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

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

Tagum City. 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 . Cephalic in labor. 37 4/7 weeks age of gestation. 1985 Civil Status: Single Address: Prk. Dokdokan Last Menstrual Period (LMP): March.Patient’s Code Name: Venus Raj Age: 25 years old Birthday: June 10. 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. 5 San Miguel ( Comp 4 ). Pregnancy Uterine. 2011 Admitting Diagnosis: G1P0.

it was only when she got pregnant she experienced blurry vision and hypertension. As she traced her family history of sicknesses. Diet Venus eats fish. Venus stated that she never had hypertension before and claimed she was healthy enough. Venus prepares for breakfast and her child’s necessities while her partner prepares for work.Venus and the father of her baby are not yet married but they planned to be married after the baptism of their child. 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. her father’s siblings only had arthritis and her grandfather and grandmother died because of an unknown cause. egg. 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. Lifestyle Venus and her partner usually wakes up at 6:00 in the morning. hotdogs and barbeques. Venus only has one sister Jupiter and Venus believes that her sister is also hypertensive because her family sometimes experiences blurry vision. 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. meat. She admitted that she seldom eats vegetables because she doesn’t like the taste especially ampalaya because of its bitterness.

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

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

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 .

success in achieving the developmental tasks leads to success with tasks in later stages of life. Failure to complete the *Choosing an tasks assigned to each occupation or career stage may lead to failure in tasks in subsequent stages. 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. She has achieved this stage. psychological and social origins during lifespan. According to this theory. which emanate from biologic. based on learning and learned behaviors. She has achieved this stage *Establishing intimate of development. She is staying in the house of her partner. She says that she and her partner are not dependent on their parents in terms of financial matters. Specific developmental tasks are assigned to the various stages of life. called developmental tasks. 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 . They do not live in the same roof with their parents.Developmental Data Theorist Robert Havighurst Theory Developmental Task Theory. *Establishing independence from parents She has already achieved this stage of development although currently she only is an attendant in an internet café.

Isolation this stage because though partner but still they did not get married. Each stage builds on the successful completion of earlier stages. She says that she will become a responsible mother for her child. In each stage the person confronts. She is planning to learn *Managing a home more about taking care of a family since she now have a baby.She does not have any *Establishing social network social groups and does not participate in any social activities. The challenges 11 Our patient belongs to Our patient did not achieve the stage of young old): Intimacy vs. and hopefully masters new challenges. 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. 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.

During the final stage of psychosexual development. Theorist Sigmund Freud Theory Psychosexual Development Theory.of stages not successfully completed may be expected to reappear as problems in the future. 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. the individual develops a stage since she has now her own family and has a new born baby. 12 .

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

B. or anatomic defect in the structure of the amniotic sac. Encyclopedia and Dictionary of Medicine and Nursing. there may be degrees of flexion so that the presenting part is the large fontanel in sincipital presentation. uterus. W. B.. usually the upper and back part as a result of flexion such that the chin is in contact with the thorax in vertex presentation. or cervix. Perinatal mortality is not increased with simple gestational hypertension. 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. Saunders) Cephalic Presentation of any part of the fetal head. A. 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.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). Risk factors for PROM can be a bacterial infection. Source: (Miller. & Allied Health) 14 . smoking. or the face in face presentation. & Keane. This standard system of counting the progression of pregnancy starts approximately two weeks before fertilization takes place. Lippincott William and Wilkins. the brow in brow presentation. C.Maternal and Child Health Nursing 5th edition. so no drug therapy is necessary Source: Pillitteri.(2007). Source: (Mosby’s Dictionary of Medicine .

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

She was oriented to the time (verbalized it was in the afternoon). Temperature=36. Respiratory rate=33 breaths per minute.9 degree Celsius. and in moderate pace. clear. Her mood and affect was appropriate to the situation. Patient is in respiratory distress. awake. 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.FHT= 142. and coherent as evidenced by the patient’s ability to comprehend words uttered by the student nurse.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). Vital Signs Vital signs taken and had the following results: Blood pressure=140/90mmHg. Pulse rate=86 beats per minute. Skin 16 . Her speech was understandable. and reason for admission (admitted that delivery is her reason of going to the hospital). and responsive as evidenced by her prompt responses to the student’s questions and statements. She also exhibited thought association and relevance in her statements. conscious. place (identified the hospital as her current location).

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

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

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

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

Extremities Muscle sizes were equal on both sides of the body. The muscles and tendons have no contractures and no tremors were noted. Abdomen Upon inspection. The nipples are round. everted. Joints move smoothly and were within full range of motion in all extremities. Muscles have equal strength on both sides. stretch marks and linea nigra were noted. Muscle tone was firm with smooth and coordinated movements were observed. equal in size. similar in color and point on the same direction. 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. which is extracted in scanty amount. Anatomy and Physiology The Endocrine System 21 .usual color. There are no discharges observed except for the colostrum.

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

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

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

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

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

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

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

or uterine lining. stimulates the corpus luteum to maintain its production of progesterone during the first trimester of pregnancy. There are several forms of estrogen but the one most important for reproduction is estradiol. 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. your monthly menstrual cycle or period. 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. This cycle begins with your first day of menstrual bleeding and ends at the start of the next period. the principle hormone secreted by the corpus luteum. The most notable outward sign of this carefully balanced interplay is. The endometrium. Progesterone. on the changes they themselves produce. starts to grow. and androgen. progesterone. so that an elegant cycle of feedback and response dictates their levels. and the luteal (secretory) phase when the corpus luteum is prepared to help maintain a possible pregnancy. The corpus luteum continues to secrete progesterone during the first three months of pregnancy until the 32 . and reaches its greatest thickness during the luteal phase. the lining is then discarded in the menstrual flow. If conception fails to occur. 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. and the cycle begins anew. Estrogen. a substance secreted by the ovary. is chiefly responsible for preparing the endometrium to accept a fertilized egg. Progesterone. in turn. of course.the uterus. This entire circle of changes is directed by the on/off production of six key hormones. In addition to being responsible for the development of sexual characteristics in women. perhaps the three most well-known are estrogen. Androgen While many hormones interact in the reproductive process. Production of these hormones depends.

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

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

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

com/article/261435-overview A woman who is pregnant for the first time has the possibility of having gestational hypertension.ncl. 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. therefore increasing the blood 36 Remarks  Justification The patient encountered hypertension during her pregnancy . Source: Maternal & Child Health Nursing. dried fish.medscape Primigravida  .uk/cgi-bin/omd?primigravida Diet  Eating a balanced diet and The patient is a primigravida. ac. Since this is the first time that the patient got pregnant The patient’s diet consists of instant a contributory to her illness. Justification The patient is pregnant keeping your weight within healthy levels may help to reduce the chances of you developing complications. barbecues which are not nutritious. Source: http://cancerweb. ` Precipitating Factors Pregnancy Remarks  Rationale Gestational hypertension occurs in up to 5% of all pregnancies Source: http://emedicine.

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 . Increased Vascular throughout spasm your X Increase blood flow  Patient has edema on lower extremities. A pregnant woman with Predisposing factor Hereditary who gestational is has hypertension experiencing a blood Precipitating Factors Hypertension Pregnancy Primigravida Diet hypertension above. the visual center in the prostaglandin brain. in interstitial fluid Heart is force to volume ≥ 2. 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 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.pressure.5 to 3 L may be pump caused by increased capillary Vasoconstricti filtration pressure and capillary on permeability.

38 .


> assess blood & blood forming tissue functioning > serves as reference for future procedures involving blood products. > For the management of hypertension. Documented in Meds 40 Sheet Done Refer . causing cell death. 10. Refer to Table Results Done. Documented in Medication Sheet Done. > inhibits synthesis of bacterial cell wall. 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. > 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. > Bactericidal action against sensitive organisms. 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. > To provide sufficient electrolytes and calories and as a source of water for hydration. Refer to Table Results 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. resulting in a depression of contraction. Admitted 1/10/11 Done. Refer to Table Results Done. Documented in Meds Sheet Done. > For the treatment of essential hypertension > Inhibits the influx of calcium through the cell membrane. Documented in IV sheet Done. > Proper referral for any unusual change in patient’s condition or problems with Remark Done.e.Date Ordered Jan. i. Placed in Patient’s Chart Done VS recorded in patient’s chart Done Done.

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 .15 L Clinical Significance Nursing Responsibili ty > patient education to reduce anxiety related to the procedure Type of Test CBC * RBC’s.20 – 6.DIAGNOSTIC EXAMS Date Ordere d Jan.88 17.65 0. 10. 2011 Normal Value Hemoglobin RBC Count WBC Count Neutrophil Lymphocyte s 115 – 155 g/L 4.25 – 0.35 Patient’ s Result 119 4.55 – 0.85 H 0. Hgb.0 x10^3/uL 0.10 x10^6/uL 5.0 – 18.8 0.

10. i. 2011 Date Ordered Jan. 10.Date Ordered Jan. 10. 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.e. Nursing Responsibility > patient education about the procedure Nursing Responsibility > Instruct patient to obtain midstream. Date Ordered Jan. transfusion > avoid blood related complications Patient’s Result Negative Clinical Significance > No presence of albumin which indicates proteinuria. 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 .

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

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

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

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

active herpes genitalis. IM). when adequate uterine activity fails to achieve satisfactory response. 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). significant cephalopelvic disproportion. Rh problems. postabortion uterine bleeding Antihemorrhagic. control of postpartum bleeding or hemorrhage (IV. prolonged use in uterine inertia or severe toxemia. 47 Contraindications . inadequate. total placenta previa. cases of fetal distress in which delivery is not imminent. as adjunctive therapy in the management of inevitable or incomplete abortion (IV). maternal diabetes. hypertonic or hyperactive uterine patterns. obstetric emergencies in which surgical intervention is preferred. stimulation reinforcement of labor. 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. stimulation of uterine contractions during third stage of labor (IV). as in selected cases of uterine inertia (IV). Hypersensitivity to the drug. Initiation or improvement of uterine contractions to achieve early vaginal delivery for maternal or fetal reasons (IV).Brand Name Classification Pitocin • • • • • • • 7 “U” Uterine – active agents Antihemorrhagic. induction of labor in patients with a medical indication for the initiation of labor (eg. undeliverable fetal position. when vaginal delivery is contraindicated (eg. postpartum uterine bleeding Diagnostic aid. vasa previa. invasive cervical carcinoma. placental reserve Diagnostic aid.

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

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

• Tell patient that if patch becomes displaced. 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. Nursing Responsibilities • Advise patient to apply patch the night before a planned trip. • 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. Nightingale’s emphasis on surroundings reflected a predominant concern when sanitation was a major health problem in the late 1800s. • Advice patient that eyes may be sensitive to light while wearing patch. headache. dizziness) when transdermal system is used for longer than 72 hours.followed by depression). vomiting. Transdermal method releases a controlled therapeutic amount of drug. • Alert patient to possible withdrawal signs or symptoms (nausea. TransdermScop is effective if applied 2 or 3 hours before experiencing motion but is more effective if applied 12 hours before. he should remove it and apply another patch on a fresh skin site behind the ear. Nightingale 50 .

She recorded her directions regarding ventilation. and noise in Notes on Nursing: What It Is and What Is Not. She contributed to nursing theory by explicating a philosophical approach to nursing with a focus on nursing and the patient-environment relationship. She is also renowned for pioneering statistical analysis. diet. which she applied to health and professional nursing. 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. 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. light. and noise – would contribute to the reparative process and the health of the patient. warmth. light. warmth. The floors were mopped. diet. cleanliness.believed that disease was a reparative process and that the manipulation of the patient’s surroundings. cleanliness. in collaboration with other members of the health team or exclusively and independently by the nurse herself” 51 .ventilation. She did not subscribe to the germ theory that was being postulated during her lifetime. Health teachings on cleanliness were also done by the student nurses to help the patient promote a healthy process of wellness. Nightingale’s beliefs regarding nursing formed the foundation for professional nursing and distinguished nursing from the work of domestic servants.

King’s Goal Attainment Theory This theory wants to incorporate the concept of the nurse and the patient mutually communicating information. The focus of the nurse is to help the individual maintain health and function in an appropriate role. 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. We are also involved in her Cure. It describes a situation in which two people. then there is a better chance of getting better. and taking action to attain goals. 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 core aspect deals with the innermost feelings and motivations of the patient. usually strangers. giving necessary interventions and health teachings. come together in a health care organization to help or be helped to maintain a state of health. The care aspect represents intimate bodily care of the patient. each representing one aspect of nursing. it is also important that we become an advocate which means that we are there as a friend to her. The cure aspect tells how the nurse helps the patient and family through the medical aspect of care. listening to her problems and empathizing with her. the patient’s therapeutic self-care is very important. and having a good nurse-patient relationship . As nurses. 52 . we serve as advisers guiding her on her health. If the patient is determined to be cured,cooperation is needed and if she is eager to comply with her treatment. establishing goals. Relation to Patient: Care is given by the nurses through providing comfort.To help the patient fully recover.Lydia Hall’s theory of nursing involves three interlocking circles.

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

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

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

Suggest moist heat to be GOAL MET applied 3-5 minutes prior to After 1 hour of feeding. 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. 2. to the area and enhance milk1) Patient ejection reflex (let-down). 1. 3. “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. 2011 10:00 AM 56 . 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 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. Encourage the use of breast 11. ®use of supplemental feedings may breastfeeding lessen infant’s desire for and able to demonstrate breastfeed the proper 4. the mechanisms involve technique in lactation.lutvita. Explain the benefits of breast breastfeeding feeding.wordpre ss. Recommend avoidance or was able to overuse of supplemental feedings explain the significance of and pacifier unless indicated. the proper breast care The use of breastfeeding and most especially the proper supplements is breast feeding position. nursing care and ®This will improve perfusion management: 2.

®to limit fatigue and promotes relaxation 7. ®vitamin C is a water soluble vitamin that usually increase P A T T E R N 57 . Discuss importance of adequate nutrition/ fluid intake. 6. or other vitamin/ mineral supplements such as vitamin C. prenatal vitamins. as indicated.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. Encourage frequent rest periods. and the knowledge of correct technique lessen discomfort during breastfeeding and contributes to successful or effective breastfeeding. 8. prevent sore nipple. Support the patient and provide information to correct breastfeeding techniques. such as changing positions from one feeding to next ® to distribute sucking pressure.

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

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

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

After 4 hours span of care. After 2-4 hours span of care. the body’s first line of defense. either qualitative or quantitative. 4. my patient was able to: a. the patient will be able to: 1. and/or the mucous membranes allow invasion by pathogens. January 11.) Maintain aseptic techniques with procedures towards patient. 2011 2. 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. bacterium.) Discuss to patient and family members to limit number of visitors. @ 12:00 pm ® Reduce the risk of infection. Identify protect them from the probable cause inevitable injuries and of infection exposures that occur throughout the course of living. fungus. Identify things that might expose her to infection ® To know the baseline data of the patient. .7’C -1 day post vaginal delivery -w/ diaper 2011 “bago paning tahi akong kinatawo. @ 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.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. may alter to different degrees humoral and cell mediated immune responses. ® To protect against infection. or other parasite) invades a susceptible host.) Monitor the vital signs. Breaks in the integument. virus.) Observe performance of personal hygiene practices.. Goal Met.g. thereby representing the most common of secondary immunodeficiency. 61 ® Limits exposure to bacteria / infections. Infections occur when an organism (e. 3.) Perform meticulous hand washing by caregivers and patient. 5. ® Prevent cross contamination or bacterial colonization. Nutritional deficiencies.

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

Kung and Murr -Stay with the patient magkakwarta mi. pagbudget ani the patient’s problem such as use of with situation ron. Pocket Guide ® to assess coping abilities and makatabang thoughts of man by Doenges. 180-184 63 . aron naa mi pang patient to cope easily pp. ® to identify successful na mapadako ug techniques that can be used in tarong ang amoang -poor eye current situation anak.” way of living other resources . 2011 4:00 pm Coping-Stress Ineffective After the 3-hour -Introduce self to patient GOAL met Tolerance Coping teaching. the client will January 10.Determine previous methods of and can be The patient verbalized. skills sharing gihapon ko sa akong Moorhouse bana. 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.January Subjective: 10. dealing with life problems stressful to “Paningkamotan nako Objective: some people. 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. okey lang -Ascertain client’s understanding basta kompleto ang of current situation and its impact pamilya. ® Continuous support may help magnegosyo na lang ko. Maski wala mi contact kwarta. Maski wala Nurse’s -second koy trabaho.

-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 .

norms and expectations. and obligations. Within 1-2 hours of nursing care and management. 10th Edition. acceptance of self. e.” “mao ni akong pinaka una na baby.) Establish rapport with the patient. 2. ® To gain trust and cooperation of the patient. F. 2 0 1 1 @ 4:00 PM “Una pa man nako ni na anak. situational Bibliography: or health illness transition.) Provide an environment perception and conducive to learning.g.) verbalized understanding of 3.A. 5. 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.) provide opportunities for Company. January 10.) Identify type of role role expectations dysfunctions. 403 ® enhances self concept and promote commitment to goals.) Verbalize realistic 2. Davis 4. ® This will facilitate learning.) 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 . occurred and problem.Date & Time Cues Need Nursing Diagnosis Objective of Care Interventions Evaluation Subjective: J A N A U R Y 10. 3. 2011 5:30 pm “Goal Met” 1. Wala pa kaayo ko kabalo kung unsa ang buhaton. Marillyn E. ® pattern of behavior and self expression that do not match the environmental context. patient to exercise control Copyright 2006. our patient will 1.) talk with family ® Patient must have a about situations and comprehensive changes that have understanding of the Doenges. Philadelphia.magkalisod pakog adjust ani” -as verbalized by the patient. Pages over as much as possible. Nurse’s Pocket Guide limitations imposed. developmental.

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

her partner immediately finds ways to provide necessary medications and other needs to achieve faster recovery. 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. the doctor gave a new prescription of drugs. Every time. Environment  During her stay in the hospital. the room was 67 . 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.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.

3 = FAIR 2. DISCHARGE PLAN Medication • Educate the patient about the importance of strict compliance to the therapeutic regimen. This means that the client has a good chance of recovering from her illness.Gestational is common with ages 35 and above as well as 20 and below.6 = POOR 1.2857  Fair: (0*2)/7 =0 Grandma  Good: (5*3)/7 = 2. Total 2 0 5 Computation:  Poor: (2*1)/7 =.1428 2 Total: 2.0 = GOOD General Prognosis: The general prognosis of the client is good.4-3.good in which the staff maintained the cleanliness for the benefit of their patients Age  The patient’s age is 25 yrs old hypertension .7-2. 68 .4285 = Good Scoring for General Prognosis: 1-1.

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

Diet • Encourage patient to eat a variety of nutritious food like fruits and vegetables once instructed by the physician. • Instruct patient to take vitamins as ordered.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. RECOMMENDATION 70 . • Advise the patient and family to carry out follow-up diagnostic examinations. • Instruct the family to report any unusual signs and symptoms experienced by the patient.

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

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

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