A Nursing Care Plan on

Gestational Hypertension

In Partial Fulfillment of the

Requirements in NCM 207– RLE

Delivery Room Rotation

Submitted to:

Trina Domanais, RN, MN

Clinical Instructor

Submitted by:

Hannah Bianca Baniel, St. N.

BSN 2N– Group 5

October 26, 2022

 CLUSTERED DATA/CUES
NURSING DIAGNOSIS PRIORITY

Activity/ Exercise
• “Lipong ra gamay, hanap hanap akong panan aw, init
sa lawas”
• VS @ 5:04 AM, Oct 14
-BP: 158/97. -CR: 82
-RR: 23 -PR: 78
-Temp: 37.1
• Baby Out: 4:08 AM, October 14, 2022
• BP Monitoring
Time Reading
3:20 AM 150/100 Ineffective Peripheral Tissue Perfusion related to
4: 08 AM 130/90 increased peripheral vascular resistance as evidenced High
(Baby Out) by elevated blood pressure
4: 13 AM 110/90
(Placenta out)
4: 17 AM 140/90
(Episioraphy)
4: 20 AM 140/90
(Before blood extraction)
4:26 AM 130/100
(End of Episioraphy)
5:04 AM 158/97
5:25 AM 146/85
5: 43 AM 131/63
5: 56 AM 129/73
• Medications: Magnesium Sulfate via IV x3 doses
 CLUSTERED DATA/CUES PRIORITY

Health Perception/Health Management

• VS @ 10:30 PM
-BP: 110/80
-CR: 82
-PR: 80
-RR: 22
-Temp: 36.6

• Lab Results
-Hemoglobin: 112
-Blood Type: O+
Low
• Vaccines
-Johnson & Johnson w/ 1x Moderna booster

• EFW: 3.1 kg
• FHT: LLQ
• IE Results as of 10: 30 PM
-5 cm dilated
-80% effaced
- -3
-intact bag of water
-cephalic
 Nutritional/Metabolic
• IV @ 12:00AM D5LR 1L at 120cc/hr Low
Cognitive/Perceptual
• Verbalization of “agay sakita uy” or “dali lang kay sakit kaayo"
• Observable facial grimacing
• Strong Uterine Contractions with 2-6 mins interval lasting 60-120
seconds T D I I Medium
• Labor Pains: 7/10 1:22 AM 97 4mins S

• 4th Degree Laceration 1:26 AM 149 6mins S

• Medications: Lidocaine 1:32 AM 95 3mins S

1:35 AM 77 4mins S
Sexual/ Reproductive
• AOG 39 weeks
• G: 1 P: 1 A: 0 Low
• T: 1 P: 0 A: 0 L: 0
Role-Relationship
• First-time mother Medium
Elimination
• Stool: 1
• Urine: 1 Medium
• w/ Diaper soaked in blood; changed once
• Medications: Fleet Enema
Sleep/ Rest
• Short naps in between contractions lasting approximately 15-30 Low
mins
Self- Concept
• Self-assured
• Absence of signs of embarrassment Low
• Displayed comfortability despite crowd
• Verbalized “dili ko maulaw kay nagkat on mana sila”
Stress Tolerance
• Self- Reassurance
• Deep Breaths during Contractions
• Reiteration of motivation “excited kayko mameet akong baby. Low
unta ma okay na ni (referring to bp) para makita na nako si baby”
• Bearing down
Value- Belief
• Verbalized “Lord Tabang” during painful contractions and prior to Low
delivery
Name of Patient: KS Age: 32 y.o. Sex: F Attending Physician: Dr. Taoho Room #: 440-1

Chief Complaint: Labor Pain Diagnosis: Ineffective Peripheral Tissue Perfusion

DATE/ CUES NE NURSING PATIENT PLANNING/INTERVENTION IMPLE EVALUATION

TIME ED DIAGNOSIS OUTCOME (At least 10 interventions. MENT
Include rationale, cite your ATION
sources @ the bibliography)
10/14/22 Subjective: Diagnosis 1. Within 30 10/14/22
1. Administer the medications
5: 04 “Lipong ra gamay, A minutes to as ordered by the physician 1 5: 56 AM
AM hanap hanap akong C Ineffective 1 hour of Goal Met
R: Medications are vital
panan aw, init sa lawas” T Peripheral administeri
especially in emergency
as verbalized by the I Tissue ng After injecting
situations. In some cases,
client. V Perfusion medication Magnesium
patients may not realize the
I related to and Sulfate IVTT as
danger of their condition as
Objective: T increased rendering ordered by Dr.
some have high pain
• VS @ 5: 04 AM, Y peripheral nursing Taoho and
Oct 14 tolerance however the posing
/ vascular interventio monitoring px
-BP: 158/97 threat continually increases
-CR: 82 E resistance as ns: vital signs, bp
-PR: 78 with time, so it is essential to
X evidenced by A. Blood went down to
-RR: 23 give the appropriate
-Temp: 37.1 E elevated blood pressure 146/85 after 1st
medications to the patient to
R pressure will start to dose, 131/63
• BP Monitoring manage their current
C gradually after 2nd dose
3:20 AM-
150/100
 4:08 AM- 130/90 I lower condition and keep them and 129/73 after
4:13 AM- 110/90
S Rationale: down. away from further harm. 3rd dose
4:17 AM- 140/90
4:20 AM- 140/90 E Pregnant Specifically
4:26 AM-
women are , display a 2. Monitor Vital Signs before, 2
130/100
5:04 AM- 158/97 prone to bp within during and after medication 10/14/22
5:25 AM- 146/85
hypertension as the range R: To keep track of the 6: 26 AM
5:43 AM- 131/63
5:56 AM- 129/73 their systemic of 150/90 progress of the patient’s vital Goal Met
• Skin warm to
circulation or lower signs and the effectivity of the Patient
touch
• Displays slight require extra after 1st drug administered verbalized relief
reddening work to dose from discomfort
• IV @ 12:00AM
D5LR 1L at compensate for MgSo4, 3. Educate Patient of their 3 “wala nay lipong,
120cc/hr blood loss and and condition- its causes, dili na hanap
• Medications:
Magnesium lack of oxygen continually consequences, and treatment akong panan aw.
Sulfate 1g IVTT that is decreasing R: Awareness play a huge pwede na ko
essentially the for part in gaining the patient’s magpahulay?”
life supply to the successive cooperation in Nursing vital signs are
unborn baby. In doses Management. By explaining stable, health
relation to this, their condition to them, you teachings given,
Ineffective B. Verbalize make them understand what cleared for
Peripheral comfort, they are experiencing and rooming out
Tissue and how to deal with it properly. VS @ 6: 15AM
Perfusion absence of BP: 120/80
happens when blurry This also helps lessen CR: 83
there is lack of vision and anxiety. PR: 80
oxygenated dizziness RR: 20
blood flow to 4. Promote increased comfort 4 Temp: 36. 7
2. Vital signs
areas of the to patient by swiping an
should
body. Proper alcohol swab in the iv-
have gone
perfusion is injection site
back to
detrimental to R: MgSO4 is stingy in the skin
baseline
the function of and veins, the cooling effect of
normal
organs and alcohol swab helps lessen the Hannah Bianca
body systems pain Baniel, St. N
BP: 110/70
as organs and
to 130/90
tissues that are 5. Elevate the patient’s head 5
CR: 80 -
not perfusing R: Raising the head of the
100
will die. This bed decreases the amount of
PR: 80-90
occurrence blood returning to the heart
RR: 16-20
prompts the due to the effects of gravity
Temp:
blood vessels to
35.6-36.7
constrict and 6.Assess the client for 6
increasing 3. Prior to visual disturbances.
peripheral rooming
R: Alteration in the
vascular out, health
sensorium may indicate
resistance teachings inadequate cerebral
causing are to be perfusion secondary to
elevated blood given. decreased cardiac output.
pressure levels. Discharge
Vision changes are due to
instructions
arteriolar vasospasms and
,
decreased blood circulation
Source: prescribed
to the retina.
medication
Mayo
s and 7. Perform Post-partum care 7
Foundatio
n for schedule such as changing of diaper
Medical
for and gown, perineal flushing,
Education
and postpartum monitoring vital signs, sitz
Research.
checkup to bath, offering pillow or padded
(2022,
April 15). follow once ring when sitting, provide
Preeclamp
settled in icepack, ensuring proper
sia. Mayo
Clinic. room contraction and hardening of
Retrieved
October the uterus, monitoring ability
27, 2022, to void and offering laxative to
from
https://ww avoid constipation, check
w.mayocli perineal area for tears and
nic.org/dis
eases- infection, and promote
conditions/ breastfeeding while teaching
preeclamp
sia/sympto the mother proper latching
ms-
technique.
causes/sy
c- R: The major purpose of
20355745
postpartum and postnatal
#:~:text=P
reeclamps care are to maintain and
ia%20is%
promote the health of the
20one%20
high%20bl woman and her baby and to
ood,gestat
foster an environment that
ional%20h
ypertensio offers help and support to the
n%20may
family. These measures also
%20devel
op%20pre help reduce the risk of
eclampsia.
infection and complications in
mothers after delivery.

8. Encourage regular exercise 8

for weight loss after
pregnancy and explain its
benefits
R: Postpartum weight may
affect posing health
conditions and either worsen
or prevent. So, teaching the
patient to manage it early
would be best to avoid
complications

9. Prior to discharge instruct 9

patient to continually and
consistently monitor their
blood pressure through a
digital bp if unable to use
manual
R: Consistently taking
medications and maintenance
is not an assurance that post-
partum hypertension will
cease to persist. At any point
during the period of treatment,
bp can still spike or
irregularities may occur, so it
is best to keep a log or record
of your blood pressure at least
once a day
 10. Encourage Patient to be 10
present during regular
scheduled post-partum
check-ups with their physician
R: As one health team, it is
also the nurse’s responsibility
to make sure their patient
goes back to their doctor on
schedule to have them
checked for progress or
possible deterioration.

Bibliography

M;, H. (n.d.). The role of magnesium in hypertension and cardiovascular disease. Journal of clinical hypertension (Greenwich, Conn.).
Retrieved October 27, 2022, from https://pubmed.ncbi.nlm.nih.gov/22051430/

Mayo Foundation for Medical Education and Research. (2022, April 15). Preeclampsia. Mayo Clinic. Retrieved October 27, 2022, from
https://www.mayoclinic.org/diseases-conditions/preeclampsia/symptoms-causes/syc-
20355745#:~:text=Preeclampsia%20is%20one%20high%20blood,gestational%20hypertension%20may%20develop%20preeclampsia
FDA recommends against prolonged use of magnesium sulfate to stop pre ... (n.d.). Retrieved October 26, 2022, from
https://www.fda.gov/media/85971/download

Postpartum hypertension: When a new mom's blood pressure is too high: Heart: Your pregnancy matters: UT southwestern medical
center. Heart | Your Pregnancy Matters | UT Southwestern Medical Center. (n.d.). Retrieved October 27, 2022, from
https://utswmed.org/medblog/postpartum-high-blood-pressure/

Postpartum preeclampsia: Causes, symptoms & treatment. Cleveland Clinic. (n.d.). Retrieved October 27, 2022, from
https://my.clevelandclinic.org/health/diseases/17733-postpartum-preeclampsia

Herdman, H. T., Kamitsuru, S., & Lopes, C. T. (n.d.). Nursing Diagnoses Definitions and Classifications (12th ed.). Thieme.