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Medical Diagnosis: Pre-Eclampsia

Problem: Decreased Cardiac Output RT Decreased Venous Return

Assessment Nursing Scientific Planning Interventions Rationale Evaluation


Diagnosis Explanation
Subjective: Decreased Inadequate blood Short Term: 1. Establish 1. To gain pt’s Short Term:
Patient may Cardiac output r/t is pumped by the rapport trust and
verbalize After 3 hrs of The pt shall have
decreased heart to meet the 2. Monitor and cooperation
nursing displayed
venous return metabolic assess VS 2. To obtain
• Palpitations interventions, hemodynamic
secondary to demands of the 3. Assess the pt’s baseline
• Fatigue the pt will display general 3. To stability (blood
severe body. It resulted
• Shortness of hemodynamic physical determine pressure within
preeclampsia from a systemic
breath/dyspn stability AEB condition presence of closer range)
AEB altered BP vaso
ea blood pressure abnormality
and edema constriction in the
• anxiety body caused by within her normal 4. Determine
baseline vital Long Term:
preeclampsia. range
signs/hemodyn
Vasoconstriction is 4. Provides The pt shall have
amic
Objective: the decrease in the opportunitie demonstrated
Long Term: parameters
diameter of the s to track activities that
including
Patient blood vessels changes
After 3 days of peripheral reduce the
manifested: which occur in
nursing pulses. workload of the
diseases like
interventions, heart (stress
• Weight gain pregnancy-induced
hypertension. the pt will management,
• Edema
Decreased blood demonstrate 5. Review signs of therapeutic
• Variations in
supply leads to a activities that impending medication
BP reading
decrease in venous reduce the failure /shock. regimen
• Restlessness
return, thus there workload of the program,
is a relatively 5. To prevent
heart (stress balanced
smaller amount of hypovolemi
management, 6. Position with activity/ rest
blood expelled by c shock
Patient’s fetus therapeutic HOB flat or plan)
may manifest: the ventricles of
medication keep trunk
the heart.
regimen horizontal while
• Jugular vein raising legs 20
program,
distention to 30 degrees

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• Cold clammy balanced (contraindicate 6. To increase
skin activity/ rest d in congestive venous
• Arrhythmaia plan) state in which return
semi-fowler’s
• crackles
position is
• Prolonged
preferred)
capillary refill

7. Promote
adequate rest,
by decreasing
stimuli,
providing quiet
environment

8. Maintain
patency of 7. To
invasive maximize
intravascular sleep
monitoring and periods
infusion lines.
Tape
connections.

9. Avoid activities
such as
isometric 8. To prevent
exercises, air embolus
rectal and/or
stimulation, exsanguinat
vomiting, and

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spasmodic ion.
coughing.
Administer
stool softener
as indicated.

10. Encourage pt
to breathe 9. May
deeply in/out stimulate a
during valsalva
activities that response
increase risk
for valsalva
effect.

11. Provide
psychological
support.
Maintain calm
attitude
butadmit
concerns if
questioned by
the client.

12. Encourage 10. This


relaxation prevents
techniques. exertion of
too much
workload to
the heart.
13. Elevate

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edematous
extremities and
avoid
restrictive
clothing.
11. Honesty
can be
14. Provide for diet reassuring
restrictions. when so
much
activity and
“worry” are
apparent to
the patient.

15. Monitor intake


and output.

12. To reduce
anxiety

16. Discuss
significant
signs and
symptoms that
need to be
reported to the 13. To promote
healthcare comfort
provider ( e.g.
muscle cramps,
d/a, dizziness,
skin rashes).

14. To enhance
17. Encourage pt’s

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changing therapeutic
positions regimen
slowly,
dangling legs
before
standing.
15. To
determine
18. Give fluid
information balance
about positive
signs of
improvement
such as
decreased 16. May be sign
edema, of drug
improved vital toxicity
signs / and/or
circulation). mineral loss
19. Administer , especially
supplemental potassium.
oxygen as
indicated.

20. Administer due


meds.

17. To reduce
risk of
orthostatic
hypotension

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18. To provide
encourage
ment.

19. To increase
oxygen
available to
tissues

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