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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 (CvSU) DON SEVERINO DE LAS ALAS CAMPUS Indang, Cavite

College of Nursing

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.

OB CASE: MILD PRE-ECLAMPSIA

Presented by: ARDON, CAROLYN C. BSN 3-2

Presented to: LEVEL IIi INSTRUCTORS

In Partial Fulfillment of the Requirements in NURS 55 for the Degree Bachelor of Science in Nursing

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 (CvSU) DON SEVERINO DE LAS ALAS CAMPUS Indang, Cavite

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.

College of Nursing

TABLE OF CONTENTS

I. II. III. IV. V. VI. VII. VIII. IX.

Demographic Data ...

Reason for Seeking Health Care .. 1 History of Present Illness . 2 Past Medical History Heredo familial History Physical Examination Diagnostic Test Review Of System Case Management Medical Management Nursing Management 2 3

I.

Demographic Data A. Clients Name: Evangeline Sanchez Pastoril B. Address: B41 L5 Tahanan Yaman General Trias Cavite C. Age: 28 y/o D. Birth date: October 09 1983 E. Birth Place: Leyte F. Gender: Female G. Religion: Catholic H. Occupation: Saleslady Date Of Interview: June 22 2012 Primary Informant: Mrs. E.S.P Other Source: Chart Date Of Admission: June 22 2012 Time Of admission : 01:50 am

II.

Reason For Seeking Health Care For monthly checkup

III.

History Of Present illness Admitting Diagnosis: G1P0 Pregnancy Uterine 32 5/7 weeks AOG not in labor: Mild Pre-Eclampsia Mrs. ESP verbalized that during her 2nd check up at Wellness Care Mangahan, her OB referred her to Trece GEAMH because of her sudden increased of blood pressure (160/110 mMhg). June 22 2012 she went to Trece GEAMH with her sister and consult there but the doctor insisted to admit her at that same day. Prior to admission, she stated that she feels dizziness and light headedness so she drink a glass of water and take some rest.

IV.

Past Medical History Mrs. ESP has no known childhood/adult disease nor major injuries or accident met. She has also no known allergies in foods or medicine and doesnt undergo in any operation. It was her first time to be hospitalized because of her pregnancy at Trece General Emillio Aguinaldo Memorial Hospital June 12 2012 at 1:50 am due to Mild Pre-Eclampsia. She stated that she was fully immunized and receive three dosage of Tetanus Toxoid.

V.

OB GYNECOLOGICAL History Mrs. ESP verbalized that she had her first menstruation when she was12 years old. Her last menstruation is on November 05 2011 and stopped at November 08 2011. She has a 28 cycle which happens for three days and consume 2-3 sanitary napkins per day. When menstruation occurs, she often experience dysmenorrhea and to relief the pain, she take Mydol and take some snaps. Her EDC is July 12 2012 and AOG is 32weeks 5/7 days. G1P0T0A0L0M0

VI.

HEREDO-FAMILIAL History Genogram Paternal Side Maternal Side

J.D HPN

C.D AW

CP AW

KP AW

JD AW

ES

MPE

LEGEND: = DEAD = MALE = FEMALE = Pregnant Client // = SEPARATED MPE = Mild Pre Eclampsia A/W = Alive and Well HPN =Hypertension The diagram shows that the family has known hereditary disease in both maternal and paternal side including the patient which is hypertension but still alive. The rest of the family is alive and well. The relationship of the patient and her husband is separated 5 months ago.

VII.

Physical Examination COMPREHENSIVE PHYSICAL EXAMINATION

DATE ASSESSED: June 22 2012 A. Vital Signs / Fetal Heart Tone ASSESSED TEMPERATURE BLOOD PRESSURE PULSE RATE HEART RATE 4 PM 37 C 160 / 100 mMhG 98 bpm 20 cpm 5 PM 36.6 C 170 / 100 mMhg 100 bpm 18 cpm TIME 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM FHT 142 b/min 138 b/min 140 b/min 143 b/min 148 b/min 141 b/min

B. General Survey ASSESSED Posture and Gait ACTUAL FINDING Uncoordinated movement along with Activities of daily Living Slightly bend during walking and sitting Over All hygiene and grooming Properly Dressed Well groomed Clean and neat appearance Body and breathe odor Obvious of signs of distress/ illness Absence of foul body odor and bad breathe (+) Facial grimace due to pain on injected site of medication Presence of lesion and edema on both lower extremities Attitude Look irritated due to hot environment Cooperative during interview Quality and quantity of organization Her voice is clear and understandable

of thought/speech

Has sense of humor and logical sequence

C. Focused Assessment BODY PART EXAMINED INTEGUMENT SKIN I: color, uniformity, edema, lesions P: moisture, temperature, turgor Has a slightly dark skin complexion (+) Edema is graded as 3 as noticeably deep pitting and swollen lower extremities (+) Crust lesion in lower extremities Slightly moist skin Warmed to touch and uniform temperature HAIR I: evenness of growth of hair thickness, texture, oiliness, infection or infestation, body hair P; smoothness Nail I: plate shape, texture, bed color, surrounding tissues P:Blanch Test Round nails Smooth in texture Pinkish nail bed No hangnails Blanch Test done: generally less than 4 seconds prompt return usual color HEAD SKULL AND FACE I: size, shape, symmetry, facial features, eyes for edema and Rounded Normocephalic and symmetry prominences Has evenly distributed thick hair No infestation or infection Variable amount of hair No lice ACTUAL FINDING

hollowness P: nodules, masses, depression

Smooth texture Absence of nodules and masses Symmetrical facial movement Absence of edema Symmetrical facial features

EYES AND VISION I; EYEBROWS for distribution and alignment, quality and movement Hair evenly distributed Symmetrically aligned Equal movement

I: EYELASHES for evenness of distribution and direction of curl

Equally distributed Slightly curled outward

I: EYELIDS for surface characteristics, position in relation to cornea, ability to blink and frequency

Bilateral blinking Skin Intact No discharge and discoloration

I: BULBAR AND PALPEBRAL CONJUCTIVA for color, texture and lesion

No visible lesion Sclera appears white Transparent Palpebral conjunctiva is pink

I/P: LACRIMAL GLAND SAC for edema, tenderness and tearing

Not tender Absence of edema and tearing

I: CORNEA for clarity , texture and sensitivity

Transparent Smooth and shiny appearance

I: PUPILS for color, shape, symmetry of size, direct and consensual reaction to light and accommodation EARS AND HEARING I: AURICLES for color, symmetry and position, P: for texture elasticity and areas of tenderness

Black in color Equal in size Iris is flat and Rounded

Same color as facial skin Symmetrical Auricle aligned with outer cantus of eye Mobile, firm and not tender Pinna recoils after it is folded

NOSE AND SINUSES I: NOSE for deviation in shape, size, color, flaring, discharge P: for tenderness , masses, displacement Symmetric and straight No discharge and flaring Uniform color Absence of lesion Not tender Nasal septum is intact and in midline No masses or nodules Air moves freely as the client breathe MOUTH/OROPHARYNX I: LIPS for symmetry contour, color, texture, moisture, lesion Has uniform pink color Soft moist and smooth texture Ability to purse lips

I: TEETH for alignment, loss, dental fillings and caries

32 adult teeth Absence of fillings and carries Smooth and slightly yellowish teeth

I: GUMS for bleeding, color, retraction, lesions, swelling

No retraction of gums Smooth and shiny No swelling and lesion Pink in color

I: TONGUE for position, color, texture, movement, as well as the base of the tongue, mouth floor and frenulum

Central position Pink in color Moist, thin whitish coating Absence of lesion Moves freely and not tender

I: UVULA for position and mobility

Located at the midline Pink in color

I: TONSILS for color, discharge and size NECK I: NECK MUSCLE for abnormal swelling or masses, head movement and muscle strength P: LYMPH NODES for enlargement P: TRACHEA for lateral division THORAX AND LUNGS I: for shape and symmetry from posterior-lateral views, spinal alignment for deformities Pa: temperature, bulges,

No discharge Pink in color

Muscles are equal in size Head is centered Has smooth movements with no discomforts Has equal strength Lymph nodes are palpable Trachea is center

With a Heart Beat of 98 bpm With a Respiratory rate of 20 cpm With equal chest symmetry Warmed to touched

tenderness, Aus: abnormal breath sounds, BREAST AND AXILLAE I: BREAST for size, symmetry, contour or shape, discoloration, retraction, swelling or edema I: AREOLA for size, shape, position, color, discharge, lesion I:NIPPLES for size, shape, position, color, discharge, lesion ABDOMEN I: skin integrity, contour and hernia, girth

No pain felt when palpated No adventitious sounds

The client is refused to assessed

(+) striae With fundic height of 34 cm FHT heard upon auscultation on right lower quadrant (+) linea nigra

MUSCUSKELETAL I: MUSCLES for size, contractures, fasciculation, tremors, P: tonicity, flaccidity, smoothness of movement and strength I: BONES for structure, deformity P: for edemaand tendreness (+) edema on both lower extremities Color is even Warmed to touched Can complete range of motion Can counter act gravity and resistance

VIII. Diagnostic Test


Name: Evangeline pastoral Room No./Ward:OB Hospital No.: 308267 Date: 6-22-12 ( )Main ( ) Annex

Age:28 y/o B-Date: 10 91893

( ) Male ( ) Female Case No.: 223292

CLINICAL CHEMISTRY TEAT RBS FBS BUN CREATININE URIC ACID CHOLESTEROL TRIGLYCERIDES HDL LDL VLDL SGPT( AIT) SGOT (AST) ALK.PHOS AMYLASE T.PROTEIN ALBUMIN GLOBULIN A/G RATIO T. BILIBURIN SODIUM POTTASIUM CHLORIDE CALCIUM HBA1C 141.5 3.37 110.3 12.7 30.6 2.95 56.5 RESULT REFERENCE RANGES 4.4-6.6 mmol/L 3.8 6.06 mmol/L 2.49-6.42 mmol/L M- 62-150 mmol/L F- 44-106 mmol/L 89.25-416.5 mmol/L 3.0-6.2 mmol/L .40-1.86 mmol/L 0.78-1.95 mmol/L 1.71-4.62 mmol/L 0-47 IU/L 0.26-1.04 mmol/L 10-4-IU/L 25-90 IU/L 40-180 I g/L 35-52 g/L 23-35 g/L 1.1-2.5 g/L 1.7-20.5 mmol/L Up to 5.1 mmol/L 135-148 mmol/L 3.5-5.6 mmol/L 96-106 mmol/L 1.13-1.31 Eq/L 4.5-6.3%

IX.

Review Of System

X.

CaseManagement A. Medical Management B. Case Management

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