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Table of Contents
Chapter 1 – Introduction
Objectives
Chapter 2 – Assessment
Nursing Health History
Personal Data of the Patient
Chief Complaints
History of Present Illness
Past Medical History
Family Health History
Physical Assessment
Diagnostic Procedure
Anatomy and Physiology of the Systems affected
a. Pathophysiology
Chapter 3 – Planning
A. List of Prioritized Nursing Diagnoses
B. NCP
C. Drug Study
Chapter 2 Assessment
A. Personal Data
Name: A.K.A ‘CHURVA”
Age: 30 yrs old
Sex: Female
Address: Baclaran City
The patient was admitted Dec 1 2007 at 11: am; chief complaint was severe abdominal
pain and increasing B/P.
She was admitted in Sta. Rita Medical Hospital.
There’s a history of hypertension in the client’s family. Her mother had hypertension.
3. Diagnostic Procedures
System
The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body and
pick up waste materials and toxins for elimination. This system is made up of the heart, the
veins, the arteries, and the capillaries.
Circulation is achieved by a continuous one-way movement of blood throughout the body. The
network of blood vessels that flow through the body is so extensive that blood flows within
close proximity to almost every cell.
Heart
The heart is a muscular pump that propels blood throughout the body. The heart is located
between the lungs, slightly to the left of center in the chest. The heart is broken down into
four chambers including:
• The right atrium, which is a chamber which receives oxygen- poor blood from the
veins.
• The right ventricle which pumps the oxygen-poor blood from the right atrium to the
lungs.
• The left atrium which receives the now oxygen-rich blood that is returning from the
lungs.
• The left ventricle, which pumps the oxygenated blood through the arteries to the rest
of the body.
Blood Vessels
Blood vessels are broken down into three groups: the arteries which carry blood out of the
heart to the capillaries, the veins which transport oxygen-poor blood back to the heart, and
the capillaries which transfer oxygen and other nutrients into the cells and removes carbon
dioxide and other metabolic waste from these body tissues.
Blood Pressure
Blood pressure is the force exerted by the blood against the walls of the blood vessels. The
output or direct pumping of the heart and the resistance to blood flow in the vessels
determines blood pressure. Resistance is determined by blood viscosity and by friction
between the blood and the wall of the blood vessel.
Blood pressure = blood flow x resistance.
Vasopasm
Peripheral Arteriole
Vasoconstriction
PREGNANCY-INDUCED
HYPERTENSION
Chapter 3 – Planning
Priority: 1. Acute pain 2. Risk for infection 3. Self-care deficit
Independent
Subjective Cues: Acute pain related Within 8 hrs nursing > Provide information and > Promotes problem Goals met.
“Masakit ang tahi ko,” to surgical incision intervention the patient anticipatory guidance regarding solving, helps reduce pain
as verbalized by the as evidenced by will: causes of discomfort and associated with anxiety
patient. facial mask of appropriate interventions. and fear of the unknown,
pain. > Identify and use and provides sense of
appropriate interventions control.
to manage
pain/discomfort. > Reposition client, reduce > Relaxes muscles, and
noxious stimuli, and offer comfort redirects attention away
Objective Cues: > Verbalize lessening of measures, e.g., back rubs. from painful sensations.
level of pain. Encourage use of breathing and Promotes comfort, and
(+) Guarding relaxation techniques and reduces unpleasant
behavior > Appear relaxed, able to distraction (stimulation of distractions, enhancing
(+) Facial mask of sleep/rest appropriately. cutaneous tissue). sense of well-being.
pain
> Encourage early ambulation. > Decreases gas formation
and promotes peristalsis to
relieve discomfort of gas
accumulation, which often
peaks on 3rd day after
Collaborative cesarean birth.
> Administer analgesics every 3–4 > Promotes comfort, which
hr prn. Medicate lactating client improves psychological
45–60 min before breastfeeding. status and enhances
mobility. Use of medication
with limited ability to cross
into milk allows lactating
mother to enjoy feeding
without adverse effects on
infant.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Collaborative
> Administer analgesic agent > Reduces discomfort, which
every 3–4 hr, as needed. could interfere with ability to
engage in self-care.
Chapter III Implementation
Medical Management - Drug Study
Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibilities
Arthrotec (Diclofenac Used for treatmentfor Check if the client takes the
Na) rheumatoid,
ARTHROTEC is ARTHROTEC is • .abdominal pain medication. Check for the doctor’s
indicated for contraindicated in • diarrhea
arthritis,dysmenorrheal, order and if it is the right patient.
treatment of the signs patients with • GI symptoms
headache, post partum Observe for any effect and if any
and symptoms of hypersensitivity to
pain. side effects occur inform physician.
osteoarthritis or diclofenac or to
Arthrotec contains
rheumatoid arthritis in misoprostol or other
dicoflenac sodium and Carefully consider the potential
patients at high risk of prostaglandins.
misoprostol. benefits and risks of ARTHROTEC
developing NSAID-
Administration of and other treatment options before
induced gastric and
misoprotol to women who deciding to use ARTHROTEC. Use
duodenal ulcers and
are pregnant can cause the lowest effective dose for the
their complications.
abortion, premature birth , shortest duration consistent with
or birth defects. Uterine individual patient treatment ...
rupture has been reported
when misoprostol was ARTHROTEC is
asministered in pregnant administered as
women to induce labor or
to induce abortion beyond ARTHROTEC 50 (50
the 8th week of pregnancy. mg diclofenac
sodium/200 mcg
misoprostol) or as
ARTHROTEC 75 (75
mg diclofenac
sodium/200 mcg
misoprostol).
Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibiliries
the drug or to
penicillin itself.
Chapter IV Discharge Planning
Medication
Drug to be continued, Hydralazine (Apresoline) oral. For maintenance, adjust dosage to the
lowest effective levels.
Exercise
The client should limit the no. of stairs she climbs to one flight/dayfor the first week at
home. Beginning the second week, if her lochial discharge is normal, she may start to increase
this activity. Limit stair climbing to only when necessary for first two weeks.
Treatment
Advice client to monitor blood pressure, take prescribed medications and perform wound
care as needed.
Health Teaching
Teaching should focus on action to maintain comfort, to promote healing and restore
wellness.
avoid heavy work (lifting or straining) for at least first 3 weeks after birth.
(it is usually advised that she doesn’t return to an outside for at least 3 weeks (better 6
weeks) not only for her own health but also for enjoyment of the early weeks with her
newborn. Explore with th client what she consider heavy work)
get lots of sleep. Sleep when baby sleeps.
(Client should at least 1 rest period a day and try to get a good night’s sleep. She can rest
during the day when her newborn is sleeping.)
take advantage of help from others.
avoid having sexual intercourse at least a month
call your health care provider if you have any of the warning signs of sickness:
(fever greater than100F, severe pain, redness or swelling in the incision site, foul smelling
vaginal discharge, increase bleeding, back ache or severe abdominal pain or cramping
(unrelieved by medication).)
report increasing pain, swelling, or opening or gaping of wound edges.
teach the client how to change wound dressings and perform wound care.
instruct client to use pain medication as ordered.
emphasize the importance of hygiene and hand washing to prevent infection
Diet
The client’s diet is high protein and low sodium diet.