Subjective cue:“Nabantayan nako nga murag nikalit lang ug dako akong timbang” as verbalized by the patient.

Objective cues:- variations in blood pressure

- edema on the extremities

- vital signs taken as follows:BP= 150/120 mmHg

PR= 96 bpm

RR= 24 cpm

T= 36.6 C

Decreased cardiac output related to decreased venous return.

General:After 6 hours of nursing interventions, the patient will reduce blood pressure or cardiac workload.

Specific:After 6 hours of nursing interventions, the patient will be able to identify the signs of cardiac decompensation.

1. Monitored blood pressure of the patient. Measured in both arms or thighs three times, 3-5 minutes apart while patient was at rest, then seated, then stood for initial evaluation.-Independent nursing intervention

2. Observed skin color, moisture, temperature, and capillary refill time.-Independent nursing intervention

3. Noted dependent or general edema.-Independent nursing intervention

4. Implemented dietary sodium, fat, and cholesterol restrictions as indicated.-Collaborative nursing intervention

5. Avoided the use of restraints. May increase agitation and increase the cardiac workload.-Independent nursing

1. Comparison of pressures provides a more complete picture of vascular involvement or scope of the problem.2. Presence of pallor, cool, skin moist, and delayed capillary refill time may be due to peripheral vasoconstriction.3. May indicate heart failure, renal or vascular impairment.

4. These restrictions can help manage fluid retention and with associated hypertensive response, which decrease cardiac workload.5. To minimize/correct causative factors, maximize cardiac output.6. Reduces physical stress and tension that affect blood pressure and course of hypertension.7. Can reduce stressful stimuli, produce calming effect thereby reduce blood pressure.8. Help reduce sympathetic stimulation, promotes relaxation.9. To promote venous return.10. Provides encouragement and promotes wellness.

After 6 hours of nursing interventions, patient was able reduce blood pressure or cardiac workload and was able to identify the signs of cardiac decompensation.

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Objective cues:- edema formation on the extremities

- visual changes

- dry mouth and cracked lips

Deficient fluid volume related to protein loss as evidenced by edema, visual changes, and dry mouth with cracked lips.

General:After 6 hours of nursing interventions, patient will:

a.) be able to know the causative factors that affects the sudden increase of BP during pregnancy.

b.) demonstrate a positive attitude toward the nurse’s teachings.

Specific:Within 6 hours of nursing interventions, patient will:

a.) maintain fluid volume at a functional level.

b.) attain stable vital signs.

c.) have moist mucous membranes.

1. Assessed patient’s vital signs (BP, temperature, PR, and RR) and noted strength of peripheral pulses.-Independent nursing intervention2. Observed urinary output, color, and measured amount and specific gravity. Measured or estimated other fluid losses.-Inependent nursing intervention3. Reviewed laboratory data.-Collaborative nursing intervention4. Evaluated nutritional status, noted current intake, weight changes, and problems with oral intake.-Independent nursing intervention5. Provided nutritious diet via appropriate route; gave adequate free water with enteral feedings.-Dependent nursing intervention6. Bathed less frequently using mild cleanser/soap, and provided optimal skin care with suitable emollients.-Independent nursing intervention7. Provided frequent oral care.-Independent nursing intervention8. Discussed factors related to occurrence of deficit, as individually appropriate.-Independent nursing intervention9. Instructed to limit intake of alcoholic/caffeinated beverages.-Independent nursing intervention10. Changed position frequently.

1. To evaluate degree of fluid deficit.

2. To more accurately determine replacement needs.3. To evaluate degree of fluid deficit.4. To assess causative/precipitating factors.5. To correct or replace fluid losses to reverse pathophysiological mechanisms.6. To maintain skin integrity and prevent excessive dryness.7. To prevent injury from dryness.8. Early identification of risk factor can decrease occurrence and severity of complications associated with hypovolemia.

9. Alcohol or caffeinated beverage tends to exert a diuretic effect.

10. To promote comfort and safety.

After 6 hours of nursing interventions, patient was able to attain normal conditioning, participated in the actions which improved body’s normal fluid volume, and was able to know the causative factors that affect high BP.

intervention

6. Maintained activity restrictions.-Independent nursing intervention

7. Instructed in relaxation techniques, and guided imagery.-Independent nursing intervention

8. Provided calm, restful surroundings, minimized environmental noise.-Independent nursing intervention

9. Provided for adequate rest, positioned patient for maximum comfort.-Independent nursing intervention

10. Gave information about positive signs of improvement, such as decreased edema, improved vital signs/circulation.-Independent nursing intervention

Vital signs taken as follows:

BP= 150/120

Ineffective tissue perfusion related to vasoconstriction

General:After 6 hours of nursing interventions,

1. Monitored blood pressure every 2 hours.-Independent nursing intervention

1. For baseline information.2. To note degree of impairment or organ involvement.

After 6 hours of nursing interventions, patient was able to know the factors that affect her condition, verbalized

mmHg

PR= 96 bpm

RR= 24 cpm

T= 36.6 C

of blood vessels. the patient will be able to know the factors affecting her condition.

Specific:After 6 hours of nursing interventions, the patient will be able to verbalize understanding of condition and demonstrate behaviors to improve circulation.

2. Determined presence of visual, sensory/motor changes, headache, dizziness, altered mental status, personality changes.-Independent nursing intervention3. Instructed to eat low and salt low fat diet.- Independent nursing intervention4. Administered anti-hypertensive drug prescribed by the physician.-Dependent nursing intervention5. Noted reports of nausea/vomiting.-Independent nursing intervention6. Encouraged discussion of feelings regarding prognosis/long-term effects of the condition.-Independent nursing intervention7. Referred to specific support groups, counseling, as appropriate.-Collaborative nursing intervention

8. Evaluated vital signs, noted changes in BP, heart rate, and respirations.

3. Sodium tends to be excreted at a faster rate.4. To control the blood pressure and to avoid other complications.5. To note degree of impairment.6. To promote wellness.7. Promotes wellness.8. To know whether patient’s condition has changed or not.9. To assess causative or contributing factors.

10. Enhances venous return.

understanding of condition, and demonstrated behaviors that improved circulation.

-Independent nursing intervention

9. Evaluated for signs of infection, especially when immune system is compromised.-Independent nursing intervention

10. Encouraged ambulation when possible.-Independent nursing intervention