Punyetang ncp - NCP PDF

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ASSESSM ENT

DIAGNOSI S

Subjectiv e: “Sumasak it po ang ulo ko ay nahihilo ako” as verbalize d by the pt

Gestation al hypertens ion as evidence d by 150/100 mmHg

Objective: Vs PR- 120 bpm RR23cpm BP150/100 mmHg Fatigabilit y

BACKGROU ND INFORMAT ION Gestational hypertensi on is diagnosed when blood pressure readings are higher than 140/90 mmHg in a woman who had normal blood pressure prior to 20 weeks and has no proteinuria (excess protein in the urine)

PLANNIN G

INTERVENTION

RATIONALE

EVALUATI ON

SHORT TERM:

Independent 1. Establish rapport 2. ▪Monitor blood pressure of the patient every 30 mins. 3. Promote bed rest in a recumbe nt position to aid in the secretion of sodium 4. Provide calm, restful surround ings, minimize environ mental activity or noise. 5. encourag e restrictio n of sodium and fat

Independent 1. ▪ to gain pt’s and cooperati on 2. ▪to monitor for fluctuatio n in blood pressure 3. Bedrest is also associate d with an increase in sodium excretion by the kidneys and, as water tends to follow sodium, this leads to sodium diuresis that contribut es to the reduction in plasma volume 4. ▪help reduce sympathe tic stimulati on, promotes relaxation

SHORT TERM:

After 4 hours of nursing interventi on, the patient will be able to maintain less than blood pressure of 130/90 mmHg

DEPENDENT:

After 4 hours of nursing interventi on, the client was able to maintain less than blood pressure 0f 130/90 mmHg. The goal was met

5. Reducin g sodium and fat intake both lowers BP and helps prevent cardiov ascular events DEPENDENT:...