Preeclampsia

CASE PRESENTATION ON PREECLAMPSIA
CONTENTS
1
2 3 4 5
Objectives Introduction Statistics Patients Profile Nursing Health History

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CONTENTS
6 7 8 9 10
Gordons Physical Assessment Laboratory Result Course in the Ward Anatomy and Physiology
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CONTENTS
11 12 13 14
Pathophysiology Nursing Care Plan Drug Study Discharge Plan
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GENERAL OBJECTIVE
This case presentation was conducted for us to be able to gain improved depth of insight and perspective on patients with regard to their affliction for the purpose of gaining functional and applicable and proper nursing
SPECIFIC OBJECTIVES
At the end of the case presentation, the students will be able to: Define preeclampsia and its classifications. Identify the signs and symptoms and the possible complications associated with this disease.
Know what organ/s of the body are involved or is affected by the disease process and recognize what function of the body were altered by this condition Understand the pathophysiology of pre eclampsia based on the signs and symptoms manifested by the patient.
Enumerate the necessary medications needed and be familiar to its mode of action. Apply different nursing interventions and make use of the process as a framework for the overall care for the patient that would enable us to render the appropriate and effective interventions.
INTRODUCTION
Pre-eclampsia
Originally it was called TOXEMIA. Is a condition which vasospasm occurs during pregnancy in both small and large arteries. It appears likely that there are substances from the placenta that can cause endothelial dysfunction in the maternal blood vessels of susceptible women.
Pre-eclampsia may develop from 20 weeks gestation (it is considered early onset before 32 weeks, which is associated with increased morbidity). Pre-eclampsia may also occur up to six weeks post-partum.
It is the most common of the dangerous pregnancy complications. it may affect both the mother and the unborn child.
Cardinal signs: hypertension proteinuria edema
CLASSIFICATIONS OF PRE ECLAMPSIA
1.Gestational Hypertension Manifestations: BP of 140/90 mmHg No proteinuria No edema
2. Mild Preeclampsia Manifestations:
BP of 140/90 mmHg 1+ to 2+ proteinuria on a random sample or reagent strip test
weight gain of more than 2 lbs/week in the 2nd trimester and 1 lb/ week in the 3rd trimester Slight edema in upper extremities and face
Nursing Interventions: Monitor blood pressure. Promote bed rest (left lateral recumbent position)
Promote good nutrition moderate to high protein and low to moderate sodium) Provide emotional support. Administer magnesium sulfate.
3. Severe Preeclampsia Manifestations: BP of 160/110 mmHg higher on 2 occasions at least 6 hours apart 3+ or 4+ proteinuria on random urine sample or more than 5g in a 24- hour sample. Oliguria (approximately 400- 600 ml/24 hrs)
Cerebral or visual disturbances Severe headaches Epigastric pain Nausea and vomiting Pulmonary edema Hepatic dysfunction Thrombocytopenia Intrauterine growth restriction
Nursing interventions: Complete bed rest Support a nutritious diet. (high protein and low to moderate sodium) Monitor maternal wellbeing.
Administration of sulfate, fluid and electrolyte replacements and sedative hypertensive such as diazepam or Phenobarbital or an anticonvulsant such as phenytoin.
If severe, preeclampsia progresses to fulminant pre-eclampsia, with headaches, visual disturbances, and epigastric pain, and further to HELLP syndrome and eclampsia. Placental abruption is associated with hypertensive pregnancies. These are life-threatening conditions for both the developing baby and the mother.
Ophthalmoscopic examination may reveal vascular spasm, papilledema, retinal edema or detachment, and arteriovenous nicking or hemorrhage.
D. Eclampsia It causes seizures. These seizures

usually happen in women who have severe preeclampsia. However, they can occur with mild preeclampsia. The fetal prognosis is poor. Manifestations: loss of consciousness. jerking movements of the arms and legs. loss of control of bladder or bowels.
CLINICAL MANIFESTATIONS
Severe headaches Vomiting blood Excessive swelling of the feet and hands (edema) Oliguria Hematuria Rapid heartbeat Dizziness
Excessive nausea and vomiting Ringing or buzzing sound in ears Drowsiness Fever Double vision Blurred vision Sudden blindness
Risk factors:
Family history of preeclampsia Nulliparity African- American descent Chronic hypertension (high blood pressure before becoming pregnant). Hydatidiform
Urinary tract infection Renal disease Diabetes
Multiple gestation Primiparas younger than 20 of age or age more than 40. Preeclampsia in a previous pregnancy
Obesity: Body weight is strongly correlated with progressively increased risk, ranging from 4.3% for women with a BMI <20 kg/m to 13.3% in those with a BMI >35 kg/m Low socioeconomic backgrounds
Complications of Preeclampsia
Intrauterine growth restriction (IUGR) Oligohydramnios Risk of placental abruption Risk of preterm delivery (often iatrogenic) Coagulopathy/ DIC (disseminated intravascular coagulation)
Stillbirth Seizures and coma Pulmonary and cerebral edema Renal failure Maternal hepatic damage Hemolysis HELLP syndrome Thrombocytopenia
Medical
Management
Monitor BP, proteinuria and edema. Assess for placental separation, headache and visual disturbance, epigastric pain, and altered level of consciousness. Ausculted lungs for crackles or diminished lungs sounds that might indicate pulmonary edema Signs of impending seizure. Institute seizure precautions. Seizures may occur up to 72 hours after delivery.
Protecting the patient is key- side rails up and padded, suction accessible, O2 available. Monitor vital signs and FHR. Minimize external stimuli; promote rest and relaxation Measure and record urine output, protein level, and specific gravity. Assess for edema of face, arms, hands, legs, ankles, and feet. Also assess for pulmonary edema.
Weigh the client daily. Assess deep tendon reflexes every 4 hours. Administer Magnesium sulfate. Address emotional and psychosocial needs
Diagnostic Tests
A. Blood pressure test The blood pressure is monitored at least every 4 hours. Nursing Responsibility Explain the procedure. Discuss the purpose of test. Assist woman to the same position for each reading, preferably she should be in sitting position, if the pressure is greater than 140/90 mmHg, reposition the woman to her left side, wait 5 minutes and repeat the reading. If the pressure is continues to be elevated, Determine if the woman is experiencing headache, blurred vision or epigastric pain. Reposition the woman comfortably on her left side supported by pillows. Record the blood pressure per agency protocol. If the pressure was taken twice, record each reading, noting the time of each and maternal position.
B. Urine Protein test A.k.a 24-Hour Urine Protein; Urine Total Protein; Urine Protein to Creatinine Ratio; UPCR. It is used to detect protein in the urine, to help evaluate and monitor kidney function, and to help detect and diagnose early kidney damage and disease. Dipstick a strip of cellulose chemically impregnated to render its sensitivity to protein, glucose, or other substances in the urine.
The concentration of urinary
protein in random samples is highly variable, and urinary dipstick readings have correlated poorly in recent studies with the amount of proteinuria found in 24-hour readings in women with gestational hypertension.
Nursing Responsibility
Explain to the patient that the urine protein test detects
the proteins in the urine. Tell the patient that the test usually requires urine protection over a 24-hr period; random collection can be done. Instruct the patient not to eat foods that can color the urine, before the test. Inform the patient not to exercise strenuously before the test. Ask the patient if she is menstruating or close to starting your menstrual period. Instruct the patient to stop taking certain medicines that color the urine. Ask the patient if she is taking diuretics which may affect the test results. Collect the patients urine over a 24-hour period, discarding the first specimen and retain the last. Instruct the patient that he may resume her usual medications, as ordered.
C. Blood urea nitrogen (BUN) and serum creatinine

Measures the amount of nitrogen in your blood that comes from the waste product urea. A BUN test is done to see how well your kidneys are working. If your kidneys are not able to remove urea from the blood normally, your BUN level rises.
1. Explain the procedure. 2. Discuss the purpose. 3. Instruct the patient not to eat a lot of meat or other protein in 24 hours before having blood urea nitrogen (BUN) test. 4. Ask the patient if she is taking any medications (antibiotics) that can affect BUN results.
D. Liver function tests: Liver enzymes (AST, ALT, LDH, Bilirubin)

1.Liver function tests (LFTs or LFs), which include liver enzymes, are groups of clinical biochemistry laboratory blood assays designed to give information about the state of a patient's liver.
1. Alanine transaminase (ALT) - ALT is raised
in acute liver damage. When hepatocytes (liver cells) are damaged, this enzyme is leaked into the blood. It is also known as serum glutamic pyruvate transaminase (SGPT) or alanine aminotransferase (ALAT). 2. Aspartate transaminase (AST) - AST is raised in conditions of acute liver damage, however it is not liver-specific. AST to ALT ratio is at times used to differentiate the underlying cause of liver damage. It is also known as serum glutamic oxaloacetic transaminase (SGOT) or aspartate aminotransferase (ASAT)
1. Bilirubin is a breakdown product of
heme. The liver is responsible for clearing the blood of bilirubin. It does this by the following mechanism: bilirubin is taken up into hepatocytes, conjugated (modified to make it water-soluble), and secreted into the bile, which is excreted into the intestine. 2. Lactate dehydrogenase (LDH Lactate dehydrogenase is an enzyme found in many body tissues, including the liver. Elevated levels of LDH may indicate liver damage.
Explain to the patient that this test is
used to assess liver function. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture. Inform the patient that she need not restrict food and fluids. Notify the laboratory and physician of medications the patient is taking that may effect test results; they may need to be restricted.
E. Hematology (blood cell counts) It is a common blood test that evaluates the three major types of cells in the blood: red blood cells, white blood cells, and platelets including hematocrit and hemoglobin.. It is a series of tests used to evaluate the composition and concentration of the cellular components of blood. Nursing Responsibility
Explain and instruct the patient that this test is to detect abnormal blood conditions. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture. Inform the patient that she need not restrict food and fluids.
F. Coagulation studies Hemolysis, elevated liver enzyme levels, and a low platelet count (HELLP syndrome) characterize severe eclampsia. A unique form of coagulopathy is also associated with this disorder.
Thrombin time This test is used to screen for abnormalities in the conversion of fibrinogen to fibrin. Prothrombin time (PT) The PT measures the function of the extrinsic and common pathways of the coagulation cascade. Activated partial thromboplastin time (aPTT) The aPTT measures the function of the intrinsic and common pathways of the coagulation cascade.When the aPTT test is being used to monitor the effect of heparin, the test is done before the first dose of heparin and then as necessary to monitor therapeutic dosage.
Nursing Responsibility 1. Explain and instruct patient about the
procedure. 2. Informed the patient about the importance of the test/ studies. 3. Before administering the test, ask the patient to list the medications she is taking. 4. Ask the patient whether or not he or she has recently experienced active bleeding, acute infection or illness, or undergone a blood transfusion., as these factors could adversely affect their coagulation test results.
Medical Management Monitor BP, proteinuria and edema. Assess for placental separation, headache and visual disturbance, epigastric pain, and altered level of consciousness. Ausculted lungs for crackles or diminished lungs sounds that might indicate pulmonary edema Signs of impending seizure. Institute seizure precautions. Seizures may occur up to 72 hours after delivery. Protecting the patient is key- side rails up and padded, suction accessible, O2 available. Monitor vital signs and FHR.
Minimize external stimuli; promote rest and
relaxation Measure and record urine output, protein level, and specific gravity. Assess for edema of face, arms, hands, legs, ankles, and feet. Also assess for pulmonary edema. Weigh the client daily. Assess deep tendon reflexes every 4 hours. Administer Magnesium sulfate to promote diuresis, reduce blood pressure, and prevent seizures. Address emotional and psychosocial needs.
Treatment: 1. Anti-Hypertensive Therapy Antihypertensives may reduce maternal and fetal mortality among pregnancy patients with hypertension as compared to placebo according to a randomized controlled trial . 2. Magnesium sulfate In some cases, women with preeclampsia or eclampsia can be stabilized temporarily with magnesium sulfate intravenously to forestall seizures while steroid injections are administered to promote fetal lung maturation.
3. Dietary and Nutritional Factors Adequate nutrition is important to promote fetal growth and maternal wellbeing. 4. Exercise Improves muscle tone, circulation and sense of wellbeing.
5. Avoid ACE inhibitors - possible fetal effects 6. Avoid Angiotensin II (AII) receptor antagonists 7. Bed rest - in mild cases 8. Induced labor - once the condition is stable. 8. Caesarian section - once the condition is stable. 9. Normal delivery - some babies are born vaginally; in other cases caesarian is chosen
STATISTICS
International statistics
Country Region
Incidence rate Preeclampsia in North America
Population
Estimated Used
INTERNATIONAL
457,969 179,487 Preeclampsia in Europe 293,655,4051 32,507,8742
USA Canada
Britain (United Kingdom) France Germany
32,422 32,504 44,339 Preeclampsia in Asia
60,270,708 for UK2 60,424,2132 82,424,6092
China India Indonesia
698,703 572,945 128,273 Preeclampsia in Eastern Europe
1,298,847,6242 1,065,070,6072 238,452,9522
Russia Ukraine Uzbekistan
77,449 25,677 14,207
143,974,0592 47,732,0792 26,410,4162
Country Region
Incidence rate
Population Estimated Used
Preeclampsia in the Middle East Egypt Iran Turkey 40,946 36,312 37,060 Preeclampsia in South America Brazil Colombia Mexico 399,035 122,760 256,462 Preeclampsia in Africa Congo kinshasa Ethiopia South Africa 31,371 38,374 23,910 58,317,0302 71,336,5712 44,448,4702 184,101,1092 42,310,7752 104,959,5942 76,117,4212 67,503,2052 68,893,9182
Interpretation: the above data shows that america (north and south) that includes 75% of black race has the highest incidence rate of having preeclampsia. According to the april 2001 issue of obsterics and gynecolgy, americanafricans/african-americans are 3.1 times more likely to develop preeclampsia than white women (quality of prenatal care may also play a role). It means that black women are prone to develop such disease than white women, therefore race is one of the risk factor of preeclampsia as proven on the above data.
Local
Statistics
CAGAYAN VALLEY MEDICAL CENTER

MONTH 15-19 Y/O 2009 20-44 Y/O 15-19 Y/O 2010 20-44 Y/O
January February March April May June July August September October November December Total
0 0 0 0 1 0 0 0 1 1 0 0 3
2 2 2 0 4 2 3 1 2 2 1 1 22
1 0 0 0 0 0
1 0 1 1 2 2
Interpretation: The above data for local statistics of preeclampsia from CVMC shows that patients under 20-44 y/o is greater than that of 15-19 y/o. On the year 2009, 22 out of 25 patients who was diagnosed of preeclampsia were under 22-44 y/o, same is through on the year 2010 (from January to June) where in 7 out of 8 patients is also under 20-44 y/o. This only mean that AGE is one of the risk factors of developing such disease where in <20 to >44 y/o is the age bracket for those who are at risk.
Patients profile
Name: R.R Address : Baggao, Cagayan Birthday: September 18, 1992 Age: 17 years old Birthplace: Baggao, Cagayan Religion: Roman Catholic Occupation: None Fathers Name: M.R. Mothers Name: R.P. Date of Admission: August 2, 2010 Time of Admission: 5:10 pm
Attending Physician: Dr. Divina Gracia Arellano Chief Complaint: Elevated BP, labor pains Admitting Diagnosis: Pregnancy Uterine 39 1/7 weeks of gestation Cephalic in beginning labor, G1P0, Pre-eclampsia primigravida
Principal Diagnosis: Pregnancy uterine 39 1/7 wks AOG, cephalic delivered operatively to live full term baby girl BW = 3175 g APGAR Score = 8/9 = 38- 39 wks G1P1 (1001)
Principal Operative procedure: Preeclampsia severe Transient Uterine Atony Young Primigravida Other Operation: Emergency primary low segment caesarean section
NURSING HEALTH HISTORY
PRESENT
HISTORY
According to Mrs. R.R, she had an abdominal pain that was started on the day she was admitted at CVMC. She noted that the intensity of the pain was best felt every time she had a contraction. When we asked her about the rate of the pain from 0- 10, she responded immediately and rated it as 8/10. When we asked about other unusual feelings is she suffering, she answered dizziness, fatigue and headache. The patient also had pitting edema on her lower extremities; the patient had a pitting edema of +2 upon admission.
PAST
HISTORY
Mrs. R.R verbalized that it was her first time to be confined in a hospital however she has a previous check-up in their barangay clinic due to her pregnancy. The patient said that she only had fever, cough and colds as her childhood illness. According to her, she takes OTC drugs such as paracetamol for fever, neozep for cough and colds and alaxan for body pain. She also completed all her childhood vaccinations and has no noted allergies on foods and drugs. She also said that she never got involved in any accident. She never underwent any surgeries before apart from her present surgery which is CS due to fetal distress.
FAMILY
HISTORY
The patient stated she is living with her husband. She said that their current state of health was okay except her because she was admitted at CVMC due to labor and suffering from pre eclampsia with the BP of 140/100 mmHg. The patient stated that they have no history of hypertension, DM, asthma, TB and cancer. She also said that she was the first member of the family who suffered from pre eclampsia.
SOCIAL
HISTORY
Mrs. R.R. is the youngest in the family. She stated that she is in good term with them. According to her she is a shy type person however she can still mingle and socialize with her friend. She said that she has no vices. The patient stated that she finished 2nd year high school while her husband finished grade 6. When asked about her familys financial status, she said that they dont belong in middle class instead she emphasized that financial aspect is causing a problem in providing their needs. Farming is the primary source of their income but they are just a tenant. Lastly, she said they have no practices and beliefs that could affect their health.
OB
HISTORY
Mrs. R.R had her menarche when she was 10y/o. She has a menstrual cycle of 5 days interval consuming 2 pads a day but she is not experiencing dysmenorrhea. She had her coitarche last November 2009. Her LMP was on November 1, 2009. She suffered dizziness, nausea and vomiting and sometimes fainting so she decided to have a check- up on their barangay clinic last December 16, 2009. Her Ob score is G1P0. On the same day she was given a ferrous sulphate and is taken twice daily. She said that she was having her prenatal check- up at least once a month. Her EDD was on August 8, 2010 and have an AOG of 39 1/7
GORDONS 11 FUNCTIONAL PATTERN
Gordons 11 Functional Pattern
Before Hospitalization
During Hospitalization
HEALTH PERCEPTIONHEALTH MANAGEMENT PATTER
The patient defines health as the absence of any disease or illness. According to the patient, she is taking ferrous sulfate twice a day during her pregnancy and whenever she got sick, she managed it by taking OTC drugs such as paracetamol for fever, neozep for cough and colds, and alaxan for body pain.
The patient declares that health is very important to an individual. She is worrying on her condition because she may not take care of her baby well due to her condition. She follows properly the entire doctors order because she wants to recover as soon as possible for her baby.
NUTRITIONALMETABOLIC PATTERN
The patient verbalized that her The patient was on NPO. The IVF favorite meals during her of the patient are D5LRS 1L x 30 pregnancy were mango, junk gtts/min @ the level of 50ml foods, santol and pritong isda. hooked @ the right arm, PNSS 1L According to the patient, she eats x KVO @ the level of 550cc + a large amount of rice and drinks second line of 250cc of Blood 7 glasses of water a day. She is not transfusion hooked @ the left arm. drinking coke, milk and cold water and not eating halo-halo. She also takes snack in between meals.
COGNITIVE PERCEPTUAL PATTERN
The patient just finish second year high school. She understands tagalog, itawis, Ilocano and English. She doesnt have any problem with her senses.
The patient is not experiencing dizziness and blurred vision. She answers questions minimally and sometimes dont focus to the questions. The patient is turning side to side to prevent bed sore. Legs are elevated due to the edema at her lower extremities. She has difficulty in moving due to the pain. The patient verbalized that she has difficulty in sleeping because of the environment. She takes a nap for at least 20 minutes. She gets sleep at 6pm to 4am but not continuous.
ACTIVITY- EXERCISE According to the patient, she walks always and she still PATTERN washes their clothes and
dishes which serve as her daily exercises.
SLEEP- REST PATTERN
According to the patient, she usually sleeps at 6pm and wakes up at 5am. She takes a nap for 2 hours at noon. She has no difficulty in getting sleep.
ELIMINATION PATTERN
The patient defecates 2x a day The patient has IFC inserted. with bulky and well formed The urine color is yellow with stool. She urinates 7x a day an amount of 675cc. There is a with a yellow amber in color. presence of flatus but no bowel She has no difficulty in movement. defecating and urinating. According to the patient, she The patient feels body was happy when she got weakness due to her condition pregnant. She is excited to see but despite of that she is herself with her growing excited to be a mother. baby. The patient feels the support of her family especially her husband. She cannot perform her role due to her condition.
The patient has a good relationship with her parents and siblings. She is the youngest among the 8 children of her parents. She loves her husband and excited to be a mother of their first child. She is a caring and a loving wife to her husband.
SELF PERCEPTIONSELF CONCEPT PATTERN ROLERELATIONSHIP PATTERN
COPING STRESS PATTERN
She verbalized that whenever she The patient verbalized that she is has a problem, she is sharing it sharing her feelings with her with her parents and her mother and husband. She just husband. Sometimes, if she is thinks her baby to ease the pain stress she managed it by watching she feels. She doesnt think that tv and by socializing with their she is problem to her family. neighbors. The patient had her menarche The patient is very happy in giving when she was 10 years old. She birth of their first child which is a has no problem with her baby girl. menstruation and dont experience dysmenorrhea during menstruation. She had her coitarche last November 2, 2009. They are not using any contraceptive method. The patient is a Roman Catholic According to the patient, she and she attends the mass 3x a always prays at night to recover month. She often prays at night. from her condition and for the She verbalized that she do believe wellness of her baby. She always in quack doctor but never asks guidance and a good health consulted to them. from God.
SEXUALITYREPRODUCTIVE PATTERN
VALUE- BELIEF PATTERN
PHYSICAL ASSESSMENT
Date assessed: August 4, 2010 Time assessed: 5:30 am General Appearance: Received patient lying on bed with IFC at 100 cc level with ongoing IVF of D5LRS 1L + 10 U oxytocin x 30 gtts/min @ the level of 50 ml hooked @ the right arm, and PNSS 1L x KVO + second line of 250cc of Blood transfusion hooked @ the left arm, patent and infusing well. The age of the patient appeared appropriate with the weather, time, & situation. Latest vital signs: BP: 110/ 80 mmHg BT: 36.7 0C RR: 23 cpm CR: 91 bpm Weight: 52 kg Height: 153 cm BMI: 20.5 (normal)
AREA ASSESSED
METHOD USED Inspection
NORMAL FINDINGS
ACTUAL FINDINGS
REMARKS
SKIN
COLOR
TEXTURE
TEMPERATUR E
Light to deep Varies from brown deep to brown to light Smooth Warm to touch, Uniform When pinched, skin goes back to previous state in 1- 2 seconds Smooth Warm to touch, Uniform When pinched, skin goes back to previous state in 4 seconds
Normal
Palpation Palpation
Normal Normal
Palpation
SKIN TURGOR
Due to presence of edema
Presence of lesions
Inspection
No lesions
No lesions
Normal
Inspection
Uniformity
Uniform except Uniform except areas exposed areas exposed to to sun; areas of sun Lighter pigmentation (palm, lips, nail beds) in dark skinned people Dry, skin folds Dry, skin folds are are normally moist normally moist Epidermis is Epidermis is uniformly thin, uniformly thin, thickened thickened callous callous
Normal
Palpation
Normal
Moisture
Palpation & Inspection
Normal
Thickness
HAIR
Color Distributi on Texture Presence of parasites
Inspection Black (depending on race) Evenly distributed hair Black Normal Inspection Evenly distributed hair Normal
Palpation Inspection
Silky, shiny, Silky, shiny, and resilient and resilient No infection No infection or infestation or infestation
Normal Normal
SCALP
Symmetry Inspection Appearan ce
Inspection Symmetrical Symmetrical Absence of lesions Absence of lesions Normal Normal
NAILS
Color (nail Inspection bed) Shape Inspection Pinkish Pinkish Normal
Convex Convex curve (160 curve (160 degrees) degrees) Smooth intact epidermis
Normal
Texture Inspection Smooth tissue intact surroundi epidermis ng nail Capillary refill test Palpation
Normal
Prompt Prompt return of return of pink or pink or usual color usual color (1-2 (1-2
Normal
HEAD
Shape Inspection Normoceph Normoceph alic alic Rounded with smooth skull contour with (-) nodules Rounded with smooth skull contour with (-) nodules Normal Normal Appearan Inspection ce
Size and Inspection Appropriate Appropriate circumfer to body to body ence size and size and shape shape
Normal
FACE
Symmetry Inspection Symmetric Symmetric Normal
EYEBROWS
Distributi Inspection Equally Equally on distributed distributed Quality of Inspection Eyebrows Eyebrows movement moves the moves the same way same way Alignment Inspection Aligned Aligned Normal
Normal
Normal
EYELASHES
Evenness Inspection Equally distributed Slightly curved outward Equally distributed Slightly curved outward Normal
Direction of curl
Inspection
Normal
EYELIDS
Ability to Inspection blink Has the Has the ability to ability to blink; blink blink; blink bilaterally bilaterally Normal
Frequency Inspection 15 to 20 18 blinks/ of blink blinks/ min min
Normal
EYES
Color Conjunctiva Inspection Inspection White sclera White sclera Pink palpebral Pink palpebral conjunctiva conjunctiva Normal Normal
CORNEA
Appearan Inspection ce Shiny Shiny Normal
PUPILS
Color Shape Inspection Inspection Black, no Black, no cloudiness cloudiness Rounded Rounded Normal Normal Normal
Extra Inspection Both eyes Both eyes ocular are are movement coordinatedcoordinated Visual acquity Inspection She was She was able to able to read prints read prints without without wearing wearing eyeglasses eyeglasses
Normal
EARS Color
Inspection Same with the color of the face Same with the color of the face Normal
Symmetr y
Inspection
Symmetrical Symmetrical to the head to the head and face and face
Normal
Positio n
Inspection
Lateral to the eyebrows & auricles in line with the cantus of the eye
Lateral to the eyebrows & auricles in line with the cantus of the eye
Normal
NOSE
Color Inspection Same with Same with the color of the color of the face the face Normal
Tendernes Palpation No No s and tenderness tenderness masses and massesand masses Patency Inspection Air moves Air moves freely freely
Normal
Normal Normal
Discharge Inspection No (-) or flaring discharge discharge and flaring and (-) flaring Tendernes palpation not tender, Not tender, s no lesions no lesions
Normal
MOUTH
Lips
Inspection Uniform pink Uniform pink color, soft, color, soft, moist and moist and smooth in smooth in texture texture Can purse lipsCan purse lips Normal
Ability to purse lips Buccal Mucosa
Inspection
Normal
Inspection
Moist, smooth, soft and glistening; pink in color
Moist, smooth, soft and glistening; pink in color
Normal
Teeth
Inspection
No tartars, no no tartars, no dental caries, dental caries, complete set complete set of teeth of teeth.
normal
Gums
Inspection
pink in color, pink in color, moist and firm moist and firm freely, moving, freely, moving, centered centered roughened roughened from from papillae;no papillae;no lesion lesion positioned in the middle positioned in the middle
Normal
Tongue
Inspection
Normal
Ovula
Inspection
Normal
NECK
Position Inspection Centrally located between the shoulders. Centrally located between the shoulders. Normal
Mobility
Inspection
Can move Can move spontaneously spontaneously in all directions. in all directions. no tenderness no tenderness
Normal
Lymph nodes
Palpation
Normal
THORAX AND LUNGS

Symmetry Inspection Chest Chest expands expands symmetrically symmetrically during during respiration; respiration; effortless. effortless. Intact; no tenderness, no mass. Resonance chest expands fully and symmetrically Normal
Chest wall
Inspection Intact; no and Palpation tenderness, no mass. Percussion Palpation Resonance full and symmetric chest expansion
Normal
Percussion sound Chest expansion
Normal Normal
Breath sounds
Auscultation
BronchoBronchovesicular vesicular breath sound breath sound
Normal
ABDOMEN
Skin condition Inspection Brown/follows general body color Brown Normal
Bowel sounds
Auscultation Audible bowel Bowel sounds Due to sounds (15- of 10/ decrease 20/ minutes) minutes peristalsis Palpation Inspection No tenderness (+) tenderness Due to CS delivery Normal
Tenderness Umbilicus
Midline and Midline and inverted, no inverted, no sign of sign of discoloration discoloration Flat, round scaphoid No ascites Flat, round scaphoid No ascites
Abdominal contour Ascites
Inspection Percussion
Normal Normal
HEART
Heart sound Auscultation Dull, no Dull, no murmurs, murmurs, absence of s3 absence of s3 and s4 sound. and s4 sound. Normal
Heart rate Precordium
Auscultation Inspection, Auscultation and palpation
Regular, 60100 bpm
Regular, 78 bpm
Normal Normal
Adynamic, Adynamic, point of point of maximum maximum impulses impulses (PMI) is at the (PMI) is at the 5th ICS for 5th ICS for adult at the adult at the left left midclavicular midclavicular line. line.
UPPER EXTREMITIES
Color Inspection Light to Light to deep brown deep brown Normal
Symmetry Inspection Symmetric Symmetric al al Skin Palpation Warm and Warm and characterist equal equal ic temperatur temperatur e, no e, no edema and edema and tenderness. tenderness.
Normal Normal
ROM
Inspection
Full ROM without pain
Has difficulty moving
Due to CS delivery
LOWER
Color Symmetry Skin characteri stic ROM
Inspection Inspection Palpation
EXTREMITIES
Light to deep brown Symmetrical Warm and equal temperature, no edema and tenderness. Full ROM without pain Light to deep brown Symmetrical (+) Edema Normal Normal Due to increased tubular reabsorption of sodium Due to CS delivery
Inspection
Has difficulty moving her lower extremities (+) edema
Edema
Inspection and Palpation
No edema
Due to increased tubular reabsorption of sodium Normal
Muscle
Palpation
Present, equal Present, equal
LABORATORY RESULTS
August 2, 2010
General Chemistry
Normal Values Urea Creatinine Uric Acid AST(aspartate aminotransferase ) ALT (alanine transaminase) LDH 2.50-7.10mmo/L 53-115.0 mol/L 149.0-506.0 umol/L 14-59 U/L Result 3.05 mmol/L 84.8 umol/L 274.2 umol/L 32 U/L Remarks Normal Normal Normal Normal
9-72 U/L 313-618 U/L
22 U/L 798 U/L
Normal Due to possible liver damage
August 2, 2010
Urinalysis
Normal Values Result Remarks
Color Transparency pH Specific gravity Albumin
Yellow amber Clear 4.5-7.5 1.010-1.030 1-15 mg/dl
Yellow clear 6.5 1.010 Trace
normal normal Normal Normal

Due to increase permeability
August 3, 2010
Hematology
Normal Values
Hemoglobin Mass Concentration 120-160 g/L
Result
88 25% 160
Remarks
Due to increase plasma volume Due to blood loss Normal
Erythrocyte 33%-35% Volume Fraction Thrombocyte Number Concentration 150-160 x 109/L
Leukocyte Number 4.5-14 x 109/L Concentration Neutrophils Lymphocytes 45%-73 % 22%-40%
2.6
Due to infection
63% 37%
Normal Normal
August 3, 2010
Blood Grouping
Serial Number Blood Type PRBC 10-4861 A Rh Compatibility Positive Expiration Date
Serial Number Blood Type PRBC 10-4868 A
Rh Compatibility Positive
Expiration Date
August 5, 2010
Hematology
Normal Values
Hemoglobin Mass Concentration 120-160 g/L
Result
93
Remarks
Due to increase plasma volume Due to blood loss Due to surgical incision Due to infection
Erythrocyte 33%-35% Volume Fraction Thrombocyte Number Concentration Leukocyte Number Concentration Neutrophils Lymphocytes 150-160 x 109/L
27% 140
4.5-14 x 109/L
28.98
45-73% 22-40%
90% 10%
Due to infection Due to infection
COURSE IN THE WARD
DATE
DOCTORS ORDER
RATIONALE
To monitor health condition and for further observation For legal purposes
NURSING RESPONSIBILITIES
August 2,Please admit at LR-DR 2010 BP=150/100 HR=80 Secure consent for RR=22 admission T=36.4 G1P0 LMP= Nov. 1, Soft diet then NPO once 2009 AOG= 39 1/7on active labor weeks TPR every shift and FH=32 cm record FHT=140s IE= Nuliparus outlet Cervical dilatation= 1Dx: CBC with APC cm U/A Cephalic (-) BOW, (-)epigastric SGPT/SGOT pain Clear breathBUN sounds
Obtained initial database Secured consent, signed for admission and management
To prevent aspiration Diet emphasized to the patient For baseline data and TPR taken and to note for progress recorded. Referred any deviations from normal ranges >To test blood Ensured patients components request form and >To evaluate presence prepared and of foreign substances explained to the in the urine. patient about the >For liver function test procedure >To determine kidney function
DATE
DOCTORS ORDER
Tx: give 4 g Magnesium Sulfate slow IV push now then 5 g deep IM on both buttocks as loading dose then 5 g deep IM on alternating buttocks q 4 hours in 24 hours as maintenance dose. Methyldopa 500 mg q 8 hours
RATIONALE
To prevent and control seizure
Administered medication effectively and observed the 10 Rs in giving the mediation. Monitored the blood pressure
To lower blood pressure Administered medication effectively and observed the 10 Rs in giving the mediation. Monitored the blood pressure IFC inserted aseptically Ensured accurate I & O measurement. Administered medication effectively and observed the 10 Rs
Insert IFC aseptically and For bladder training connect to urine bag I & O q shift and record Pre meds on call: Hydroxizine 25 mg Medazolam 1 g Nalbuphine 5 mg To monitor fluid and electrolyte balance >To relieve pain
DATE
DOCTORS ORDER
Hook to EFM
RATIONALE
To check for fetal heart rate and uterine activity
Position the client, monitored and recorded the FHR and uterine activity Kept watch
Labor watch
To check for the progress of cervical dilatation To rule out magnesium toxicity
Watch out for Magnesium toxicity
Monitored patients v/s VS and FHT monitored and recorded
VS and FHT q hour and To monitor fetal record distress Routine perineal preparation
To prepare both the Positioned the mother and baby for patient and delivery cleaned the perineal area. For collaborative intervention Referred properly
Refer accordingly
DATE
August 2, 2010 9 pm BP= 160/90 Cx= 1 cm dilated 50% effaced Cephalic (+) BOW, -3
DOCTORS ORDER
NPO once in active labor Hook to EFM now then q 4 hours
RATIONALE
To prevent aspiration
Instructed patient not to eat anything
To monitor for fetal Position the heart rate and client, monitored uterine activity and recorded the FHR and uterine activity To view the fundus Prepared the patient for such procedure For further evaluation To watch out for progress in labor To evaluate any changes Followed up all labs Kept watch VS and FHT monitored and recorded
For fundoscopy
Follow up all labs Continue labor watch Monitor VS, FHT
DATE
DOCTORS ORDER
RATIONALE
August 3, May transfer 2010 patient to ward 9:30 am CR=91 Refer RR=23 BP=100/ 80 T=38.4 C Paracetamol for fever 300 mg/IV q 4 for fever
For proper management For collaborative intervention
Patient transferred to OB Referred accordingly.
To decrease Administer body medication temperature effectively and relive fever. and observed the 10 Rs in giving the mediation. For collaborative Referred accordingly.
Refer
DATE
DOCTORS ORDER
RATIONALE
August 4, May have GLEMCD 2010 7:55 am BP=110/80 Afebrile (+) flatus IVF: PNSS 1L x KVO (-) BM adequate
Instructed patient to To prevent aspiration. GLEMCD ishave a general fluid intake only except the diet for the milk and soft drinks. patients undergone after surgery.
For rehydration
Checked IVF line patency and regulated. Checked for signs of phlebitis and infiltration medication effectively and observed the 10 Rs in giving the mediation. Administered medication effectively and observed the 10 Rs in giving the mediation.
Continue IV Coamoxiclav
To prevent infection Administered
Tramadol 50 mg/IV q 8 To relieve pain x 24 For iron replacement Ferrous fumarate + vitamin B complex 1 cap TID
DATE
DOCTORS ORDER
Insert 2 bisacodyl supp/rectum now
RATIONALE
To increase GI motility.
Positioned patient and administered medication effectively and observed the 10 Rs in giving the mediation. Checked IV line patency and regulated. Checked for signs of phlebitis and infiltration
Continue BT
for blood replacement
Encourage early ambulation Watch out for bleeding
To enhance venous Encouraged return. patient To prevent complications. Watched out for patient for bleeding.
DATE
DOCTORS ORDER
RATIONALE
Soft diet is the diet after GLEMCD for patients postoperatively For rehydration
August 5, Soft diet 2010 7:20 am BP:180/120 (+) flatus IVF: PNSS 1L x KVO (+) BM
Instructed patient to eat foods only such as lugaw. Checked IVF line patency and regulated. Checked for signs of phlebitis and infiltration medication effectively and observed the 10 Rs in giving the mediation. Administered medication effectively and observed the 10 Rs in giving the medication with BP precaution
Continue meds
For patients recoveryAdministered
Give captopril 25 mg To decrease BP SL now then PRN for BP greater than or equal to 130/90
DATE
DOCTORS ORDER
Continue ambulation For 24 post BT,CBC with APC at 10:00 am today
RATIONALE
To prevent paralytic ileus For blood replacement
Instructed patient to have a walk and Secured request form for the procedure. Explained the importance of the procedure. Prepared the patient for the procedure.
Continue magnesium To prevent seizure sulphate, then maintenance dose
Updated Kardex and transcribed orders in medication sheet and medication card. Explained the action of the drugs. observed the 10 Rs in giving the medication Monitored and recorded intake and output
Maintain IFC
For I and O monitoring
DATE
DOCTORS ORDER
RATIONALE
August 6, Full diet For adequate 2010 nutrition 9:00 am BP=150/ IVF: D5LRS 1L x For fluid and KVO electrolyte 100 balance.
Emphasized diet of the patient. Checked IVF line patency and regulated. Checked for signs of phlebitis and infiltration.
Started Start hydralazine To decrease drip elevated blood Hydralazine drip. Checked IVF line pressure patency and regulated. Checked for signs of phlebitis and infiltration.
DATE
DOCTORS ORDER
RATIONALE
August 07, IVF: D5LRS 1L x KVO Route for 2010 emergency drugs 7:55am BP: 130/90 (-) cough With febrile episodes Full diet For adequate (+)breast nutrition pain (+)phlebitis Continue To decrease hydralazinne drip elevated blood pressure
Checked IVF line patency and regulated. Checked for signs of phlebitis and infiltration
Emphasized diet of the patient. Continued Hydralazine drip. Checked IVF line patency and regulated. Checked for signs of phlebitis and infiltration.
Spinorolactone +
To eliminate
Administered
DATE
DOCTORS ORDER
RATIONALE
Reinsert IV line to other site.
hooked IVF line, To continue parenteral nutrition checked for
patency and regulated. Checked for signs of phlebitis and infiltration Administered medication effectively and observed the 10 Rs in giving the mediation.
Continue oral meds
For fast recovery
V/S + IV q1* and For close record monitoring.
Vital signs monitored and recorded until stable. IV regulated and checked for patency
DATE
DOCTORS ORDER
RATIONALE
For adequate nutrition Route for emergency drugs
August 08, DAT 2010 7:30 am Afebrile IVF x KVO With febrile episodes (+)cough (-)breast pain (-)phlebitis Consume BP:130/80 hydralazine drip Latest CBC(08/05/ 10)
Emphasized diet of the patient.

Checked IVF line patency and regulated. Checked for signs of phlebitis and infiltration Consumed Hydralazine drip. Checked IVF line patency and regulated.Checked for signs of phlebitis and infiltration. Secured request form for the procedure. Explained the importance of the procedure. Prepared the patient for the procedure.
To lower elevated blood pressure
For repeat CBC with For futher evaluation APC blood culture and sensitivity CXR- PA
DATE
DOCTORS ORDER
RATIONALE
For patients recovery.
Continue oral meds
Administered medication effectively and observed the 10 Rs in giving the mediation
Daily wound careTo prevent

infection
Cleaned wound aseptically and changed wound dressing as doctors order. Vital signs monitored and recorded until stable. IV regulated and checked for patency
Monitor V/S q1* For close monitoring. and record
Refer.
For collaborative
Referred accordingly
DATE
DOCTORS ORDER
RATIONALE
Full diet August 09,2010 7:43 am BP: 150/100 IVF D5LRS 1L x KVO Afebrile With febrile episodes (+) occl cough Clear Continue oral meds breath sounds
For adequate nutrition

Route for emergency drugs For patients recovery
Emphasized diet of the patient.
. Checked IVF line patency and regulated.Checked for signs of phlebitis and infiltration. Administered medication effectively and observed the 10 Rs in giving the mediation.
Secured request form for the procedure. Explained the importance of the procedure. Prepared the patient for the
Please follow up CBC For further with APC request, evaluation blood CS + CXRofficial reading and attach to chart
DATE
DOCTORS ORDER
RATIONALE
Daily wound careTo prevent infection
Cleaned wound aseptically and changed wound dressing as doctors order. .Vital signs monitored and recorded until stable. IV regulated and checked for patency
Instructed patient to have a walk
V/S + IV q1* and For close monitoring record
Continue ambulation
To prevent paralytic ileus
Refer
For collaborative intervention
Referred accordingly
ANATOMY AND PHYSIOLOGY
Anatomy and Physiology of Female Reproductive System
Functions: 1. Puberty: It is the time of life in which the individual capable of sexual reproduction. It occurs on average between the ages of 10 and 14 years. It marked the maturation of the reproductive organs and development of secondary sex characteristics or external physical evidence of sexual maturity.
2. Menstrual cycle: Refers to the recurring changes that take place in the womans reproductive tract that associated with menstruation and intermenstruation. Hormones and pituitary gland regulate these cyclical changes. There are two main components of the menstrual cycle, the ovarian and uterine cycle.
Ovarian cycle: Occurs in response to two anterior pituitary hormones: folliclestimulating hormone (FSH) and luteinizing hormone (LH).
Follicular Phase: at the beginning of each menstrual cycle, a follicle on one of the ovaries begins to develop in response to rising of FSH level. The follicle produces estrogen, wjich causes the ovum contained within the follicle to mature. When the pituitary gland detects high level of estrogen from the mature follicle, it releases LH. This now causes the follicle to burst open, releasing the mature ovum called ovulation; occurs on a day of 14 of a 28 day cycle.
LUTEAL PHASE: LH remains increase and cause the remnants of the follicle to develop into a yellow body called the corpus luteum. It secretes a hormone called progesterone. If fertilization does take place, the corpus luteum begins to degenerate and estrogen and progesterone levels fall. It leads back to the day 1 of the cycle and the follicular begins a new.
Uterine cycle: Changes in the uterine lining.

MENSTRUAL PHASE: Day 1 of the menstrual cycle is marked by the onset of menstruation. During the menstrual phase of the uterine cycle, the uterine lining is shed because of low levels of progesterone and estrogen. At the same, a follicle is beginning to develop and starts producing estrogen. The menstrual phase ends when the menstrual period stops on approximately 5 days.
PROLIFERATIVE PHASE: When estrogen levels are high enough, the endometrium begins to regenerate. Estrogen stimulates blood vessels to develop. The blood vessels in turn bring nutrients and oxygen to the uterine lining and it begins to grow and become thicker. The proliferative phase ends with ovulation on day 14. SECRETORY PASE: After ovulation, the corpus luteum begins to produce progesterone. This hormone causes the uterine lining to become rich in nutrients in preparation for pregnancy. Estrogen levels also remain high so that the lining is maintained. If pregnancy does not occur, the corpus luteum gradually degenerates and the woman enters the ischemic phase of the menstrual cycle.
ISCHEMIC PHASE: On days 27 and 28, estrogen and progesterone levels fall because th corpus luteum is no longer producing them. Without these hormones to maintain the blood vessel network, the uterine lining becomes ischemic. When the lining starts to slough, the woman have come full cycle and is once again at day 1 of the menstrual cycle.
External Structures:
Mons pubis: A rounded fatty pad located atop at the symphysis pubis. Coarse pubic hair and skin cover the mons. It protects the pelvic bones during sexual intercourse.
Labia major and minora: The labia majora; are paired fatty tissue folds that extend anteriorly from the mons pubis and then join posteriorly to the true perineum, covered by the pubic hair , vascular and contain oil and sweat glands. Labia minora; paired erectile tissue folds that extend anteriorly from the clitoris and then join posteriorly to the fourchette, where the labia meet. Their thinner than the majora, are hairless, contain oil glands and are sensitive to stimulation.
Clitoris: The most sensitive part, compose of an erectile tissue, allows the woman to experience sexual pleasure and orgasm during sexual stimulation. Vestibule: It is the area between the labia minora. The urethral meatus, paraurethral glands, vaginal opening, and bartholin glands are located here. Perineum: The perineum and the muscles of the pelvic floor are capable of great expansion during birth to allow for the delivery of the fetus. It is the site of episiotomy is sometimes done.
Internal Structures:
Vagina: It leads from the vulva to uterus. The opening lies within the vestibule from which slopes up and backward to the cervix. The inner folds or the rugae, allow the vagina to stretch during birth to accommodate the full-term infant. It has ph of 5 and it is acidic to protect the vagina from infection. It receives the penis during intercourse and the exit point of menstrual flow.
Uterus: A hollow-pear shape muscular structure located within the pelvic cavity between the bladder and the rectum. It rest just above the urinary bladder. It prepares the pregnancy each month, protect and nourish the growing fetus and to aid in childbirth.
CERVIX: Tubular structure that connects the vagina and the uterus. It allows the sperm to enter and menstrual flow to exit. During childbirth, it must fully dilate so that the baby can be born. UTERINE ISTHMUS: It connects the cervix to the main body of the uterus. It is referred to the lower uterine segment. Thinnest portion of the uterus, does not participate in contraction during labor but it is the most likely to rupture.
CORPUS and FUNDUS: Corpus is the main body of the uterus and the fundus is the top most portion of the uterus. They are made up of three layers. The perimetrieum, myometrium, and the endometrium. Perineum is the tough outer layer that supports the uterus, myometriun is the mscular layer that is responsible for the contractions during labor, endometrium is the vascular mucosal inner layer, it changes under hormonal influence every month in preparation for possible conception and pregnancy.
FALLOPIAN TUBES: (AKA oviducts) Tiny and muscular corridors that arise from a lateral position on the superior surface of the uterus near the fundus and extend out on either side toward the ovaries. The functions are to provide a site for fertilization, a passageway and nourishing, warm environment for the fertilized egg to travel to the uterus. It is divided into three ssections:
ISTHMUS: It is the one third of the tube that connects to the uterus AMPULA: It is the middle portion of the tube and connects the isthmus with the infundibullum. INFUNDIBULLUM: the outer layer that opens into the lower abdominal cavity.
OVARIES: Located on either side of the uterus. The function is to produce the female hormones estrogen and progesterone which are responsible for female secondary sex characteristics and for regulating menstrual cycle in response to anterior pituitary hormones.
Cardiovascular changes Tremendous demands are made upon the cardiovascular system during pregnancy. The heart has to handle the increased load of an expanded blood volume. It also must adjust to the demands of organs systems with the increased workloads, such as the kidneys and uterus. In addition, the heart is physically pushed upward and to the left by the enlarging uterus, which may cause systolic murmurs.
Normally the blood pressure decreases slightly during pregnancy, particularly in the second trimester. The heart rate raises by 10 to 15 beats per minute on a average. Cardiac output increases, beginning in the early weeks of pregnancy and continuing throughout the pregnancy. During the late pregnancy, the gravid uterus can compress the womans vena cava and aorta causing the blood pressure to fall when the woman is in the supine position. This condition is called supine hypotension syndrome. The woman may feel light-headed and dizzy; her skin may exhibit pallor and clamminess. The treatment for this condition is to reposition the woman to a lateral position. The traditional position is left side-lying.
- Y O G H O T L A P IO S Y H P
www.themegallery.com
PATHOPHYSIOLOGY
PRE-ECLAMPSIA PREDISPOSING PRECIPITATING FACTORS *Age(<20->40 y/o) *Family history *Lifestyle Nutrition *Primiparity FACTORS trophobl *Diet and astic *Pre-existing hypertension cells to materna l arteries Release of placental factor (factor X) Aggregation of fibrin, platelets and lipophages
Invasion of endovascular
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PATHOPHYSIOLOGY
A B
partial or complete blockage on arterioles placental infarction
replacement of endothelium, destruction of medialmusculoelastic tissue and change in fibrinoid in the vessel wall placental ischemia
increased platelet activation vasospasm
C
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PATHOPHYSIOLOGY
C
increase blood pressure hypertension kidney pancreas epigastric pain placenta eyes blurred vision brain decrease perfusion to organs
hyperreflexia
seizure
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PATHOPHYSIOLOGY
D
decrease GFR decrease urine output increase reabsorption in tubules increase sodium and water retention edema
E
fetal distress active labor Emergency caesarian section
increase creatinine increase level glumerular permeability proteinuria
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NURSING CARE PLAN
Assessment
Subjective: Masakit ang sugat ko as verbalized by the patient. Pain scale: 8/10 Objective: Restlessness Facial grimace
Diagnosis
Planning
Interventions
Rationale
Evaluation
For baseline Acute pain After 2 hours, Monitored the patient vital signs and data and to r/t traumatized will verbalize recorded note progress. a decrease nerve pain from To promote endings pain scale of secondary 8/10 to 2/10 Positioned the comfort patient to surgical comfortably on incision. bed Pain is Encouraged subjected and verbalization of it cant be felt by other feelings To promote nonpharmalogi cal pain management
Goal met. After 2 hours, the patient pain scale was decreased from 8/10 to 2/10
Provided comfort measures such as repositioning
Assessment
Diagnosis
Planning
Interventions
Rationale
Evaluation
Instructed in To distract use of attention and relaxation reduce tension techniques such as focused breathing Encouraged To distract diversional attention activities by initiating conversation to the patient Administered For medication as collaborative function ordered
Assessment
Diagnosis
Planning
Interventions
Rationale
Evaluation
Subjective: After 3- 4 Monitored vital For baseline data Goal met. Activity signs and recorded and to note After the Hindi ko hours of intolerance progress. nursing masyadong nursing r/t edema on Positioned the interventions, maigalaw ang interventions, patient To promote the lower the patient ha paa ko as the patient will comfortably comfort used/ extremities be able to use verbalized by identified Encouraged the patient. /identify techniques to To know what enhance verbalization of Objective: techniques to feeling nursing activity Body enhance interventions are intolerance weakness activity needed Inability to intolerance Assisted patient perform during moving or Ensures safety on going in the activity and additional comfort room support for client (+) edema on the feet
Planned for progressive increase in activity May improve level as tolerated with progressive by the patient training
Assessment
Diagnosis
Planning
Interventions
Encouraged passive ROM
Rationale
TO maintain muscle strength and joint range of motion
Evaluation
Encouraged the To conserve client to have energy adequate rest and sleep Adjusted activities To prevent overexertion
Provided positive Helps to atmosphere minimize frustration Assisted with activities and To protect client monitored clients from injury use of assistive device Promoted To enhance comfort measures ability to participate in activities
Assessment Diagnosis
Planning
Interventions
Rationale
Evaluation
Subjective: Impaired After 1-2 Monitored vital For baseline Goal met Masakit skin hours of the signs and recorded data and to note After the Positioned the progress. ang sugat integrity r/t nursing nursing ko as surgical interventions, patient comfortably To promote interventions assessed wound comfort verbalized by incision the patient will for intactness the patient the patient. participate in participated Wound Objective: prevention in prevention dehiscence (+) surgical measures and occurs with measures and excessive stress treatment incision treatment Encouraged Warm program verbalization of on a new program
feelings incision To know what nursing assessed for signs interventions of infection will be performed Stressed the Purulent importance of hand drainage is an washing indication of infection To control the spread of infection.
Encouraged To aid in the patient to tissue repair eat foods rich in protein. Applied appropriate dressing. To help in wound healing
To prevent Kept the area infection clean/dry These can Discouraged cause further rubbing and injury and scratching delay healing To prevent infection
Instructed the patient in proper care of area
Assessmen Diagnosis t
Planning
Interventions Rationale Evaluation
Subjective Ineffectiv After 3 Monitored For Goal met. : e tissue hours of vital signs baseline After 3 namam perfusion the and data and hours of anas ang r/t nursing recorded to note the paa ko vasocons interventio progress. nursing To as triction ns, the interventi verbalized of blood patient Positioned promote ons, the by the vessels will be the patient comfort patient patient 2T able to comfortably To know had Objective: edema demonstra Encourage what demonstr d Edema te nursing -ated noted on behaviors verbalizatio interventi behaviors lower to improve n of ons will to extremitie circulation feelings be improve s perform circulatio Cold, This n clammy may Checked indicate skin for calf thrombus tenderness formation (homans
Assessmen Diagnosis Planning Interventions t
Rationale
Evaluation
Reinforced Contracti Goal met. leg ng the leg After 3 exercises muscle hours of taught decreases the nursing preoperativ venous interventio ely stasis and ns, the encourages patient had good demonstrat venous ed return behaviors To reduce to improve Encourage tension circulation d used of relaxation techniques Enhances Encourage venous d early return ambulation For Elevated venous feet on bed return
Assessmen Diagnosi t s
Planning
Intervention Rationale s
Evaluation
Monitored For Subjective: Impaired After 2 Goal met hinde physical hours of the vital signs baseline After 2 ako mobility nursing and data and to hours of the masyadong r/t intervention recorded note nursing surgical s, the progress. intervention makagalaw incision patient will Positioned To s, the as be able to the patient promote patient verbalized verbalize comfortably comfort verbalized by the understandi on bed understandi Encourage patient ng of ng of To know situation Objective: situation d verbalizatio what Difficulty and and moving individual n of feelings nursing individual interventio treatment Body treatment ns will be regimen and weakness regimen and Scheduled performed safety safety To reduce measures measures. activities with fatigue adequate rest periods during the Enhances day Encourage sense of
Assessmen Diagnosis Planning Interventions t
Rationale
Evaluatio n
Encouraged Maximizes adequate energy intake of production nutritious foods Mobility Facilitated aids can increase transfer level of training by mobility using appropriate assistance of persons or devices Patients may be Provided reluctant to positive reinforcemen move due to fear of t during falling activit Kept side rails up and To promote a safe environment
Assessment Diagnosis Planning Interventions Rationale Evaluation For Subjective: Deficient After 2 Monitored Goal met di ko alam knowledge hours of the vital signs and baseline After 2 hours kung ano ang r/t lack of nursing recorded data and to of t he dapat gawin informatio intervention Positioned note nursing sa sakit ko n about s, the the patient progress. interventions as verbalized the current patient will comfortably on To , he patient by the condition verbalize bed promote verbalized patient understandi Encouraged comfort understandin Objective: ng of verbalization of g of current To know condition Primigravid current feelings what a condition and Instructed in nursing OB score: and treatment intervention G1P0 treatment use of relaxation s are techniques needed To such as focused promote breathing comfort Determined clients ability /readiness and The client may not e barriers to
Assessmen Diagnosis t
Planning Interventions Assessed the level of the clients capabilities and the possibilities of the situation Provided information relevant only to the situation Discussed clients perception of need
Rationale May need to help SO(s) or caregivers to learn
Evaluatio n
To prevent overload
So that client feels competent and respected
Promotes Provided active role for sense of control over client in situation learning process
DRUG STUDY
NAME OF DRUG
CLASSIFICATI ON
ACTION
INDICATION
ADVERSE REACTION
CNS: ALERT! Watch for GENERIC Anti-convulsant May decrease Acute drowsiness, NAME: acetylcholine nephritis, to respiratory depression depressed Magnesium released by control reflexes, flaccid and signs and Sulfate nerve hypertension paralysis, symptoms of heart impulses, but Short term block. hypothermia Keep IV calcium its treatment for CV: hypotension, DOSAGE anticonvulsant constipation gluconate available to flushing, AND mechanism is To correct or bradycardia, reverse magnesium FREQUENC unknown. prevent intoxication. circulatory Y: Check magnesium hypomagnesime collapse, 5 g every 4 a in patients on depressed level after repeated cardiac function doses hours in 24 parenteral EENT: diplopia hours nutrition METABOLIC: Signs of hypocalcemia hypermagnesemia RESPI: begin to appear at respiratory levels of 4 mEq/L paralysis Observe neonates for SKIN: signs of magnesium diaphoresis toxicity.
NAME OF DRUG CLASSIFICATI ON GENERIC NAME: ANTIHYPERMETHYLDOPA TENSIVE BRAND NAME: DRUG ALDOMET DOSAGE AND FREQUENCY: 500 mg every 8 hours
ACTION
INDICATI ON
ADVERSE REACTION
CNS: headache, asthenia, weakness, dizziness, sedation, decreased mental acuity, depression, paresthesia, parkinsonism, Bells palsy, involuntary choreoathetotic movements CV: bradycardia, edema, orthostatic hypitension, myocarditis EENT: nasal congestion GI: nausea, vomiting, diarrhea, constipation, abdominal distention, colitis, dry mouth, sore or black tongue, pancreatitis GU: breast enlargement, gynecomastia, failure to ejaculate, erectile dysfunction HEMATOLOGIC: eosinophilia, hemolytic anemia HEPA: hepatitis OTHER: fever
NURSING RESPONSIBILI TIES Monitor periodic counts to detect adverse hematologic reactions. Monitor liver function test and check for signs and symptoms of hepatic dysfunction. Check for edema or weight gain to help determine if diuretic should be added to regimen. Monitor blood pressure.
HyperStimulates CNS alpha- tension adrenergic receptors decreasing sympathetic stimulation to heart and blood vessel. Also reduces arterial and plasma renin pressure
NAME OF DRUG
CLASSIFICA TION
ACTION
INDICATION
ADVERSE REACTION
ANTIMechanism of Symptomatic relief CNS: drowsiness,WARNING: Determine and treat underlying cause EMETIC, action is of anxiety and tensioninvoluntary HYDROXYZINE ANTIunknown; associated with motor activity of vomiting. Drug may mask signs and symptoms BRAND HISTAMIN actions may be psychoneurosis including tremor of serious conditions, such Management of NAME: E due to and seizures as brain tumor, intestinal VISTARIL suppression of pruritus due to GI; dry mouth, obstruction, or appendicitis. subcortical allergic conditions, reflux, WARNING: Do not DOSAGE areas of the such as chronic constipation administer parenteral AND CNS; has urticaria, atopic and GU; urinary solution subcutaneously, FREQUENC clinically contact dermatosis retention IV, or intra-arterially; Y: demonstrated and in histamineRESPIRATORY: tissue necrosis has 25 mg antihistaminic, mediated pruritus wheezing, occurred with Sedation when used dyspnea, chest subcutaneous and intraanalgesic, arterial injection, and antispasmodic,a as a premedication tightness hemolysis with IV ntiemetic, mild and following general injection. antisecretory, anesthesia Give Im injections deep Control of nausea and into a large muscle: in bronchodilator and vomiting adults, use upper outer Management of the activity. quadrant of buttocks or acutely disturbed or midlateral thigh; in children, use midlateral hysterical patients GENERIC NAME:
thigh muscles; use deltoid area only if well developed.
NAME OF DRUG
CLASSIFICA TION
ACTION
INDICATION
ADVERSE REACTION
GENERIC NAME: OXYTOCIC OXYTOCIN BRAND NAME: PITOCIN DOSAGE AND FREQUENCY: 10 units
ANTEPARTUM: To WARNING: Reserve for Synthetic form of an CV: cardiac endogenous hormone initiate or improve uterine arrhythmias, PVCs, medical use, not elective produced in the contractions to achieve hypertension, induction. Ensure fetal position and size hypothalamus and stored early vaginal delivery; subarachnoid in the posterior pituitary; stimulation or hemorrhage and absence of complications stimulates the uterus, reinforcement of labor in FETAL EFFECTS: that are contraindicated with especially the gravid uterus selected cases of uterine fetal bradycardia, oxytocin before therapy just before parturition, and inertia; management of neonatal jaundice, low WARNING: Ensure causes myoepithelium of inevitable or incomplete APGAR scores continuous observation of the lacteal glands to abortion; second trimester GI: nausea and patient receiving IV oxytocin contract, which results in abortion vomiting for induction or stimulation of POSPARTUM: To milk ejection in lactating GU: postpartum labor, fetal monitoring is women. produce uterine hemorrhage, uterine preferred. Regulate rate of oxytocin contractions during the rupture, pelvic third stage of labor and to hematoma, uterine delivery to establish uterine control postpartum hypertonicity, spasm, contractions that are similar to bleeding or hemorrhage titanic contractions, normal labor, monitor rate and Lactation deficiency rupture of the uterus strength of contractions; To evaluate fetal distress,with excessive dosage discontinue drug and notify treatment of breast or hypersensitivity physician at any sign of uterine engorgement OTHER: anaphylactic hyperactivity or spasm. reactions, maternal and WARNING: Monitor fetal deaths when used maternal BP during oxytocin to induce labor or in administration; discontinue drug first or second stages ofand notify physician with any labor, afibrogenemia, sign of hypertensive emergency Monitor neonate for jaundice severe water intoxication with seizures and coma
NAME OF CLASSIFICATI DRUG ON GENERIC NAME: OPIOID AGONISTNALBUPHINE ANTAGONIST HYDROCHL ANALGESIC ORIDE BRAND NAME: NUBAIN DOSAGE AND FREQUENC Y: 5 mg
ACTION
INDICATION
ADVERSE REACTION
Relief of Acts as an CNS: sedation, clamminess, WARNING: Taper agonist at moderate to severe sweating, headache, dosage when discontinuing specific opioid pain nervousness, restlessness, after prolonged use to Preoperative receptors in depression, crying, avoid withdrawal the CNS to analgesia, as a confusion, faintness, symptoms produce supplement to hostility, unusual dreams, WARNING: Keep analgesia and surgical hallucinations, euphoria, opioid antagonist and sedation but anesthesia, and for dysphoria, unreality, facilities for assisted or also acts to obstetric analgesia dizziness, vertigo, floating controlled respiration cause during labor and feeling, feeling of heaviness, available in case of hallucinations delivery numbness, tingling, respiratory depression Prevention and flushing, warmth Reassure patient about and is an antagonist at treatment of EENT: blurred vision about addiction liability; mu receptors. intrathecal CV; hypotension, most patients who receive morphine-induced hypertension, bradycardia, opiates for medical pruritus after tachycardia reasons do not develop cesarean section DERMATOLOGIC: dependence syndromes. pruritus, burning, urticaria GI: nausea, vomiting, cramps, dyspepsia, bitter taste, dry mouth
NAME OF DRUG
CLASSIFICATION
INDICATION
ACTION
ADVERSE REACTION
NURSING RESPONSIBILITI ES
GENERIC NAME:
BISACODYL
LAXATIVE
BRAND NAME:
DULCOLAX
DOSAGE AND FREQUENC Y: Suppository
Constipation, Increases relief of peristalsis & evacuation in motor activity hemorrhoid of s, prep for the small barium intestines by enema, acting directly preoperative on the smooth and postmuscles operative
GI: Occasional Monitor abdominal frequency & discomfort, character of soreness in stool Monitor anal region occurrence of adverse reaction
NAME OF DRUG CLASSIFICATIO N
ACTION
INDICATION
ADVERSE REACTION
NURSING RESPONSIBILITIES Assess patient for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate Ranitidine may be added to total parenteral nutrition solution Instruct patient on proper use of OTC preparation as indicated. Remind patient to take once daily prescription drug at bedtime for best results Instruct patient to take without regard to meals because absorption isnt affected by food
GENERIC ANTI ULCER, NAME: ANTIHISTAMI RANITIDINE NE HYDROCHLORI DE BRAND NAME: ZANTAC DOSAGE AND FREQUENCY: 50 mg IV every 8 hours
Completely inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretions
Duodenal and gastric ulcers Maintenance therapy for gastric and duodenal ulcer GERD Erosive esophagitis Heartburn
CNS: vertigo, headache, malaise EENT: blurred vision HEPATIC: jaundice OTHER: burning and itching at injection site
NAME OF DRUG
CLASSIFICATI ON
ACTION
INDICATION
ADVERSE REACTION
GENERIC ANTINAME: INFECTIVE COAMOXICLAV BRAND NAME: CLAVULIN DOSAGE AND FREQUENCY : 1.2 grams IV q 8
Lower Inhibits CNS: lethargy, transpeptidase, respiratory tract hallucinations, anxiety, preventing infections, otitis confusion, agitation, cross-linking of media, sinusitis, depression, dizziness, bacterial cell skin and skinfatigue, hyperactivity, wall and leading structure insomnia, behavioral to cell death. infections, and changes, seizures (with Addition of urinary tract high doses) clavulanate (a infections (UTIs) GI: nausea, vomiting, beta-lactam) caused by increases drug's susceptible strains diarrhea, abdominal resistance to of gram-negative pain, stomatitis, beta-lactamase and gram-positive glossitis, gastritis, black "hairy" tongue, (an enzyme organisms furry tongue, Serious produced by enterocolitis, bacteria that infections and pseudomembranous may inactivate communityamoxicillin). acquired colitis pneumonia GU: vaginitis, Recurrent or nephropathy, persistent acute interstitial nephritis otitis media Hematologic: anemia, thrombocytopenia, thrombocytopenic purpura, leukopenia, hemolytic anemia, agranulocytosis, bone narrow depression, eosinophilia Hepatic: cholestatic hepatitis
Monitor patient carefully for signs and symptoms of hypersensitivity reaction. Monitor for seizures when giving high doses. Check patient's temperature and watch for other signs and symptoms of superinfection, especially oral or rectal candidiasis.
NAME OF DRUG
GENERIC NAME: CAPTOPRIL DOSAGE AND FREQUENCY: 25 mg SL
CLASSIFICATI ON
ACTION
INDICATION
ADVERSE REACTION
CNS: dizziness , fainting, headache, malaise, fatigue, fever CV: tachycardia, hypotension, angina pectoris GI: abdominal pain, anorexia, constipation, diarrhea, dry mouth, dysgeusia, nausea, vomiting HEMATOLOGIC: leucopenia, agranulocytosis, pancytopenia, anemia, thrombocytopenia METABOLIC: hyperkalemia RESPI: dyspnea, dry, persistent, nonproductive cough SKIN: urticarial rash, maculopapular rash, pruritus, alopecia OTHER: angioedema
Monitor patients blood pressure and pulse rate frequently. ALERT! Elderly patientsmay be more sensitive to drugs hypotensive effects. Assess patient for signs of angioedema. Drug causes the most frequent occurrence of cough compared with other ACE inhibitors. In patients with impaired renal function or collagen vascular disease, monitor WBC and differential counts before starting treatment, every 2 weeks for the first 3 months of therapy and periodically thereafter.
ANTIInhibits ACE, HYPERTENSIVE preventing DRUG conversion of
Hypertension Diabetic nephropathy angiotensin I to Heart failure angiotensin II, a Left ventricular potent dysfunction after vasoconstrictor. acute MI Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium and water retention and lowers blood pressure.
NAME OF DRUG
CLASSIFICATIO N
ACTION
INDICATION
ADVERSE REACTION
NURSING RESPONSIBILIT IES
GENERIC NAME: ASCORBIC ACID BRAND NAME: MORIAMIN DOSAGE AND FREQUENCY: 50 mg/tab OD
NUTRITIONA Stimulates L DRUG collagen formation and tissue repair, involve on oxidationreduction reaction
RDA CNS: Frank and faintness, clinical scurvy dizziness Extensive GI: diarrhea, burns, delayed heart burn, fracture and nausea, wound healing, vomiting postoperative wound healing, severe febrile or chronic disease state. To prevent Vitamin C deficiency To acidify urine
When giving for urine acidification, check urine pH to ensure efficacy. Do not take more ascorbic acid than what is prescribed or than is directed on the package.
DRUG NAME CLASSIFICA TION
ACTION
INDICATION
ADVERSE EFFECT
NURSING RESPONSIBILITY
Ketorolac tromethmine
short-term CNS: assess for durg allergies. Nonopioid Antiassess for history of renal analgesic inflammator management headache, NSAID y and of pain dizziness, impairment. analgesic Ophthalmi somnolence, be aware that patient may Dosage and activity c; relief of insomnia. be at increased risk for CV frequency: 30 inhibits ocular DERMATOLO events, GI bleeding, renal mg IV q 6 prostaglandi itching due GIC: rash toxicity, monitor accordingly. do not use during labor, ns and to seasonal GI: nausea, leokotriene conjunctivitis dyspepsia, Gi delivey, or while nursing. protect vials from light. synthesis. and relief of pain, administer every 6 hour to postoperative constipation inflammation GU: renal maintain serum levels and after cataract impairment control pain. surgery. HEMATOLOG every effort will be made to IC: bleeding administer the drug on time to RESPIRATOR control pain, dizziness, Y: dyspnea, drowsiness. do not use ophthalmic drops hemoptysis with contact lenses. Report sore throat, fever, rash, itching, swelling
DRUG NAME
CLASSIFICAT ACTION ION
INDICATION
ADVERSE EFFECT
Routine Generic oxytocic A partial CNS: name: agonist or management headache, Methylergon antagonist after delivery dizziness, of the ovine maleate at alphatinnitus, Brand receptors; as placenta diaphoresis Treatment CV: name a result, I :methergine increases he of postpartum hypertension, atony and strength, palpitations, hemorrhage chest pain, duration, Uterine Dosage and and dyspnea stimulation frequency: frequency ofduring the GI: nausea, 1 amp uterine second stage vomiting contractions of labor following the delivery of the anterior shoulder
assess for drug allergies. Administer by IM injection or orally unless emergency requires IV use Monitor postpartum women for BP changes and amount and character of vaginal bleeding Discontinue if signs of toxicity occur Avoid prolonged use of the drug Not needed for longer than 1 week Client may experience nausea, vomiting, dizziness and headache Report difficulty in breathing, headache, numb or cold extremities, severe abdominal cramping
DRUG NAME CLASSIFICA TION
ACTION
INDICATION ADVERSE EFFECT NURSING RESPONSIBILITY
Paracetamol Dosage and frequency: 300 mg/ IV q 4
Analgesic Antipyretic: Temporary CNS: headache, assess for drug allergies. antipyretic reduces fever reduction of CV: hypertension, Do not exceed the by acting fever, chest pain, recommended drug Reduce dosage with hepatic directly on the temporary dyspnea, hypothalamic reduction of myocardial damageimpairment heat-regulating minor aches GI: hepatic toxicity Avoid using multiple center to cause and pains and failure, preparations containing this vasodilation caused by jaundice drug and sweating, common cold GU: acute renal Give drug with food if GI which helps and influenza, failure upset occur dissipate heat head ache, sore HYPERSENSIIVI Discontinue drug if Analgesic: site throat, tooth TY: rash,feer hypersensitivity reaction occur Report rash, bruising and ache, back mechanism of ache, menstrual action unclear cramp, minor arthritis pain and muscle aches
DRUG NAME CLASSIFIC ATION
ACTION
INDICATION
ADVERSE EFFECT
Hydralazine
Assess for drug Antihypert Acts directly Oral: essential CNS: ensive on vascular hypertension headache, hypersensitivity Give oral drug with food to vasodilaor smooth alone or in CV: muscle to combination palpitations, increase ioavailability cause with other tachycardia, Use parenteral drug vasodilation, drugs hypotension immediately after opening primarily Parenteral: GI: anorexia, ampule Withdraw drug gradually, anteriolar, severe vomiting, decreasing essential nausea, especially when patients who peripheral hypertension diarrhea have experienced marked BP resistance; when drug GU: reduction Discontinue or reevaluate maintains or cannot be impotence increase renal given orally HYPERSENS therapy if patient develops and cerebral or when need IIVITY: rash, symptoms of peripheral blood flow to lower BP is fever, chills, neuritis Take this drug exactly as urgent hepaitis prescribed Client may experienced dizziness, weakness Report persistent or severe constipation, malaise, muscle aching, numbness
DRUG NAME CLASSIFIC ATION
ACTION
INDICATION Preprocedural sedation. Aids in the induction of anesthesia and as part of balanced anesthesia.
ADVERSE NURSINGRESPONSIBILIT EFFECT Y Hypersensitivit Assess level of sedation and y level of consciousness Chronic throughout and for 2-6 hr respiratory following administration. insufficiency Monitor BP, pulse and respiration continuously during IV administration. Oxygen and resuscitative equipment should be immediately available. If overdose occurs, monitor pulse, respiration , and BP continuously. Maintain patent airway and assist ventilation as needed. If hypotension occurs, treatment includes IV fluids, repositioning and vasopressors. The effects of midazolam can be reversed with flumazenil (Romazicon).
MEDAZOL- Anti-anxiety Short-term AM agents sedation Sedative/hypn Postoperative otics anesthesia Dosage: 1 gram
DRUG
CLASSIFICATI ON
ACTION
INDICATION
ADVERSE EFFECT
GENERIC Diuretics NAME: SPINOROLAC TONE BRAND NAME: Aldactone, Novospiroton , Spiractine
To enhance Potassium- Edema CNS: sparing Hypertension headache, absortion give drug diuretics, Diuretic drowsiness, with meals Protect drug form antagonizes induced lethurgy, aldosteronei hypokalemia confusion, light Monitor n the distalTo detect ataxia tubules, primary GI: diarrhea, electrolytes level, increase aldosteronism gastric fluid intake and soduim andTo manage bleeding, output, weght, and water primary ulceration, BP Inform laboratory secretions aldosteronism cramping Heart failure gastritis, that patient is taking as adjunct to vomiting spinorolactone ACE inhibitor GU: inability because drug may or loop to maintain interfere with test diuretics, with erection, that measure or wothout menstrual digoxin level cardiac disturbances Watch for glycosides HEMATOLOG hyperchloremic Hirsutism in Y: metabolic acidosis, woman agranulocyto which may occur Premenstrual sis during therapy, syndome SKIN: especially in patients Acne vulgaris urticaria, with hepatic hirsutism, cirrhosis. maculopapul Instruct patient to
dose and route: Co-Amoxiclav 625mg/tab 1 tab 3x a day for 1 week Mefenamic Acid 500mg/cap 1 cap 3x a day for pain Fe Fumarate and Vit. B Complex 1 cap 2x a day EXERCISE Advised to have light exercises as tolerated and encouraged to ambulate. TREATMENT Informed patient about the purpose, actions and side effects of the medications given to her. Explained to her the importance of taking her medications to her health and instructed her to continue her medications at home. HYGIENE Advised patient to maintain proper hygiene like oral care such as gurgling and brushing of teeth every after meals, cleaning of ears at least 23 times a week, and cut her nails once a week. Advised her to take a bath daily and do hand washing. Wash her breast thoroughly before feeding the baby. OPD Advised patient for her follow up check-up on August 16, 2010 at the OPD ward of CVMC. DIET Emphasized to the patient the importance of DAT diet in promoting her health status. Advised patient to eat 3 times daily and not to skip meals, eat nutritious foods such as fruits and vegetables. Encouraged also patient to increased fluid intake to prevent dehydration. SPIRITUAL Encouraged patient to attend the mass every Sunday and to pray

Preeclampsia

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Preeclampsia

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CASE PRESENTATION ON PREECLAMPSIA

Objectives Introduction Statistics Patients Profile Nursing Health History

Pathophysiology Nursing Care Plan Drug Study Discharge Plan

Cardinal signs: hypertension proteinuria edema

CLASSIFICATIONS OF PRE ECLAMPSIA

1.Gestational Hypertension Manifestations: BP of 140/90 mmHg No proteinuria No edema

2. Mild Preeclampsia Manifestations:

BP of 140/90 mmHg 1+ to 2+ proteinuria on a random sample or reagent strip test

D. Eclampsia It causes seizures. These seizures

Urinary tract infection Renal disease Diabetes

The concentration of urinary

C. Blood urea nitrogen (BUN) and serum creatinine

D. Liver function tests: Liver enzymes (AST, ALT, LDH, Bilirubin)

1. Alanine transaminase (ALT) - ALT is raised

1. Bilirubin is a breakdown product of

Nursing Responsibility 1. Explain and instruct patient about the

Minimize external stimuli; promote rest and

Incidence rate Preeclampsia in North America

Britain (United Kingdom) France Germany

32,422 32,504 44,339 Preeclampsia in Asia

60,270,708 for UK2 60,424,2132 82,424,6092

China India Indonesia

698,703 572,945 128,273 Preeclampsia in Eastern Europe

1,298,847,6242 1,065,070,6072 238,452,9522

Russia Ukraine Uzbekistan

77,449 25,677 14,207

143,974,0592 47,732,0792 26,410,4162

Population Estimated Used

CAGAYAN VALLEY MEDICAL CENTER

NURSING HEALTH HISTORY

GORDONS 11 FUNCTIONAL PATTERN

Gordons 11 Functional Pattern

HEALTH PERCEPTIONHEALTH MANAGEMENT PATTER

Gordons 11 Functional Pattern

COGNITIVE PERCEPTUAL PATTERN

SLEEP- REST PATTERN

Gordons 11 Functional Pattern

SELF PERCEPTIONSELF CONCEPT PATTERN ROLERELATIONSHIP PATTERN

Gordons 11 Functional Pattern

COPING STRESS PATTERN

VALUE- BELIEF PATTERN

METHOD USED Inspection

Due to presence of edema

Frequency Inspection 15 to 20 18 blinks/ of blink blinks/ min min

Ability to purse lips Buccal Mucosa

Moist, smooth, soft and glistening; pink in color

Moist, smooth, soft and glistening; pink in color

THORAX AND LUNGS

Percussion sound Chest expansion

BronchoBronchovesicular vesicular breath sound breath sound

Abdominal contour Ascites

Heart rate Precordium

Auscultation Inspection, Auscultation and palpation

Regular, 60100 bpm

Full ROM without pain

Has difficulty moving

Has difficulty moving her lower extremities (+) edema

Inspection and Palpation

Due to increased tubular reabsorption of sodium Normal

Present, equal Present, equal

9-72 U/L 313-618 U/L

22 U/L 798 U/L