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Nursing Diagnosis

Nursing Diagnosis: Altered


tissue perfusion (Cerebral,
peripheral and renal)
Possible Etiologies: (Related
to)
Arterial vasospasm/
constriction of blood
vessels
Decreased
prostaglandin levels
Sensitivity to
angiotensin II
Impaired glomerular
perfusion
Decreased
uteroplacental
perfusion
Increased cardiac
workload
Vascular damage
Red blood cell damage
Alteration in liver
function in severe
cases
Unusual sensitivity to
blood loss probably
because of leakage of
blood components into
the extravascular
space.

Objective

Nursing Interventions

Rationale

Goals/Objectives
Short term goal:
Client will
demonstrate adequate
perfusion, as
evidenced by stable
vital signs, palpable
pulses, and alert and
oriented, absence of
seizure episodes,
balanced intake and
output, decrease in
presence of edema and
good fetal status
evaluation within a
week.
Long term goal:
Client will
demonstrate readiness
during the postpartal
period in monitoring
ones health and
involving oneself to
dietary restrictions and
medical follow up
checkups and
intervention.

Nursing Actions
1. Monitor vital signs,
palpate peripheral pulses
and note capillary refill,
assess urinary output,
weigh client daily and
evaluate changes in
mentation.
2. Place client on left
recumbent position.
Monitor maternal wellbeing periodically.
3. Administer oxygen as
prescribed.
4. Ensure safety by putting
the side rails always up
and monitor client for
tonic- clonic convulsions.
5. Insert Foley catheter as
indicated by the physician
and monitor urine output.
6. Administer Magnesium
Sulfate as ordered by the
physician and monitor for
signs for toxicity.
7. Administer fluids as
prescribed.
8. Assist in the delivery of
the baby.

Rationale
1. Indicators of adequacy of
systemic perfusion, fluid/ blood,
needs, and developing
complications.
2. This is to avoid uterine pressure
on the vena cava and prevent
supine hypotension syndrome.
3. Womans BP should be taken at
least every 4 hours to detect for
increase which is a warning of
worsening; if fluctuating, it
should be done hourly.
4. To ensure supply of oxygen to
both the mother and the fetus.
5. Convulsions are evident in
Eclampsia so it should be
watched out and monitored.
6. Urine output should be in
congruence with fluid intake.
7. This drug is usually given to
control the blood pressure of
clients with pregnancy induced
hypertension.
8. Replacement of fluids maintains
circulating volume and tissue
perfusion. Delivery of the baby is
considered the only cure for
Eclampsia.

Evaluation

Outcome
Criteria:
Clients blood
pressure is
below
140/90mmHg,
urine output of
above
30ml/hour,
fetal heart rate
is between
120-160 beats
per min,
absence of
seizure
episodes,
decrease in
presence of
edema.
Client
verbalizes
plans upon
discharge,
participates
during lecturediscussion
sessions, and

Defining characteristics:
(Evidenced by)
Elevated blood
pressure
Edema, especially of
the hands and face
Sudden weight gain
Proteinuria (1+ up to
4+)
Hyperreflexia
Headache
Visual disturbances
Epigastric pain
Fetal status
Decreased urine
output
Rales, if pulmonary
edema is present
Elevated BUN,
creatinine, uric acid
Decreased hematocrit
and haemoglobin
Seizure

demonstrates
willingness to
perform
monitoring
measures.

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