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CASE

PRESENTATION
ON
PREECLAMPSIA
CONTENTS
1 Objectives
2 Introduction
3 Statistics
4 Patients Profile
5 Nursing Health History
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CONTENTS
6 Gordons
7 Physical Assessment
8 Laboratory Result
9 Course in the Ward
10 Anatomy and Physiology
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CONTENTS
11 Pathophysiology
12 Nursing Care Plan
13 Drug Study
14 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
interventions.
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-
It is the most common
of the dangerous
pregnancy
complications.
it may affect both the
mother and the unborn
child.
3 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 well-
being.
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
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
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.
Nursing Responsibility
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.
Nursing Responsibility
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
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.
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
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
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.
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
well- being.
4. Exercise
Improves muscle tone, circulation and
sense of well- being.
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
STATISTICS
International
statistics
Country Region Incidence rate Population Estimated Used

INTERNATIONAL
Preeclampsia in North America

USA 457,969 293,655,4051

Canada 179,487 32,507,8742

Preeclampsia in Europe

Britain (United Kingdom) 32,422 60,270,708 for UK2

France 32,504 60,424,2132

Germany 44,339 82,424,6092

Preeclampsia in Asia

China 698,703 1,298,847,6242

India 572,945 1,065,070,6072

Indonesia 128,273 238,452,9522

Preeclampsia in Eastern Europe

Russia 77,449 143,974,0592

Ukraine 25,677 47,732,0792

Uzbekistan 14,207 26,410,4162


Country Region Incidence rate Population Estimated Used

Preeclampsia in the Middle East

Egypt 40,946 76,117,4212

Iran 36,312 67,503,2052

Turkey 37,060 68,893,9182

Preeclampsia in South America

Brazil 399,035 184,101,1092

Colombia 122,760 42,310,7752

Mexico 256,462 104,959,5942

Preeclampsia in Africa

Congo kinshasa 31,371 58,317,0302

Ethiopia 38,374 71,336,5712

South Africa 23,910 44,448,4702


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, american-africans/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 2009 2010

15-19 Y/O 20-44 Y/O 15-19 Y/O 20-44 Y/O

January 0 2 1 1

February 0 2 0 0

March 0 2 0 1

April 0 0 0 1

May 1 4 0 2

June 0 2 0 2

July 0 3

August 0 1

September 1 2

October 1 2

November 0 1

December 0 1

Total 3 22 1 7
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
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
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 weeks upon admission.
GORDONS 11
FUNCTIONAL
PATTERN
Gordons 11 Functional
Pattern Before Hospitalization During Hospitalization

HEALTH The patient defines health as The patient declares that health
the absence of any disease or is very important to an
PERCEPTION- illness. According to the patient, individual. She is worrying on
HEALTH she is taking ferrous sulfate her condition because she may
twice a day during her not take care of her baby well
MANAGEMENT pregnancy and whenever she due to her condition. She follows
PATTER got sick, she managed it by properly the entire doctors
taking OTC drugs such as order because she wants to
paracetamol for fever, neozep recover as soon as possible for
for cough and colds, and alaxan her baby.
for body pain.

NUTRITIONAL- The patient verbalized that her The patient was on NPO. The
favorite meals during her IVF of the patient are D5LRS 1L
METABOLIC pregnancy were mango, junk x 30 gtts/min @ the level of 50ml
PATTERN foods, santol and pritong isda. hooked @ the right arm, PNSS
According to the patient, she 1L x KVO @ the level of 550cc +
eats a large amount of rice and second line of 250cc of Blood
drinks 7 glasses of water a day. transfusion hooked @ the left
She is not drinking coke, milk arm.
and cold water and not eating
halo-halo. She also takes snack
in between meals.
Gordons 11 Functional
Pattern Before Hospitalization During Hospitalization

COGNITIVE The patient just finish The patient is not


second year high school. She experiencing dizziness and
PERCEPTUAL understands tagalog, itawis, blurred vision. She answers
PATTERN Ilocano and English. She questions minimally and
doesnt have any problem sometimes dont focus to the
with her senses. questions.

ACTIVITY- According to the patient, The patient is turning side to


she walks always and she side to prevent bed sore.
EXERCISE still washes their clothes and Legs are elevated due to the
PATTERN dishes which serve as her edema at her lower
daily exercises. extremities. She has
difficulty in moving due to
the pain.
SLEEP- REST According to the patient, The patient verbalized that
she usually sleeps at 6pm she has difficulty in sleeping
PATTERN and wakes up at 5am. She because of the environment.
takes a nap for 2 hours at She takes a nap for at least
noon. She has no difficulty 20 minutes. She gets sleep at
in getting sleep. 6pm to 4am but not
continuous.
Gordons 11 Functional
Pattern Before Hospitalization During Hospitalization

ELIMINATION The patient defecates 2x a The patient has IFC inserted.


day with bulky and well The urine color is yellow
PATTERN formed stool. She urinates with an amount of 675cc.
7x a day with a yellow There is a presence of flatus
amber in color. She has no but no bowel movement.
difficulty in defecating and
urinating.
SELF PERCEPTION- According to the patient, The patient feels body
she was happy when she got weakness due to her
SELF CONCEPT pregnant. She is excited to condition but despite of that
PATTERN see herself with her growing she is excited to be a mother.
baby.
ROLE- The patient feels the The patient has a good
support of her family relationship with her parents
RELATIONSHIP especially her husband. She and siblings. She is the youngest
PATTERN among the 8 children of her
cannot perform her role due
parents. She loves her husband
to her condition. and excited to be a mother of
their first child. She is a caring
and a loving wife to her
husband.
Gordons 11 Functional
Pattern Before Hospitalization During Hospitalization

COPING STRESS She verbalized that whenever The patient verbalized that she
she has a problem, she is is sharing her feelings with her
PATTERN sharing it with her parents and mother and husband. She just
her husband. Sometimes, if she thinks her baby to ease the pain
is stress she managed it by she feels. She doesnt think that
watching tv and by socializing she is problem to her family.
with their neighbors.

SEXUALITY- The patient had her menarche The patient is very happy in
when she was 10 years old. She giving birth of their first child
REPRODUCTIVE has no problem with her which is a baby girl.
PATTERN 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 According to the patient, she
Catholic and she attends the always prays at night to recover
VALUE- BELIEF mass 3x a month. She often from her condition and for the
PATTERN prays at night. She verbalized wellness of her baby. She always
that she do believe in quack asks guidance and a good health
doctor but never consulted to from God.
them.
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 METHOD NORMAL ACTUAL REMARKS
ASSESSED USED FINDINGS FINDINGS

SKIN
Inspection Light to deep Varies from Normal
brown deep to brown
COLOR to light

TEXTURE Palpation Smooth Smooth Normal

Palpation Warm to Warm to Normal


TEMPERATUR touch, touch,
E Uniform Uniform
Palpation When When Due to
pinched, pinched, presence
SKIN skin goes skin goes of edema
TURGOR back back
to previous to previous
state in 1- 2 state in 4
Presence Inspection No lesions No lesions Normal

of
lesions
Inspection Uniform except Uniform except Normal
areas exposed areas exposed
to to
sun; areas of sun
Uniformity Lighter
pigmentation
(palm,
lips, nail beds)
in
dark skinned
people
Palpation Dry, skin folds Dry, skin folds Normal
are are
Moisture normally moist normally moist

Palpation & Epidermis is Epidermis is Normal


Inspection uniformly thin, uniformly thin,
thickened thickened
Thickness callous callous
HAIR
Color Inspection Black Black Normal
(depending on
race)
Distributio Inspection Evenly Evenly Normal
n distributed distributed
hair hair
Texture Palpation Silky, shiny, Silky, shiny, Normal
and resilient and resilient

Presence Inspection No infection or No infection or Normal


of infestation infestation
parasites
SCALP

Symmetry Inspection Symmetrical Symmetrical Normal


NAILS
Color (nail Inspection Pinkish Pinkish Normal
bed)

Shape Inspection Convex Convex Normal


curve (160 curve (160
degrees) degrees)

Texture Inspection Smooth Smooth Normal


tissue intact intact
surroundin epidermis epidermis
g nail
Capillary Palpation Prompt Prompt Normal
refill test return of return of
pink or pink or
usual color usual color
(1-2 (1-2
HEAD
Shape Inspection Normoceph Normoceph Normal
alic alic
Appearanc Inspection Rounded Rounded Normal
e with smooth with smooth
skull skull
contour with contour with
(-) nodules (-) nodules
Size and Inspection Appropriate Appropriate Normal
circumfere to body size to body size
nce and shape and shape

FACE
Symmetry Inspection Symmetrica Symmetrica Normal
l l
EYEBROWS
Distributio Inspection Equally Equally Normal
n distributed distributed

Quality of Inspection Eyebrows Eyebrows Normal


movement moves the moves the
same way same way

Alignment Inspection Aligned Aligned Normal

EYELASHES
Evenness Inspection Equally Equally Normal
distributed distributed

Direction of Inspection Slightly Slightly Normal


curl curved curved
outward outward
EYELIDS
Ability to Inspection Has the Has the Normal
blink ability to ability to
blink; blink blink; blink
bilaterally bilaterally
Frequency Inspection 15 to 20 18 blinks/ Normal
of blink blinks/ min min

EYES
Color Inspection White sclera White sclera Normal

Conjunctiva Inspection Pink palpebral Pink palpebral Normal


conjunctiva conjunctiva

CORNEA
Appearanc Inspection Shiny Shiny Normal
e (clarity)
PUPILS
Color Inspection Black, no Black, no Normal
cloudiness cloudiness

Shape Inspection Rounded Rounded Normal

Extra Inspection Both eyes Both eyes Normal


ocular are are
movement coordinated coordinated
Visual Inspection She was She was Normal
acquity able to read able to read
prints prints
without without
wearing wearing
eyeglasses eyeglasses
EARS
Inspection Same with the Same with the Normal
Color color of the color of the
face face

Symmetr Inspection Symmetrical Symmetrical Normal


to the head to the head
y and face and face

Inspection Lateral to the Lateral to the Normal


Position eyebrows & eyebrows &
auricles in line auricles in line
with the with the
cantus of the cantus of the
eye eye
NOSE
Inspection Same with Same with Normal
Color the color of the color of
the face the face

Tendernes Palpation No No Normal


s and tenderness tenderness
masses and masses and masses
Patency Inspection Air moves Air moves Normal
freely freely
Discharge Inspection No (-) Normal
or flaring discharge discharge
and flaring and (-)
flaring
Tendernes palpation not tender, Not tender, Normal
s no lesions no lesions
MOUTH
Lips Inspection Uniform pink Uniform pink Normal
color, soft, color, soft,
moist and moist and
smooth in smooth in
texture texture

Ability to Inspection Can purse lips Can purse lips Normal


purse lips
Buccal Inspection Moist, Moist, Normal
Mucosa smooth, soft smooth,
and glistening; soft and
pink in color glistening;
pink in color
Teeth Inspection No tartars, no no tartars, no normal
dental caries, dental caries,
complete set complete set
of teeth of
teeth.
Gums Inspection pink in color, pink in color, Normal
moist and firm moist and firm

Tongue Inspection freely, moving, freely, moving, Normal


centered centered
roughened from roughened from
papillae;no papillae;no
lesion lesion
Ovula Inspection positioned in positioned in Normal
the middle the middle

NECK
Position Inspection Centrally Centrally Normal
located located
between the between the
shoulders. shoulders.
Mobility Inspection Can move Can move Normal
spontaneously spontaneously
in all directions. in all directions.
Lymph nodes Palpation no tenderness no tenderness Normal
or inflammation or inflammation
present, no pain present, no pain
THORAX AND LUNGS
Symmetry Inspection Chest Chest Normal
expands expands
symmetrically symmetrically
during during
respiration; respiration;
effortless. effortless.
Chest wall Inspection Intact; no Intact; no Normal
and Palpation tenderness, tenderness,
no mass. no mass.

Percussion Percussion Resonance Resonance Normal


sound
Chest Palpation full and chest expands Normal
expansion symmetric fully and
chest symmetrically
expansion
Breath Auscultation Broncho- Broncho- Normal
sounds vesicular vesicular
breath sound breath sound
ABDOMEN
Skin Inspection Brown/follows Brown Normal
condition general body
color

Bowel Auscultation Audible bowel Bowel sounds Due to


sounds sounds (15- of 10/ minutes decrease
20/ minutes) peristalsis

Tenderness Palpation No (+) tenderness Due to CS


tenderness delivery
Umbilicus Inspection Midline and Midline and Normal
inverted, no inverted, no
sign of sign of
discoloration discoloration
Abdominal Inspection Flat, round Flat, round Normal
contour scaphoid scaphoid
Ascites Percussion No ascites No ascites Normal
HEART
Heart sound Auscultation Dull, no Dull, no Normal
murmurs, murmurs,
absence of s3 absence of s3
and s4 sound. and s4 sound.

Heart rate Auscultation Regular, 60- Regular, 78 Normal


100 bpm bpm

Precordium Inspection, Adynamic, Adynamic, Normal


Auscultation point of point of
and maximum maximum
palpation 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 Normal
deep brown deep brown
Symmetry Inspection Symmetrica Symmetrica Normal
l l
Skin Palpation Warm and Warm and Normal
characteristi equal equal
c temperature temperature
, no edema , no edema
and and
tenderness. tenderness.
ROM Inspection Full ROM Has Due to CS
without pain difficulty delivery
moving
Muscle tone Palpation Present, Present, Normal
equal equal
LOWER EXTREMITIES
Color Inspection Light to deep Light to deep Normal
brown brown

Symmetry Inspection Symmetrical Symmetrical Normal

Skin Palpation Warm and (+) Edema Due to


equal increased
characteris temperature, no tubular
tic edema and reabsorption of
tenderness. sodium

ROM Inspection Full ROM Has difficulty Due to CS


without pain moving her delivery
lower
extremities
Edema Inspection and No edema (+) edema Due to
Palpation increased
tubular
reabsorption of
sodium
LABORATORY
RESULTS
August 2, 2010
General Chemistry
Normal Values Result Remarks

Urea 2.50-7.10mmo/L 3.05 mmol/L Normal


Creatinine 53-115.0 mol/L 84.8 umol/L Normal
Uric Acid 149.0-506.0 274.2 umol/L Normal
umol/L
AST(aspartate 14-59 U/L 32 U/L Normal
aminotransfera
se)
ALT (alanine 9-72 U/L 22 U/L Normal
transaminase)
LDH 313-618 U/L 798 U/L Due to
possible liver
damage
August 2, 2010
Urinalysis
Normal Values Result Remarks

Color Yellow amber Yellow normal


Transparency Clear clear normal

pH 4.5-7.5 6.5 Normal


Specific 1.010-1.030 1.010 Normal
gravity
Albumin 1-15 mg/dl Trace Due to
increase
permeability
August 3, 2010
Hematology

Normal Values Result Remarks

Hemoglobin Mass 120-160 g/L 88 Due to increase


Concentration plasma volume
Erythrocyte 33%-35% 25% Due to blood loss
Volume Fraction
Thrombocyte 150-160 x 109/L 160 Normal
Number
Concentration
Leukocyte 4.5-14 x 109/L 2.6 Due to infection
Number
Concentration
Neutrophils 45%-73 % 63% Normal
Lymphocytes 22%-40% 37% Normal
August 3, 2010
Blood Grouping

Serial Blood Type Rh Expiration


Number Compatibility Date
PRBC 10-4861 A Positive

Serial Blood Type Rh Expiration


Number Compatibility Date
PRBC 10-4868 A Positive
August 5, 2010
Hematology
Normal Values Result Remarks

Hemoglobin 120-160 g/L 93 Due to increase


Mass plasma volume
Concentration
Erythrocyte 33%-35% 27% Due to blood loss
Volume Fraction
Thrombocyte 150-160 x 109/L 140 Due to surgical
Number incision
Concentration
Leukocyte 4.5-14 x 109/L 28.98 Due to infection
Number
Concentration
Neutrophils 45-73% 90% Due to infection
Lymphocytes 22-40% 10% Due to infection
COURSE IN
THE WARD
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES
August 2, Please admit at LR-DR To monitor health Obtained initial
2010 condition and for further database
BP=150/100 observation
HR=80
Secure consent for For legal purposes Secured consent,
RR=22
admission signed for admission
T=36.4
and management
G1P0
LMP= Nov. 1, Soft diet then NPO once To prevent aspiration Diet emphasized to
2009 on active labor the patient
AOG= 39 1/7 TPR every shift and For baseline data and to TPR taken and
weeks record note for progress recorded. Referred
FH=32 cm any deviations from
FHT=140s normal ranges
IE= Nuliparus
outlet Dx: >To test blood Ensured patients
Cervical CBC with APC components request form and
dilatation= 1 U/A >To evaluate presence prepared and
cm of foreign substances in explained to the
Cephalic the urine. patient about the
(-) BOW, SGPT/SGOT >For liver function test procedure
(-)epigastric BUN >To determine kidney
pain function
Clear breath IVF: D5LRS 1L + 10 u To maintain fluid and IVF hooked,
sounds Oxytocin to run for 12-15 electrolyte balance and regulated at desired
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES
Tx: give 4 g Magnesium To prevent and control Administered
Sulfate slow IV push now seizure medication effectively
then 5 g deep IM on both and observed the 10
buttocks as loading dose then Rs in giving the
5 g deep IM on alternating mediation. Monitored
buttocks q 4 hours in 24 the blood pressure
hours as maintenance dose.
Methyldopa 500 mg q 8 To lower blood pressure Administered
hours medication effectively
and observed the 10
Rs in giving the
mediation. Monitored
the blood pressure
Insert IFC aseptically and For bladder training IFC inserted
connect to urine bag aseptically

I & O q shift and record To monitor fluid and Ensured accurate I &
electrolyte balance O measurement.

Pre meds on call: Administered


Hydroxizine 25 mg >To relieve pain medication effectively
Medazolam 1 g and observed the 10
Nalbuphine 5 mg Rs in giving the
mediation.
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

Hook to EFM To check for fetal heart Position the client,


rate and uterine monitored and
activity recorded the FHR
and uterine activity

Labor watch To check for the Kept watch


progress of cervical
dilatation

Watch out for To rule out magnesium Monitored patients


Magnesium toxicity toxicity v/s
VS and FHT q hour and To monitor fetal VS and FHT
record distress monitored and
recorded

Routine perineal To prepare both the Positioned the


preparation mother and baby for patient and cleaned
delivery the perineal area.

Refer accordingly For collaborative Referred properly


intervention
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES
August 2, NPO once in active To prevent Instructed patient
2010 9 pm labor aspiration not to eat
BP= anything
160/90 Hook to EFM now To monitor for fetal Position the
Cx= 1 cm then q 4 hours heart rate and client, monitored
dilated uterine activity and recorded the
50% FHR and uterine
effaced activity
Cephalic
(+) BOW, - For fundoscopy To view the fundus Prepared the
3 patient for such
procedure
Follow up all labs For further Followed up all
evaluation labs
Continue labor watch To watch out for Kept watch
progress in labor
Monitor VS, FHT To evaluate any VS and FHT
changes monitored and
recorded
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

August 3, May transfer For proper Patient


2010 patient to ward management transferred to
9:30 am OB
CR=91 Refer For collaborative Referred
RR=23 intervention accordingly.
BP=100/
80 Paracetamol for To decrease Administer
T=38.4 C fever 300 mg/IV q 4 body medication
for fever temperature and effectively and
relive fever. observed the
10 Rs in
giving the
mediation.
Refer For collaborative Referred
intervention accordingly.
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

August 4, May have GLEMCD To prevent aspiration. Instructed patient to


GLEMCD is the diet have a general fluid
2010 7:55
for the patients intake only except
am milk and soft drinks.
undergone after
BP=110/80
surgery.
Afebrile
(+) flatus IVF: PNSS 1L x KVO For rehydration Checked IVF line
patency and
(-) BM regulated.
adequate Checked for signs of
phlebitis and
infiltration
Continue IV Co- To prevent infection Administered
amoxiclav medication effectively
and observed the 10
Rs in giving the
mediation.
Tramadol 50 mg/IV q 8 x To relieve pain Administered
24 For iron replacement medication effectively
Ferrous fumarate + and observed the 10
Rs in giving the
vitamin B complex 1 cap
mediation.
TID
Ascorbic acid 50 mg/tab Administered
For vitamin supplement
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

Insert 2 bisacodyl To increase GI Positioned patient


supp/rectum now motility. and administered
medication
effectively and
observed the 10
Rs in giving the
mediation.
Continue BT for blood Checked IV line
replacement patency and
regulated.
Checked for signs
of phlebitis and
infiltration
Encourage early To enhance venous Encouraged
ambulation return. patient
Watch out for bleeding To prevent Watched out for
complications. patient for
bleeding.
Refer accordingly For collaborative Referred
intervention accordingly
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

August 5, Soft diet Soft diet is the diet Instructed patient to


after GLEMCD for eat foods only such as
2010
patients lugaw.
7:20 am
postoperatively
BP:180/12
0 IVF: PNSS 1L x KVO For rehydration Checked IVF line
patency and
(+) flatus regulated.
(+) BM Checked for signs of
phlebitis and
infiltration

Continue meds For patients recovery Administered


medication effectively
and observed the 10
Rs in giving the
mediation.

Give captopril 25 mg SL To decrease BP Administered


now then PRN for BP medication effectively
greater than or equal to and observed the 10
Rs in giving the
130/90
medication with BP
precaution
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

Continue ambulation To prevent paralytic ileus Instructed patient to


have a walk and
For 24 post BT,CBC with For blood replacement Secured request form
APC at 10:00 am today for the procedure.
Explained the
importance of the
procedure. Prepared
the patient for the
procedure.
Continue magnesium To prevent seizure Updated Kardex and
sulphate, then maintenance transcribed orders in
dose medication sheet and
medication card.
Explained the action
of the drugs.
observed the 10 Rs in
giving the medication
Maintain IFC Monitored and
For I and O monitoring recorded intake and
output
Monitor urine output q 1 and To determine fluid loss Monitored urine and
record and overload recorded
Refer For collaborative Referred accordingly
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

August 6, Full diet For adequate Emphasized diet


2010 nutrition of the patient.
9:00 am IVF: D5LRS 1L x For fluid and Checked IVF line
BP=150/ KVO electrolyte patency and
100 regulated.
balance. Checked for signs
of phlebitis and
infiltration.

Start hydralazine To decrease Started


drip elevated blood Hydralazine drip.
Checked IVF line
pressure patency and
regulated.
Checked for signs
of phlebitis and
infiltration.
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

August 07, IVF: D5LRS 1L x KVO Route for Checked IVF line
patency and
2010 emergency drugs
regulated.
7:55am Checked for signs of
BP: 130/90 phlebitis and
(-) cough infiltration
With febrile
episodes Full diet For adequate Emphasized diet
(+)breast nutrition of the patient.
pain
(+)phlebitis Continue To decrease Continued
hydralazinne drip elevated blood Hydralazine drip.
pressure Checked IVF line
patency and
regulated.
Checked for signs
of phlebitis and
infiltration.

Spinorolactone + To eliminate excess Administered


medication effectively
HCTZ x OD x 5 days fluid
and observed the 10
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

Reinsert IV line to To continue hooked IVF line,


parenteral nutrition checked for
other site. patency and
regulated.
Checked for signs
of phlebitis and
infiltration
Continue oral For fast recovery Administered
medication
meds effectively and
observed the 10
Rs in giving the
mediation.
V/S + IV q1* and For close Vital signs
record monitoring. monitored and
recorded until
stable. IV
regulated and
checked for
patency
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

August 08, DAT For adequate Emphasized diet


2010 7:30 nutrition of the patient.
am
Afebrile IVF x KVO Route for Checked IVF line
patency and
With febrile emergency drugs
regulated.
episodes Checked for signs of
(+)cough phlebitis and
infiltration
(-)breast
pain Consume hydralazine To lower elevated Consumed
(-)phlebitis drip blood pressure Hydralazine drip.
BP:130/80 Checked IVF line
patency and
Latest regulated.Checked for
CBC(08/05 signs of phlebitis and
/10) infiltration.
For repeat CBC with For futher evaluation Secured request form
for the procedure.
APC blood culture and
Explained the
sensitivity CXR- PA importance of the
procedure. Prepared
the patient for the
procedure.
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

Continue oral For patients recovery. Administered


medication
meds effectively and
observed the 10
Rs in giving the
mediation
Daily wound care To prevent infection Cleaned wound
aseptically and
changed wound
dressing as
doctors order.

Monitor V/S q1* For close Vital signs


and record monitoring. monitored and
recorded until
stable. IV
regulated and
checked for
patency
Refer. For collaborative Referred
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

August Full diet For adequate Emphasized diet


09,2010 of the patient.
7:43 am nutrition
BP: IVF D5LRS 1L x KVO Route for . Checked IVF line
150/100 patency and
emergency regulated.Checked
Afebrile
With febrile drugs for signs of phlebitis
and infiltration.
episodes
(+) occl Continue oral meds
cough
For patients Administered
medication
Clear recovery effectively and
breath observed the 10 Rs
sounds in giving the
mediation.

Please follow up CBC For further Secured request form


for the procedure.
with APC request, evaluation
Explained the
blood CS + CXR- importance of the
official reading and procedure. Prepared
attach to chart the patient for the
procedure
DATE DOCTORS ORDER RATIONALE NURSING
RESPONSIBILITIES

Daily wound care To prevent infection Cleaned wound


aseptically and
changed wound
dressing as
doctors order.

V/S + IV q1* and For close monitoring .Vital signs


monitored and
record recorded until
stable. IV regulated
and checked for
patency

Continue To prevent paralytic ileus


Instructed patient to
have a walk
ambulation

Refer For collaborative Referred


intervention 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
Ovarian cycle: Occurs in response to two
anterior pituitary hormones: follicle-
stimulating 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
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
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:
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
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
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PATHOPHYSIOLOGY
PRE-ECLAMPSIA
PREDISPOSING
PRECIPITATING
FACTORS FACTORS
*Family history trophobla *Diet*Lifestyle
and
*Age(<20->40 y/o)
Nutrition stic
*Pre-existing hypertension
*Primiparity cells to
maternal
arteries
Release of placental factor (factor X)

Invasion of Aggregation of endovascul


fibrin, platelets
and lipophages
A B Company Logo
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PATHOPHYSIOLOGY
A B

replacement of endothelium, partial or complete


destruction of medialmusculoelastic blockage on arterioles
tissue and change in fibrinoid in the
vessel wall placental infarction

placental increased platelet


ischemia activation
vasospasm

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PATHOPHYSIOLOGY
C

increase blood decrease perfusion


pressure to organs

hypertension

kidney pancreas placenta eyes brain


epigastric pain blurred vision

D E hyperreflexia seizure

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PATHOPHYSIOLOGY
D E
fetal distress
decrease increase
GFR reabsorption active labor
in tubules
decrease Emergency
urine increase sodium caesarian
output and water section
retention
increase
creatinine edema
increase
level glumerular
permeability

proteinuria
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NURSING
CARE PLAN
Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Acute pain After 2 Monitored For Goal met.


Masakit r/t hours, the vital signs and baseline data
After 2
ang sugat ko traumatize patient will recorded and to note hours, the
as verbalized verbalize a
d nerve progress. patient
by the patient. decrease
endings pain scale
Pain scale: pain from
secondary pain scale of Positioned To promote was
8/10
to surgical 8/10 to 2/10 the patient comfort decreased
Objective:
Restlessness incision. comfortably from 8/10
Facial on bed to 2/10
grimace
Encouraged Pain is
verbalization subjected
of feelings and it cant
be felt by
other

Provided To promote
comfort nonpharmalo
measures such gical pain
as
repositioning
management 1
Assessment Diagnosis Planning Interventions Rationale Evaluation

Instructed in To distract
use of attention and
relaxation reduce
techniques tension
such as
focused
breathing

Encouraged To distract
diversional attention
activities by
initiating
conversation
to the patient

Administere For
d medication collaborative
as ordered function
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Activity After 3- 4 Monitored For baseline Goal met.
Hindi ko intolerance hours of vital signs and data and to note After the
masyadong nursing recorded progress. nursing
r/t edema intervention
maigalaw ang interventions, Positioned the To promote
on the s, the patient
paa ko as the patient patient comfort had used/
lower
verbalized by will be able to comfortably identified
the patient. extremities use /identify
techniques
Objective: techniques to Encouraged To know what to enhance
Body enhance verbalization of nursing activity
feeling interventions are intolerance
weakness activity
needed
Inability to intolerance
perform Assisted Ensures safety
activity patient during and additional
(+) edema moving or on support for client
on the feet going in the
comfort room

Planned for May improve


progressive with progressive
increase in training
activity level as
tolerated by the
patient
2
Assessment Diagnosis Planning Interventions Rationale Evaluation
Encouraged TO maintain
passive ROM muscle strength
and joint range
of motion
Encouraged To conserve
the client to have energy
adequate rest
and sleep

Adjusted To prevent
activities overexertion

Provided Helps to
positive minimize
atmosphere frustration

Assisted with To protect


activities and client from
monitored injury
clients use of
assistive device

Promoted To enhance
comfort ability to
measures 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 data and to After the
ang sugat integrity nursing recorded note progress. nursing
Positioned the To promote
ko as r/t interventions intervention
patient comfort
verbalized surgical , the patient s, the
comfortably
by the incision will assessed Wound patient
patient. participate in wound for dehiscence participated
Objective: prevention intactness occurs with in
(+) measures excessive prevention
surgical and stress on a measures
incision treatment new incision and
Encouraged To know
Warm program treatment
verbalization of what nursing
program
feelings interventions
will be
performed
assessed for Purulent
signs of infection drainage is an
indication of
Stressed the infection
importance of To control
hand washing the spread of 3
Encouraged To aid in
the patient to tissue repair
eat foods rich
in protein.

Applied To help in
appropriate wound
dressing. healing

Kept the To prevent


area clean/dry infection

Discouraged These can


rubbing and cause
scratching further
injury and
delay healing

Instructed To prevent
the patient in infection
proper care of
area
Assessmen Diagnosis Planning Interventions Rationale Evaluation
t
Subjective Ineffectiv After 3 Monitored For Goal met.
: e tissue hours of vital signs baseline After 3
namam perfusion the nursing and data and hours of
anas ang r/t interventio recorded to note the
paa ko as vasocons ns, the progress. nursing
verbalized triction of patient will To interventi
by the blood be able to Positioned promote ons, the
patient vessels demonstrat the patient comfort patient
Objective: 2T e behaviors comfortably To know had
Edema edema to improve Encourage what demonstr-
noted on circulation d nursing ated
lower verbalization interventi behaviors
extremities of feelings ons will to
Cold, be improve
clammy perform circulatio
skin This n
Checked may
for calf indicate
tenderness thrombus
(homans formation 4
Assessme Diagnosis Planning Interventions Rationale Evaluation
nt
Reinforced Contractin Goal met.
leg exercises g the leg After 3
taught muscle hours of the
preoperativel decreases nursing
y venous intervention
stasis and s, the
encourages patient had
good demonstrat
venous ed
return behaviors
Encourage To reduce to improve
d used of tension circulation
relaxation
techniques
Encourage Enhances
d early venous
ambulation return
Elevated For
feet on bed venous
return
Assessmen Diagnosi Planning Interventions Rationale Evaluation
t s
Subjective: Impaired After 2 hours Monitored For Goal met
hinde physical of the vital signs baseline After 2 hours
ako mobility nursing and recorded data and to of the
masyadong r/t interventions note nursing
makagalaw surgical , the patient Positioned progress. interventions
as incision will be able the patient To , the patient
verbalized to verbalize comfortably promote verbalized
by the understandin on bed comfort understandin
patient g of situation Encourage g of situation
Objective: and d and
Difficulty individual verbalization To know individual
moving treatment of feelings what treatment
Body regimen and nursing regimen and
weakness safety intervention safety
measures. Scheduled s will be measures
activities performed
with To reduce
adequate fatigue
rest periods
during the
day
Encourage Enhances 5
Assessmen Diagnosis Planning Interventions Rationale Evaluatio
t n
Encouraged Maximizes
adequate energy
intake of production
nutritious
foods
Mobility
Facilitated aids can
transfer increase level
training by of mobility
using
appropriate
assistance of
persons or
devices Patients
may be
Provided reluctant to
positive move due to
reinforcement fear of falling
during activit
To promote
Kept side a safe
rails up and environment
bed in low
Assessment Diagnosis Planning Interventions Rationale Evaluation
Subjective: Deficient After 2 Monitored For 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 interventions Positioned note nursing
sa sakit ko n about , the patient the patient progress. interventions
as verbalized the current will verbalize comfortably on To , he patient
by the patient condition understandi bed promote verbalized
Objective: ng of current Encouraged comfort understandin
Primigravid condition verbalization of g of current
a and feelings To know condition
OB score: treatment what and
G1P0 Instructed in nursing treatment
use of intervention
relaxation s are
techniques needed
such as To
focused promote
breathing comfort
Determined
clients ability
/readiness and
barriers to The client
learning may not e 6
Assessmen Diagnosis Planning Interventions Rationale Evaluatio
t n
Assessed the May need to
level of the help SO(s) or
clients caregivers to
capabilities and learn
the possibilities
of the situation

Provided To prevent
information overload
relevant only to
the situation

Discussed So that client


clients feels
perception of competent
need and respected

Provided
active role for Promotes
client in sense of
learning control over
process situation
DRUG STUDY
NAME OF CLASSIFICA ACTION INDICATION ADVERSE NURSING
DRUG TION REACTION RESPONSIBILITIES

GENERIC Anti- May Acute CNS: ALERT! Watch for


NAME: convulsant decrease nephritis, to drowsiness, respiratory
depressed
Magnesium acetylcholin control reflexes,
depression and signs
Sulfate e released hypertension flaccid and symptoms of
by nerve Short term paralysis, heart block.
impulses, treatment for hypothermia Keep IV calcium
DOSAGE but its constipation CV: gluconate available
hypotension,
AND anticonvulsa To correct flushing,
to reverse
FREQUEN nt or prevent bradycardia, magnesium
CY: mechanism hypomagnesi circulatory intoxication.
5 g every 4 is unknown. mea in collapse, Check magnesium
hours in 24 patients on depressed level after repeated
cardiac
hours parenteral doses
function
nutrition EENT: Signs of
diplopia hypermagnesemia
METABOLI begin to appear at
C: levels of 4 mEq/L
hypocalcemia
RESPI:
Observe neonates
respiratory for signs of
paralysis magnesium toxicity.
SKIN:
diaphoresis
NAME OF DRUG CLASSIFICA ACTION INDICAT ADVERSE NURSING
TION ION REACTION RESPONSIBI
LITIES
GENERIC NAME: ANTIHYPER- Stimulates Hyper- CNS: headache, asthenia, Monitor
METHYLDOPA TENSIVE CNS alpha- tension weakness, dizziness, periodic counts
BRAND NAME: DRUG adrenergic sedation, decreased to detect
mental acuity, depression,
ALDOMET receptors paresthesia,
adverse
DOSAGE AND decreasing parkinsonism, Bells hematologic
FREQUENCY: sympathetic palsy, involuntary reactions.
500 mg every 8 stimulation choreoathetotic Monitor liver
hours to heart and movements function test
blood CV: bradycardia, edema, and check for
vessel. Also orthostatic hypitension, signs and
myocarditis
reduces EENT: nasal congestion
symptoms of
arterial and GI: nausea, vomiting, hepatic
plasma diarrhea, constipation, dysfunction.
renin abdominal distention, Check for
pressure colitis, dry mouth, sore or edema or
black tongue, pancreatitis weight gain to
GU: breast enlargement, help determine
gynecomastia, failure to
ejaculate, erectile
if diuretic
dysfunction should be
HEMATOLOGIC: added to
eosinophilia, hemolytic regimen.
anemia Monitor
HEPA: hepatitis blood pressure.
OTHER: fever
NAME OF CLASSIFI ACTION INDICATION ADVERSE NURSING
DRUG CATION REACTION RESPONSIBILITIES
GENERIC ANTI- Mechanism of Symptomatic CNS: WARNING:
NAME: EMETIC, action is relief of anxiety drowsiness, Determine and treat
HYDROXYZINE ANTI- unknown; and tension involuntary underlying cause of
vomiting. Drug may
BRAND HISTAMI actions may associated with motor activity mask signs and
NAME: NE be due to psychoneurosis including symptoms of serious
VISTARIL suppression of Management of tremor and conditions, such as brain
subcortical pruritus due to seizures tumor, intestinal
DOSAGE areas of the allergic conditions, GI; dry mouth, obstruction, or
AND CNS; has such as chronic reflux, appendicitis.
FREQUEN clinically urticaria, atopic constipation WARNING: Do not
CY: administer parenteral
demonstrated and contact GU; urinary solution subcutaneously,
25 mg antihistaminic dermatosis and in retention IV, or intra-arterially;
, analgesic, histamine-mediated RESPIRATORY: tissue necrosis has
antispasmodic pruritus wheezing, occurred with
,antiemetic, Sedation when dyspnea, chest subcutaneous and intra-
mild used as a tightness arterial injection, and
antisecretory, premedication and hemolysis with IV
injection.
and following general Give Im injections
bronchodilato anesthesia deep into a large muscle:
r activity. Control of nausea in adults, use upper outer
and vomiting quadrant of buttocks or
Management of midlateral thigh; in
the acutely children, use midlateral
disturbed or thigh muscles; use
deltoid area only if well
hysterical patients developed.
NAME OF CLASSIFIC ACTION INDICATION ADVERSE NURSING
DRUG ATION REACTION RESPONSIBILITIES
GENERIC OXYTOCIC Synthetic form of an ANTEPARTUM: To CV: cardiac WARNING: Reserve for
NAME: endogenous hormone initiate or improve arrhythmias, PVCs, medical use, not elective
OXYTOCIN produced in the uterine contractions to hypertension, induction.
BRAND hypothalamus and achieve early vaginal subarachnoid Ensure fetal position and
NAME: stored in the posterior delivery; stimulation or hemorrhage size and absence of
PITOCIN pituitary; stimulates the reinforcement of labor FETAL EFFECTS: complications that are
DOSAGE AND uterus, especially the in selected cases of fetal bradycardia, contraindicated with
FREQUENCY: gravid uterus just before uterine inertia; neonatal jaundice, oxytocin before therapy
10 units parturition, and causes management of low APGAR scores WARNING: Ensure
myoepithelium of the inevitable or incomplete GI: nausea and continuous observation of
lacteal glands to abortion; second vomiting patient receiving IV oxytocin
contract, which results trimester abortion GU: postpartum for induction or stimulation
in milk ejection in POSPARTUM: To hemorrhage, uterine of labor, fetal monitoring is
lactating women. produce uterine rupture, pelvic preferred.
contractions during the hematoma, uterine Regulate rate of oxytocin
third stage of labor and hypertonicity, delivery to establish uterine
to control postpartum spasm, titanic contractions that are similar
bleeding or hemorrhage contractions, to normal labor, monitor rate
Lactation deficiency rupture of the uterus and strength of contractions;
To evaluate fetal with excessive discontinue drug and notify
distress, treatment of dosage or physician at any sign of
breast engorgement hypersensitivity uterine hyperactivity or
OTHER: spasm.
anaphylactic WARNING: Monitor
reactions, maternal maternal BP during oxytocin
and fetal deaths administration; discontinue
when used to induce drug and notify physician
labor or in first or with any sign of
second stages of hypertensive emergency
labor, Monitor neonate for
afibrogenemia, jaundice
severe water
intoxication with
seizures and coma
NAME OF CLASSIFICA ACTION INDICATION ADVERSE REACTION NURSING
DRUG TION RESPONSIBILITIES

GENERIC OPIOID Acts as an Relief of CNS: sedation, WARNING: Taper


NAME: AGONIST- agonist at moderate to clamminess, sweating, dosage when
NALBUPHINE ANTAGONIS specific severe pain headache, nervousness, discontinuing after
HYDROC T opioid Preoperative restlessness, depression, prolonged use to avoid
HLORIDE ANALGESIC receptors in analgesia, as a crying, confusion, withdrawal symptoms
BRAND the CNS to supplement to faintness, hostility, WARNING: Keep
NAME: produce surgical unusual dreams, opioid antagonist and
NUBAIN analgesia anesthesia, and hallucinations, euphoria, facilities for assisted or
and for obstetric dysphoria, unreality, controlled respiration
sedation but analgesia during dizziness, vertigo, available in case of
DOSAGE also acts to labor and floating feeling, feeling of respiratory depression
AND cause delivery heaviness, numbness, Reassure patient
FREQUEN hallucinatio Prevention tingling, flushing, about about addiction
CY: ns and is an and treatment warmth liability; most patients
5 mg antagonist of intrathecal EENT: blurred vision who receive opiates for
at mu morphine- CV; hypotension, medical reasons do not
receptors. induced hypertension, develop dependence
pruritus after bradycardia, tachycardia syndromes.
cesarean section DERMATOLOGIC:
pruritus, burning,
urticaria
GI: nausea, vomiting,
cramps, dyspepsia, bitter
taste, dry mouth
NAME OF CLASSIFICATION INDICATION ACTION ADVERSE NURSING
DRUG REACTION RESPONSIBILI
TIES
GENERIC LAXATIVE Constipatio Increases GI: Monitor
NAME: n, relief of peristalsis & Occasional frequency &
BISACODYL evacuation motor abdominal character of
BRAND in activity of discomfort, stool
NAME: hemorrhoid the small soreness in Monitor
DULCOLAX s, prep for intestines by anal region occurrence of
barium acting adverse
enema, directly on reaction
DOSAGE
preoperativ the smooth
AND
e and post- muscles
FREQUEN
operative
CY:
Suppository
NAME OF CLASSIFICATI ACTION INDICATION ADVERSE NURSING
DRUG ON REACTION RESPONSIBILITIES
GENERIC ANTI ULCER, Completely Duodenal and CNS: vertigo, Assess patient for
NAME: ANTIHISTAM inhibits gastric ulcers headache, abdominal pain. Note
RANITIDINE INE action of Maintenance malaise presence of blood in
emesis, stool, or gastric
HYDROCHLO histamine on therapy for EENT: aspirate
RIDE the H2 at gastric and blurred vision Ranitidine may be
BRAND receptor sites duodenal ulcer HEPATIC: added
NAME: of GERD jaundice to total parenteral
ZANTAC parietal cells, Erosive OTHER: nutrition
DOSAGE AND decreasing esophagitis burning and solution
FREQUENCY: gastric acid Heartburn itching at Instruct patient on
proper
50 mg IV every secretions injection site use of OTC preparation
8 hours 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
NAME OF CLASSIFICA ACTION INDICATION ADVERSE REACTION NURSING
DRUG TION RESPONSIBILITIES

GENERIC ANTI- Inhibits Lower CNS: lethargy, hallucinations, Monitor patient


NAME: INFECTIV transpeptidase respiratory anxiety, confusion, agitation, carefully for signs
CO- E , preventing tract infections, depression, dizziness, fatigue, and symptoms of
AMOXICL cross-linking otitis media, hyperactivity, insomnia, hypersensitivity
AV of bacterial sinusitis, skin behavioral changes, seizures reaction.
BRAND cell wall and and skin- (with high doses) Monitor for
NAME: leading to cell structure GI: nausea, vomiting, diarrhea, seizures when
CLAVULIN death. infections, and abdominal pain, stomatitis, giving high doses.
DOSAGE Addition of urinary tract glossitis, gastritis, black Check patient's
AND clavulanate (a infections "hairy" tongue, furry tongue, temperature and
FREQUEN beta-lactam) (UTIs) caused enterocolitis, watch for other
CY: increases by susceptible pseudomembranous colitis signs and
1.2 grams drug's strains of gram- GU: vaginitis, nephropathy, symptoms of
IV q 8 resistance to negative and interstitial nephritis superinfection,
beta- gram-positive Hematologic: anemia, especially oral or
lactamase (an organisms thrombocytopenia, rectal candidiasis.
enzyme Serious thrombocytopenic purpura,
produced by infections and leukopenia, hemolytic anemia,
bacteria that community- agranulocytosis, bone narrow
may inactivate acquired depression, eosinophilia
amoxicillin). pneumonia Hepatic: cholestatic hepatitis
Recurrent or Respiratory: wheezing
persistent acute Skin: rash
otitis media Other: superinfections (oral
and rectal candidiasis), fever,
anaphylaxis
NAME OF CLASSIFICA ACTION INDICATION ADVERSE NURSING
DRUG TION REACTION RESPONSIBILITI
ES
GENERIC ANTI- Inhibits ACE, Hypertension CNS: dizziness , Monitor patients
fainting, headache,
NAME: HYPERTENSI preventing Diabetic blood pressure and
CAPTOPRIL VE DRUG malaise, fatigue, fever pulse rate frequently.
conversion of nephropathy CV: tachycardia,
DOSAGE AND ALERT! Elderly
FREQUENCY:
angiotensin I to Heart failure hypotension, angina patientsmay be more
25 mg SL angiotensin II, Left ventricular pectoris
sensitive to drugs
GI: abdominal pain,
a potent dysfunction after hypotensive effects.
anorexia,
vasoconstrictor. acute MI constipation, Assess patient for
Less diarrhea, dry mouth, signs of angioedema.
angiotensin II dysgeusia, nausea, Drug causes the
vomiting most frequent
decreases
HEMATOLOGIC: occurrence of cough
peripheral leucopenia, compared with other
arterial agranulocytosis, ACE inhibitors.
resistance, pancytopenia, In patients with
anemia, impaired renal
decreasing
thrombocytopenia function or collagen
aldosterone METABOLIC:
vascular disease,
secretion, hyperkalemia
RESPI: dyspnea, dry,
monitor WBC and
which reduces differential counts
persistent,
sodium and before starting
nonproductive cough
water retention SKIN: urticarial treatment, every 2
and lowers rash, maculopapular weeks for the first 3
blood pressure. rash, pruritus, months of therapy
alopecia and periodically
OTHER: thereafter.
angioedema
NAME OF DRUG CLASSIFICAT ACTION INDICATION ADVERSE NURSING
ION REACTION RESPONSIBIL
ITIES
GENERIC NAME: NUTRITIO Stimulates RDA CNS: When
ASCORBIC ACID NAL DRUG collagen Frank and faintness, giving for
BRAND NAME: formation clinical dizziness urine
MORIAMIN and tissue scurvy GI: diarrhea, acidification,
DOSAGE AND repair, Extensive heart burn, check urine
FREQUENCY: involve on burns, nausea, pH to ensure
50 mg/tab OD oxidation- delayed vomiting efficacy.
reduction fracture and Do not take
reaction wound more
healing, ascorbic acid
postoperative than what is
wound prescribed or
healing, than is
severe febrile directed on
or chronic the package.
disease state.
To prevent
Vitamin C
deficiency
To acidify
urine
DRUG NAME CLASSIFI ACTION INDICATIO ADVERSE NURSING RESPONSIBILITY
CATION N EFFECT

Ketorolac Nonopioi Anti- short- CNS: assess for durg allergies.


tromethmine d inflammat term headache, assess for history of renal
analgesic ory and manageme dizziness, impairment.
NSAID analgesic nt of pain somnolence, be aware that patient may
Dosage and activity Ophthal insomnia. be at increased risk for CV
frequency: inhibits mic; relief DERMATOL events, GI bleeding, renal
30 mg IV q prostaglan of ocular OGIC: rash toxicity, monitor
6 dins and itching due GI: nausea, accordingly.
leokotrien to seasonal dyspepsia, Gi do not use during labor,
e conjunctivi pain, delivey, or while nursing.
synthesis. tis and constipation protect vials from light.
relief of GU: renal administer every 6 hour to
postoperati impairment maintain serum levels and
ve HEMATOLO control pain.
inflammati GIC: every effort will be made
on after bleeding to administer the drug on
cataract RESPIRATO time to control pain,
surgery. RY: dyspnea, dizziness, drowsiness.
hemoptysis do not use ophthalmic
drops with contact lenses.
Report sore throat, fever,
rash, itching, swelling
DRUG NAME CLASSIFIC ACTION INDICATION ADVERSE NURSING RESPONSIBILITY
ATION EFFECT

Generic oxytocic A partial Routine CNS: assess for drug allergies.


name: agonist or managemen headache, Administer by IM
Methylergo antagonist t after dizziness, injection or orally unless
novine at alpha- delivery of tinnitus, emergency requires IV use
maleate receptors; the placenta diaphoresis Monitor postpartum
Brand name as a result, Treatment CV: women for BP changes and
:methergine I increases of hypertension, amount and character of
postpartum
he palpitations, vaginal bleeding
atony and
strength, chest pain, Discontinue if signs of
hemorrhage
Dosage and duration, dyspnea toxicity occur
Uterine
frequency: and stimulation GI: nausea, Avoid prolonged use of
1 amp frequency during the vomiting the drug
of uterine second Not needed for longer
contractio stage of than 1 week
ns labor Client may experience
following nausea, vomiting, dizziness
the delivery and headache
of the Report difficulty in
anterior breathing, headache, numb
shoulder or cold extremities, severe
abdominal cramping
DRUG CLASSIFIC ACTION INDICATION ADVERSE NURSING RESPONSIBILITY
NAME ATION EFFECT
Paracetamol Analgesic Antipyretic: Temporary CNS: headache, assess for drug allergies.
antipyretic reduces reduction of CV: Do not exceed the
fever by fever, hypertension, recommended drug
Dosage and acting temporary chest pain, Reduce dosage with
frequency: directly on reduction of dyspnea, hepatic impairment
300 mg/ IV the minor aches myocardial Avoid using multiple
q4 hypothalami and pains damage preparations containing this
c heat- caused by GI: hepatic drug
regulating common cold toxicity and Give drug with food if GI
center to and failure, jaundice upset occur
cause influenza, GU: acute renal Discontinue drug if
vasodilation head ache, failure hypersensitivity reaction
and sore throat, HYPERSENSII occur
sweating, tooth ache, VITY: rash,feer Report rash, bruising
which helps back ache,
dissipate menstrual
heat cramp, minor
Analgesic: arthritis pain
site and and muscle
mechanism aches
of action
unclear
DRUG NAME CLASSIFI ACTION INDICATION ADVERSE NURSING RESPONSIBILITY
CATION EFFECT
Hydralazine Antihype Acts Oral: CNS: Assess for drug
rtensive directly on essential headache, hypersensitivity
vasodila vascular hypertensio CV: Give oral drug with food
or smooth n alone or in palpitations, to increase ioavailability
muscle to combination tachycardia, Use parenteral drug
cause with other hypotension immediately after opening
vasodilation drugs GI: ampule
, primarily Parenteral: anorexia, Withdraw drug gradually,
anteriolar, severe vomiting, especially when patients
decreasing essential nausea, who have experienced
peripheral hypertensio diarrhea marked BP reduction
resistance; n when drug GU: Discontinue or reevaluate
maintains or cannot be impotence therapy if patient develops
increase given orally HYPERSE symptoms of peripheral
renal and or when NSIIVITY: neuritis
cerebral need to rash, fever, Take this drug exactly as
blood flow lower BP is chills, prescribed
urgent hepaitis Client may experienced
dizziness, weakness
Report persistent or severe
constipation, malaise,
muscle aching, numbness
DRUG CLASSIFI ACTION INDICATION ADVERSE NURSINGRESPONSIBILI
NAME CATION EFFECT TY

MEDAZOL- Anti-anxiety Short-term Preprocedural Hypersensiti Assess level of sedation


AM agents sedation sedation. vity and level of consciousness
Sedative/hy Aids in the Chronic throughout and for 2-6 hr
pnotics Postoperativ induction of respiratory following administration.
Dosage: e anesthesia anesthesia and insufficiency Monitor BP, pulse and
1 gram as part of respiration continuously
balanced during IV administration.
anesthesia. 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).
DRUG CLASSIFICATI ACTION INDICATION ADVERSE NURSING
ON EFFECT RESPONSIBILITIES
GENERIC Diuretics Potassium- Edema CNS: To enhance
NAME: sparing Hypertension headache, absortion give drug
SPINOROLA diuretics, Diuretic drowsiness, with meals
CTONE antagonizes induced lethurgy, Protect drug form
BRAND aldosteronei hypokalemia confusion, light
NAME: n the distal To detect ataxia Monitor
Aldactone, tubules, primary GI: diarrhea, electrolytes level,
Novospiroto increase aldosteronis gastric fluid intake and
n, Spiractine soduim and m bleeding, output, weght, and
water To manage ulceration, BP
secretions primary cramping Inform laboratory
aldosteronis gastritis, that patient is taking
m vomiting spinorolactone
Heart failure GU: inability because drug may
as adjunct to to maintain interfere with test
ACE inhibitor erection, that measure digoxin
or loop menstrual level
diuretics, with disturbances Watch for
or wothout HEMATOLO hyperchloremic
cardiac GY: metabolic acidosis,
glycosides agranulocyt which may occur
Hirsutism in osis during therapy,
woman SKIN: especially in patients
Premenstrual urticaria, with hepatic
syndome hirsutism, cirrhosis.
DISCHARGE PLANNING
MEDICATION
Instructed to take home medications as ordered at the right time 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 2-3 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 always.
Advised the patient to maintain a close relationship with God and with her family.