Explanation Subjective: Patient may Decreased Cardiac Inadequate blood is Short Term: 1. Establish rapport 1. To gain pt’s trust Short Term: verbalize output r/t decreased pumped by the heart After 3 hrs of nursing 2. Monitor and assess and cooperation The pt shall have Palpitations venous return to meet the interventions, the pt VS 2. To obtain baseline displayed Fatigue secondary to severe metabolic demands will display 3. Assess the pt’s 3. To determine hemodynamic general physical presence of Shortness of preeclampsia AEB of the body. It hemodynamic stability (blood condition abnormality breath/dyspnea altered BP and resulted from a stability AEB blood pressure within anxiety edema systemic vaso pressure within her 4. Determine baseline 4. Provides closer range) constriction in the body normal range vital opportunities to Objective: caused by signs/hemodynami track changes Long Term: Patient manifested: preeclampsia. Long Term: c parameters The pt shall have Vasoconstriction is the After 3 days of demonstrated Weight gain including decrease in the nursing peripheral pulses. activities that reduce Edema diameter of the blood interventions, the pt the workload of the Variations in BP vessels which occur in will demonstrate 5. Review signs of 5. To prevent heart (stress reading diseases like impending failure hypovolemic shock activities that reduce management, Restlessness pregnancy-induced /shock. hypertension. the workload of the therapeutic Decreased blood supply heart (stress medication regimen Patient’s fetus may 6. Position with HOB 6. To increase venous leads to a decrease in management, program, balanced manifest: flat or keep trunk return venous return, thus therapeutic activity/ rest plan) Jugular vein horizontal while there is a relatively medication regimen raising legs 20 to distention smaller amount of program, balanced 30 degrees Cold clammy skin blood expelled by the activity/ rest plan) (contraindicated in Arrhythmaia ventricles of the heart. congestive state in crackles which semi- Prolonged fowler’s position is capillary refill preferred)
7. Promote adequate 7. To maximize sleep
rest, by decreasing periods stimuli, providing quiet environment
This NCP was made with love by NursesLabs.com
(ignore the Monkey) 8. Maintain patency 8. To prevent air of invasive embolus and/or intravascular exsanguination. monitoring and infusion lines. Tape connections.
9. Avoid activities 9. May stimulate a
such as isometric valsalva response exercises, rectal stimulation, vomiting, and spasmodic coughing. Administer stool softener as indicated.
10. Encourage pt to 10. This prevents
breathe deeply exertion of too in/out during much workload to activities that the heart. increase risk for valsalva effect.
11. Provide 11. Honesty can be
psychological reassuring when so support. Maintain much activity and calm attitude “worry” are butadmit concerns apparent to the if questioned by patient. the client.
12. Encourage 12. To reduce anxiety
relaxation techniques.
13. Elevate edematous 13. To promote
extremities and comfort avoid restrictive
This NCP was made with love by NursesLabs.com
(ignore the Monkey) clothing.
14. Provide for diet 14. To enhance pt’s
restrictions. therapeutic regimen
15. Monitor intake and 15. To determine fluid
output. balance
16. Discuss significant 16. May be sign of
signs and drug toxicity symptoms that and/or mineral loss need to be , especially reported to the potassium. healthcare provider ( e.g. muscle cramps, d/a, dizziness, skin rashes). 17. To reduce risk of orthostatic 17. Encourage hypotension changing positions slowly, dangling legs before standing.
18. Give information 18. To provide
about positive encouragement. signs of improvement such as decreased edema, improved vital signs / circulation). 19. To increase oxygen 19. Administer available to tissues supplemental oxygen as indicated.