5b - NCP

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective: Ineffective tissue After 1 hour of 1. Monitored Fetal heart rate

perfusion r/t nursing maternal and fetal patterns may reflect
vasoconstriction as intervention, the heart rate reduced placental
Objective: evidenced by blood patients blood blood flow and
BP: 170/90 pressure of 170/90 pressure will maternal pulse pattern
PR: 80 decrease from may reflect peripheral
RR: 21 170/90 mmHg to perfusion
atleast 140/90
2. Kept room quiet
mmHg Bright light can trigger
and lights dimmed
seizures
3. Maintained strict
To aid in increase
bed rest on her left
side and evacuation of sodium
maintained and encourage diuresis
continous nursing of edema fluid and
observation avoid uterine pressure
on the vena cava
4. Monitored To determine progress
maternal vs every or complication
hour
5. Kept and ensured

For immediate
drugs and oxygen
administration in case
equipment in place
of emergency
6. Noted the
presence, quality To ensure adequacy of
of the central and
blood circulation
peripheral pulses.
7. Observed for signs

that may indicate Early intervention can
an imminent reduce maternal
seizure, twitching injuries if seizure
of facial muscles, occurs
hyperactive DTR,
epigastric or RUQ
pain, and NV
8. Promoted good Stringent restriction of

nutrition salt was advised in
order to prevent edema
and stimulation of
increase blood
pressure
To aid in reducing
9. Administered
blood pressure
Methyldopa as
ordered
10. Administered
To prevent further
Magnessium
complication of
Sulfate as ordered
hypertension
and monitored
specifically seizure
DTR,maternal BP,
pulse, RR and
urine output
Subjective: Risk for Maternal Within 8 hours of the 1. Monitored symptoms These may reflect
injury r/t shift, the patient will along with maternal severity of
vasopasm remain free of injury reports of worsening preeclampsia
Objective: from the effects of illness s/a changes
BP: 170/90 preeclampsia in CNS signs, pain
PR: 80 from headache and
RR: 21 epigastric and visual
changes
2. Monitored FHR To determine progress

pattern and maternal or alert for
vital signs and complications
effects of medication
every one hour
3. Maintained a To reduce stimuli that

thereapeutic may heighten seizure
environment: quiet activity
darkened room
4. Positioned in left To prevent uterine

lateral pressure to vena cava
in the right side
5. Taught the patient Diet influences disease

the importance of progression. Foods
eating a balanced rich in protein may
pregnancy diet at replace protein loss
least TID with from
adequate protein,
calcium like beans, proteinuria,Adequate
vegetables, fruits. dietary antioxidants
Explained that her may facilitate
food should contain prostacyclin/thromboxa
no added salt and ne balance leading to
drink 8-10 glasses a vasodilation.Increasing
day fluids prevent
constipation
6. Hooked O2 2-3 lpm

as ordered To provide
supplementary oxygen
for adequate tissue
perfusion
7. Administered MgSO4
as ordered
To aid in preventing
further complication of
8. Kept calcium hypertension
gluconate in place specifically convulsion
To provide antidote
from magnessium
9. Monitored RR and toxicity
DTR
To be alert for
10. Monitored I and O magnessim toxicity
every hour
To assess for renal
perfusion from
11. Maintained a safe magnessium toxicity
environment with
padded bedside rails
and oxygen
equipment To secure and prevent
maternal injury
Subjective: Risk for Fetal injury Within 8 hours of 1. Instructed patient By resting the client, Goal met. No
r/t reduced placental the shift, injury to maintain bed a decrease in bodys fetal injury
perfusion secondary will not occur in rest metabolism and noted/occured
Objective: to vasopasm fetus as adequate blood and fetal heart
BP: 170/90 evidenced by circulation to the rate remained
PR: 80 normal fetal heart placenta occurs, thus, in normal range
RR: 21 rate (120-160bpm need of oxygen to the (120-160bpm)
FHR: 131 BPM ) fetus can be met
2. Encouraged
To prevent uterine
patient to sleep on
her left side pressure to the vena
cava on the right side
3. Monitored blood
pressure To determine
progress or
complication
4. Monitored Fetal
heart sounds and So that immediate
Fetal heart rate action can be planned
in advance whether
state of fetal heart is
weak or declining
which is indicative of
reduced oxygen
supply to the placenta
5. Monitored for
signs of Abruptio Abruptio placenta
placenta, may occur
abdominal spontaneously with
pain,uterine Hypertension
tenderness, fetal
distress signs
6. Hooked O2 as ss
ordered and To provide
regulated 2-3lpm supplementary
oxygen

5b - NCP

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5b - NCP

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What are the nursing diagnoses for the patient?

What interventions were performed for the patient?

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective tissue After 1 hour of 1. Monitored Fetal heart rate

5. Kept and ensured

7. Observed for signs

8. Promoted good Stringent restriction of

2. Monitored FHR To determine progress

3. Maintained a To reduce stimuli that

4. Positioned in left To prevent uterine

5. Taught the patient Diet influences disease

6. Hooked O2 2-3 lpm

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