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Group-5 - NCP - Ges Hyp

The nursing care plan is for a client experiencing high blood pressure and headache during pregnancy. The plan includes monitoring the client's vital signs every 2 hours, instructing bed rest, encouraging lateral positioning, and administering prescribed hypertension medicines to reduce the client's blood pressure from 180/100 to 140-160/80-90 within 3 hours. The goals are to decrease blood pressure and pain, avoid complications like pre-eclampsia, and ensure the baby's safety.

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Wallen Jey Velasco
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1K views2 pages

Group-5 - NCP - Ges Hyp

The nursing care plan is for a client experiencing high blood pressure and headache during pregnancy. The plan includes monitoring the client's vital signs every 2 hours, instructing bed rest, encouraging lateral positioning, and administering prescribed hypertension medicines to reduce the client's blood pressure from 180/100 to 140-160/80-90 within 3 hours. The goals are to decrease blood pressure and pain, avoid complications like pre-eclampsia, and ensure the baby's safety.

Uploaded by

Wallen Jey Velasco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Risk for Ineffective Within the 3 hours The nurse: After the 3 hours
Cerebral Tissue Perfusion implementation of nursing 1. Established rapport To gain trust and implementation of nursing
’’Sumasakit ang ulo ko at related to care, the client will be with the client. cooperation in rendering care, the client was able
ang bigat ng pakiramdam vasoconstriction able to: nursing care. It also to:
ko.’’ as stated by the secondary to makes the client calm and
client. hypertension as  Decrease blood feels comfortable.  Decreased blood
evidenced by 180/100 pressure from pressure from
blood pressure. 180/100 to the range 2. Closely monitored the To see the progress of 180/100 to 160/90
OBJECTIVE DATA: of 140-160/80-90 client’s vital signs the client and to avoid GOAL WAS MET
every 2 hours any complications.
 BP: 180/100 mmHg  Lessen the pain caused especially blood  Lessened the pain
 PR: 102bpm by headache pressure level. caused by headache.
 RR: 24 cpm GOAL WAS MET
 T: 37.0 C  Avoid from 3. Monitored the fetal To ensure that the baby
complications such as heart tone every 2 inside is safe.  Avoid from
pre-eclampsia due to hours. complications such as
gestational pre-eclampsia due to
hypertension 4. Instructed the patient To lower blood pressure gestational
to have bed rest and levels, improve cardiac hypertension
avoid environmental rate, and enhance renal- GOAL WAS MET
stressors. placental perfusion.

5. Encouraged the client Lateral recumbent


to rest in a lateral position decreases
recumbent position. pressure on the vena
cava, increasing venous
return and circulatory
NURSING CARE PLAN

volume. This enhances


placental and renal
perfusion, reduces
adrenal activity, and may
lower blood pressure.

6. Provide helping To alleviate the pain by


position of comfort promoting non-
and suggest use of pharmacological pain
relaxation technique management. It also
and deep breathing soothes and relaxes the
exercise. Provide client that also promotes
comfort measures comfort and calmness.
such as repositioning
or quiet environment.

7. Encouraged the Having an emotional


significant other to support by her significant
spend time with client. other helps the client to
endure and manage the
situation.
DEPENDENT:
8. Administered To lower blood pressure
hypertensive levels. Common
medicines as antihypertensives for
prescribed. gestational hypertension
include hydralazine and
nifedipine.

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