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Defining Characteristics Nursing Diagnosis Background Knowledge Desired Outcome Nursing Intervention Rationale Evaluation

The nursing diagnosis was decreased cardiac output related to decreased venous return due to preeclampsia. The desired outcome after 8 hours of nursing intervention was for the patient to be able to participate in activities that reduce blood pressure or cardiac workload. The nursing interventions included monitoring blood pressure, observing skin signs, noting edema, providing a calm environment, instructing relaxation techniques, implementing dietary restrictions, administering medications, and encouraging proper hygiene.

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2K views2 pages

Defining Characteristics Nursing Diagnosis Background Knowledge Desired Outcome Nursing Intervention Rationale Evaluation

The nursing diagnosis was decreased cardiac output related to decreased venous return due to preeclampsia. The desired outcome after 8 hours of nursing intervention was for the patient to be able to participate in activities that reduce blood pressure or cardiac workload. The nursing interventions included monitoring blood pressure, observing skin signs, noting edema, providing a calm environment, instructing relaxation techniques, implementing dietary restrictions, administering medications, and encouraging proper hygiene.

Uploaded by

narsD
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Defining Nursing Background Desired Nursing Intervention Rationale Evaluation

Characteristics Diagnosis Knowledge Outcome

Subjective: “tumaasa Decreased Preeclampsia is a After 8 hours Monitor blood pressure of -Comparison of pressures After 8 hours of
daw yung BP ko” as cardiac output common problem of nursing the patient. Measure provides a more complete nursing
verbalized by the patient related to during pregnancy. interventions, in both arms or thighs three picture of vascular involvement interventions,
decreased The condition the patient will be times, 3-5 minutes apart or scope of the problem. the patient was
O: received patient on venous return sometimes referred to able to while patient is at rest, then able to
bed, awake, and as pregnancy induced participate in sitting, then standing for participate in
breastfeeding her baby hypertension which is activities that initial evaluation activities that
-without IVF defined by high blood reduce blood reduce blood
-without FC pressure and excess pressure or 2. Observe skin colour, -Presence of pallor, cool, moist pressure or
-with minimal lochial protein in the urine cardiac work moisture, temperature and skin and delayed capillary refill cardiac work
discharges after 20 weeks of load. capillary refill time. time may be due to peripheral load.
-guarded movements pregnancy. Often, vasoconstriction
noted preeclampsia causes
-variation in blood only modest increases
pressure note in blood pressure. Left 3. Note dependent
-May indicate heart failure,
-with vital signs of: untreated, however, or general edema
renal or vascular impairment.
T=36.5 C preeclampsia can
P=83 bpm lead to serious and
R=19 cpm fatal
BP=130/90 mmHg complications for both -Help reduce sympathetic
4. Provide calm, restful
stimulation, promotes relaxation
the mother and the surroundings, minimize
baby environmental activity or noise

-Reduces physical stress


5. Maintain activity restrictions
and tension that affect blood
pressure

-Can reduce stressful stimuli,


6. Instruct in relaxation
produce calming effect, thereby
Source: techniques, and guided
Medical Surgical Nursing reduce blood pressure.
By Joyce M. Black imagery
7th Edition
Medical Surgical Nursing
By Donna Ignatavitious
9th Edition
7.Implement dietary
sodium, fat, and -These restrictions can help
cholesterol manage fluid retention and with
restrictions as associated hypertensive
indicated. response, which decrease
cardiac workload.

8. Administer oral medications


as ordered

9. Encourage proper personal


hygiene -These promotes sense of well
being and aid in faster recovery

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