URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

NURSING CARE PLAN (NCP)

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Problem, Etiology, Short Term Goal: Independent: Short Term Goal
Signs S.M.A.R.T. +  Assessment Evaluation
(P.E.S.) format Evidence
The patient Monitor blood pressure of the Comparison of
verbalizes that Pregnancy Induced patient. Measure in both pressures provides 1.) After 8 hours of
she feels mild Hypertension related to 1.) After 8 hours of arms or thighs three times, a more complete nursing
headache and, abnormal blood profile nursing 3-5minutes apart while picture of vascular interventions, the
she reported and/or clotting factors interventions, the patient is at rest, then involvement or patient was able to
no other evidenced by elevated patient will sitting, then standing for scope of the participate in
symptoms. blood pressure. participate in initial evaluation. problem. activities that
activities that reduce blood
reduce blood  Therapeutic pressure or cardiac
pressure or cardiac workload.
workload. Establish measures to lessen
likelihood of seizures; i.e.,
keep room quiet and dimly Lessens
lit, limit visitors, plan and environmental
coordinate care, and promote factors that may
rest. stimulate irritable
cerebrum and
cause a convulsive
 Educative state.

Emphasize importance of
patient promptly reporting
signs/symptoms of CNS
involvement.
Delayed treatment
or progressive
Dependent: onset of symptoms
 Assessment may result in tonic-
clonic convulsions
Observe skin color, moisture or eclampsia.
temperature and capillary
refill time.

 Therapeutic
Presence of pallor,
Maintain activity restrictions. cool, moist skin
and delayed
capillary refill time
 Educative may be due to
peripheral
Instruct in relaxation vasoconstriction.
techniques, and guided
imagery.

Reduces physical
stress and tension
Interdependent/Collabora that affect blood
tive pressure and
 Assessment course of
hypertension.
Monitor for signs of
Disseminated Intravascular
Coagulation (DIC) Can reduce
easy/spontaneous bruising, stressful stimuli,
prolonged bleeding, produce calming
epistaxis, GI bleeding. effect, thereby
reduce blood
 Therapeutic pressure.

Hospitalize if Central Nervous

 Educative Abruption
placentae with
Explain to the patient that release of
it's important to go to all of thromboplastin
their prenatal visits. predisposes patient
to DIC.

Immediate
introduction of
therapy helps to
ensure safety and
limit complications.
 Seeing your doctor
regularly helps
ensure you have
the healthiest
pregnancy possible.
Objective: INFERENCE Long Term Goal: Long term Goal
Scientific Explanation S.M.A.R.T.+ Evaluation
(Diagram Form) Evidence
Blood pressure
was found to
be elevated at
145/100 Abnormal blood After 1 month, the After 1 month, the
mmHg during profile and/or clotting patient will be free patient is free of
a routine factors. of signs of cerebral signs of cerebral
antenatal clinic ischemia (visual ischemia (visual
visit. On disturbances, disturbances,
physical headache, changes headache, changes
examination, in mentation). in mentation).
she was
tachycardic
with heart rate
100 beats per Pregnancy Induced
minute. Body Hypertension
mass index
was 16.9
kg/m2 and she Evidenced by
had no elevated blood
cushingoid pressure.
features. Heart
sounds were
normal, and
there were no
signs
suggestive of
congestive
heart failure.
Radial-femoral
pulses were
congruent, and
there were no
audible renal
bruits.