ANSWERS:

1.
-blood pressure greater than 30 mm Hg diastolic,
- Edema.
-Excess protein in your urine (proteinuria) or additional signs of
kidney problems.
-Severe headaches.
-Changes in vision, including temporary loss of vision, blurred vision
or light sensitivity.
-Upper abdominal pain, usually under your ribs on the right side.

2.The patient has a history of miscarriage, preterm and term

pregnancy , a history of preeclampsia on her second pregnancy,
experienced of headache and nape pain, blood pressure is 150/100,
also experienced mild uterine contractions, cervix is 2 cm dilated with
intact bag of water, presence of protein +2 and Bipedal edema.

3. Multiple gestation,has history of pre-eclampsia, High blood

pressure(150/100),
Presence of protein in urine (proteinuria), headache and nape pain,
age (38).

4 .The child might be preterm , stillbirth , infant death, impair fetal

growth,and lack of oxygen and nutrients. Preeclampsia affects the
arteries carrying blood to the placenta. If the placenta doesn't get
enough blood, your baby may receive inadequate blood and oxygen
and fewer nutrients. This can lead to slow growth known as fetal
growth restriction, low birth weight or preterm birth.

5. nursing interventions:
 Note for Vital Signs
 Abstain from tobacco or caffeine use for 30 minutes before
measurement
 Take BP in upright position
-For the accuracy of data
 For patients in hospital BP can be taken sitting up or in left
lateral recumbent position, patient’s arm at level of heart
-For accuracy of data
 Close monitoring of the mother and her fetus will be needed.
Tests for the mother might include blood and urine tests to see
if the preeclampsia is progressing, such as tests to assess
platelet counts, liver enzymes, kidney function, and urinary
protein levels. Tests for the fetus might include ultrasound,
 heart rate monitoring, assessment of fetal growth, and amniotic
fluid assessment.
-For baseline data
 To help prevent further complications, Ask the mother to go on
bed rest to try to lower blood pressure and increase blood flow
to the placenta.
-To prevent other complications
 Treatment in the hospital might include intravenous medication
to control blood pressure and prevent seizures or other
complications, as well as steroid injections.
-Steroid is to help speed up the development of the fetus's
lungs.
 Anticonvulsive medication, such as magnesium sulfate might be
used
- to prevent a seizure.
Magnesium Sulfate
-Inform the patient that this drug is use to prevent seizure
and is given intravenously , and inform the mother that
she may experience uncomfortably warm, headache, dry
mouth, nausea, and blurred vision.
6.
 Health educate the mother about pre-eclampsia
- Giving the right information to the mother helps them to
understand the risk factor , management and treatment
about it.
 A pregnant woman should immediately call her health care
provider if any of the signs or symptoms of severe disease
develop, or if she has decreased fetal activity, vaginal bleeding,
abdominal pain, or frequent uterine contractions.
-this might affect the fetus if the mother will not call the health
provider, developing of any signs or symptoms has greater
chance of having pre-eclampsia.
 Inform the mother that clinical signs of preeclampsia can
appear suddenly. Never
underestimate the importance of even mild BP
elevationscomplicating a pregnancy.
- blood pressure puts you at risk of heart attack, stroke and
other major complications and it can be dangerous for the
infant.
7. OB SCORE
G4P2T1P1A1L2= Gravida is 4 because she is currently pregnant
and has a history of miscarriage, preterm and term pregnancy. Para is 2
because she got history of preterm and term pregnancy. Term is 1 because
of her term history of pregnancy , Preterm is 1 because of her preterm
history of pregnancy ,Abortion is 1 because she has history of miscarriage,
living is 2 because of her term and pre term history of pregnancy. M is 1
because she is currently pregnant with twins.

EDD: September 05 2019 ( last menstrual period)

-3 months
----------------------
June 05 2019
+ 7
----------------------
June 12 2019
+ 1
--------------------
EDD= June 12, 2020

30
-
AOG : Sept 05
-----
Sept 25
Oct 31
Nov 30
Dec 31
Jan 30
Feb 28
March 31
April 13
------
219 days divided by 7
AOG = 31 weeks and 2/7 days

8. NURSING CARE PLAN (* NEXT PAGE )

 9. If the pregnant woman is uncooperative and irritable with me , as a
nursing student I should be humble all the time rather than becoming
defensive and being wise to respond calmly to the patient and treat her with
respect. If my patient is uncooperative, I’ll try to identify the underlying
reason and do a certain action and empathize with her, saying something
like, "I understand how upsetting this must be for you." and I’ll  will calmly
explain the consequences of her refusal and if my is angry enough to
verbally abuse me, I will remain calm and professional. I will keep some
distance between me and the patient and not to respond until the verbal
barrage is over. When it is, this is the time for me to speak softly and call
the patient by name. I truly understand that pregnant women are very
moody and easily irritated so I will do my very best to understand them with
all my heart as part of my dream profession.

ASSESSME NURSING PLANNIN IMPLEMENTATI RATIONALE EVALUATION

NT DIAGNOS G ON
IS
Subjective: Deficient After 3 1. Establishes 1. After 3 days of
“Sumasakit knowledg days of data base and Establishes nursing
po kasi e related nursing provides data base intervention
yung ulo to interventio information. and provides patient, the
at batok Unfamiliar n patient, Provide information. client was able
ko lagi ity with the client information about Provide to:
dok” as informatio will be areas in which information
verbalized n able to: learning is about areas Identify
by the resources needed. Taking in which signs/symptoms
client. evidenced Identify information can learning is requiring
by signs/symp improve needed. medical
Objective: Developm toms understanding Taking evaluation.
-Blood ent of requiring and reduce fear, information
pressure preventabl medical helping to can improve Patient
= 150/100 e evaluation. facilitate the understandi performs
complicati treatment plan ng necessary
-Presence
ons Patient for the client. and reduce f procedures
of
performs ear, helping correctly.
proteinuri
necessary to facilitate
a (2+)
procedures the Patient
- Bipedal
correctly. treatment verbalizes
edema
plan for the understanding
Patient client. of disease
verbalizes process and
2. Provide
understand 2. Helps appropriate
information about
ing of ensure that treatment plan.
signs/symptoms
disease patient
indicating
process seeks timely Patient initiate
worsening of
and treatment lifestyle/behavi
condition, and
appropriat and may or changes as
instruct patient
e prevent indicated.
when to notify
treatment worsening
healthcare
plan. of
provider.
preeclampti
Patient c state or
initiate additional
lifestyle/be complication
havior s.
changes as
indicated. 3 Have patient 3. Fears and
informed of anxieties
health status, can be
results of when compounded
tests, and fetal when
well-being.. patient/coup
 le does not
have
adequate
information
about the
state of the
disease
process or
its impact
on patient
4. Educate and and fetus.
assist family
members in
4.
learning the
Encourages
procedure for
cooperation
home monitoring
in treatment
of BP, as
regimen,
indicated.
allows
immediate
intervention
as needed,
and may
provide
reassurance
that efforts
are
beneficial.
5. Review self-
testing of urine
for protein.
Reinforce 5. A test
rationale for and result of 2+
implications of or greater is
testing. vital and
needs to be
reported to
healthcare
provider.
Urine
specimen
contaminate
d by vaginal
discharge or
RBCs may
produce
6. Provide positive test
information about result for
ensuring enough protein.
protein in diet for
patient with 6. Protein is
possible or mild essential for
preeclampsia. intravascula
r and
extravascula
r fluid
regulation.