Eclampsia
Sample —for ideas only. Your own case → Create.
| Assessment data (subjective and objective findings relevant to THIS diagnosis) | Goals / expected outcomes | Nursing intervention | Rationale | Evaluation |
|---|---|---|---|---|
| Observe for irregular or shallow breathing, use of accessory muscles, cyanosis, and monitor SpO2 and respiratory rate closely; auscultate lung sounds for crackles indicating pulmonary edema. | Patient will maintain effective gas exchange as evidenced by respiratory rate within normal limits and SpO2 above 95% on room air or prescribed oxygen. | Monitor respiratory rate, depth, and effort every 15 minutes during acute phase. | Early detection of respiratory compromise allows prompt intervention. | Respiratory parameters remain stable or improve. |
| Administer supplemental oxygen as ordered to maintain adequate oxygenation. | Increases oxygen availability to tissues and prevents hypoxia. | Oxygen saturation maintained at target level. | ||
| Position patient to optimize lung expansion, such as semi-Fowler’s position. | Facilitates lung expansion and improves ventilation. | Patient tolerates position with improved respiratory status. | ||
| Encourage deep breathing and coughing exercises when patient is alert and able. | Promotes airway clearance and prevents atelectasis. | Patient demonstrates effective coughing and improved breath sounds. | ||
| Prepare for possible airway management including suctioning or intubation if respiratory status deteriorates. | Ensures airway patency and adequate ventilation in case of respiratory failure. | Airway maintained patent; interventions performed as needed. |
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