HISTORY OF THE PATIENT Past Medical History Ms. Zumba experienced measles, mumps, and chickenpox as a child.

She also experienced diarrhea, fever, cough, colds and self-medicates with over the counter medications like paracetamol and cough medications before she became pregnant. She has completed all her immunizations and included one shots of tetanus toxoid during her prenatal visits. She had her menarche at the age of 12 years old. She has no known allergies. This was the second time the patient was admitted in the hospital. She was never been hospitalized before other than her first pregnancy. She has taken prescribed ferrous sulfate regularly at home. She had her last menstrual period in September 5, 2012 and had calculated the Expected Date of Confinement @ June 12, 2012. Ms. Zumba had her first delivery in the hospital with no complications included. She had at least 2 prenatal visits in their nearest Health Center which started when she was 6 months and 9 months pregnant. She had a shot of tetanus toxoid once at that time. She also had an ultrasound examination during the 37th week of her pregnancy. The health care worker advised her to have her delivery at the hospital because she has a high blood pressure and edema was noted at her lower extremities, hands and face. The health worker also instructed her that when contractions became frequent with long durations she must go immediately at the hospital.

History of Present Illness

10 hours prior to admission, patient went to the district hospital due to ruptured bag of water. Upon taking her vital signs, elevation of blood pressure was noted at 150/110 mmHg, she was started an intravenous line of D5LR 1L at 30 gtts/min. She was then given hydralazine 5 mg IVTT(2 doses) and loading dose of magnesium sulphate 5 gms on both buttocks Intramuscularly and MgSO4 4 gms as IVTT. Her BP lowered to 140/110 then she was referred to DRH for further evaluation and tests. After being seen and examined by her attending physician, high blood pressure, and pitting edema of about 2mm were noted and diagnosed as G2P1 (1001) Pregnancy Uterine 39 weeks, Age of Gestation, Cephalic in Labor, PROM, Mild Pre-Ecclampsia. They have obtain a blood pressure of 140/110 mmHg in the ER and urine albumin 2+. They retained the present venoclysis of D5LR 1L @ 120 cc/hr and prescribed antihypertensive and antibiotic medications.

Assessment of the Patient

Systems

Mild Preeclampsia Physical Examination

Mild Normal Findings Preeclampsia Review of Systems Patient reported of headache sometimes absent or transient and dizziness Appearance and behavior; posture must be relaxed. Clients should be dressed appropriately with the season, age, and gender. Grooming and hygiene should be proper and neat. Client should typically be able to state their name, location, the date, month, season, and time of the day. Ability to form words (articulation) should be understood and clear. (An Introduction to Health and Physical Assessment in Nursing by DAmico and Barbarito; Physical Examination and Health Assessment by Carolyn Jarvis)

Interpretations

GENERAL APPEARANCE

General Appearance and Behavior Patients appearance is appropriate with age, oriented, awake, coherent, normal, and symmetrical facial features. She was wearing a patients gown, and was properly groomed. She was responsive and eye contact was established during the interview. (Normal) A weight gain of more than 2 lb/wk in the second trimester Weight gain of more than 1lb/wk in the third trimester Edema begins to accumulate in the lower part of the body, hands and face: slight pitting edema +1

Neurologic

Reflexes are normal (using Patient reported DTR 2 the reflex hammer, check for Headache the biceps, patellar, and Patient reported

ankle deep tendon reflexes.)

of dizziness

Head/Hair/Face

Edema may be noted in the Patient reported face of headache sometimes absent or transient and dizziness Chloasma is present None

EENT

Patient reported no visual disturbances at this stage Neck The thyroid may be None palpable( normal findings) Thorax/Lungs none none Back none none Breast and Dark areola none Axilla The breast are enlarged

Cardiovascular/ Peripheral Vascular

Blood reading of 140/90 mmHg x 2, 4-6 hr apart, no more than 1 wk apart CRT is > 3 seconds

Patient report headache dizziness

may of and

GIT

none

GUT

Patient may report absent epigastric pain at this stage Quantitative 24-hr urine None analysis: Proteinuria of 0.3g in a 24-hr specimen Qualitative dipstick: 30 mg/dl (/+) on dipstick Urine output: Output matching intake, 30 ml/hr or <650 ml/24hr Serum Creatinine: Normal

Musculoskeletal

Reflexes may be normal

Extremities

Patient reported of limitation of motion due to edema that begins to accumulate in the upper part of the body Edema begins to Patient reported accumulate in the upper part of limitation of of the body: slight pitting motion due to edema +1 edema that CRT is > 3 seconds begins to accumulate in the upper part

Hematologic Social Status

None

of the body None Ms. Churva is 26 years of age, a high school graduate and lives inNewBataan together with her family. According to her,she has a good relationship with her family. She talks to her family and able to interact with other patient. Her family was there to give her support and to show their love for her. She has engaged in any organizations in their community according to her. Carrying out emotional feelings through words and facial expressions are normal signs of present physical condition (Nursing Fundamentals by Daniels) The client was able to manage to interact with others. She was cooperative during the interview.

Emotional Status

She reported that

She was supported by her parents and husband in terms of emotional problems and comforts her emotionally.

Client was able to cope with problems because her family was there to support and comfort her emotionally. The clients level of consciousness, orientation and speech is normal.

Mental State

*Level of Consciousness. The client was conscious and coherent. She was responsive during the interview. Ms. Churva was aware of her present condition. *Orientation. The client stated properly the date,

Clients should be able to reason, to find meaning, and make judgment from information, to demonstrate rational thinking and perceive realistically.

place and time. She can identify things or names being asked and able to answer all questions asked * Speech.The client speaks Tagalog and Bisaya fluently. She is able to read and speaks clearly and utter words that easily to understand. Body Temperature Heres a table showing the body temperature of the client: 6/5/12 6/6/12 6/8/12 6/9/12 Respiratory Status Temperature 36.4-37.2C 36.2-37C 36.5-37.1C 36.6-37C For axillary route, it should range from 35.4-37.4C (95.899.4F) obtained 5minutes time for accurate measurement. . (Health assessment and rd physicalexamination 3 edition by Mary Ellen Zator Estes) The clients temperature assessed via axillary route and obtained in five minutes was found to be within the normal range.

The client has a regular breathing pattern. Bulging of the ICS was not seen as well as retractions in the intercostal spaces. The use of accessory muscles was not seen while the client is breathing. The table below shows the respiratory rate of the client: Respiratory Rate 6/5/12 20-29

The normal findings of respiratory status for an adult include the following:16-20 breaths per minute, no use of accessory muscles when breathing, respirations should be even, not labored and regular and no cough noted.(Weber: Nurses Handbook of Health Assessment)

6/6/12 6/8/12 6/9/12

breaths/minute 20-24 breaths/minute 18-20 breaths/minute 20-24 breaths/minute

Her respirations were normally heard by the unaided ear a 2-4 centimeters from the clients nose with absent nasal flaring. There were no pulsations as well as masses and tenderness. There were no rales, wheezes or stridor heard.

VI. COURSE IN THE WARD

Brief Description Of The Patient Stay From Admission Until Discharge

Daily Enumeration of Physicians Order & Procedures Done

Date/Shift/Time June 5, 2012 7-3shift 7:10am

Physicians Order Admit under Dr. Dazo/ Dr. Astillo/Dr.Ducducan Consent to Care Vital Signs every 1 hour NPO D5LR 1L at 30 gtts/min Labs: Complete Blood Count(CBC), Blood Typing (BT), Platelet Count(PC), Urinalysis(UA),HbsAg, Creatinine, Serum Urine Albumin(SUA), SGPT EFM Medications: Ampicillin 1gm every 6 hours ANST( ) Hydralazine 5gm PRN IVTT DBP110mmHg Methyldopa 250 mg every 6 hours FHT every hour Retain FBC Refer Dr. Astillo

Procedures Done Dependent Nursing Functions: V/S Monitoring: BP RR PR Temp Secured consent for admission Instructed patient to take nothing by mouth Started venoclysis of #1 D5LR 1 Liter regulated at 30 gtts/minute. Follow-up laboratory results. Attached to Electronic Fetal Monitor (EFM). Monitored Fetal Heart Rate Inserted/maintain indwelling catheter, as indicated.

Nurses Notes Independent Nsg. Functions Promote proper body positioning to promote comfort, such as semi fowlers position. Advise the patient to sleep 8 hours each night and to nap or rest for 2 hours in the afternoon. Instruct the patient in in basic deep chest breathing, which is similar to normal breathing but slower and deeper. Encourage client to acknowledge and express feelings. Promote bed rest Weigh daily at same time of day, on same scale, with same equipment and clothing. Nurses Notes

Date/Shift/Time

Physicians Order

Procedures Done

June 5, 2012 3-11 shift 8:45 pm 9:00 pm

For EFM Now Left Lateral Decubitus Position O2 at 2 Liters/minute

VS Monitored: BP RR Dr. PR Ducducan Temp Monitored EFM. Postpartum Order: (PPO) Placed On Left Lateral DAT Decubitus Position To HR II (High Risk 2) Oxygen Therapy Started And Incorporate 20 units of Oxytocin @ 30 Regulated At 2 Liters/Minute. gtts/minute Maintain oxygen therapy as Medications: ordered. Co-Amoxiclav 625 mg TID Delivered By Outlet Forcep Ketorolac 10mg TID Extraction FeSO4 1 cap OD Incorporated Intravenous Fluid Nifedipine 5mg q 6 hrs With 20 Units Of Oxytocin Keep Uterus Well Contracted Regulated At 30 Gtts/Minute Perineal Care BID Administered Medications Dr. Dazo Checked For Unusualities Kept Uterus Firm And Contracted Perineal Care Done

Evaluate edematous extremities, change position frequently. Assess skin, face, and dependent areas for edema. Evaluate degree of edema (on scale of +1 +4). Determine pain history, e.g. location of pain, frequency, duration, and intensity using pain scale and relief measures used. Place in comfortable position as appropriate Carefully monitor intake and output at least every 4 hours. Increased patients activity level as tolerated; for example, ambulate and increase self-care measures performed by patient.

Date/Shift/Time

Physicians Order

Procedures Done

Nurses Notes

June 6, 2012 7-3 shift 7:00 am

Continue Meds IE Done Possible MGH tomorrow BP 110/80 mmHg Refer for Hypertension/BP/Profuse Vaginal Medications given Bleeding Checked for unusualities Dr. VS monitored Ducducan

Inform patient about: Proper use of medication and possible adverse reactions. Benefits of low-fat, lowcholesterol diet. Need to avoid straining with bowel movements. Nurses Notes Educate Patient regarding: Environmental safety measures. Fluid restriction and diet. Ways to prevent infection.

Date/Shift/Time June 7, 2012 7-3 shift 8:00 am

Physicians Order MGH DAT Medications: Follow-up Check-up 6/13/12 @ OPD Advised Dr. Astillo

Procedures Done VS Monitored Intake and output monitored.