Republic of the PhilippinesCAVITE STATE UNIVERSITYDon Severino De las Alas CampusIndang, Cavite(046) 415-0010/415-0011 / (046) 415-0012E-mail: cvsu@asia.comVISIONA premier university in historic Cavite recognized for excellence in the development of morally upright and globally competitive individuals.MISSION Cavite State University shall provide excellent, equitable and relevant educational opportunities in the arts, science and technology through quality instruction and relevant research and development activities.It shall produce professional, skilled and morally upright individuals for global competitiveness.

College 0f Nursing

NURSING CARE PLAN

Diagnosis: Severe pre-eclampsia

Area: Labor Room (Batangas Medical Center)

NURSING CARE PLANProblem no.

ASSESSMENTNURSING DIAGNOSISSCIENTIFIC RATIONALEOBJECTIVENURSING INTERVENTIONSCIENFIC RATIONALEEVALUATION

Subjective cues: The client verbalized, medyo namamaga yung paa ko.

Objective cues: Bipedal edema +2 pitting edema Weight gain +3 proteinuria UO = 400 ml

Fluid volume excess r/t fluid retention secondary to pregnancy.Vasospasm

Interstitial effects

Diffusion of fluidfrom bloodstreaminto interstitial tissue

EDEMAAfter 4 hours of nursing intervention, clients edema will be reduce from +2 to +1. Assess fluid status:a. Daily weightb. Intake and output balancec. Skin turgor and presence of edemad. Blood pressure, pulse rate, and rhythme. Respiratory rate and effort

Instruct client to reduce sodium intake and to increase water intake

Elevate edematous extremities.

Change position frequently.

Provide cold compress

Provide cool and dry environment

Refer accordingly Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions.

To help reduce extracellular volume and drinking lots of water actually reduces retention.

To increase venous return and, in turn, decrease edema.

To prevent fluid accumulation in dependent areas.

To reduce swelling

To reduce swelling and avoids worsening because heat aggravates edema.

For further management and evaluationAfter 4 hours of nursing intervention, the goal was partially met.