Preeclampsia
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 |
|---|---|---|---|---|
| Patient may report headache, visual disturbances, or epigastric pain; elevated blood pressure readings; decreased urine output; edema; laboratory signs of organ dysfunction (e.g., elevated liver enzymes, proteinuria) | Patient will maintain adequate tissue perfusion as evidenced by stable blood pressure within target range, absence of organ dysfunction, and adequate urine output (>30 mL/hr) | Monitor blood pressure frequently (every 15-30 minutes initially) | Early detection of hypertension severity helps prevent complications and guides treatment | Blood pressure readings remain within acceptable limits or improve with treatment |
| Assess urine output hourly and check for proteinuria | Reduced urine output and proteinuria indicate renal perfusion impairment | Urine output is adequate (>30 mL/hr) and proteinuria levels stabilize or decrease | ||
| Observe for signs of organ dysfunction such as headache, visual changes, or epigastric pain | These symptoms may indicate worsening vasospasm and ischemia | Patient reports no worsening symptoms or symptoms resolve | ||
| Elevate legs and maintain bed rest as ordered | Promotes venous return and reduces peripheral edema | Edema is reduced or remains stable without progression | ||
| Administer antihypertensive medications as prescribed | Medications help control blood pressure and improve perfusion | Blood pressure is controlled within target range |
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