ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION

Objective: Ineffective tissue After 10 minutes of * Maintain a patent * The priority care After 10 minutes of
perfusion related to nursing airway. for a woman with a nursing
* Pale looking vasoconstriction of intervention the seizure is to intervention the
* edematous blood vessels patient will maintain a patent client manifested
* Blood pressure: secondary to manifest an airway. This is an increase in
200?140mmHg eclamptic seizure. increase in necessary to oxygenation as
* Temperature: oxygenation as maintain maternal evidenced of
39.5 degree evidenced of and fetal adequate normal skin color,
Celsius. normal skin color, oxygenation and to pinkish mucosa,
* Halt respirations pinkish mucosa, prevent fetal good capillary refill
10cpm. good capillary refill bradycardia. and good breathing
* Pulse Rate: and good breathing *Don’t put a pattern. Therefore,
96bpm pattern. tongue blade * Doing so can the plan was met.
* Hyperactive between a cause broken teeth
patellar reflex. woman’s teeth. which could then
* Nauseated be aspirated.
* Urinary output of
20mL/hr. * Administer * To protect the
* delayed capillary oxygen by face fetus during
refill. mask. eclamptic stage.
*twitching of facial
muscle. * To measure
* Arms flexed. * Assess oxygen oxygen saturation
saturation via pulse of the patient’s
oximeter. blood.

* To assess the
* Apply an external condition of the
fetal heart monitor. fetus if one is not
already in place to
assess it.
 * To prevent
* Give her nothing aspiration.
to eat or drink by
mouth.
* To prevent
* During the tonic aspiration. If the
phase turn a woman was not
woman on her side placed on her side
to allow secretions during tonic phase
to drain from her she may aspirate
mouth. the saliva that
collected from her
mouth.

* This drug
* During clonic prevents seizure.
stage of a seizure Administering this
Magnesium sulfate drug was an
or diazepam may emergency
be administered. measure at this
time.