Cues/Data Nursing Backgro Long Short Intervention Rationale Evaluation

Diagnos und Term Term

is Knowled Goal Goal
ge

Subjective Acute Unpleasa To As the Independent:

Cues: pain nt FHT falls Goal Met
related sensory within 1. Establish 1. To gain
“Minsan to and the rapport patient’ At the end of
pabalik-balik altered emotional normal s trust the shift, the
na sumasakit blood experienc range, at and FHT was
ang ulo ko pati pressure e arising the end cooper maintained
din yung hita as from of the ation. within the
at batok ko,” evidence actual or nursing 2. Monitor normal range:
as verbalized d by BP potential shift, and assess FHT-158 bpm.
by the patient of tissue FHT vital signs.
140/90, damage should 2. To The client was
“Humihiga facial or remain obtain able to
nalang ako grimace, describe within 3. Monitor baselin verbalize
para mawala and in terms normal FHT every e data. understanding
yung sakit,” guarding of such range hour. about the
added by the behavior damage; and the 3. A relationship of
patient. s sudden or client will change managing the
slow be able of FHT preeclampsia
Objective onset of to (normal and the safety
Cues: any verbalize : 120- of her baby.
intensity her 160
• BP of from mild understa bpm) is
140/90 to severe nding an
mm HG with an about 4. Instruct indicat
• intermitt anticipate the risk the patient or of
ent d or to fetal to assume fetal
headach predictabl injury left lateral distress
 e (Pain e end and preeclam position. .
Scale of a duration psia
6/10) of less could
• on and than six cause
off slight months. and the 5. Promote 4. To
pain at therapeu bed rest avoid
the tic putting
nape manage pressur
which ment e in the
she that inferior
rated as could vena
5/10- limit this cava.
rate risk.
• facial
grimace 5. To
noticed increas
• guardin e
g 6. Instruct uteropl
behavior the acental
mother on circulat
the ion and
possible prevent
complicati too
ons the much
disease workloa
can cause d in the
the fetus. heart.

7. Discuss
importanc
e of the
 adequate
circulation
of the
blood into
the 6. To
placenta. enhanc
e
patient’
s
particip
ation in
8. Ensure the
adequate treatm
maternal ent
hydration. regime
n.

Dependent:
7. For
1. Administer patient
oxygen as informa
indicated. tion

2. Administer
medicatio
ns as
prescribed
 8. Matern
al
dehydr
ation
and
hypovo
lemia
decrea
ses
placent
al
perfusi
on and
oxygen
supply

1. To
help in
respirat
ion

(References:
Nurse’s Pocket
Guide-11th
edition;
Fundamentals of
Nursing 8th
Edition- Kozier,
Erb et.al;
Maternal and
Child Nursing-
Pillitteri.)