NURSING CARE PLAN

1. Patient’s Profile

Full Name: Selmo, Mary Rose Nickname: Mary Rose

Gender: Female Age: 23 years old

Birth date: May 6, 1986

Birth place: Bokod, Benguet

Father: Rufino Selmo occupation: Senior Plant

Mechanic

Mother: Mercedes Selmo occupation: housekeeper

Address: Ambuklao, Bokod, Benguet

Civil Status: Single Religion: Roman Catholic

Nationality: Filipino

Educational Attainment: college graduate- Nurse

INFORMANT: patient

2. Health History

a. Chief Complaint The client is complaining on Labor Pains and Vaginal Discharge

b. History of Present IllnessAccording to the patient 3 months prior to the admission when she was

diagnosed with Pregnancy Induced Hypertension (PIH) during her first prenatal check up. She admits that she has failed in compliance with her follow up check up. With this no medications or maintenance was taken and claims that her condition was stable. A week prior to admission, she had Hypertension episodes with no other associated signs and symptoms. One day prior to admission the patient experienced hypogastric pain and minimal vaginal discharge (blood tinge noted). According to her physician her cervix was also dilated at 1.5 cm.

LMP: August 5, 2009 EDB: May 12, 2010

c. Past Medical HistoryThe patient claimed of having chicken pox, measles and mumps during her

childhood. She had no asthma or hypertension and has not encountered any accidents nor major operations done. She claims that she has no allergies to food and drugs.

OB-Gyne History

OB Score: G1P0

Pre-natal History

Patient was 23, cognizant of pregnancy at 4 weeks AOG through amenorrhea from a previously regular menstrual cycle. Pregnancy test was done at home revealing

positive result. The pregnancy was unplanned but wanted with attempts of abortion by taking in 2 tablets of Misoprostol, vaginal spotting was resolved 3 days after. First prenatal check-up was instituted at the Health center during her first trimester where CBC requested revealing normal results and urine analysis was also done revealing UTI, the patient was given cephalexin for 1 week. The client admits that she did not return due to the location of their house. The patient experienced nausea and vomiting, breast tenderness and pregnancy test was done at home. The patient is taking multivitamins and Ferrous Sulfate and Ascorbic Acid. She said that she has not undergone ultrasound.

Menstrual History

Menarche was at age 12 years old with the duration of 5 days and twice per month for her first six month and monthly thereafter. She consumes 2 to 3 fully soaked pads without dysmenorrhea.

Sexual History

First sexual contact was at the age 23 with (+) vaginal bleeding and dyspereunia. Claims to have only 1 sexual partner-monogamous. Last sexual contact was at September 2009.

Gyne History

She had no gynecologic illness, no foul smell vaginal discharge, and no vaginitis. She had not undergone any operation, PAP smear, vaccination and no Family Planning Method used.

Family History

She is the fourth among 5 siblings. Hypertension, Cardiovascular disease and asthma is present on both father and mother side.

Social and Environmental

The patient is a college graduate-nurse and currently is not working. The patient lives in a concrete house with 3 rooms and 8 occupants with good interpersonal relationship. Source of water for domestic purposes is from the spring and drinking water is bought from the refilling station. Toilet is flush type. Patient is a non-smoker and non-alcoholic beverage drinker.

Blood Type: A+ Spouse: Not known

Review of Systems

1. General

(-) Fever, (-)Weakness, (-)Nausea, (-)Vomiting, (-)Dizziness, (+)Hypogastric Pain, (+)Uterine Contractions, (-)Headache, (+) weight gain

2. Integumentary System

(-) Rashes, (-)Pruritus

3. Head

(-) Lesions, (-)Swelling

a. Eyes

(-) Tearing, (-)Redness

b. Ears

(-) discharges

c. Nose

(-) Sneezing, (-)Colds, (-)Epistaxis, (-) Discharges

d. Mouth and Throat

(-) Gum Bleeding, (-)Swelling, (-)Dysphagia

4. Neck

(-) Mass, (-) Lesions

5. Respiratory System

(-) Cough, (-)Phlegm, (-)Dyspnea

6. Cardiac System

(-) Palpitations, (+)Edema, (-)Dyspnea, (-)Orthopnea, (-)Easy Fatigability

7. Gatrointestinal Tract

(-) Diarrhea, (-)Abdominal Distention, (-)Nausea, (-)Substernal Pain, (-)Vomiting

8. Genitourinary Tract

(+) Bloody Discharges, (-)Hematuria, (-)Dysuria, (-)Watery Vaginal Discharges

(+) Urinary Frequency

9. Muskuloskeletal System

(-) Stiffness, (-)Joint Pains, (-)bipedal Edema, (-)Pain

10. Hematologic System

(-) Bleeding Tendencies, (-)Varicosities, (-)bruising Petechiae, (-)Hematoma

11. Endocrine System

(-) Polyphagia, (-)Hyperactivity, (-)Heat/Cold Intolerance, (-)Profuse Sweating

12. Nervous System

(-) Convulsions, (-)Tremors, (-) Fainting

COURSE OF CONFINEMENT

The patient was confined at February 15, 2010 with the chief complaint of labor pain and vaginal discharge. She was transported to the OB ward via wheelchair. The patient had series of laboratory exams such as CBC, ultrasound, Plasma/ Serum Test, biometry. As of present the patient is taking Methyldopa, Paracetamol, Catapres and hydralazine. The patient is also under O2 therapy at 2Lpm and an ongoing Plain NSS IVF at 15 gtts/min.

Drug Index

Generic name ParacetamolBrand name Biogesic

Drug classification Antipyretic; analgesic (non-opiod)

MOA: Inhibits prostaglandin

Indications: Relief of fever, minor aches & pains.

Contraindications: Anemia, cardiac & pulmonary disease. Hepatic or severe renal disease.

Adverse effect: Allergic skin reactions & GI disturbances.

Nursing Considerations >Check for allergic reactions>monitor the patient for any adverse effect

Generic name MethydopaBrand name Aldomet

Drug classification Antihypertensive

MOA: Aldomet (methyldopa) is an effective antihypertensive agent that reduces both supine and standing blood pressure. Symptomatic postural hypotension, exercise hypotension and diurnal blood pressure variations rarely occur. By adjustment of dosage, morning hypotension can be prevented without sacrificing control of afternoon blood pressure.Methyldopa has no direct effect on cardiac function and usually does not reduce glomerular filtration rate, renal blood flow or filtration fraction. Cardiac output usually is maintained without cardiac acceleration. In some patients, the heart rate is slowed.Because of relative freedom from adverse effects on kidney function,methyldopa can be of benefit in the control of high blood pressure, even in the presence of renal impairment. It

may help arrest or retard the progression of renal function impairment and damage due to sustained elevation of blood pressure.Normal or elevated plasma renin activity may decrease in the course ofmethyldopa therapy.The ability to inhibit dopa decarboxylase and to deplete animal tissues of norepinephrine resides solely in the L-isomer (methyldopa). In man, the antihypertensive activity appears to be due solely to the L-isomer.

Indications: Hypertension (mild, moderate or severe)

Contraindications: Patients with active hepatic disease eg, acute hepatitis and active cirrhosis; with hypersensitivity (including hepatic disorders associated with previousmethyldopa therapy) to any component of Aldomet (see Precautions); on therapy with monoamine oxidase (MAO) inhibitors.

Adverse effect: Sedation, usually transient, may occur during the initial period of therapy or whenever the dose is increased. Headache, asthenia or weakness may be noted as early and transient symptoms.Significant side effects due to Aldomet have been infrequent and this agent usually is well tolerated.The following reactions have been reported:Central Nervous System: Sedation (usually transient), headache, asthenia or weakness, paresthesias, parkinsonism, Bell's palsy, involuntary choreoathetotic movements. Psychic disturbances including nightmares, impaired mental acuity and reversible mild psychoses or depression. Dizziness, lightheadedness and symptoms of cerebrovascular insufficiency (may be due to lowering of blood pressure).Cardiovascular: Bradycardia, prolonged carotid sinus hypersensitivity, aggravation of angina pectoris. Orthostatic hypotension (decrease daily dosage). Edema (and weight gain) usually relieved by use of a diuretic. (Discontinue methyldopa if edema progresses or signs of heart failure appear.)

Gastrointestinal: Nausea, vomiting, distention, constipation, flatus, diarrhea, colitis, mild dryness of mouth, sore or "black" tongue, pancreatitis, sialoadenitis.Hepatic: Liver disorders including hepatitis, jaundice, abnormal liver function tests.Hematologic: Positive Coombs' test, hemolytic anemia, bone marrow depression, leukopenia, granulocytopenia, thrombocytopenia, eosinophilia. Positive tests for antinuclear antibody, LE cells and rheumatoid factor.Allergic: Drug-related fever and lupus-like syndrome, myocarditis, pericarditis.Dermatologic: Rash, as in eczema or lichenoid eruption, toxic epidermal necrolysis.Others: Nasal stuffiness, rise in BUN, breast enlargement, gynecomastia, lactation, hyperprolactinemia, amenorrhea, impotence, decreased libido, mild arthralgia, with or without joint swelling, myalgia.

Nursing Considerations >Advise the patient to have ample rest periods>Tell the client and her significant others not to walk alone to avoid any accidents due to drowsiness> observe the 10 rights in drug administration

Generic name Hydralazine HCl

Brand name Apresoline

Drug classification Antihypertensives 

Indications: HTN, chronic CHF

Contraindications: Known hypersensitivity to hydralazine or dihydralazine & any of the excipients. Idiopathic SLE & related diseases. Severe tachycardia & heart failure w/ high-cardiac output. Myocardial insufficiency due to mechanical obstruction. Isolated right ventricular heart failure due to pulmonary HTN. Dissecting aortic aneurysm.

Adverse effect: Vasomotor reactions (eg tachycardia, hypotension, CHF). GI disturbances (eg nausea); anemia including hemolytic anemia, agranulocytosis, hepatitis,

glomerulonephritis, SLE-like syndrome (arthralgia, joint swelling, fever), headache, acute renal failure.

Nursing Considerations >Advise the patient to have ample rest periods>Tell the client and her significant others not to walk alone to avoid any accidents due to drowsiness> observe the 10 rights in drug administration

Generic name Clonidine HCl

Brand name Catapres

Drug classification Antihypertensives

Indications: Hypertension

Contraindications: Sick sinus syndrome

Adverse effect: Dizziness, headache, paraesthesia, sedation, gynaecomastia, confusion state, delussional perception, depression, hallucination, decreased libido, nightmare, sleep disorder, accomodation disorder, decreased lacrimation atrioventricular block, bradyarrythmia, sinus bradycardia, orthostatic hypotension. Raynauds's phenomenon, nasal dryness, alopecia, pruritus, rash, urticaria, erectile dysfunction, fatigue, malaise, colonic pseudo-obstruction, constipation, dry mouth, nausea, salivary gland pain, vomiting.

Nursing Considerations >Advise the patient to have ample rest periods>Tell the client and her significant others not to walk alone to avoid any accidents due to drowsiness> observe the 10 rights in drug administration

3. Diagnostic Results OB GYNE Ultrasound

Singleton_x__ Multifetal______ AFV 2Presentation: Cephalic Fetal Tone 2AFV: AFI 15.38 SVP__________ _ Fetal Movement 2Placental location:anterior lying Fetal Breathing 2

Grade IINST__________

Distance to Internal Os_______ Total Score0.8/8FHR 136

BiometryBPD 7.51 AOG 30w4dHC 27.12 AOG 29w4dOFD 9.62 AOG_____

AC 25.3 AOG29w4dFL 5.22 AOG27w4d

RATIOSCephalic Index (70-86%)__________

FL/AC (20-40%)_________HC/AG (0.9-1.05)_________FL/BPD (71-87%)_______

Others: Cervix= 1.63 cmDIAGNOSIS: Pregnancy uterine, 29 weeks and 2 days AOG by fetal biometry, live, singleton. in cephalic presentation. Normal amniotic fluid volume. Placenta high lying, grade II. Biophysical score 8/8, suggestive of unasphyxiated fetus. Color Doppler velocimetry of the Umbilical artery with good diastolic blood flow consistent of good umbilical blood flow.

Normal RangeUREA G: 2.9 mg/dl 135.0-148ASAT 25.5 u/l 3.5-5.3ALAT 13.5 u/l 98-107UREA 7.4 mmol/1 ref range(0.6-1.3)(00-38.0)(0.0-41.0)(2.5-6.4)

Source of Specimen: Plasma/ SerumExam Desired: Ns/K/ ChlorideMethod: Easylyte ISERESULTS

TEST RESULTS UNITNa 134.6 mmol/lK 4.73 mmol/lCl 106.0 mmol/l

Source of Specimen: Capillary BloodExam Desired: Capillary Blood SugarMethod: Medisense Optium Point of CareRESULTS Normal Values106 mg/dl 70-110 mg/dl (fasting)

74-160 mg/dl (non-fasting)

Source of Specimen:SerumExam Desired:KMethod:Easylyte (SE)RESULT

K 4.47 mmol/l

URIC 5.5 mg/dl 2.3-8.2ALBP 27.6 g/dl 35.0-41.0Crea G 3.1 mg/dl 0.6-1.3Urea 8.2 mmol/l 2.5-6.4TP 5.2 g/l 66.0-88.0Globulin 27.6 g/l 23.0-35.0A/G ratio 0.8 1.1-1.90

Colony Count: Less than 1,000 colonies/ml (Suggestive of Contamination)

CBCWBC 11.6 1oe9/L 5.0-10.00

78.8% N 45.0-75.013.1% L 20.0-40.05.08% M 0.00-12.002.30% E 0.00-5.000.7552% B 0.00-2.00

RBC 3.57 10e12/L 4.5-6.0HGB 104 g/l 110-150HCT 0.308 L/L 0.37-0.47MCV 86.4 fL 76.0-96.0MCH 29.1 pg 27.0-32.0MCHC 337 g/L 320-

360

PLT 336.10e9/L 150-400

Normocytic, Normochromic RBC’s

4. Gordon’s Functional Patterns

Health Perception- Health Management Pattern

The patient describes her condition as mild contractions with blood streaked vaginal bleeding. She was brought to the hospital via stretcher due to these complaints. The patient has no known drug and food allergies. The patient walks for at least 20 minutes as a form of exercise. She was observed to have normal capillary refill, no skin lesions with anasarca. She takes a bath everyday and do hand washing before and after eating as healthy measures to prevent acquiring diseases. The family view health as something important for survival.

Being admitted in the hospital, the client has a restricted activity because of the IVF connected to her but still a light body stretching is done every day as an exercise.

Nutritional- Metabolic Pattern

The patient has a good appetite and is not choosy when it comes to food. The patient said that both her mother and father decides for the family. She has no known food allergies. At present she has a problem in her nutritional intake due to nasal cannula and ongoing IV. But, still to ensure that she is able to manage her condition.

Elimination Pattern

The patient has no problem in urinating and elimination. The patient urinates 5-7 times a day and defecates once a day. Urine is characterized to have a pale yellow in color and aromatic. The stool is described as formed. There were no diarrhea and constipation.

Activity- Exercise pattern

On her musculoskeletal system, there is no any muscular atrophy observed. Her activities include walking and doing stretching. Her usual activity is reading books and assisting her mother with their household chores.

Sleep- Rest Pattern

The patient reported that duration of her sleep/rest is around 6 to 7 hours and wakes up at 6 in the morning.. At daytime she takes nap of 2-3 hours.

Being in the hospital, her sleeping pattern is disturbed due to monitoring of vital signs and taking in her due medicines. Even if like this, the patient ensures that she will be well rested by taking a nap in the daytime. Reading the Bible is a bed ritual for her to fall asleep.

Cognitive- Perceptual Pattern

The patient is assessed to be alert with pleasant mood. Pupils are equally round and reactive to light and accommodation.

Self Perception Self-concept Pattern

The patient is observed to have a good grooming, good body posture and normal body movements.

Role- Relationship Pattern

The patient lives with her parents. She is the fourth child among 5 siblings.

Sexuality Reproductive

The patient is a female, 23 years old with one partner and last known sexual contact was at the month of September year 2009 .

Coping- Stress Tolerance Pattern

Being in an unfamiliar environment and from the case of the client, these serves as stressor for her. The patient’s response to these are being sleep deprived. For the mother and significant others, they provide support, comfort and security to the patient by being there to help the patient in coping up.

Value- Belief Pattern

The patient is a Roman Catholic. They go to church every Sunday so as to thank the Almighty and candles are also lit every after attending the mass.

5. List of Prioritized Nursing Diagnosis Ineffective tissue perfusion related to arteriolar vasospasm secondary to

pregnancy induced hypertension- Arteriolar circulation is disrupted by alternating segments of

constriction and dilation. The vasospastic action causes damage to the blood vessels by decreasing their blood supply. The vasospasm existing in women with PIH is attributed to the extreme sensitivity of the vasculature to vasopressors

Decreased cardiac output related to decreased venous return as evidenced by edema- Pregnancy Induced Hypertension is a condition in which vasospasms occur. It is caused by altered cardiac output that injures endothelial cells of the arteries. Blood vessels becomes less resistant to pressor substances. This results to vasoconstriction and increases BP.

Activity intolerance r/t imbalance between O2 supply and demand secondary to Pulmonary edema- Activity intolerance is a condition of general weakness, sitting much of the time, oxygen imbalance, or bed rest. The patient may have weakness, blood pressure changes, and shortness of breath when activity is tried.

6. Pathophysiology

Preeclampsia is a characterized, by vasospasms, changes in the coagulation system, and disturbances in systems related to volume and BP control. Vasospasms results from an increased sensitivity to circulating pressors, such as angiotensin II, and possibly an imbalance between the prostaglandins prostacyclin and thromboxane A1.

Endothelial cell dysfunction, believed to result from decreased placental perfusion, may account for many changes in preeclampsia. Arteriolar vasospasm may cause endothelial damage and contribute to an increased capillary permeability. This increase edema and further decreases intravascular volume, predisposing the woman with preeclampsia to pulmonary edema.Immunologic factors may play an important role in the development of preeclampsia. The presence of a foreign protein, the placenta, or the fetus maybe perceived by the mother’s immune system as an antigen. This may then trigger an abnormal immunologic response. This theory is supported by the increased incidence of preeclampsia or eclampsia in first-time mothers or to multiparous woman pregnant by a new partner. Preeclampsia maybe an immune complex disease in which the maternal antibody system is overwhelmed from excessive fetal antigens in the maternal circulation. This theory seems compatible with the high incidence of preeclampsia among women exposed to a large mass of trophoblastic tissue as seen in twin pregnancies or hydatidiform moles.Genetic predisposition maybe another immunologic factor. Dekker reported a greater frequency of preeclampsia and eclampsia among daughters and granddaughters of women with a history of eclampsia, which suggests an autosomal recessive gene controlling the maternal immune response. Paternal factors are also examined.Diets in inadequate nutrients, especially protein, calcium, sodium, magnesium, and vitamin E and C, maybe an etiologic factor in preeclampsia. Some practitioners prescribed high-protein diets (90 mg supplemental protein) without caloric restriction and moderate sodium intake in the prevention and treatment of this disorder. However, data are limited regarding the association between diet and preeclampsia.Preeclampsia progress along a continuum from mild disease to severe preeclampsia, HELLP syndrome, or eclampsia. The pathophysiology of preeclampsia reflects alteration in the normal adaptations of pregnancy. Normal physiologic adaptations to pregnancy include increase blood plasma volume, vasodilation, and decreased systemic vascular

resistance, elevated cardiac output, and decreased colloid osmotic pressure. Pathologic changes in the endothelial cells of the glomeruli are uniquely characteristic of preeclampsia, particularly in nulliparous women. The main pathogenic factor is not an increase in BP but poor perfusion as a result vasospasm. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and raises BP. Function in organs such as the placenta, kidneys, liver and brain is deceased by as much as 40% to 60%

7. NCP Proper

Subjective and Objective DataSubjective:Objective: Temp - 38.2 oC; PR - 92 bpm;RR – 22cpm;BP – 180/100 (+) anasarca pallor noted capillary refill= 1-2 seconds on O2 inhalation at 2Lpm per nasal cannula

Goals (STO and LTO)STO:

After 8 hours of performing leg elevation, early ambulation when permitted, performing active and initiating passive ROM exercises the client will demonstrate improved perfusion as evidence by peripheral pulses present/equal, pink skin color, temperature stabilizes at to 36.5 to 37.5°C, and absence of tissue edema.LTO:After 2 days of continuous evaluation, examination, assessment, and nursing interventions, body temperature will remain within normal range (36.5 to 37.5 °C), free of tissue edema, and display increasing tolerance to activity

Explanation of the ProblemArteriolar circulation is disrupted by alternating segments of constriction and dilation. The vasospastic action causes damage to the blood vessels by decreasing their blood supply. The vasospasm existing in women with PIH is attributed to the extreme sensitivity of the vasculature to vasopressors

Other Part/s: Nursing Diagnosis: Ineffective tissue perfusion related to arteriolar vasospasm secondary to pregnancy induced hypertension

Intervention Rationale Criteria for Evaluation EvaluationIndependent> establishrapport

.> to gainclient’s andrelatives trust

Goal Met if the client will not

manifest any complications or worsening of the condition

Partially met if the client manifest some complications and slight improvement of her condition

Not met if the patient manifests manifest any complications and worsening of the condition

STO Met if the client After 8 hours

of performing leg elevation, early ambulation when permitted, performing active and initiating passive ROM exercises the client will demonstrate improved perfusion as evidence by peripheral pulses present/equal, pink skin color, temperature stabilizes at to 36.5 to 37.5°C, and absence

> monitor Vital Signs > to obtainbaseline data

> Initiate active or passive exercises while in bed (e.g., flex/extend/rotate foot periodically).

> These measures are designed to increase venous return from lower extremities and reduce venous stasis, as well as improve general muscle tone/strength. They also promote normal organ function and enhance general well-being..

> Instruct client to avoid rubbing /massaging the affected extremity

> This activity potentiates risk of fragmenting/dislodging thrombus causing embolization, and increasing risk of complications

> refer for anyabnormalchanges in thebody

> to medicallymanage anycomplications.

of tissue edema. Partially met if the client After

8 hours of performing leg elevation, early ambulation when permitted, performing active and initiating passive ROM exercises the client will demonstrate slight improvement in perfusion as evidence by slight changes in peripheral pulses skin color, temperature, and shrinking of tissue edema.

Not met if the clients After 8 hours of performing leg elevation, early ambulation when permitted, performing active and initiating passive ROM exercises the client have no improvement at all

LTO Met if the client After 2

days of continuous evaluation, examination, assessment, and nursing interventions her body temperature will remain within normal range (36.5 to 37.5 °C), free of tissue edema, and display increasing tolerance to activity

Partially met if after After 2

days of continuous evaluation, examination, assessment, and nursing interventions, body temperature will almost be on the normal range (36.5 to 37.5 °C), slight tissue edema, and display slight increasing tolerance to activity

not met if the client After 2 days of continuous evaluation, examination, assessment, and nursing interventions, body temperature is not within normal range (36.5 to 37.5 °C), not free of tissue edema, and no change in tolerance to activity

a. Subjective and Objective DataS: >

O: > Temp - 38.2 oC; PR - 92 bpm;RR – 22cpm;BP – 180/100 (+) anasarca pallor noted capillary refill= 1-2 seconds on O2 inhalation at 2Lpm per nasal cannula

b. Goals (STO and LTO)a) Goal: The patient will maintain blood pressure within normal range with no edema.

LTO: Within 2 to 3 days of giving antihypertensive drugs as prescribed and avoiding high salt diet, the patient will have a normal BP

ranging from 140/100 to 120/80mmHg

STO: Within 4 hours of bed rest, providing quiet environment and changing position slowly PRN, the patient will display hemodynamic

stability BP from 160/100 to 140/100mmHg.

Explanation of the Problem

- Pregnancy Induced Hypertension is a condition in which vasospasms occur. It is caused by altered cardiac output that injures endothelial cells of the arteries. Blood vessels become less resistant to pressor substances. This results to vasoconstriction and increases BP.

c. Other Part/s: Nursing Diagnosis: Decreased cardiac output related to decreased venous return as evidenced by edema

Intervention Rationale Criteria for Evaluation Evaluation>Keep client on the bed and in comfortable position > Decrease stimuli; provide quiet environment.> Encourage changing position slowlyInstruct to avoid or limit activities that may stimulate valsalva response (rectal stimulation bearing down B.M)> Encourage deep breathing exercises

> Educate to avoid high salt intake/diet

>Decreases oxygen consumption.

> To promote adequate rest

> To reduce risk for orthostatic hypotension.

> To prevent in changes in cardiac pressures or impede blood flow> High salt intake tends to lead to water retention and may worsen edema> To promote good circulation

Goal Met if the client will maintain

maintain blood pressure within normal range with no edema after nursing interventions

Partially met if the client manifest enhancement blood pressure but is still slightly elevated and is not within normal range.

Not met if the patient does not maintain blood pressure within normal range with no edema

STO

> Use pillow or cushions to raise feet and legs above heart when you are sitting or lying down

Met if the client Within 4 hours of bed rest, providing quiet environment and changing position slowly PRN, the patient will display hemodynamic stability BP from 160/100 to 140/100mmHg.

Partially met if the client Within 4 hours of bed rest, providing quiet environment and changing position slowly PRN, the patient

will have slight change in BP but not within normal range

Not met if the client Within 4 hours of bed rest, providing quiet environment and changing position slowly PRN, the patient will have elevated BP above normal and has no significant improvement

LTO Met if the client Within 2 to 3

days of giving antihypertensive drugs as prescribed and avoiding high salt diet, the patient will have a normal BP ranging from 140/100 to

120/80mmHg Partially met if the client

Within 2 to 3 days of giving antihypertensive drugs as prescribed and avoiding high salt diet, the patient will have slight change in BP but not within normal range

Not met if the client Within 2 to 3 days of giving antihypertensive drugs as prescribed and avoiding high salt diet, the patient will have elevated BP above normal

Reference>Nurse’s Pocket Guide by Doenges, Moorhouse and Murr>http://www.babycenter.com.au/pregnancy/antenatalhealth/testsandcare/bloodtests/#ixzz0hqfwu99k>http://www.mims.com/Page.aspx?menuid=mng&name=Appebon+Kid+Syrup+syr&h=appebon,kid,syrup,syr&CTRY=PH&searchstring=Appebon+Kid+Syrup+syr> Brunner and Suddhart’s Med-Surg Nursing by Smeltzer, Bare, Hinkle and Cheever>Fundamentals of Nursing Practive by Potter and Perry>Fundamentals of Nursing Practive by Kozier>Prescription Drugs by the Editors of Consumer Guide> Maternity Nursing 7th Edition by Reeder, Martin, and Koniak pg. 802)>(Mosby’s Medical Encyclopedia- Activity intolerance)