VISION

A premier university in historic Cavite

recognized for excellence in the development
of morally upright and globally competitive
individuals.

Republic of the Philippines

CAVITE STATE UNIVERSITY
Don Severino De las Alas Campus
Indang, Cavite
(046) 415-0010/415-0011 / (046) 415-0012
E-mail: cvsu@asia.com

College 0f Nursing

NURSING CARE PLAN

Diagnosis: Severe pre-eclampsia

Area: Labor Room (Batangas Medical Center)

MISSION
Cavite State University shall provide excellent,
equitable and relevant educational opportunities in
the arts, science and technology through quality
instruction and relevant research and development
activities.
It shall produce professional, skilled and
morally
upright
individuals
for
global
competitiveness.

NURSING CARE PLAN

Problem no.
ASSESSMENT
Subjective cues:
The client
verbalized,
medyo
namamaga yung
paa ko.
Objective cues:

Bipedal
edema
+2 pitting
edema
Weight gain
+3
proteinuria
UO = 400 ml

NURSING
DIAGNOSIS
Fluid volume
excess r/t fluid
retention
secondary to
pregnancy.

SCIENTIFIC
RATIONALE
Vasospasm
Interstitial
effects
Diffusion of
fluid
from
bloodstream
into interstitial
tissue

EDEMA

OBJECTIVE
After 4 hours of
nursing
intervention,
clients edema
will be reduce
from +2 to +1.

NURSING
INTERVENTION
Assess fluid status:
a. Daily weight
b. Intake and output
balance
c. Skin turgor and
presence of
edema
d. Blood pressure,
pulse rate, and
rhythm
e. Respiratory rate
and effort

Instruct client to
reduce sodium intake
and to increase water
intake

SCIENFIC
RATIONALE
Assessment
provides baseline
and ongoing
database for
monitoring changes
and evaluating
interventions.

To help reduce
extracellular
volume and
drinking lots of
water actually
reduces retention.

Elevate edematous
extremities.

To increase venous
return and, in turn,
decrease edema.

Change position
frequently.

To prevent fluid
accumulation in

EVALUATION
After 4 hours of
nursing
intervention, the
goal was
partially met.

dependent areas.

Provide cold
compress

Provide cool and dry

environment

Refer accordingly

To reduce swelling

To reduce swelling
and avoids
worsening because
heat aggravates
edema.

For further
management and
evaluation