8 hours of signs, noting will After 10 hours of
blood Perfusion r/t pressure nursing changes in BP, determine if nursing
pressure impaired interventions, heart rate, and there are interventions,
outside of transport of client will be able respiration. changes in client shall
acceptable oxygen to verbalize the health verbalize
parameter vasospasm understanding of status of the understanding of
s. condition, >Identify changes pt. condition,
therapy regimen, related to therapy regimen,
side effects of systemic and/or >Alterations side effects of
vasoconstricti medications, and peripheral in systemic medications, and
on when to contact alterations in or peripheral when to contact
a health care circulation (e.g. circulation a health care
provider. vital sign can be provider.
Long Term: changes) assessed Long Term:
intravascular After a week of primarily After a week of
fluid nursing with vital nursing
redistribution interventions, sign interventions,
client will able to client will
demonstrate >Determine demonstrate
behaviors/lifestyl duration of >This will behaviors/lifestyl
decreased e changes to problem/frequenc help e changes to
oxygen to improve y of recurrence, determine if improve
different circulation such precipitating there is circulation such
organs as relaxation factors. improvement as relaxation
techniques, and in the techniques, and

38
 exercise/dietary patients exercise/dietary
program. condition program
impaired >Encourage quite,
tissue restful
perfusion to atmosphere. >This will
ongans promote rest
and help in
the proper
distribution
of oxygen in
the body

>Caution client to
avoid activities >To
that increase conserve
cardiac work load energy/lower
(e.g. straining at s tissue
stool). oxygen
demand.

>Instruct the pt.

to take her
prescribed >Proper
medications (e.g. medication
antihypertensive will help the
agents) pt. condition

>Discuss
individual risk >To prevent
factors (e.g. onset of
family history, complication
age) s/ manage
symptoms

39
 when
condition is
present.

>To facilitate
>Instruct in blood management
pressure of
monitoring at hypertension
home. .

>Lifestyles
of people
>lifestyle changes have a very
(e.g. to much large effect
work) to the pt.
condition.
Modification
of it will help
improve the
pt. condition

>To
>Encourage use decrease
of relaxation tension level
techniques.

>Diet
>Review specific modification
dietary will help in

40
 improving
changes/restrictio the pt.’s
ns with the client condition
(e.g. reduction of
cholesterol and
triglyceride, high
or low protein
intake)

Fluid Volume deficit [isotonic] related to: Plasma protein loss

SCIENTIFIC
NURSING NURSING EXPECTED
CUES EXPLANATIO PLANNING RATIONALE
DIAGNOSIS INTERVENTION OUTCOME
N

S: Ø Fluid Volume Pregnancy Short Term: > Weigh client > Sudden, Short Term:
O: deficit induced After 4 hours routinely. significant After 4 hours of
Edema [isotonic] hypertension of nursing Encourage client weight gain nursing
formation, r/t interventions, to monitor (e.g., more interventions,
sudden Plasma client will be weight at home than client will be
weight protein loss, able to between visits. 3.3 lb (1.5 able to verbalize
gain, Decreased verbalize kg)/month in understanding
headaches, vascular understandin the second of need for
perfusion g of need for trimester or close
close more monitoring of
monitoring of than 1 lb (0.5 weight, BP,
Increased ECF weight, BP, kg)/wk in the urine protein,
urine protein, third and edema.
and edema. trimester) .

41
 . reflects
EDEMA Long Term: fluid retention.
After a week Fluid moves Long Term:
of nursing from the After a week of
interventions, vascular to nursing
Decreased client will able interstitial interventions,
water to be free of > space, client will able
absorption to signs of > Distinguish resulting in to be free of
cells edema. between edema. signs of edema.
maintaining physiological
some sodium and pathological > The
inside severe, presence of
edema of pitting edema
pregnancy. (mild, 1+ to
Monitor location 2+;3+ to 4+)
and of face,
3+ to 4+) of hands, legs,
Cell or tissue face, hands, sacral area, or
dehydration legs, sacral abdo-
area, or abdo- minal wall, or
degree of edema that
pitting. does not
Fluid volume disappear
deficit > Note signs of after 12 hr of
(isotonic) progressive or bedrest is
excessive significant.
edema
Assess for >monitor
possible Cerebral
eclampsia. edema,
possibly
leading to
> Reassess seizures

42
dietary intake of
proteins and
calories.
Provide > Adequate
information as nutrition
needed. reduces
incidence of
prenatal
hypovolemia
and
hypoperfusion
; inadequate
protein/calorie
s increases
the risk of
edema
formation and
PIH. Intake of
80–100 g of
protein may
> Monitor intake be required
and output. daily to
Note urine color replace losses
And measure
specific gravity > Urine
as indicated. output is a
sensitive
indicator of
circulatory
blood volume.
Oliguria and
specific
> Test clean, gravity of

43
voided urine for 1.040
protein each indicate
visit, severe
daily/hourly as hypovolemia
appropriate if and kidney
hospitalized. involvement
Report readings
of 2+, or > Aids in
greater. determining
degree of
severity/
progression of
condition. A
2+ reading
suggests
glomerular
edema or
spasm.
Proteinuria
affects fluid
shifts from the
vascular tree.
Note: Urine
contaminated
by vaginal
secretions
may test
positive for
protein, or
dilution may
result in a
> Assess lung false-negative
sounds and result. In

44
respiratory addition, PIH
rate/effort. may be
present
without
significant
proteinuria.

>Monitor BP and > Dyspnea

pulse. and crackles
may indicate
pulmonary
edema, which
requires
immediate
treatment.

> Elevation in
BP may occur
in response to
catecholamine
> Answer s,
questions and vasopressin,
review rationale prostaglandin
for avoiding use s, and, as
of diuretics to recent
treat edema. findings
suggest,
decreased
levels of
prostacyclin.

> Diuretics
further

45
 increase state
of dehydration
by
decreasing
intravascular
volume and
placental
> Review perfusion, and
moderate they may
sodium intake of cause
up to 6 g/day. thrombocytop
Instruct client to enia,
read food labels hyperbilirubin
and avoid foods emia, or
high in sodium alteration in
(e.g., bacon, carbohydrate
luncheon meats, metabolism in
hot dogs, fetus/newborn
canned soups, .
and potato
chips).

>Refer to > Some

dietitian as sodium intake
indicated is necessary
because
levels below
2–4 g/day
result in
greater
dehydration in
> Place client on some clients.
strict regimen of However,

46
bedrest; excess sodium
encourage may increase
lateral position. edema
formation.

> Nutritional
consult may
be beneficial
> Refer to home in determining
monitoring/day- individual
care program, needs/dietary
as appropriate. plan.

> Lateral
recumbent
position
decreases
pressure on
the vena
cava,
increasing
venous return
and
circulatory
volume

>Replace fluids > Some mildly

either orally or hypertensive
parenterally via clients without
infusion pump, proteinuria
as indicated. may be
managed on
an outpatient

47
basis if
adequate
surveillance
and support is
provided and
the
client/family
actively
participates in
the
treatment
regimen.

> Fluid
replacement
corrects
hypovolemia,
yet must be
administered
cautiously to
prevent
overload,
especially if
interstitial
fluid is drawn
back into
circulation
when activity
is reduced.
With renal
involvement,
fluid intake is
restricted; i.e.,

48
if output is
reduced (less
than 700
ml/24 hr),
total fluid
intake is
restricted to
approximate
output plus
insensible
loss.
Use of infusion
pump allows
more accurate
control
delivery of IV
fluids.

49
Risk for infection r/t inadequate primary defense secondary to broken skin

EXPECTE
NURSING SCIENTIFIC
NURSING D
CUES DIAGNOSI EXPLANATIO PLANNING RATIONALE
INTERVENTION OUTCOM
S N
E

S=Ǿ Risk for Patient Short  Establish  To gain Short

infection r/t undergone Term: rapport trust and Term:
O = may inadequate episiotomy After 8 cooperation Client
manifest primary hours of  Monitor  Serves as remains
fever, defense nursing Vital sign primary free of all
swelling on secondary interventio indicators signs and
the affected to broken Patient has an ns, client of changes symptoms
part, pain skin open wound will remain in health of
on the can be a free of all  Report status infection.
affected source of signs and fever  Early
part. infection symptoms >38°c, detection of
of infection. chills, infection
diaphoresi facilitates
s, early
Bacteria, swelling, intervention
fungus and heat, pain, .
viruses can erythema,
easily break in exudates

50
 the body on
anybody
surfaces.

Bacteria,  Initiates  Exposure to

fungus and measures infection is
viruses can to reduced
easily flow minimize
through the infection
bloodstream

 Preventing
 Discuss contact with
Patient is at with pathogens
risk of patient helps
infection and family prevent
the infection
importanc
e of
patient
avoiding
contact
with
people
who have
known or
recent
infection.  Hands are
significant
 Instruct all source of

51
 personnel contaminati
in careful on
hand
hygiene
before
and after
entering
the room  This
prevents
 Assist skin
patient in irritations
practice of
meticulou
s personal
hygiene

 Rates of
 Avoid infection
insertion greatly
of urinary increases
catheter, after
if catheter urinary
are catheterizat
necessary ion
, use strict
aseptic
technique

52
Knowledge deficit [pregnancy induced hypertension] r/t lack of exposure to the present condition

SCIENTIFIC NURSING
NURSING EXPECTED
CUES EXPLANATIO PLANNING INTERVENTIO RATIONALE
DIAGNOSIS OUTCOME
N N

53
S: “hindi Knowledge Patient never Short Term: Short Term:
ko alam deficit r/t had PIH with After 4 hours of >Assess client’s >Establishes After 4 hours
baket lack of her previous nursing knowledge of data base and of nursing
ako nag exposure to pregnancy interventions, the disease provides interventions,
ka the present client will be able process. information client will be
ganito, condition to verbalize Provide about areas in able to
nung una understanding of information which learning verbalize
ok Knowledge disease process about is needed. understanding
naman deficit and appropriate pathophysiolog Receiving of disease
pagbubu treatment plan. y of PIH, information can process and
ntis ko” implications for promote appropriate
O: Ø mother and understanding treatment
fetus; and the and reduce plan.
rationale for fear, helping to
interventions, facilitate the
procedures, and treatment plan
tests, as for the client.
needed.
> Helps ensure
that client
seeks timely
treatment and
> Provide may prevent
information worsening of
about preeclamptic
signs/symptoms state to
indicating eclamptic state
worsening of or additional
condition, and complications.
instruct
client when to
notify > Encourages

54
healthcare participation in
provider. treatment
regimen,
allows prompt
> Assist family intervention as
members in needed, and
learning the may
procedure for provide
home reassurance
monitoring of that efforts are
BP, as beneficial.
indicated.
> Reinforces
importance of
client’s
responsibility in
treatment.
> Review
techniques for > Protein is
stress necessary for
management intravascular
and diet and
restriction. extravascular
fluid regulation.
> Provide
information
about ensuring
adequate
protein in diet > A test result
for client with of 2+ or
possible or mild greater is
preeclampsia. significant and
needs to be

55
> Review self- reported to
testing of urine healthcare
for protein. provider. Urine
Reinforce specimen
rationale for contaminated
and implications by vaginal
of testing. discharge or
RBCs may
produce
positive test
result for
protein.

56