Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student Group 3________________________________ Clinical Instructor Prof. Norhanie Ali, LPN, RN________________

Area of Assignment OB Virtual Duty Date Submitted June 3, 2021_____________________________

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name Rachel Address (Not Taken) Age 30 y/o ______

Sex Female Religion (Not Taken) Civil Status (Not Taken) Occupation (Not Taken)

HABITS Frequency Amount Period/Duration

1. Tobacco x x x
2. Alcohol x x x
3. OTC-drugs/ non-prescription drugs _______________ _______ ______
(Paracetamol)

A. CHIEF COMPLAINTS:

Ankle oedema, abdominal pain & headache

B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational
responsibilities, affected diagnoses}.

A case of a pregnant woman 30 years old who is having her first baby who has an onset headache and abdominal pain, and shown swollen ankle. Patient is asthmatic, no
allergies, and eye vision are described as bit blurry. COVID 19 status is unknown.

C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for pedia)

Patient mentioned while the assessment is going on that she is asthmatic.

FAMILY HISTORY WITH GENOGRAM

(Not Mentioned)

Acquired Diseases: Heredo- familial Diseases:

Hypercholesterolemia Diabetes
Kidney Disease Heart Diseases
Tuberculosis Hypertension
Alcoholism Cancer
Drug Addiction Asthma X
Hepatitis A Epilepsy
B Mental Illness
C Rheuma/Arthritis
Others (pls. specify) Others (pls. specify)
 REVIEW OF SYSTEMS

Name Rachel Date June 2, 2021 BMI (Not Taken)_________

Vital Signs: Height (Not Taken)
Temperature 36.3oC _______ Weight (Not Taken)
Pulse 84 bpm (Apical) Observation SpO2 = 99%; FHR =_130 bpm; SFH = 36 cm;_____________
Respiration 20 brpm _______ Swollen Ankle, discomfort
Blood Pressure 165/110 mmHg_

Sample patient Assigned Case

1.GENERAL Received patient, conscious, pale, in supine position. Patient has chief complaint Symptoms of patient with pre-eclampsia are elevated blood
of headache, abdominal pain, and ankle oedema. Patient has vision problems. pressure, swelling specific body parts usually body extremities,
Patient is asthmatic and COVID-19 status is unknown. Patient has severe headaches, excessive weight gain, nausea and vomiting, vision
hypertension. Patient has seizures for 30 seconds at 11:31 am. Blood test and problems, difficulty urinating, and abdominal pain.
urine test are on progress, and COVID-19 status is unknown.

H- Head is normocephalic, with thin and short brownish hair. H- Head is normocephalic, and normal head features.
E- Eyes vision are bit blurry and shows visual disturbance. E- Vision problem
E- Ears are symmetric in shape on both sides, no lesions noted. No cerumen, and E- Ears are symmetric in shape on both sides, no lesions noted. No
2. HEENT no other discharges. cerumen, and no other discharges.
N- -No presence of skin redness, lesions, pus and blood. And No inflammation N- -No presence of skin redness, lesions, pus and blood. And No
noted. inflammation noted.
T- Normal size tonsils, pinkish in color. No swelling and no dysphagia. T- Normal size tonsils, pinkish in color. No swelling and no
dysphagia.

3. INTEGUMENTARY Patient shows an ankle oedema and pale skin. Patient has swollen part of body, face or body extremities.
4. RESPIRATORY Patient experiences productive abdominal pain and headache. Substernal and subcostal retractions. Respiratory rate of 20 brpm.

5. CARDIOVASCULAR Pulse palpated on apical area, with a pulse rate of 84 bpm. Heart sounds are clear and normal. But later shows decreased of cardiac output as
evidence by the elevated and severe hypertension.

6. DIGESTIVE Patient is eating normally eating for three times in a day. Patient has appetite. Normal bowel sounds. Excessive weight gain.

7. EXCRETORY Possible of excess protein in urine and damage the kidney’s filter and its function.

8. MUSCULOSKELETAL Patient’s legs and knee felt pain as evidenced by reflex hammer test.

Patient is awake and conscious to time and place. Smell and taste were assessed to patients’ condition. Eyes, Skin, and Ears:. Patient’s pupils are
9. NERVOUS reflective to light but has a bit blurry vision, 3 blinks per minute. Patient had seizures or eclampsia fit which affects brain.

10. ENDOCRINE No enlargement and inflammation of glands. Normal hair growth.

 DRUG STUDY

Prescribed and
BRAND NAME Mechanism
Recommended
GENERIC NAME Of Indication Contraindication Adverse Reaction Nursing Responsibilities
dosage, frequency, route
CLASSIFICATION Action
of administration
Generic name: Laxative The mechanism of action Orally to relieve acute Myocardial damage; Body as a Whole: Observe constantly when
magnesium sulfate Adult: PO 10–15 g of magnesium sulfate is constipation and to heart block; cardiac Flushing, sweating, given IV. Check BP and
Brand name: Epsom Salt once/d thought to trigger evacuate bowel in arrest except for certain extreme thirst, sedation, pulse q10–15 min or
Classification: Preeclampsia, cerebral vasodilation, preparation for x-ray of arrhythmias; IV confusion, depressed more often if indicated.
Gatrointestinal agent; Eclampsia thus reducing ischemia intestines. Parenterally administration during reflexes or no reflexes, Lab tests: Monitor
anticonvulsant Adult: IM/IV 4 g in 250 generated by cerebral to control seizures in the 2 h preceding muscle weakness, flaccid plasma magnesium levels
mL D5W infused slowly, vasospasm during an toxemia of pregnancy, delivery; PO use in paralysis, hypothermia. in patients receiving drug
followed by 4–5 g IM in eclamptic event. The epilepsy, and acute patients with abdominal CV: Hypotension, parenterally (normal:
alternate buttocks q4h substance also acts nephritis and for pain, nausea, vomiting, depressed cardiac 1.8–3.0 mEq/L).
Hypomagnesemia competitively in blocking prophylaxis and fecal impaction, or function, complete heart Early indicators of
Seizures the entry treatment of intestinal irritation, block, circulatory magnesium toxicity
Adult: IM/IV Mild, 1 g of calcium into hypomagnesemia. obstruction, or collapse. include cathartic effect,
q6h for 4 synaptic endings, Topically to reduce perforation. Respiratory: Respirator y profound thirst, feeling
doses; Severe, 250 thereby altering edema, inflammation, paralysis. of warmth, sedation,
mg/kg infused over 4 h neuromuscular and itching. confusion, depressed
Child: IV 20–100 mg/kg transmission. deep tendon reflexes,
q4–6h prn and muscle weakness.
Total Parenteral Monitor respiratory rate
Nutrition closely.
Adult: IV 0.5–3 g/d Check urinary output.
Observed newborns of
mothers.

Generic name: oxytoxin Antepartum Synthetic, watersoluble Pitocin is indicated to Hypersensitivity to Body as a Whole: Fetal Start flow charts to
Brand name: Pitocin Adult: IV Start at 1 polypeptide consisting of produce uterine oxytocin; significant trauma from too rapid record maternal BP and
Classification: Oxytoxic mU/min, may increase eight amino acids, contractions du ring the cephalopelvic propulsion through other vital signs, I&O
by 1 mU/min q15min identical third stage of labor and disproportion, pelvis, fetal death, ratio, weight, strength,
(max: 20 mU/min) pharmacologically to the to control postpartum unfavorable fetal anaphylactic reactions, duration, and frequency
Postpartum oxytocic principle of bleeding or hemorrhage. position or postpartum hemorrhage. of contractions, as well
Adult: IV Infuse a total of posterior pituitary. presentations that are CV: Fetal bradycardia as fetal heart tone and
10 U at a rate of 20–40 undeliverable without and arrhythmias, rate, before instituting
mU/min after delivery conversion before maternal cardiac treatment. Monitor fetal
 To Promote Milk delivery, obstetric arrhythmias, heart rate and maternal
Ejection emergencies in which hypertensive episodes, BP and pulse at least
Adult: Nasal 1 spray or 1 benefit-to-risk ratio for subarachnoid q15min during infusion
drop in 1 or both nostrils mother or fetus favors hemorrhage, increased period; evaluate tonus of
2–3 min before nursing surgical intervention, blood flow, fatal myometrium during and
or pumping fetal distress in which afibrinogenemia, between contractions
delivery is not imminent, Endocrine: ADH effects and record on flow chart.
prematurity, placenta leading to severe water Stop infusion to prevent
previa. intoxication and fetal anoxia, turn patient
hyponatremia, on her side, and notify
hypotension. physician if contractions
CNS: Fetal intracranial are prolonged.
hemorrhage, anxiety.
Respiratory: Fetal
hypoxia, maternal
dyspnea.

Nifedipine Classification 40 mg IV PRN Inhibits calcium Management of: Contraindicated in: CNS: headache, •Monitor BP and pulse
Therapeutic: transport into Hypertension (extended- Hypersensitivity; Sick abnormal dreams, before therapy, during
antianginals, myocardial and vascular release only), Angina sinus syndrome; 2nd- or anxiety, confusion, dose titration, and
antihypertensives smooth muscle cells, pectoris, Vasospastic 3rd-degree AV block dizziness, drowsiness, periodically during
Pharmacologic: calcium resulting in inhibition of (Prinzmetal’s) angina. (unless an artificial jitteriness, nervousness, therapy. •Monitor intake
channel blockers excitation-contraction Unlabeled Uses: pacemaker is in place); psychiatric disturbances, and output ratios and
Pregnancy Category coupling and subsequent Prevention of migraine Systolic BP <90 mm Hg; weakness. EENT: blurred daily weight. •Angina:
contraction. Therapeutic headache. Management Coadministration with vision, disturbed Assess location, duration,
Effects: Systemic of HF or cardiomyopathy. grapefruit juice, rifampin, equilibrium, epistaxis, intensity, and
vasodilation, resulting in rifabutin, phenobarbital, tinnitus. Resp: cough, precipitating factors of
decreased BP. Coronary phenytoin, dyspnea, shortness of patient’s anginal pain.
vasodilation, resulting in carbamazepine, or St. breath. CV: •Lab Test
decreased frequency and John's wort. ARRHYTHMIAS, HF, Considerations: Total
severity of attacks of peripheral edema, serum calcium
angina. ROUTE/DOSAGE PO: concentrations are not
(Adults ): 10–30 mg 3 affected by calcium
times daily (not to channel blockers.
exceed 180 mg/day), or •Monitor serum
10–20 mg twice daily as potassium periodically.
immediate—release Hypokalemia increases
form, or 30–90 mg once risk of arrhythmias;
daily as sustained- should be corrected.
release (CC, XL) form (not
 to exceed 90–120
mg/day).

Paracetamol Adult 500-1,000 mg 4-6 Used to relieve pain and Symptomatic Nephrotoxicity. Haematological reactions Assess patient for history
Analgesics (Non-Opioid) hr. Max: 4,000 mg fever. management of pain & including of liver disease or alcohol
& Antipyretics daily. Childn 6-12 yr 250- fever associated w/ thrombocytopenia, abuse.
Belongs to the class of 500 mg, 1-5 yr 120-250 common childhood leukopenia &
anilide preparations. mg, 3 mth-1 yr 60-120 disorders, tonsillitis, methemoglobinemia
mg, <3 mth 10 mg/kg. upper resp tract resulting to cyanosis.
infections, post Renal damage in long-
immunization reactions term use. Skin rashes &
& other conditions other hypersensitivity
including prevention of reactions.
febrile convulsion. Short
term management of OA
of the knee & suitable
substitute for patients
sensitive to aspirin.

Hydralazine Intravenous Description: Hydralazine Used in the treatment of Idiopathic systemic lupus Significant: SLE-like Monitor blood pressure
Belongs to the class of Adult: Initially, 5-10 mg is a direct-acting hypertension. erythematosus (SLE) and syndrome, blood and heart rate; CBC and
hydrazinophthalazine via slow inj, may repeat vasodilator which acts related diseases, severe dyscrasias (e.g. reduction antinuclear antibody
derivatives. after 20-30 minutes if predominantly on the tachycardia, heart failure in Hb and RBC count, (ANA) titer prior to
necessary. Alternatively, arterioles. The exact associated with high leucopenia, therapy and periodically
via infusion at a rate of mechanism of action is cardiac output(e.g. agranulocytosis, thereafter; urine analysis
0.2-0.3 mg/min. unknown, but it is thyrotoxicosis), purpura), postural at intervals of approx 6
Maintenance: 0.5-0.15 thought to exert its myocardial insufficiency hypotension, peripheral months during long-term
mg/min. vasodilating effect due to mechanical neuritis, anginal attacks, treatment.
Oral through direct relaxation obstruction (e.g. aortic or ECG changes.
Congestive heart failure of vascular smooth mitral stenosis or Cardiac
Adult: In combination muscle by inhibition of constrictive pericarditis), disorders: Tachycardia,
with nitrate: Initially, 25 Ca release from the cor pulmonale, dissecting palpitation.
mg 3-4 times daily, may sarcoplasmic reticulum aortic aneurysm, Gastrointestinal
increase dose every 2 and inhibition of myosin coronary artery disease disorders: Diarrhoea,
days if necessary. phosphorylation in the (CAD), mitral valvular nausea, vomiting,
Maintenance: 50-75 mg arterial smooth muscle rheumatic heart disease, paralytic ileus,
4 times daily. cells. porphyria. constipation.
Oral Onset: 10-80 minutes Metabolism and
Hypertension (IV). nutrition
Adult: In combination Duration: Up to 12 hours disorders: Anorexia,
with ß-blockers and (IV/IM). oedema.
diuretics: Initially, 25 mg Pharmacokinetics: Musculoskeletal and
bid, increase gradually Absorption: Rapidly connective tissue
according to response. absorbed from the disorders: Arthralgia,
Max: 200 mg daily. gastrointestinal tract. joint swelling, myalgia.
Bioavailability: Approx Nervous system
22-69%, depending on disorders: Headache,
acetylator status. Time to dizziness.
peak plasma Renal and urinary
concentration: 1-2 hours disorders: Reduced
(oral). urinary volume.
Distribution: Crosses Vascular
placenta, enters disorders: Flushing,
breastmilk (small orthostatic hypotension.
amounts). Plasma
protein binding: 87%.
Metabolism: Undergoes
extensive first-pass
metabolism in the liver
via acetylation.
Excretion: Via urine as
metabolites. Elimination
half-life: 3-7 hours.
 NURSING ASSESSMENT II

Name Rachel Age 30 y/o____ Sex Female ____

Inclusive Dates of Care _ _

NORMAL PATTERN CLINICAL APPRAISAL

Day 1 Day 2 DAY 3 DAY 4

1.ACTIVITIES- REST Patient spends most of her time on Patient spends most of her time on Patient was active and conscious. Patient was active and conscious.
a. Activities bed because of her headache. Pt. bed because of her circumstances. Patient has been at bed at rest and Patient has been at bed at rest and
b. Rest can sometimes communicate with Pt. can sometimes communicate sleep from time to time. sleep from time to time.
c. Sleeping pattern the health care provider. Pt.’s with the health care provider. Pt.’s
sleeping pattern is no mentioned. sleeping pattern is is not mentioned.

2.NUTRITIONAL- METABOLIC
a. Typical intake(food, fluid) Patient has restrictions with fluid Patient has restrictions with fluid Patient has restrictions with fluid Patient has restrictions with fluid
b. Diet and has limitations with food intake. and has limitations with food intake. and has limitations with food intake. and has limitations with food intake.
c. Diet restrictions No supplement food given to the No supplement food given to the No supplement food given to the No supplement food given to the
d. Weight patient. patient. patient. patient.
e. Medications/supplement
food

3. ELIMINATION
a. Urine (frequency, color, Urine characteristics are normal and Urine samples has been taken to Frequent urination, and color is pink Frequent urination, and color is pink
transparency) has no unusualties reported by the test. or cola-colored. or cola-colored.
patient.
The patient bowel inflammation and The patient bowel inflammation and
b. Bowel (frequency, color, Bowel characteristics are normal The patient bowel inflammation and has defecated during the shift, the has defecated during the shift, the
consistency) and has no unusualties reported by has defecated during the shift, the stool is slightly watery and yellow stool is slightly watery and yellow
the patient. stool is slightly watery and yellow brown in color. brown in color.
brown in color.
4. EGO INTEGRITY
a. Perception of self The patient is irritable and has visual The patient is irritable and has visual The patient was calmed and when The patient was calmed and when
b. Coping Mechanism disturbance due to discomfort. disturbance due to discomfort. every time she feels uncomfortable, every time she feels uncomfortable,
c. Support System she used to call health care provider she used to call health care provider
d. Mood/Affect to inform them. to inform them

5. NEURO-SENSORY
a. Mental state Patient was active and there were Patient is sleeping most of the time. Patient is sleeping most of the time. Patient is sleeping most of the time.
no mental abnormalities seen on
the patient.

b. Condition of five senses: Patient had no impairment on her Upon assessment, patient has blurry Upon assessment, patient has blurry Upon assessment, patient has good
(sight, hearing, smell, taste, five senses and it is developing well sight, and good hearing and touch sight, and good hearing and touch sight, and good hearing and touch
touch) and functioning well senses. Smell and taste are working senses. Smell and taste are working senses. Smell and taste are working
well. She eats well and always well. She eats well and always well. She eats well and always
hungry. hungry. hungry.

6. OXYGENATION Not Taken T= 36.3oC Not taken T= 36.8oC

a. Vital signs Not Taken HR= 84 bpm 20 cpm HR= 91 bpm
Temperature Not Taken RR = 20 brpm 84 bpm RR = 20 brpm
Respiratory rate Not Taken BP = 165/110 mmHg 120/80 BP = 110/80 mmHg
Heart rate Not Taken SpO2 = 99% Not taken SpO2 = 998%
Blood pressure Not Taken FHR = 130 bpm Normal breath sounds FHR = 130 bpm
b. Lung sounds Not Taken SFH = 36 cm SFH = 36 cm
c. History of Respiratory Not Taken Respiration problem due to seizure Respiration problem due to seizure
Problems occurred 30 seconds. occurred 30 seconds.

7. PAIN-COMFORT
a. Pain (location, onset, Headache occurred but patient Headache and abdominal pain. Pain Pain has been relieved. Pain has been relieved.
character, intensity, didn’t reported. scale was not mentioned.
duration,
associated symptoms,
aggravation)
 b. Comfort Irritable due to headache. Irritable and discomfort due to Patient is comfortable. Patient is comfortable.
measures/Alleviation headache and abdominal pain.

c. Medications No medication taken for headache. Paracetamol and IV analgesics has No medication. No medication.
been given.

8. HYGIENE AND ACTIVITIES Patient is bathed and changes her She has been provided with bed Bat. She has been provided with bed Bat. She has been provided with bed Bat.
OF DAILY LIVING clothes every day. Patient’s spends Patient spends most of her time on Patient spends most of her time on Patient spends most of her time on
most of the day sleeping but when bed and sleeps most of the time bed and sleeps most of the time bed and sleeps most of the time
awake, she felt uncomfortable because of her present condition. because of her present condition. because of her present condition.

9. SEXUALITY

a. female (menarche, menstrual 30 years old preganant woman with 30 years old preganant woman with 30 years old preganant woman with 30 years old preganant woman with
cycle, civil status, number of 39 weeks of gestation. 39 weeks of gestation. 39 weeks of gestation. 39 weeks of gestation.
children, reproductive status) Last menstrual cycle was 11-12 Need cesarian section due to pre
months ago. eclampsia.
b. male (circumcision, civil
status, number of children)
 ANATOMY AND PHYSIOLOGY

THE CIRCULATORY (CARDIOVASCULAR) SYSTEM

 The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body andpick up waste materials and toxins for
elimination. This system is made up of the heart, theveins, the arteries, and the capillaries.
 Circulation is achieved by a continuous one-way movement of blood throughout the body. Thenetwork of blood vessels that flow
through the body is so extensive that blood flows withinclose proximity to almost every cell.
HEART
The heart is a muscular pump that propels blood throughout the body. The heart is locatedbetween the lungs, slightly to the left of
center in the chest. The heart is broken down intofour chambers including:
 The right atrium, which is a chamber which receives oxygen- poor blood from the veins.
 The right ventricle which pumps the oxygen-poor blood from the right atrium to the lungs.
 The left atrium which receives the now oxygen-rich blood that is returning from the lungs.
 The left ventricle, which pumps the oxygenated blood through the arteries to the rest of the body.
Blood Vessels
Blood vessels are broken down into three groups: the arteries which carry blood out of theheart to the capillaries, the veins which
transport oxygen-poor blood back to the heart, andthe capillaries which transfer oxygen and other nutrients into the cells and removes
carbondioxide and other metabolic waste from these body tissues.
Blood Pressure
Blood pressure is the force exerted by the blood against the walls of the blood vessels. Theoutput or direct pumping of the heart and the resistance to blood flow in the
vesselsdetermines blood pressure. Resistance is determined by blood viscosity and by friction
1. 5. between the blood and the wall of the blood vessel.Blood pressure = blood flow x resistance.

FEMALE REPRODUCTIVE SYSTEM

 The female reproductive system is made up of the internal and external sex organs that functions in reproductions of new
offspring. In the human the female reproduction is immature at birth and develops to maturity and puberty to be able to produce
gametes, and to carry fetus full term.

The Internal sex organs

• Uterus or womb - is a hollow, pear shapes organs that is the home to developing fetus.

• Fallopian tube – these are narrow tubes are attached to the upper part of the uterus and searve as tunnels for the ova.

• Ovaries – a small. The oval shaped glands that are located either side uterus.

The External sex organs

• Labia majora – the labia majora enclosed and protect the other external reproductive organs.

• Labia minora – literally translated as small lips, the labia minora can be very small or up inches wide.

• Clitoris – the two labia minora meet at the clitoris.

• Vaginal opening – also called the vaginal vestibule or intoitus, is the opening into the vaginal.
 MEDICAL MANAGEMENT

Ideal: Delivery of the Baby

The most effective treatment for preeclampsia is delivery. Woman is at increased risk of seizures, placental abruption, stroke and possibly severe bleeding until the blood pressure decreases. If
it's too early in your pregnancy, delivery may not be the best thing for the baby.

Expedited birth is generally indicated in severe pre-eclampsia or in a fetus of greater than 37 weeks gestation. An attempt may be made to defer birth at very early gestations around the limits
of viability. Mode of birth/delivery: will depend on maternal and fetal factors (gestation, presentation); will require multidisciplinary consultation; if the fetus is <34 weeks gestation, and
maternal condition stable, consider deferring delivery to allow time for steroids to be administered: and if induction of labor is undertaken with oxytocin/ARM, an oxytocin infusion must be
delivered in a concentrated dose via a syringe driver pump.

Second stage management: Operative birth is not routinely required for the second stage but may be necessary if the BP is poorly controlled, woman has symptoms of severe cerebral
irritability, or progress is inadequate.

Third stage management should be actively managed: oxytocin 10 IU bolus IV for third stage

Postpartum Immediate Management

Most women will show signs of recovery within the first 24 hours of delivery; however a minority will remain unstable or deteriorate after delivery. As the majority of eclamptic seizures occur
after the birth, close monitoring should therefore continue until the BP is stable, diuresis has occurred and urine output has normalized, and blood investigations (FBE, LFT’s, U and Es) are
stable/improving.
 NURSING MANAGEMENT

Ideal:
Assessment
Assessment for delivery starts at the second stage of labor, which is the full cervical dilatation until the birth of the baby. This would be a crucial time since the mother would need to deliver her
baby at this stage without any troubles and with her strength intact so she could push for a normal vaginal delivery.
 Assess the vital signs including pulse oxygen level.
 Assess her breathing techniques if they are effective or could add to the difficulty that the mother might be experiencing.
 Assess the fetal heart sounds to make sure that there is no occlusion in the cord th
 at could hinder fetal circulation.
 Assess if the environment is comfortable for both the mother and the baby.
 Assess the level of consciousness.
 Assess for the presence of edema.
 Assess for headache and visual disturbances.
 Assess for epigastric pain, it should occur every 8 hours.
 Assess the intake and output, it should be monitored hourly.

Diagnosis
Pre-eclampsia is a multi-system disorder unique to human pregnancy characterized by hypertension and involvement of one or more other organ systems and/or the fetus. Raised blood
pressure is commonly, but not always, the first manifestation. Proteinuria is the most commonly recognized additional feature after hypertension but should no longer be considered mandatory
to make the clinical diagnosis.
 Risk for developing pre-eclampsia related to increase cardiac output as evidence by BP of 165/100mmHg, a severe headache, and visual blurring.

Planning
 Invasive monitoring of BP and V/S useful for severe pre-eclampsia.
 Maintain a strict fluid chart.
 Careful fluid balance is aimed at avoiding fluid overload.
 Prepare DR/OR since delivery might happen at any time.
 Closely monitor the fetal heart rate and sounds.

Implementation
Now that the care plan is already established, time to take some action and implement those interventions listed on your cheat sheet.
 SURGICAL MANAGEMENT

There is no surgical treatment for preeclampsia. A cesarean section delivery is used when: A rapid delivery is medically needed for the mother's or baby's well-being or survival.

• Cesarian delivery (C-section) is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Increased cardiac output:  Maintain or enhance Get an assist and help from To review the patient due to  BP within acceptable
Patient verbalized, “I feel elevated blood pressure of cardiovascular Obstetric Registrar increase of blood pressure limits for individual.
really strange and not 165/110 mmHg related to functioning.  Cardiovascular and
myself”. vasospasm  Prevent INDEPENDENT: systemic
complications. Measure and Monitor the Serial measurements using complications
OBJECTIVE CUES:  Provide information blood pressure of the patient. correct equipment provide a prevented or
Px has ankle oedema, about disease more complete picture of minimized.
headache, and abdominal process, prognosis, vascular involvement and  Disease process,
pain. Px is asthmatic. Px is in and treatment scope of problem. prognosis, and
discomfort. Px had regimen. Progressive diastolic readings therapeutic regimen
uncomplicated pregnancy. Px  Support active client above 120 mm Hg are understood.
showed increase of Blood control of condition. considered first accelerated,  Necessary lifestyle or
Pressure. then malignant (very severe). behavioral changes
Systolic hypertension also is initiated.
V/S Recorded: an established risk factor for  Patient deliver the
T= 36.3oC cerebrovascular disease and baby without or with
HR= 84 bpm ischemic heart disease even maximized control of
RR = 20 brpm when diastolic pressure is not condition.
BP = 165/110 elevated.  Plan in place to meet
SpO2 = 99% needs after
FHR = 130 bpm Note presence and quality of Bounding carotid, jugular, discharge.
SFH = 36 cm central and peripheral pulses. radial, and femoral pulses
may be observed and
palpated. Pulses in the legs
and feet may be diminished,
reflecting effects of
vasoconstriction and venous
congestion.

Auscultate heart tones and S4 is commonly heard in

breath sounds. severely hypertensive clients
because of the presence of
atrial hypertrophy.
Development of S3 indicates
ventricular hypertrophy and
impaired cardiac functioning.
 Presence of crackles or
wheezes may indicate
pulmonary congestion
secondary to developing or
chronic heart failure.

Observe skin color, moisture, Presence of pallor; cool,

temperature, and capillary moist skin; and delayed
refill time. capillary refill time may be
due to peripheral
vasoconstriction or reflect
cardiac decompensation and
decreased output.

Note presence and location Indicates heart or kidney

of edema. failure or vascular
impairment.

Provide calm, restful Helps reduce sympathetic

surroundings, minimize stimulation and promotes
environmental activity and relaxation.
noise. Consider limiting the
number of visitors or length
of visitation.

Maintain activity restrictions Reduces physical stress and

during crisis situation such as tension that affect BP and the
bedrest or chair rest and course of hypertension.
schedule periods of
uninterrupted rest; assist
client with self-care activities
as needed.

Provide comfort measures, Decreases discomfort and

such as back and neck may reduce sympathetic
massage or elevation of head. stimulation.

Instruct in relaxation Can reduce stressful stimuli

techniques, guided imagery, and produce calming effect,
and distractions. thereby reducing BP.
Monitor response to Response to drug therapy is
medications that control BP dependent on both the
after 30 mins. individual drugs and their
synergistic effects. Because of
potential side effects and
drug interactions, it is
important to use the smallest
number and lowest dosage of
medications possible.

COLLABORATIVE:
Administer Nifedipine 10 mg Calcium channel blockers
capsule. primarily affect blood vessels
and can be used to treat
severe hypertension when a
combination of a diuretic and
a sympathetic inhibitor does
not sufficiently control BP.

Administer Hydralazine 4mg To lower the severe

IV repeat in 15 minutes. hypertension.

Implement dietary Limiting sodium and sodium-

restrictions, as indicated, rich processed foods can help
such as reducing calories and manage fluid retention and,
avoiding refined with associated hypertensive
carbohydrates, sodium, fat, response, decrease
and cholesterol. myocardial workload. A diet
rich in calcium, potassium,
and magnesium may help
lower BP.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Risk for Trauma/Suffocation  Prevent or control MANAGEMENT: Minimizes injury should  Seizure activity
None related to Eclampsia fit or seizure activity. Keep padded side rails up frequent or generalized controlled.
seizure.  Protect client from with bed in lowest position, seizures occur while client is  Complications and
OBJECTIVE CUES: injury. or place bed up against wall, in bed. injury prevented.
Px has ankle oedema,  Maintain airway and and add floor pad if rails are  Capable, competent
headache, and abdominal respiratory function. not available or appropriate. self-image displayed.
pain. Px is asthmatic. Px is in  Promote positive self-  Disease process,
discomfort. Px had esteem. Maintain strict bed rest if Client may feel restless, need prognosis,
uncomplicated pregnancy up  Provide information prodromal signs or aura is to ambulate or even defecate therapeutic regimen,
until now. about disease experienced. Explain during aural phase, thereby and limitations
process, prognosis, necessity for these actions. inadvertently removing self understood.
V/S Recorded: and treatment needs. from safe environment and  Plan in place to meet
T= 36.3oC easy observation. needs after
HR= 84 bpm Understanding importance of discharge.
RR = 20 brpm providing for own safety
BP = 165/110 needs may enhance client
SpO2 = 99% cooperation.
FHR = 130 bpm
SFH = 36 cm Stay with client during and Promotes client safety and
after seizure. reduces sense of isolation
during event.

Turn head to side and suction Helps maintain airway and

airway as indicated. Insert reduces risk of oral trauma
soft bite block per facility but should not be “forced” or
protocol, only if jaw relaxed. inserted when teeth are
clenched because dental and
soft tissue damage may
result. Note: Current practice
is mixed regarding the use of
airways during seizure
activity. (Refer to ND: risk for
ineffective Airway Clearance,
following.)

Perform neurological and Documents postictal state

vital sign checks after seizure: and time and completeness
level of consciousness, of recovery to normal state.
orientation, ability to comply May identify additional safety
with simple commands, concerns to be addressed.
ability to speak, memory of Client may be confused,
incident, weakness or motor disoriented, and possibly
deficits, blood pressure (BP), amnesic after the seizure and
pulse, and respiratory rate. need help to regain control
Reorient client following and alleviate anxiety. May
seizure activity. display behavior of motor or
Allow postictal “automatic” psychic origin that seems
behavior without interfering inappropriate or irrelevant
while providing for time and place. Attempts
environmental protection. to control or prevent activity
Investigate reports of pain. may result in client becoming
aggressive or combative. May
be result of repetitive muscle
contractions or symptom of
injury incurred, requiring
further evaluation and
intervention.

Document preseizure activity, Helps localize the cerebral

presence of aura or unusual area of involvement and may
behavior, type of seizure be useful in chronic
activity, such as location and conditions in helping client
duration of motor activity, and so prepare for or manage
loss of consciousness, seizure activity.
incontinence, eye activity,
respiratory impairment, and
cyanosis, and frequency or
recurrence. Note whether
client fell, expressed
vocalizations, drooled, or had
automatisms, such as lip
smacking, chewing, and
picking at clothes.

COLLABORATIVE:
Administer medication as To control the seizure of the
indicated such as Magnesium patient or act as an
Sulfate 4mg IV. anticonvulsant drug.

Perform blood test and

Monitor AED drug levels and Blood levels of the various
document corresponding side AEDs should be evaluated on
effects and frequency of a regular basis. Blood levels
seizure activity. should also be done when
breakthrough seizures occur
or any change occurs in the
client’s status. Standard
therapeutic level may not be
optimal for individual client if
untoward side effects
develop or seizures are not
controlled.
Prepare for/assist with more
intensive interventions as Vagal nerve stimulation,
indicated. magnetic beam therapy,
electrode implantation, or
other surgical interventions,
such as temporal lobectomy,
may be done for intractable
seizures or well localized
epileptogenic lesions when
client is disabled and at high
risk for serious injury. Success
has been reported with
gamma ray radiosurgery for
the treatment of multiple
seizure activity that has
otherwise been difficult to
control.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Acute pain located at  Control pain and INDEPENDENT:  Pain relieved or
Patient verbalized, “I’ve had abdomen and head related to promote comfort. Investigate verbal reports of To indicates the causes of controlled.
this awful headache and It Eclampsia.  Prevent pain, noting specific location pain and the factors affecting  Hemodynamically
thought it was gonna go” and complications. and intensity (0 to 10 scale). it. stable.
described her tummy with, “A  Provide information Note factors that aggravate  Complications
lot worse”. about disease and relieve pain. prevented or
process, prognosis, minimized.
OBJECTIVE CUES: and treatment needs. Maintain bed rest during Decreases stimulation of  Disease process,
Px has ankle oedema, acute attack and provide pancreatic secretions, prognosis, potential
headache, and abdominal quiet, restful environment. thereby reducing pain. complications, and
pain. Px is asthmatic. Px is in therapeutic regimen
discomfort. Px had Promote position of comfort, Reduces abdominal pressure understood.
uncomplicated pregnancy. such as turning one side. and tension, providing some  Plan in place to meet
Encourage relaxation measure of comfort and pain needs after
V/S Recorded: techniques, such as guided relief. Note: Supine position discharge.
T= 36.3oC imagery and visualization. often increases pain.
HR= 84 bpm
RR = 20 brpm Keep environment free of Sensory stimulation can
BP = 165/110 food odors. activate pancreatic enzymes,
SpO2 = 99% increasing pain.
FHR = 130 bpm
SFH = 36 cm COLLABORATIVE:
Administer medication as To control and lessen the
indicated such as pain of the patient
Paracetamol and IV
analgesics.