ACKNOWLEDGEMENT We, the students of BSN-3E Group 3 would like to give our heartfelt gratitude to the following people who

have been part of the success of this Case Presentation.

First and foremost, for the Administration for giving us an opportunity to be exposed in different areas in the hospital that would definitely increase the knowledge of each student concerning the nursing profession. To our Clinical Instructors, especially, Ma’am Nancy Bargamento RN, Ma’am Lory Anne H. David RN, and Ma’am Brenda A. Morales, RN for their patience in guiding and imparting knowledge to us especially for being there to guide us in every step of our Clinical exposure. Also to the staff of DR in Davao Regional Hospital, for their patience and help during our DR duty.

A special thanks to our client and her family for allowing us to conduct an extensive interview with her.

For our family and friends who have been so supportive to us throughout this whole experience. For being there to give us encouragement when it was needed the most. And lastly our sincerest thanks to the Lord Almighty who has been there in every step of our lives especially at this time of so much pressure in our chosen field.


INTRODUCTION Motherhood is what women most often dream about. Conception and giving birth to a child is the greatest gift we could ever imagine. Despite the risks and associated complications, a mother could jeopardize it all for a safe and healthy delivery. In our exposure and duty we had in the Delivery Room of Davao Regional Hospital, we have encountered and interacted with these mothers whose life had been to a great peril. As we have seen the plight of our patients, we have realized the importance of a healthy conception and lifestyle that may have contributed to the most common complications of pregnancy. The exposure enhanced our skills holistically and effectively in dealing and addressing to the different needs of our client. By doing research, our knowledge broadens and we were able to dig deeper and discover the nature, etiology and background of our client’s condition, thus proper management was also known. As student nurses of Ateneo, we believe in the principle of magis. We do not only confine ourselves and be merely satisfied with the plain folded facts, instead we strive to know the truth and seize for the best. We also kept in mind and inculcated within us to be men and women for others. That is why we would like to grab this opportunity to study a case related to Maternal and child nursing so that by the time that we would encounter same case, we could effectively render the appropriate nursing care and promote optimum wellness to that patient. We believe that by choosing Venus Raj to be the case of our study, we would be able to advance our knowledge and skills and extend our promise of devoting ourselves to those committed of our care. After being exposed with some common complications of pregnancy of unknown etiologies, we decided to study the case, Gestational Hypertension. Hypertension or high blood pressure is a chronic medical condition in which the blood pressure in the arteries is elevated. Gestational Hypertension which is a common complication of pregnancy is characterized by the development of new arterial hypertension only during pregnancy after 20 weeks AOG. As of 2008 based on WHO report, about 20% is affected globally and 13% for the whole Philippines with a maternal mortality rate of less than 1% in the developed world. The treatment may vary from the severity of the patient’s condition but the greatest cure for the said disease is to deliver the baby and hope for the best. OBJECTIVES 2

General Objectives: This case study aims to make the group formulate and deliver a specific, measurable, attainable, realistic, and time-bounded plan of care that would help us gain new and deeper understanding about Gestational Hypertension and the management of this disorder by presenting the substantial and comprehensive study conducted to Venus Raj, a patient diagnosed with Gestational Hypertension admitted on January 10, 2011 at the Davao Regional Hospital.

Specific Objectives: That within 3 days span of exposure in OB Ward, the group will be able to: a. Select a patient to be the subject of their case study; b. Establish a good patient-nurse relationship as well as with the patient’s significant others; c. Present an introduction regarding their patient and her condition, gestational hypertension, including its common complications, and its nursing implications to nursing research, education, and practice; d. Formulate objectives to serve as a guide in the completion of this case study; e. Present the necessary and pertinent data about the patient including the patient’s comprehensive health history; f. Trace and discuss any hereditary disease or disorder that could have

precipitated the patient to such condition through the genogram; g. Present a complete definition of the diagnosis from 3 different sources in order for readers to understand the patient’s disorder; 3

q. Identify and present the prognosis of the patient and the justification for this. as well as the possible examinations that can be done.h. Enumerate the references utilized in the making of this case study. Conduct and present a thorough head-to-toe assessment of the patient. Discuss the anatomy and physiology of the affected system k. Present the developmental data of the patient and present at least 3 Nursing Theories applicable to the case presented. Formulate and present individualized nursing care plans for the patient. p. Trace the Pathophysiology of the disease process. Discuss the pharmacologic treatment given to the patient from the time she has been admitted. PATIENT’S DATA 4 . clinical significance and nursing responsibilities before and after the examination. l. including the etiology. and r. n. precipitating and the predisposing factors that could have contributed to the disease process as well as the Symptomatology of the disease. and present the possible management that can be performed to the to her. Discuss the actual medical management that was done to the patient to manage her condition. Create a discharge plan by using the METHOD system which is applicable to the patient. j. o. m. Present the actual laboratory and diagnostic examinations conducted on the patient with its corresponding results and normal values. i.

Cephalic in labor. Davao Del Norte Nationality: Filipino Religion: Catholic Occupation: Internet Café Attendant Educational Attainment: High school graduate Economic Status: Low CLINICAL DATA Admitting Date: January 10. Dokdokan Last Menstrual Period (LMP): March. Pregnancy Uterine. Tagum City. 1985 Civil Status: Single Address: Prk. Gestational Hypertension Vital signs upon Admission: BP – 140/100 mmHg Attending Physician: Dr. 2009 Source of information/ Informants: Patient and Patient’s Chart FAMILY BACKGROUND AND HEALTH HISTORY 5 . 5 San Miguel ( Comp 4 ).Patient’s Code Name: Venus Raj Age: 25 years old Birthday: June 10. 2011 Admitting Diagnosis: G1P0. 37 4/7 weeks age of gestation.

Diet Venus eats fish. Lifestyle Venus and her partner usually wakes up at 6:00 in the morning. Venus lives in her partner’s house in Tagum City and only the both of them lives inside the house because Venus’s partner Coco owns the house. Venus stated that she never had hypertension before and claimed she was healthy enough. egg. As she traced her family history of sicknesses. meat. She admitted that she seldom eats vegetables because she doesn’t like the taste especially ampalaya because of its bitterness. She admitted that her mother and the brothers and sisters of her mother are all hypertensive including the her mother’s father or her grandfather died because of cardiac arrest at her father’s side. but as soon as she knew that she was pregnant she then immediately decided to stop working 6 . Venus before she was pregnant works as a internet café attendant in Downtown Tagum. it was only when she got pregnant she experienced blurry vision and hypertension. Venus prepares for breakfast and her child’s necessities while her partner prepares for work. Venus only has one sister Jupiter and Venus believes that her sister is also hypertensive because her family sometimes experiences blurry vision. hotdogs and barbeques.Venus and the father of her baby are not yet married but they planned to be married after the baptism of their child. her father’s siblings only had arthritis and her grandfather and grandmother died because of an unknown cause.

Usually her monthly period lasts for 5 to 7 days. According to her. It is usually heavy for the first three days of menstruation. cough. She has regular monthly cycles. It was when Venus felt dizzy that they went to the hospital. History of Past Illness Venus does not have any allergies. Menstrual History Venus’s menarche occurred when she was around 14 years old. and colds. According to her. When they arrived at the Davao 7 . History of Present Illness Venus felt mild to moderate uterine contractions and told her partner about it. Her last menstrual period (LMP) was last March 2009. Her past illnesses are fever. she does not feel any painful menstruation or dysmenorrhea. They did not immediately go to the hospital since Venus can still tolerate the pain. and her partner works as a craftsman.and just stay in her partner’s house to focus herself on her 1st pregnancy. making necklaces made up of clay and sells them anywhere around the region. she had chickenpox and measles during her childhood and never has had any worse condition before. Mostly Venus and her partner Coco bonds on weekends touring around the park of downtown Tagum and always goes to church every Sunday morning.

it was then she knew that she was hypertensive because her Doctor told her and she was diagnosed with Gestational Hypertension. she admitted that she was partly excited with the child and was anxious because of the severe pain she might feel while delivering her child. When we interviewed Venus. Nevertheless.Regional Hospital. Effects/ Expectations of Present Illness to Self and Family Venus and her partner Coco was so positive about her 1st pregnancy. 8 . she was very optimistic that the child would bring more than happiness but rather give her a sense of purpose to herself. Venus and Coco’s Family are in full support of Venus’s pregnancy.

Genogram Grand ma 1 Grandpa Grandpa 1 1 Grand ma Grandpa Grandpa 2 2 2 Uncle Uncle 1 1 Uncle Uncle 2 2 Uncle Uncle 3 3 Aun t1 Aun t2 Aun t3 Aun t4 Father Father Moth er Uncle Uncle 1 1 Aun t1 Aun t2 Aun t3 Jupit er Venu s Raj Coco Coco Martin Martin 9 .

She is staying in the house of her partner. called developmental tasks. based on learning and learned behaviors. which emanate from biologic. success in achieving the developmental tasks leads to success with tasks in later stages of life. She has achieved this stage. She says that she and her partner are not dependent on their parents in terms of financial matters. They do not live in the same roof with their parents. *Establishing independence from parents She has already achieved this stage of development although currently she only is an attendant in an internet café. She has achieved this stage *Establishing intimate of development. She and relationships her partner are planning to get married right after the christening of their 1st baby Our patient has achieved *selecting a life partner this stage of development. psychological and social origins during lifespan. She found a live in partner Developmental Task Result and Justification Our patient is 25 years old and belong to the 40 years) and the following are the tasks: Our patient has achieved adulthood early adulthood (21 to some of the tasks in early 10 . Specific developmental tasks are assigned to the various stages of life.Developmental Data Theorist Robert Havighurst Theory Developmental Task Theory. According to this theory. Failure to complete the *Choosing an tasks assigned to each occupation or career stage may lead to failure in tasks in subsequent stages.

In each stage the person confronts. The challenges 11 Our patient belongs to Our patient did not achieve the stage of young old): Intimacy vs.She does not have any *Establishing social network social groups and does not participate in any social activities. She is planning to learn *Managing a home more about taking care of a family since she now have a baby. She says that she will become a responsible mother for her child. and hopefully masters new challenges. adult (20 to 34 years she already had a live in . She is yet a new mother but *Rearing children she is already taking care of her baby. Each stage builds on the successful completion of earlier stages. Isolation this stage because though partner but still they did not get married. She has achieved this stage *Starting a family although she is still planning on how to start managing their family Psychosocial Erik Erickson development theory describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood.

Theorist Sigmund Freud Theory Psychosexual Development Theory.of stages not successfully completed may be expected to reappear as problems in the future. 12 . it is a theory of how our sexuality starts from a very young age Stage Result and Justification Venus achieved this Our patient belongs to the genital stage. During the final stage of psychosexual development. the individual develops a stage since she has now her own family and has a new born baby.

Age of Gestation. Pregnancy Uterine. Gestation Hypertension.and develops through various fixations. the individual should now be well-balanced. Cephalic in Labor. Source: (Harrison’s Principles of Internal Medicine 2) 13 . DEFINITION OF COMPLETE DIAGNOSIS Diagnosis: G1P1. If these stages are not psychologically completed and released. strong sexual interest in the opposite sex. warm and caring. Uterine Pregnancy A normal pregnancy occurs when a fertilized egg is implanted in the uterus (womb) and an embryo grows. interest in the welfare of others grows during this stage. PROM. Where in earlier stages the focus was solely on individual needs. 37 4/7 weeks. The goal of this stage is to establish a balance between the various life areas. If the other stages have been completed successfully. we can be trapped by them and they may lead to various defense mechanisms to avoid the anxiety produced from the conflict in and leaving of the stage.

Saunders) Cephalic Presentation of any part of the fetal head.Age of Gestation It is usually considered to be the age of an embryo or fetus (or newborn infant) from the first day of the woman's last menstrual period (LMP). A.(2007). & Keane. & Allied Health) 14 . or the face in face presentation. so no drug therapy is necessary Source: Pillitteri.Maternal and Child Health Nursing 5th edition. B. smoking. the brow in brow presentation. Lippincott William and Wilkins. W. uterus. or anatomic defect in the structure of the amniotic sac. This standard system of counting the progression of pregnancy starts approximately two weeks before fertilization takes place. Source: (Harrison’s Principles of Internal Medicine 2) Gestational Hypertension A woman is said to have a gestational hypertension when she develops an elevated blood pressure (140/90 mmHg) but has no protienuria or edema. Encyclopedia and Dictionary of Medicine and Nursing. Risk factors for PROM can be a bacterial infection. C.B. there may be degrees of flexion so that the presenting part is the large fontanel in sincipital presentation. Source: (Miller. Nursing. Page 427 Premature rupture of membranes (PROM) is a condition that occurs in pregnancy when there is rupture of the membranes (rupture of the amniotic sac and chorion) more than an hour before the onset of labor. Source: (Mosby’s Dictionary of Medicine .. or cervix. usually the upper and back part as a result of flexion such that the chin is in contact with the thorax in vertex presentation. Perinatal mortality is not increased with simple gestational hypertension.

PHYSICAL ASSESSMENT Patient’s Code Name: Venus Raj Age: 25 years old Gender: Female General Survey 15 .

The patient had a cooperative attitude towards the student nurse as evidenced by her willingness to participate in the physical assessment that was to be performed. conscious.Received on bed on moderate high back rest. person (identified the student nurse as the person she is to and uttered the name of the watcher when asked to do so). She was oriented to the time (verbalized it was in the afternoon). Respiratory rate=33 breaths per minute. Her mood and affect was appropriate to the situation. place (identified the hospital as her current location). Her speech was understandable. She also exhibited thought association and relevance in her statements. and reason for admission (admitted that delivery is her reason of going to the hospital). and in moderate pace. awake. Vital Signs Vital signs taken and had the following results: Blood pressure=140/90mmHg. Patient is in respiratory distress. clear. Pulse rate=86 beats per minute. Skin 16 .FHT= 142. and coherent as evidenced by the patient’s ability to comprehend words uttered by the student nurse. Temperature=36.9 degree Celsius. and responsive as evidenced by her prompt responses to the student’s questions and statements.

Prompt return of usual color. no pallor. Upon inspection. and uniform in consistency as evidenced by absence of nodules or masses. which is darker than normal. No infection or infestations were noted upon inspection and palpation of the patient’s hairline and scalp. Symmetry in anatomy and movement were noted in facial features as evidenced by 17 . or erythema was noted Her axillae are excessively moist and accumulated dirt was observed. Epidermis surrounding the nails was intact and no lesions or paronychia were noted. normocephalic. oily. cyanosis. Scalp was smooth and without lesions. lumps. Skull was smooth upon palpation. hair was long and slightly brown in color. which is less than 2 seconds. Frontal. jaundice. Hair Upon inspection. or masses upon palpation. Skin temperature was uniform in all extremities upon palpation. and evenly distributed as evidenced by the absence of areas of alopecia along the scalp. nail base was firm and fingernails had a smooth texture. and symmetrical. Nails Nail bed was pale pink in color. Skin turgor was good as manifested by skin immediately springing back to previous state when pinched. Upon palpation. Nail body had a convex curvature. Her hair is thick.The patient’s skin color was generally light brown and uniform all throughout the body except under her axillae. was noted when blanch test was performed on fingernails. parietal and occipital lobes were prominent upon inspection and palpation. Skull and Face Skull was rounded.

Upon palpation. auricles were mobile. shiny and smooth in surface with details of the iris visible upon inspection. Cornea was transparent. downward. auricles were of the same color with facial skin. Eyelashes were also evenly distributed and were slightly curled outward.eyebrows moving simultaneously when patient was asked to raise eyebows. and eyelids closing simultaneously when asked to close and open eyes voluntarily. and the pinna being folded forward without resistance and recoiling after folding. Cerumen was present but was not impacted or excessive in amount. Lids close symmetrically both voluntarily and blinking (bilateral). cheeks moving in unison when she was asked to puff her cheeks and was asked to smile and show the teeth. Blinking was present when cornea was attempted to be touched. Pupils were black in color. 18 . and not tender as evidenced by the auricle being pulled upward. skin of eyelids was intact and no discharges and discolorations were present. Pupillary response to illumination was brisk and equal as evidenced by constricting of both illuminated and non-illuminated pupils upon illumination. and backward without resistance. Ears and Hearing Upon inspection. Eyes and Vision Hair of eyebrows were evenly distributed and periorbital skin was intact without swelling or inflammation. and were aligned with the outer canthus of each eye. firm. smooth border. Eyebrows were symmetrically aligned and exhibited equal movement when patient was asked to raise eyebrows and frown. were symmetrically aligned with each other. equal in size and had a round. She can response to normal voice tones as manifested by answering the questions raised by the student nurse. Upon inspection.

Upon palpation. Patient exhibited ability to purse lips when asked to do so. Gums were pinkish and were moist and firm. outer lips were dark. and was easily raised by the patient. flex laterally 19 . tenderness or lesions were not noted. No swelling or ulcerations were noted. moist.Nose and Smell Upon inspection. external nose was symmetric. The mucosa of the nasal passages was pink and no lesions were present along the passages. Nasal septum was intact and in midline. Uvula was positioned in midline of soft palate when patient was asked to say “ah”. Tongue was in central position and pink in color. smooth in texture and symmetrical in contour. Tongue was able to move freely from side to side. Mouth Upon inspection. hyperextend. it was observed that she has slightly bad breath. Tongue base was smooth with prominent veins. Head movement was coordinated when patient was asked to flex. neck veins were not distended or visible. Nasal patency was present as evidenced by air moving freely when she was asked to breath in air through each nares when the other nares and mouth are closed. Missing tooth was noted on her right upper molar. Moreover. Neck Upon inspection. No abnormal discharges or flaring were noted. Also. Teeth were smooth. No tenderness or bleeding was noted. pale yellow. She was able to swallow without difficulty. Thick whitish coating on the surface of the tongue was noted. Teeth were properly aligned. and shiny. the nose was with uniform color with facial skin. Her neck muscles were functional as evidenced by her ability to hold the head erect and centered.

Peripheral pulses were present on all four extremities and had symmetrical pulse volumes. bilaterally the same. The skin over the posterior thorax was intact. Prompt return of usual color was noted when blanch test was performed on fingernails. Shoulder muscles were of equal strength when asked to raise the shoulders. Breasts The breasts of the patient are round in shape and look engorged. trachea was at midline of the neck. and darker than the 20 . The skin is uniform in color with the abdomen and chest. and the right and left shoulders and hips are of the same height when the patient was asked to stand erect. Cardiac rhythm was regular and cardiac rate was 86 bpm and within normal range (60-100 bpm). Also. heart sounds were normal. Upon auscultation over the trachea and anterior lung lobes. the left breast is slightly larger than the right breast. However. The spinal column is straight. Respiratory rate was 33 cpm and was within the normal range (12-20 cpm). Lymph nodes were not palpable. The areolas are round. Normal breath sounds were auscultated over the periphery of the posterior lung lobes. quiet. normal breath sounds were noted.and rotate head laterally. uniform in temperature and color with the rest of the body. rhythmic and effortless respirations were noted. Peripheral pulses were regular and were within normal range. Cardiovascular and Peripheral Vascular Upon auscultation. chest expansion was symmetrical upon inspection and palpation. Upon inspection of the anterior thorax. Thorax and Lungs The shape of the thorax from posterior and lateral views is symmetric. Upon palpation.

The nipples are round. everted. Muscles have equal strength on both sides. which is extracted in scanty amount. Extremities Muscle sizes were equal on both sides of the body.usual color. equal in size. Joints move smoothly and were within full range of motion in all extremities. There are no discharges observed except for the colostrum. The muscles and tendons have no contractures and no tremors were noted. similar in color and point on the same direction. stretch marks and linea nigra were noted. Abdomen Upon inspection. Anatomy and Physiology The Endocrine System 21 . Muscle tone was firm with smooth and coordinated movements were observed. Presence of edema noted on lower extremities with a grade of +2 upon inspection. The abdomen looks distended since her uterus did not yet return to its pre-pregnancy state.

The nervous system sends electrical messages to control and coordinate the body. These glands are ductless. and naked mole rats exert control of their respective colonies via pheromones. A hormone is a specific messenger molecule synthesized and secreted by a group of specialized cells called an endocrine gland. which means that their secretions (hormones) are released directly into the bloodstream and travel to elsewhere in the body to target organs. One common use for pheromones is as attractants in mating. but uses chemicals to “communicate”. Note that this is in contrast to our digestive glands. It has been found that pheromones in male sweat and/or sweat from another “dominant” female will both 22 . Pheromones are widely studied in insects and are the basis for some kinds of Japanese beetle and gypsy moth traps. but are used to send signals to other members of the same species. While pheromones have not been so widely studied in humans. These chemicals are known as hormones. ants. Queen bees. Pheromones are also communication chemicals. which have ducts for releasing the digestive enzymes. some interesting studies have been done in recent years on pheromonal control of menstrual cycles in women. upon which they act. The endocrine system has a similar job.

influence/regulate the cycles of women when smeared on their upper lip, just below the nose. Also, there is evidence that continued reception of a given man’s pheromone(s) by a woman in the weeks just after ovulation/fertilization can significantly increase the chances of successful implantation of the new baby in her uterus. Pheromones are also used for things like territorial markers (urine) and alarm signals. Each hormone’s shape is specific and can be recognized by the corresponding target cells. The binding sites on the target cells are called hormone receptors. Many hormones come in antagonistic pairs that have opposite effects on the target organs. For example, insulin and glucagon have opposite effects on the liver’s control of blood sugar level. Insulin lowers the blood sugar level by instructing the liver to take glucose out of circulation and store it, while glucagon instructs the liver to release some of its stored supply to raise the blood sugar level. Much hormonal regulation depends on feedback loops to maintain balance and homeostasis. There are three general classes (groups) of hormones. These are classified by chemical structure, not function.

steroid hormones including prostaglandins which function especially in a variety of female functions (aspirin inhibits synthesis of prostaglandins, some of which cause “cramps”) and the sex hormones all of which are lipids made from cholesterol,

• •

amino acid derivatives (like epinephrine) which are derived from amino acids, especially tyrosine, and peptide hormones (like insulin) which is the most numerous/diverse group of hormones.

The major human endocrine glands which play major roles in pregnancy are: 1. the hypothalamus


The hypothalamus is located in the lower central part of the brain. This part of the brain is important in regulation of satiety, metabolism, and body temperature. In addition, it secretes hormones that stimulate or suppress the release of hormones in the pituitary gland. Many of these hormones are releasing hormones, which are secreted into an artery (the hypophyseal portal system) that carries them directly to the pituitary gland. In the pituitary gland, these releasing hormones signal secretion of stimulating hormones. The hypothalamus also secretes a hormone called somatostatin, which causes the pituitary gland to stop the release of growth hormone. 2. The pituitary gland


The pituitary gland is located at the base of the brain beneath the hypothalamus and is no larger than a pea. It is often considered the most important part of the endocrine system because it produces hormones that control many functions of other endocrine glands. When the pituitary gland does not produce one or more of its hormones or not enough of them, it is called hypopituitarism. The pituitary gland is divided into two parts: the anterior lobe

(adenohypohysis) and the posterior lobe (neurohypophysis). The anterior lobe produces the following hormones, which are regulated by the hypothalamus:

Growth hormone - Stimulates growth of bone and tissue (growth hormone

deficiency in children results in growth failure. Growth hormone deficiency in adults results in problems in maintaining proper amounts of body fat and muscle and bone mass. It is also involved in emotional well-being.)

Thyroid-stimulating hormone (TSH) - Stimulates the thyroid gland to produce

thyroid hormones (A lack of thyroid hormones either because of a defect in the pituitary or the thyroid itself is called hypothyroidism.)

Adrenocorticotropin hormone (ACTH) - Stimulates the adrenal gland to

produce several related steroid hormones

Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) - Hormones

that control sexual function and production of the sex steroids, estrogen and progesterone in females or testosterone in males

Prolactin - Hormone that stimulates milk production in females

The posterior lobe produces the following hormones, which are not regulated by the hypothalamus:
• •

Antidiuretic hormone (vasopressin) - Controls water loss by the kidneys Oxytocin - Contracts the uterus during childbirth and stimulates milk



shielded by a hood of flesh. 3. located under the labia majora. estrogens promotes: • • • The development of the breasts Distribution of fat evidenced in the hips. When stimulated sexually. fleshy tissue surround the entrance to the vagina and the urinary opening: the labia majora. and the labia minora. The clitoris.The hormones secreted by the posterior pituitary are actually produced in the brain and carried to the pituitary gland through nerves. the estrogens and progesterone. At the onset of puberty. progesterone and estrogens are responsible for the changes that occur in the uterus during the female menstrual cycle. The Female Reproductive System Our overview of the reproductive system begins at the external genital area— or vulva—which runs from the pubic area downward to the rectum. These steroid hormones contribute to the development and function of the female reproductive organs and sex characteristics. legs. is a relatively short organ (less than one inch long). or inner folds. They are stored in the pituitary gland. and breast Maturation of reproductive organs such as the uterus and vagina Progesterone causes the uterine lining to thicken in preparation for pregnancy. Gonads Ovaries Two groups of female sex hormones are produced in the ovaries. Two folds of fatty. the clitoris can become erect like a man's 26 . or outer folds. Together.

the mucus tends to be thick and sparse.) HOW THE SYSTEM FITS TOGETHER 27 . the lower portion or neck of the uterus. Like the vagina. After intercourse. the cervix has dual reproductive functions. if a sperm encounters an ovum (egg). In the reproductive process. where the embryo grows into a fetus during pregnancy. serving as the avenue of birth through which the new baby enters the world. shots and implants.penis. the vagina functions as a two-way street. and hostile to sperm. The Cervix The vagina ends at the cervix. But when an egg is ready for fertilization and estrogen levels are high the mucus then becomes thin and slippery. offering a much more friendly environment to sperm as they struggle towards their goal. estrogen and progesterone. conception occurs. the quality and quantity of which is governed by monthly fluctuations in the levels of the two principle sex hormones. accepting the penis and sperm during intercourse and roughly nine months later. ridged sheath connecting the external genitals to the uterus. stretches when you insert a tampon or have intercourse. sparse. The cervix is lined with mucus. One of the ways they prevent conception is to render the cervical mucus thick. When estrogen levels are low. The hymen. then proceed through the uterus to the fallopian tubes where. which makes it difficult for sperm to reach the fallopian tubes. The Vagina The vagina is a muscular. a thin membrane protecting the entrance of the vagina. (This phenomenon is employed by birth control pills. sperm ejaculated in the vagina pass through the cervix.

The cervical canal expands to roughly 50 times its normal width in order to accommodate the passage of the baby during birth. In this cutaway view. where fertilization by a sperm will occur. over the course of nine months.Deep within the pelvic region lie the specialized female organs that make conception and pregnancy possible. the cervix acts as the passage through which the baby exits the uterus into the vagina. are narrow conduits connecting each ovary to the uterus. where an egg. you can see how the cervix acts as the gateway between the vagina and the uterus. at the end of pregnancy. grow to be a newborn child. Like the cervical canal. Riding atop the uterus are the two ovaries. the uterus expands considerably during the reproductive process. The Uterus The uterus is the muscular organ which holds the developing baby during the nine months after conception. A CLOSER LOOK AT THE UTERUS 28 . the organ grows to from 10 to 20 times its normal size during pregnancy. The fallopian tubes. will be nurtured and. storehouse of all a woman's eggs. In fact. if fertilized. Later.

ready to conduct a mature egg away from the ovary and on into the uterus. you can also see how the fallopian tubes cradle the ovaries in their feathery fimbria. if conception does not occur. one of which is attached to the ovary. Each month the uterus goes through a cyclical change. which nurtures the developing egg. then. or endometrium. The trumpet-shaped part near the ovary has about 20 to 25 feathery projections called fimbria. Each of these tubes is roughly five inches long and ranges in width from about one inch at the end next to the ovary. first building up its endometrium or inner lining to receive a fertilized egg. From this angle. the two ovaries. It is the fimbria that each month urge an egg to exit the ovary and begin its trip towards the uterus. The Ovaries 29 . shedding the unused tissue through the vagina in the monthly process called menstruation. the fallopian tubes connect the rest of the system to the ultimate source of the eggs. to the diameter of a strand of thin spaghetti.Note the thick muscular walls—crucial when the baby is ready for delivery—and the lush inner lining. The Fallopian Tubes Beyond the uterus.

Then. roughly 300 mature eggs are produced for potential conception. begin to ripen. if conception fails to occur. The egg within the dominant follicle continues ripening to maturity. when the reproductive system is activated by a cascade of substances called sex hormones. Once a sperm unites with the egg. expelled from the body during menstruation. its surrounding gelatinous coat releases substances that prevent more sperm from entering. They are among the first organs to be formed as a female baby develops in the uterus. During the course of an average reproductive lifespan. each encased in a sac called a follicle. From that point on. which has been primed by the sex hormones to accept and nurture it.000. If fertilization is to occur. each month about 20 egg cells. it enters the uterus and implants itself on the endometrium. Responding selectively to the sex hormones. A newborn infant has between 1 million to 2 million egg cells. About four or five days after fertilization. The Corpus Luteum The fertilized egg then continues on its journey through the fallopian tube. For every egg that matures and undergoes ovulation. it exits the ovary and enters the adjacent fallopian tube to be either fertilized or. one follicle becomes dominant while the others shrink away. it usually happens when the egg's journey is about onethird complete. the number begins to decrease rapidly. the structures that will become the ovaries house roughly 6 to 7 million potential egg cells. By puberty the number has plummeted to 300. The egg cells remain inactive until puberty. Then. helped by the feathery fimbria. FROM FOLLICLE TO “YELLOW BODY” 30 . so that by menopause. only a few thousand remain. roughly a thousand will fail. At the 20-week mark.The ovaries are a woman's storehouse of egg cells.

Meanwhile.Host to a lifetime supply of eggs.” In turn. the follicle that held the egg still has a critical role to play. the ovaries each month launch about 20 contenders towards potential conception. after which it shrinks and dries up. which prepares the lining of the uterus for pregnancy. however. that give it a yellowish tinge. If conception occurs. or “yellow body. Once a mature egg has begun its trip through the fallopian tube. the winning follicle gives off increasing amounts of the hormone estrogen. First it shrinks markedly. which surrounds the baby in 31 . a hormone from the developing placenta. eventually becoming a speck of fibrous scar tissue. two of the hormones critical to reproduction. The resulting structure. or lipids. In a non-pregnant woman. now called the corpus luteum (yellow body). the corpus luteum lasts for about 14 days. remnants of the winning follicle form the corpus luteum. Each ripens in a supporting follicle. then begins to accumulate fatty substances. growth of which is triggered by the aptly named “follicle-stimulating hormone. produces progesterone and estradiol.” Progesterone from the corpus luteum halts development of the remaining follicles and brings the lining of the uterus to peak preparedness.

and reaches its greatest thickness during the luteal phase. If conception fails to occur. The endometrium. Reproduction: The Role of Hormones Conception and pregnancy are governed by the egg and flow of sex hormones that each month prompt crucial changes in your reproductive system. on the changes they themselves produce. This entire circle of changes is directed by the on/off production of six key hormones. your monthly menstrual cycle or period. Progesterone. is chiefly responsible for preparing the endometrium to accept a fertilized egg. estrogen governs the monthly thickening of the endometrium and the quantity and quality of cervical and vaginal mucus so important to the successful passage of the sperm. in turn. perhaps the three most well-known are estrogen. There are several forms of estrogen but the one most important for reproduction is estradiol. of course. Androgen While many hormones interact in the reproductive process. and the luteal (secretory) phase when the corpus luteum is prepared to help maintain a possible pregnancy. Production of these hormones depends.the uterus. The average cycle is from 25 to 34 days and the average menstrual flow lasts from 3 to 5 days The menstrual cycle has two distinct phases: the follicular (proliferative) phase during which the egg grows and gets ready to enter the fallopian tube. stimulates the corpus luteum to maintain its production of progesterone during the first trimester of pregnancy. The most notable outward sign of this carefully balanced interplay is. the lining is then discarded in the menstrual flow. a substance secreted by the ovary. the principle hormone secreted by the corpus luteum. progesterone. Estrogen. and androgen. In addition to being responsible for the development of sexual characteristics in women. or uterine lining. The corpus luteum continues to secrete progesterone during the first three months of pregnancy until the 32 . Progesterone. starts to grow. and the cycle begins anew. so that an elegant cycle of feedback and response dictates their levels. This cycle begins with your first day of menstrual bleeding and ends at the start of the next period.

when production is highest. Androgen is produced by follicle cells in the ovary and is converted into additional estrogen. These two hormones. Gonadotropins GnRH does its work through two intermediaries: follicle stimulating hormone (FSH for short) and luteinizing hormone (LH for short). Later. the pulses come at hourly intervals. a gland located at the base of the brain.placenta can fend for itself. the cycle starts again. or follicular. they slack off to about once every two or three hours. Finally. the pituitary responds by increasing its release of FSH and LH. KEY PLAYERS IN THE MONTHLY HORMONAL CYCLE 33 . known as gonadotropins. When levels of GnRH rise in your bloodstream. Gonadotropin Releasing Hormone Called “GnRH” for short. the ovary and the egg-containing follicles. doubling or even tripling productin of GnRH. During the first. The two hormones are then free to begin working changes in the ultimate target. declining levels of estrogen in your bloodstream spark the hypothalamus into a burst of activity. are produced by the pituitary gland. this is the hormone that governs the level of estrogen in your body. Androgen causes the disappearance of all of the follicles not destined to produce an egg during a given monthly cycle. Production occurs in pulses. during the luteal phase. At the end of your mentstrual cycle. It is produced by the hypothalamus. phase of your cycle. as the luteal phase ends and estrogen levels reach their lowest ebb.

perpetuating production of progesterone. If conception occurs. which in turn prompt production of estrogen and progesterone in the ovaries.Two master hormones govern all the others. High progesterone levels shut down production of GnRH. Gonadotropin Releasing Hormone (GnRH) from the hypothalamus in the brain sparks release of follicle stimulating hormone and luteinizing hormone from the pituitary gland. Human Chorionic Gonadotropin (HCG) from the developing placenta takes over. ETIOLOGY Predisposing Remarks Rationale Justification 34 . leaving HCG in control for the duration of the pregnancy.

conception. pregnancy. women develop high blood pressure while they are pregnant (often called gestational hypertension). Source: http://www. Our patient belongs to the brown race so this factor is considered to 35 . Source: http://www. high blood pressure are more likely to have blood certain complications However.htm Brown race had the highest risk of gestational hypertension/preeclampsia. Many times. history of hypertension is present because her mother is also hypertensive. History of Hypertension  com/professionals/14332_1155. during some pregnancy than those with normal pressure.nih. Source: http://www. com/40/1197.asp Women with pre-existing. or chronic.nih. usually after the 20th Age is not a week.ncbi. that are more common in this age and 20 years group also may interfere with below.html predisposing factor in the patient’s case because the gestational Citation: Women over age 35 may be hypertension less an fertile egg than younger women only affects less women ages because they tend to ovulate (release pregnant from the ovaries) frequently. but it can also develop at the time of delivery or right after delivery.nhlbi. Source: Race  /health/public/heart/hbp/hbp_preg. PIH The patient is currently develops during the second half of 25years old.emaxhealth. gov /pubmed/ 16949421 According to the patient’s family background.factors Age X PIH is more common in pregnant women over age 40. Certain health conditions 35 and above.

Source: http://cancerweb. barbecues which are not nutritious. Since this is the first time that the patient got pregnant The patient’s diet consists of instant A woman who is pregnant for the first time has the possibility of having gestational hypertension. ` Precipitating Factors Pregnancy Remarks  Rationale Gestational hypertension occurs in up to 5% of all pregnancies Source: http://emedicine.medscape Primigravida  .uk/cgi-bin/omd?primigravida Diet  Eating a balanced diet and The patient is a primigravida.ncl. therefore increasing the blood 36 Remarks  Justification The patient encountered hypertension during her pregnancy . dried fish. ac. 4th Edition by Adele Pillitteri SYMPTOMATOLOGY Symptom Rationale This happens because the heart is forced to pump against the Hypertension rising peripheral vascular resistance due to vasospasm. Justification The patient is pregnant keeping your weight within healthy levels may help to reduce the chances of you developing a contributory to her illness. Source: Maternal & Child Health Nursing.

Headache An increase in headaches Decrease prostacycli n Increase the first trimester is during thromboxa believed to be caused by the ne surge of hormones along with an increase in the blood volume circulating Edema body.pressure. Increased Vascular throughout spasm your X Increase blood flow  Patient has edema on lower extremities. pressure of 140/90 mm Hg and Increase cardiac output Increased blood pressure due to cerebral hypertension which will Visual Disturbances  The patient stated that whenever her blood pressure Injures increases she endothelial cells experience The patient did not experience headache Interrupts the lead to the damage of cerebral action of cortex. A pregnant woman with Predisposing factor Hereditary who gestational is has hypertension experiencing a blood Precipitating Factors Hypertension Pregnancy Primigravida Diet hypertension above. Decrease blood flow Pathophysiology Increase blood pressure Lack of nutrients distribution into the placenta GESTATION AL HYPERTENS ION If treated Prolonged life Medications: Methyldopa Nifedipine Magnessium Sulfate If not treated: Maternal 37 Death Fetal Death . in interstitial fluid Heart is force to volume ≥ 2.5 to 3 L may be pump caused by increased capillary Vasoconstricti filtration pressure and capillary on permeability. the visual center in the prostaglandin brain.

38 .


> To document patient’s agreement for admission and management > Regular monitoring of patient’s condition and to determine any abnormalities or deviations from normal range > To closely monitor baby’s Fetal Heart Rate and determine deviation from normal range. Placed in Patient’s Chart Done VS recorded in patient’s chart Done Done. transfusion > avoid blood related complications > evaluates urine for the presence of albumin > used to screen for and detect HBV infections > to keep track of the heart rate of the baby (fetus) and the strength and duration of the contractions of the uterus. Documented in IV sheet Done. > For the treatment of essential hypertension > Inhibits the influx of calcium through the cell membrane. Documented in Meds 40 Sheet Done Refer . resulting in a depression of contraction. causing cell death. > To provide sufficient electrolytes and calories and as a source of water for hydration. i. Refer to Table Results Done. > assess blood & blood forming tissue functioning > serves as reference for future procedures involving blood products. 2011 9:20AM Doctor’s Order Admit patient to DR Secure consent Rationale > To monitor and give proper treatment and medication for the patient during labor and delivery. Refer to Table Results Done. > inhibits synthesis of bacterial cell wall. Documented in Meds Sheet Done. Documented in Medication Sheet Done. Refer to Table Results Done. > For the management of hypertension. > Proper referral for any unusual change in patient’s condition or problems with Remark Done. > Bactericidal action against sensitive organisms. 10. Refer to Table Results Done. Monitor VS q1° FHT q30¹ Diagnostic procedures: • CBC • Blood Typing of of • Urine Albumin of • HBsAg of EFM Venoclysis with D5LR 1L at 30gtts/min Medications: • Ampicillin 1g q6° • Hydralazine 5mg IVTT PRN for DBP>100mmHg • Nifedipine 5mg q8° Done.Date Ordered Jan.e. Admitted 1/10/11 Done.

25 – 0. Hct are important indicators of the oxygen-carrying capacity of the blood * WBC’s are an indicator of immune function * Platelet is indicator clotting capacity of the blood Differential Count *indicator of bacterial or viral infection *provides detailed percentage of the major types of WBC ( detailed status of immune function) > indicate infection > low resistance to infection 41 .0 – 18.15 L Clinical Significance Nursing Responsibili ty > patient education to reduce anxiety related to the procedure Type of Test CBC * RBC’s.0 x10^3/uL 0.8 0.88 17.35 Patient’ s Result 119 4.20 – 6.85 H 0.55 – 0.65 0. 2011 Normal Value Hemoglobin RBC Count WBC Count Neutrophil Lymphocyte s 115 – 155 g/L 4.DIAGNOSTIC EXAMS Date Ordere d Jan. Hgb. 10.10 x10^6/uL 5.

2011 Urinalysis (albumin) * evaluates urine for the presence of albumin Type of Test HbsAg (hepatitis B surface antigen) * used to screen for and detect HBV infections Patient’s Result Nonreactive Clinical Significance > patient is currently not infected with hepatitis B Nursing Responsibility > patient education about the procedure 42 . 2011 Date Ordered Jan. Nursing Responsibility > patient education about the procedure Nursing Responsibility > Instruct patient to obtain midstream.Date Ordered Jan.e. Date Ordered Jan. 10. transfusion > avoid blood related complications Patient’s Result Negative Clinical Significance > No presence of albumin which indicates proteinuria. 2011 Blood Typing Type of Test Blood Type Blood Type Rh Type of Test Patient’s Result A Positive Clinical Significance > serves as reference for future procedure involving blood products. 10. 10. i.

chronic stable angina and hypertension. CNS: dizziness. Dilates coronary vessels in both normal and ischemic tissues and inhibits spasms of coronary arteries Indication Contraindication Adverse reaction For the management of vasospastic angina. Respiratory: dyspnea. hypotension. respiratory infection. Barbiturates / ↓ Nifedipine effects Cimetidine / ↑ Bioavailability of nifedepine Ensure that patients do not chew or divide SR tablets. headache. increased HR that result from peripheral vasolidations If therapy is to be discontinued. Monitor patient carefully (BP. • • • CV: peripheral and pulmonary edema. cough. sleep disturbances. Afeditab Calcium channel blocker Antianginal Antihypertensive 5mg 1 cap q8° Inhibits the influx of calcium through the cell membrane. gradually decrease dosage to prevent withdrawal syndrome Maintain fluid intake of 2-3 L/day to avoid constipation 43 Drug interaction • • • • • • • Nursing intervention . cardiac rhythm.Drug Study Generic Name Nifedipine Brand Name Classification Suggested dose Mode of Action Adalat CC. chest congestion. and output) while drug is being adjusted to therapeutic dose Note any hypotensive response. Hypersensitivity. palpitations. resulting in a depression of contraction.

Salmonella. streptococci. causing cell death. mirabilis. Principen Classification Suggested dose Mode of Action Indication Antibiotic. vomiting (eat frequent small meals). P. sweating. Ampicillin Generic Name Brand Name Ampicillin sodium Oral:Ampicin (CAN). E. enterococci. flushing. light-headedness. muscle cramps. gram-positive organisms (penicillin G–sensitive staphylococci. Nu-Ampi ( CAN).• • • Avoid activities that require mental alertness until drug effects realized. nausea. Apo-Ampi (CAN). Penicillin 1g q6° IVTT Bactericidal action against sensitive organisms. operating dangerous machinery. take special precautions to avoid falling). or other allergens. CNS: Lethargy. palpitations. hallucinations. dizziness. N. pneumococci) Meningitis caused by Neisseria meningitidis Unlabeled use: Prophylaxis in cesarean section in certain high-risk patients Contraindicated with allergies to penicillins. Use cautiously with renal disorders. joint stiffness. gonorrhoeae. Novo-Ampicillin (CAN). Penbritin (CAN). sexual difficulties (reversible) Report persistent headache. vertigo (avoid driving. cephalosporins. may cause dizziness or lightheadedness. Inform patient for possible side effects: Nausea. inhibits synthesis of bacterial cell wall. coli. influenzae. H. • Treatment of infections caused by susceptible strains of Shigella. seizures CV: CHF 44 • • Contraindication • • • • Adverse reaction .

abdominal pain. GI upset (eat frequent small meals). Take this drug around-the-clock. chloramphenicol Decreased efficacy of hormonal contraceptives. thrombocytopenia. atrophy can occur. atenolol with ampicillin Check IV site carefully for signs of thrombosis or drug reaction. stomatitis. thrombosis at injection site (parenteral) Other: Superinfections—oral and rectal moniliasis. phlebitis. wheezing. Monitor injection sites. prolonged bleeding time Hypersensitivity: Rash. vomiting. anaphylaxis Local: Pain. do not give with fruit juice or soft drinks. nausea. leukopenia. pseudomembranous colitis. nonspecific hepatitis GU: Nephritis Hematologic: Anemia. vomiting. Drug interaction • • • • • Nursing intervention • • • • • • Generic name Hydralazine 45 . Administer oral drug on an empty stomach. diarrhea. vaginitis Increased ampicillin effect with probenecid Increased risk of rash with allopurinol Increased bleeding effect with heparin. You may experience these side effects: Nausea. sore mouth. Take the full course of therapy. enterocolitis. neutropenia. oral anticoagulants Decreased effectiveness with tetracyclines. 1 hr before or 2 hr after meals with a full glass of water.• • • • • • GI: Glossitis. fever. gastritis. bloody diarrhea. do not stop taking the drug if you feel better. black "hairy" tongue. Do not give IM injections in the same site. furry tongue. diarrhea.

I&OLE prep. death Weight daily. ANA titer before starting therapy and during treatment. congestive heart failure. Assess for fever. notify prescriber. Coronary artery disease. hydralazine works by relaxing blood vessels (arterioles more than venules) and increasing the supply of blood and oxygen to the heart while reducing its workload. and hypertension secondary to preeclampsia/eclampsia. mitral valvular rheumatic heart disease. alone or as an adjunct. joint pain. Check for . palpitations. • Also for the management of moderate to severe hypertension. norepinephrine / increase tachycardia. For the treatment of essential hypertension. • • •       Diarrhea Headache Nausea or Vomiting Indomethacin/decrease hydralazine effects Sympathomimetics (epinephrine. headache. soar throat (lupus like symptoms). Responsibilities Generic Name Oxytocin 46 . Vasodilator Agents 5mg IVTT PRN for DBP > 100mmHg A vasodilator. nausea • Indication Contraindication Adverse Reaction Drug Interaction Nsg.Brand name Apresoline Classification Suggested Dose Mode of Action Antihypertensive Agents. tachycardia. rash. angina Aconite / Increase Toxixity.

prolonged use in uterine inertia or severe toxemia. cases of fetal distress in which delivery is not imminent. significant cephalopelvic disproportion. invasive cervical carcinoma. utero-placental insufficiency Lactation stimulant Oxytocic at 10 gtts /min to incorporate on present IVF Ordered Dosage Mechanism Action Indication of It stimulates uterine contractions by acting via receptors in uterine muscles in induction and augmentation of labour. inadequate. Hypersensitivity to the drug. vasa previa. as in selected cases of uterine inertia (IV). preeclampsia at or near term) when in the best interest of mother and fetus or when membranes are prematurely ruptured and delivery is indicated (IV). placental reserve Diagnostic aid. active herpes genitalis. as adjunctive therapy in the management of inevitable or incomplete abortion (IV). IM). when vaginal delivery is contraindicated (eg. maternal diabetes. total placenta previa. undeliverable fetal position. Rh problems.Brand Name Classification Pitocin • • • • • • • 7 “U” Uterine – active agents Antihemorrhagic. when adequate uterine activity fails to achieve satisfactory response. postpartum uterine bleeding Diagnostic aid. 47 Contraindications . stimulation reinforcement of labor. postabortion uterine bleeding Antihemorrhagic. hypertonic or hyperactive uterine patterns. obstetric emergencies in which surgical intervention is preferred. Initiation or improvement of uterine contractions to achieve early vaginal delivery for maternal or fetal reasons (IV). control of postpartum bleeding or hemorrhage (IV. induction of labor in patients with a medical indication for the initiation of labor (eg. stimulation of uterine contractions during third stage of labor (IV).

• Rash. closing of the throat. as well as syringes and needles. IM. • Sudden weight gain or excessive swelling. Drug Interactions: Droxidopa because its actions and side effects may be increased by Oxytocin . • Instruct patient to keep this product. • If Oxytocin contains particles or is discoloured. do not use it. rash. continued bleeding or changes in heart rate. out of the reach of children. more intense or abrupt contractions of the uterus. vomiting. face. Dispose it properly after use. Excessive vaginal bleeding. Nursing Responsibilities • Monitor vital signs and uterine contractions • Assess patient for hypersensitivity / contraindications before use. • Confusion.prolapse of the cord). Not for intradermal. possibly resulting in high blood pressure. subcutaneous. • Difficulty breathing. • Administer by IV infusion only. • Difficulty urinating. hives. swelling of the lips. rash. • Chest pain or irregular heart beat. or fainting). Allergic reaction: (shortness of breath. IV bolus. Oxytocin when given with vasopressors increases their vasconstricting effect – resulting in hypertensive crisis. or if the vial is cracked or damaged in any way. • Do not reuse materials. • Severe headache. • Advise patient to check with their physician the risks of using oxytocin during pregnancy and breastfeeding. Hyoscine NBB Side/Adverse Reaction Generic Name 48 . or seizures. or tongue. • Instruct patient to report immediately if difficulty of breathing. or intra-arterial administration in this situation. Nausea.

nausea. tachycardia from cardiac insufficiency. hot. hyperthyroidism. or flushed skin. coronary artery disease. chronic pulmonary disease. restlessness. tachycardia. myasthenia gravis. 49 . absence of bowel sounds. or toxic megacolon. obstructive disease of the GI tract. • Contraindicated in patients with hypersensitive to belladonna or barbiturates. and delusions. drug can cause heat stroke. May effect neural pathways originating in the inner ear to inhibit nausea and vomiting.Brand Name Classification Ordered Dosage Mechanism Action Ascopen Belladona alkaloid. • Use cautiously in patients with autonomicneuropathy.Delirium.Spasms of the delivery pathways during the parturition. or ulcerative colitis. rambling speech. paranoid behavior. preanesthetic sedation and obstetric amnesia with analgesics . heart failure. known as suspected GI infection. arrhythmias. increased respiratory rate. vomiting. asthma. papillary dilation. CNSstimulations. visual hallucinations. Indication Contraindications Side/Adverse Reaction Overdose may produce temporary paralysis of ciliary muscle. hyperthermia. and psychosis (marked by agitation. • Use cautiously in patients in hot or humid environments. antimuscarinic 1amp IVTT q2° x 3doses of Inhibits muscarinic actions of acetylcholine on autonomic effectors innervated by postganglionic cholinergic neurons. • Contraindicated in patients with angleclosure glaucoma. intestinal atony.Spastic states . unstable CV status in acute hemorrhage. hiatal hernia with ferlux esophagitis. • Use cautiously in children. palpitations. EKG abnormalities. obstructive uropathy. hepatc or renal disease. hypertension. dry. paralytic ileus.To prevent nausea and vomiting from motion sickness . rash over face or upper trunk. . manual extraction of the placenta.

Nursing Responsibilities • Advise patient to apply patch the night before a planned trip. • Alert patient to possible withdrawal signs or symptoms (nausea. dizziness) when transdermal system is used for longer than 72 hours. headache. Transdermal method releases a controlled therapeutic amount of drug. TransdermScop is effective if applied 2 or 3 hours before experiencing motion but is more effective if applied 12 hours before. • Tell patient that if patch becomes displaced. Nightingale’s emphasis on surroundings reflected a predominant concern when sanitation was a major health problem in the late 1800s. Nightingale 50 . Advice patient to wear sunglasses for comfort  Urge patient to report urinary hesitancy or urine retention Nursing Theories Florence Nightingale Florence Nightingale’s work is closely related to her philosophical orientation of the patient-environment interaction and the principles and rules on which nursing practice was founded. vomiting. • Instruct patient to remove one patch before applying another • Instruct patient to wash and dry hands thoroughly before and after applying the transdermal patch (on dry skin behind the ear) and before touching the eye because pupil may dilate. Tell patient to discard patch after removing it and to wash application site thoroughly. • Advice patient that eyes may be sensitive to light while wearing patch. he should remove it and apply another patch on a fresh skin site behind the ear.followed by depression).

ventilation. Lydia Hall (Core Care Cure) “Nursing is a distinct body knowledge that provides nursing care to patients who are in need of nursing care in support of medical interventions. cleanliness. She contributed to nursing theory by explicating a philosophical approach to nursing with a focus on nursing and the patient-environment relationship. Nightingale’s beliefs regarding nursing formed the foundation for professional nursing and distinguished nursing from the work of domestic servants. warmth. Health teachings on cleanliness were also done by the student nurses to help the patient promote a healthy process of wellness. The floors were mopped.believed that disease was a reparative process and that the manipulation of the patient’s surroundings. light. and noise in Notes on Nursing: What It Is and What Is Not. Relation to the Patient: Cleanliness was promoted only through the bed side care that the student nurses can provide and the utilized resources that can be found in the hospital. warmth. cleanliness. She recorded her directions regarding ventilation. in collaboration with other members of the health team or exclusively and independently by the nurse herself” 51 . diet. and noise – would contribute to the reparative process and the health of the patient. She did not subscribe to the germ theory that was being postulated during her lifetime. diet. which she applied to health and professional nursing. She is also renowned for pioneering statistical analysis. light.

then there is a better chance of getting better. listening to her problems and empathizing with her. If the patient is determined to be cured,cooperation is needed and if she is eager to comply with her treatment. it is also important that we become an advocate which means that we are there as a friend to her. we serve as advisers guiding her on her health. each representing one aspect of nursing. As nurses.Lydia Hall’s theory of nursing involves three interlocking circles. and having a good nurse-patient relationship . the patient’s therapeutic self-care is very important. giving necessary interventions and health teachings. We are also involved in her Cure. The main tool the nurse uses to help the patient realize his or her motivations and to grow in self-awareness is that of reflection. The care aspect represents intimate bodily care of the patient. usually strangers.To help the patient fully recover. come together in a health care organization to help or be helped to maintain a state of health. It is also important the nurse is part of the Core because we are the one who assists not only through our hands and knowledge but also through our heart. Relation to Patient: Care is given by the nurses through providing comfort. and taking action to attain goals. The core aspect deals with the innermost feelings and motivations of the patient. The cure aspect tells how the nurse helps the patient and family through the medical aspect of care. establishing goals. The focus of the nurse is to help the individual maintain health and function in an appropriate role. King’s Goal Attainment Theory This theory wants to incorporate the concept of the nurse and the patient mutually communicating information. 52 . It describes a situation in which two people.

communication. it is also the role of the patient to cooperate with the nurse not only with the assessment but in the interventions as well. So in this case. space. 53 . Relation to Patient: Our patient had great rapport with the group and was able to establish goals and attain them.The Goal Attainment Theory addresses interaction. perception. stress and growth and development. It is important that it is not only the nurse who will identify the problem but the patient should acknowledge it as well so that there will be cooperation between them. role. transaction. time. so that they will be able to accomplish their desired goal. the patient was able to identify and cooperate with the group. Since it’s the role of the nurse to assess the patient and discuss the problems.

GOAL MET Objective: Presence of edema on lower extremities. ® Increase isotonic fluid retention. Auscultate for a third sound. 4. Assess skin. . wala ko kabalo ngano ni” 1. Plan oral fluid replacement with patient. within multiple restrictions ®Helps avoid periods without fluids. (GORDON’S) Objective of Care Within 8hr of care the patient will be able to: -understand the importance of prescribed fluid amounts. “ok sir! Dili mulapas og 1.verbalize understanding of individual dietary/fluid restrictions. and reduces sense deprivation and thirst. 2 0 1 1 “hubag akong tiil saw tuo nako na tiil. ®These are signs of fluid overload. vital signs 54 . and assess for bounding peripheral pulses.Date / Time Cues Subjective: Need N U T R I T Nsg Diagnosis Fluid volume excess related to decrease oncotic pressure secondary to proteinuria. ® Fluid management is usually calculated to replace output from all sources plus estimated insensible losses. changes in respiratory pattern. face. ® Edema occurs primarily in dependent tissues of the body 3. -list signs that requires further evaluation. 5. Administer/restrict fluids as indicated. ® Accurate I&O is necessary for 2010 determining renal function and fluid 8:00 pm replacement needs and reducing risk of fluid overload. Record accurate intake and output January 10. 6. -stabilize fluid volume -demonstrate behavior to monitor fluid status and reduce recurrence of fluid excess.5 ka litro akong imnum sa isa ka adlaw” as verbalized by the client. 2. Assess for crackles in lungs. Nursing Intervention Evaluation J A N U A R Y 10. minimize boredom of limited choices. and dependent areas for edema. I O N A L Patient understands the importance of prescribed fluid amounts. M E T 4:00 pm A B Patient stabilized fluid volume as evidenced by balanced I and O.

within client normal limits. compliance is often difficult for patients trying to maintain a normal lifestyle. Elevate edematous extremities. 8. Administer or instruct patient to take diuretics as prescribed. ®Sodium diets of 2 to 3 g are usually prescribed. decreases edema. Restrict sodium intake as prescribed.O L I C shortness of breath. depending on the acuteness or chronicity of the problem. 10. 7. ® These are early signs of pulmonary congestion. P A T T E R N 55 . Use appropriate garments. in turn. ®This prevents venous pooling. stable weight. and orthopnea. avoid crossing of legs or ankles. ®Diuretic therapy may include several different types of agents for optimal therapy. 9. For chronic patients. ® This increases venous return and.

3. learn the importance of breastfeeding uses alternative resources in breastfeeding the infant 1. minimize ®to promote breast feeding because breasmilk contains all the necessary nutrients a baby needs for the first 6 months of life 5. nursing care and ®This will improve perfusion management: 2. 2011 10:00 AM 56 . the proper breast care The use of breastfeeding and most especially the proper supplements is breast feeding position.wordpre ss.lutvita. 1. Encourage the use of breast Breastfeeding. “gamay man lang ang mulabas na gatas sa ako…” as verbalized by the patient O: • Use of commercial infant formula Improper breastfeeding technique is demonstrated Within 1-2 hours of nursing care ineffective related to and management. the mechanisms involve technique in lactation. 2. to the area and enhance milk1) Patient ejection reflex (let-down). ®use of supplemental feedings may breastfeeding lessen infant’s desire for and able to demonstrate breastfeed the proper 4. Low Milk Supply our patient will: ®low milk supply is caused by ineffective or infrequent emptying of milk that will lead to a chemical inhibitor in residual milk accumulates and decreases further milk production. Participate in activities that would promote effective breastfeeding.Date & Time J A N U A R Y S: Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation N U T R I T I O N A L M E T A www. Explain the benefits of breast breastfeeding feeding. Recommend avoidance or was able to overuse of supplemental feedings explain the significance of and pacifier unless indicated. Suggest moist heat to be GOAL MET applied 3-5 minutes prior to After 1 hour of feeding.

Encourage frequent rest periods. 6. prenatal vitamins. Support the patient and provide information to correct breastfeeding techniques.Date & Time Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation B O L I C pump with bilateral collection chamber ®using this device increases the milk supply. ®vitamin C is a water soluble vitamin that usually increase P A T T E R N 57 . prevent sore nipple. ®to limit fatigue and promotes relaxation 7. Discuss importance of adequate nutrition/ fluid intake. 8. such as changing positions from one feeding to next ® to distribute sucking pressure. and the knowledge of correct technique lessen discomfort during breastfeeding and contributes to successful or effective breastfeeding. as indicated. or other vitamin/ mineral supplements such as vitamin C.

®This will improve perfusion 10. Recommend avoidance or overuse of supplemental feedings and pacifier unless indicated. ®to promote breast feeding because breast milk contains all the necessary nutrients a baby needs for the first 6 months of life 13. Suggest moist heat to be applied 3-5 minutes prior to feeding. ®use of supplemental feedings may lessen infant’s desire for breastfeed 12. the proper breast care and most especially the proper breast feeding position. to the area and enhance milkejection reflex (let-down). Encourage the use of breast 58 . 11.Date & Time Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation breastmilk levels. Explain the benefits of breast feeding. the mechanisms involve in lactation. 9.

Support the patient and provide information to correct breastfeeding techniques. prevent sore nipple. prenatal vitamins. such as changing positions from one feeding to next ® to distribute sucking pressure. 16.Date & Time Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation pump with bilateral collection chamber ®using this device increases the milk supply. 14. as indicated. Encourage frequent rest periods. ®vitamin C is a water soluble vitamin that usually increase 59 . and the knowledge of correct technique lessen discomfort during breastfeeding and contributes to successful or effective breastfeeding. or other vitamin/ mineral supplements such as vitamin C. Discuss importance of adequate nutrition/ fluid intake. ®to limit fatigue and promotes relaxation 15.

Date & Time Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation breastmilk levels 60 .

) Discuss to patient and family members to limit number of visitors.) Observe performance of personal hygiene practices. Identify protect them from the probable cause inevitable injuries and of infection exposures that occur throughout the course of living. Infections occur when an organism (e.) Perform meticulous hand washing by caregivers and patient.) Maintain aseptic techniques with procedures towards patient.Date/ Time Cues Need Nursing Diagnosis with Rationale Objectives/ Plan Nursing Intervention with Rationale Evaluation Subjective Cue: J A N U A R Y Objective Cue: T= 36. Breaks in the integument. ® Prevent cross contamination or bacterial colonization. 5. and/or the mucous membranes allow invasion by pathogens. After 2-4 hours span of care. my patient was able to: a. @ 10:00 AM I O N H E A L T H M ® Persons at risk for infection are those whose natural defense mechanisms are inadequate to a. . @ 12:00 pm ® Reduce the risk of infection. 4. fungus.. 3. either qualitative or quantitative. January 11. Nutritional deficiencies.) Monitor the vital signs. thereby representing the most common of secondary immunodeficiency. the patient will be able to: 1. or other parasite) invades a susceptible host. 61 ® Limits exposure to bacteria / infections. After 4 hours span of care. Identify things that might expose her to infection ® To know the baseline data of the patient. Goal Met. the body’s first line of defense. virus. basabasa ang samad” H E A L T H P E R C E P T Risk for infection related to episiotomy secondary to NSVD 11. ® To protect against infection. bacterium. may alter to different degrees humoral and cell mediated immune responses.g. 2011 2.7’C -1 day post vaginal delivery -w/ diaper 2011 “bago paning tahi akong kinatawo.

Date/ Time Cues Need Nursing Diagnosis Objectives of Care Nursing Interventions Evaluation 62 .

aron naa mi pang patient to cope easily pp. Kung and Murr -Stay with the patient magkakwarta mi. to share her emotions Financial Unsa kaya ® Acknowledging will enable with regards to the -identification of other constraints namo ni greatly affect options to solve the patient to deal more appropriately situation. 180-184 63 . Pattern related to be able to meet the ®establish rapport inadequate needs of the situation “Naguol ko ba -Be eager to listen 2011 resources as evidenced by: kay naa nay available ® encourages the patient to share 7:oo pm baby tapos (Gordon’s) her feelings gamay ra baya ang -expression of feelings -Acknowledge feelings as sweldo sa The patient was able expressed akoang bana. ® Continuous support may help magnegosyo na lang ko. 2011 4:00 pm Coping-Stress Ineffective After the 3-hour -Introduce self to patient GOAL met Tolerance Coping teaching.” way of living other resources . the client will January 10.January Subjective: 10. Maski wala mi contact kwarta. skills sharing gihapon ko sa akong Moorhouse bana. Pocket Guide ® to assess coping abilities and makatabang thoughts of man by Doenges. ® to identify successful na mapadako ug techniques that can be used in tarong ang amoang -poor eye current situation anak. pagbudget ani the patient’s problem such as use of with situation ron. dealing with life problems stressful to “Paningkamotan nako Objective: some people. okey lang -Ascertain client’s understanding basta kompleto ang of current situation and its impact pamilya. Maski wala Nurse’s -second koy trabaho.Determine previous methods of and can be The patient verbalized.

-Tell patient that she can be of bac-up sa gastoson” help to her husband even if she does not go to work. ® encourages the patient -Tell patient that her ability to cope is beneficial to the whole family and not just for her ® Makes the patient more willing to cope with the problem -Allow client to react in own way without judgment ® To correct her if ever she has a wrong way of dealing with the situation 64 .

) Establish rapport with the patient. Within 1-2 hours of nursing care and management. 403 ® enhances self concept and promote commitment to goals.) provide opportunities for Company. e. Objective: ● feeling of concern ● inadequate self-confidence C O G N I T I V E P E R C E P T U A L P A T T E R N Ineffective role performance related to inadequate role preparation. 2 0 1 1 @ 4:00 PM “Una pa man nako ni na anak. January 10. 10th Edition.) Provide an environment perception and conducive to learning. Pages over as much as possible. ® To gain trust and cooperation of the patient.g. acceptance of self. developmental. 3. Marillyn E. occurred and problem. 5. and obligations. 2. patient to exercise control Copyright 2006.magkalisod pakog adjust ani” -as verbalized by the patient. our patient will 1. Davis 4.Date & Time Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation Subjective: J A N A U R Y 10. Philadelphia. 2011 5:30 pm “Goal Met” 1. norms and expectations. ® pattern of behavior and self expression that do not match the environmental context. ® This will facilitate learning. situational Bibliography: or health illness transition.) verbalized understanding of 3.) Verbalize realistic 2.) Use the technique of role rehearsals to help the Verbalized understanding of perception and acceptance of self as evidenced by: “magtinabangay nalang mi anis sa akong ka live-in sa among mahimong anak” “ kayanon namo ni no?!basta dili lang ko niya byaa” -Identified areas of 65 .) Identify type of role role expectations dysfunctions. F. Wala pa kaayo ko kabalo kung unsa ang buhaton. Nurse’s Pocket Guide limitations imposed.) talk with family ® Patient must have a about situations and comprehensive changes that have understanding of the Doenges.A.” “mao ni akong pinaka una na baby.

® To provide reinforcement and facilitate continuing of efforts 7. ® To promote self awareness.) make information available for patient to learn about role expectations or demand that may occur. 6. 8.Date & Time Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation patient develop new skills. ®provide opportunity to be proactive in dealing with changes.) encourage and give positive feedback for changes and goals achieved.) identify how patient see self as a woman in usual life style or role functioning. 66 . ® to cope with changes. weakness/need s.

Precipitating Factors  The patient is willing to change her diet in order to improve her health status and she already understands causes and effects of pregnancy. Family support  The patient’s family is very supportive especially her partner who was with her most of the time during her pregnancy and hospitalization Attitude and willingness to take medications and treatment  The patient and her significant others tried their best to comply with all her needed medications. Every time. the doctor gave a new prescription of drugs.PROGNOSIS FACTORS Onset of Illness POOR  FAIR GOOD RATIONALE She only knew that she had hypertension when she was admitted Duration of illness  Patient’s illness only occur during her pregnancy. the room was 67 . Environment  During her stay in the hospital. her partner immediately finds ways to provide necessary medications and other needs to achieve faster recovery.

68 .Gestational is common with ages 35 and above as well as 20 and below.4285 = Good Scoring for General Prognosis: 1-1.4-3.7-2.6 = POOR 1. Total 2 0 5 Computation:  Poor: (2*1)/7 =.2857  Fair: (0*2)/7 =0 Grandma  Good: (5*3)/7 = 2.good in which the staff maintained the cleanliness for the benefit of their patients Age  The patient’s age is 25 yrs old hypertension . DISCHARGE PLAN Medication • Educate the patient about the importance of strict compliance to the therapeutic regimen.0 = GOOD General Prognosis: The general prognosis of the client is good. This means that the client has a good chance of recovering from her illness.1428 2 Total: 2.3 = FAIR 2.

and don’t stop taking medication unless instructed by the physician. Practice deep breathing exercise. Treatment • Explain need of treatment after discharge and must take it seriously to prevent complication. never take someone else’s medication. • Encourage patient to do recommended exercise. Compliance of medicines is needed. Promote exercise to the patient especially ROM. • Give patient some tips in the proper administration of the drug---read medication labels carefully. Avoid doing strenuous activity which could slow down her recovery. Instruct patient and significant others to continue home medications as prescribed. Encourage early ambulation. discard outdated medications.• • • Instruct the patient to take the medication as prescribed by the doctor. Health Teaching • Encourage proper hygiene like taking a bath. and brushing of teeth every meal. • Encourage the patient to contact his physician if a new or unexpected symptom or another problem appears. and frequency (how often its supposed to be taken). Check the medication bottle for name. Check the expiration date on all medications that will be administered. • Encourage the family to maintain a clean surrounding at all times. 69 . Exercise • • • • Instruct patient to avoid strenuous activities for at least a week or a month until fully recovered. • Inform patient as well as the family the danger of non compliance to treatment regimen. before taking doses. dose.

Diet • Encourage patient to eat a variety of nutritious food like fruits and vegetables once instructed by the physician. RECOMMENDATION 70 . • Instruct the family to report any unusual signs and symptoms experienced by the patient.Out Patient Order • Inform the patient that follow-up check-ups are important to have continuous monitoring and care even after attainment of the course medical therapy. • Instruct patient to take vitamins as ordered. • Advise the patient and family to carry out follow-up diagnostic examinations.

Continue to comply with the prescribed medications and treatment plans instructed by the attending physician. • Ensure the patient’s safety needs. Client must stop drinking alcohol. protein and fats. • Assist the patient’s physiological and physical needs.  Encourage the patient express any concerns and talk to health professionals. To the student nurses: • Give health teaching and information regarding healthy lifestyle Reference 71 . instructions and proper diet. Proper diet must be emphasized especially on the proper distribution of carbohydrates. Encourage patient to have check-ups regularly. • Guide patient to follow doctor’s orders or prescribed medications. To the Family: • Give full support to the patient.To the patient: Advise patient to have a healthy lifestyle.

Kozier. Encyclopedia and Dictionary of Medicine and Nursing. Lippincott William and Wilkins. B. Fundamentals of Nursing Eighth Edition.wikepedia. & Health Professions.. C. Copyright 2007  Mosby’s Dictionary of Medicine . publishing.  Nursing Theories Book  2005 Lippincott’s Nursing Drug Guide  Mosby’s Pocket Dictionary of Medicine. Nurse’s Pocket Guide Diagnoses.(2007). Inc.Pearson Education. Nursing. and Rationales  2010 Edition Delmar Nursing Drug Handbook  http//:www. & Keane. Page 427 72 . & Allied Health  Harrison’s Principles of Internal Medicine 2  Miller. Prioritized Interventions..B. W. A. Saunders  Pillitteri. Fifth Edition by Mosby Elsevier  Erbs.Maternal and Child Health Nursing 5th edition.

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