Republic of the Philippines

CENTRAL MINDANAO UNIVERSITY

COLLEGE OF NURSING
University Town, Musuan, Maramag, Bukidnon
E-mail: nursing@cmu.edu.ph

Pregnancy Induced Hypertension:

Eclampsia

A Case Study Presented to the Faculty of the College of Nursing,

Central Mindanao University

In Partial Fulfillment of the Requirements in

NCM 66.1: MATERNAL AND CHILD AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC)

BSN 2 – C
GROUP 3

Calvez, Kyrstll Shannen A.

Sangual, Lea Margaret V.
Lagura, Chrisjay Mae R.
Sanchez, Mae Elaisa C.
Gonzales, Rosalinda G.
Ramal, Krisyll Meah T.
Arcaya, Ilert Kliene T.
Delfin, Keziah Cara I.
Montera, Jayvee A.
Bermillo, Karryll A.
Tropel, Erica M.

CLINICAL INSTRUCTORS
Mohammed Bien Kulintang, MAN, RN, CHA, OHN, LPT
Ellen Gay S. Intong, DM, RN
Jainah Rose F. Gubac, RN
Catherine A. Delfin, RN

March 17, 2021

Acknowledgement

This case study analysis will not be able to

happen without your help.

The researchers would like to extend their heartfelt gratitude to the

following who helped and inspired us to continue and made this study possible
and successful:

To the Almighty God, for giving us strength, wisdom, courage,

unconditional love and for guiding us to make everything possible.

To Ms. Jainah Rose Gubac, clinical instructor, who gave us advices and
feedbacks for the improvement of our case study and presentation. Also for her
everlasting support, effort and spending much of her time to examine our study.
Who helped us become enlightened and gave advices to improve our study.

To all of our Clinical Instructor/Panelists, who gave advises and

comments that helped in developing our research become the best as it can be.

To the authors, editors, and researchers from whom we have sourced

our needed information, concepts and ideas that is relevant to support our study.

To the Researchers’ family, for the unending support, both financially

and emotionally, and for the unfathomed love that gives us strength to keep
going.

The Researchers

Page 2 of 62
 Table of Contents

Page

PRELIMINARIES
Acknowledgement 2
Table of Contents 3

INTRODUCTION 4
Objectives 5
HEALTH HISTORY 7
Biographical Data
Chief Complaint 7
OB History 8
Obstetric Risk Factors 8
Antenatal History 9
Family History 9
Family Genogram 9
All Content of Health History 10
PHYSICAL ASSESSMENT 11
ANATOMY & PHYSIOLOGY 14
CONCEPT MAP 16
Narrative Discussion
Etiology 17
Pathophysiology 21
Symptomatology 21
Prognosis 24
LABORATORY AND DIAGOSTIC TESTS 25
MEDICAL MANAGEMENT 27
SUMMARY OF MEDICAL MANAGEMENT 41
NURSING CARE PLAN
REFERENCES

Page 3 of 62
Introduction

Definition

Pregnancy-induced hypertension or (PIH) is a form of high blood pressure

in pregnancy. It occurs in about 7 to 10 percent of all pregnancies. In pregnancy,
the blood pressure is considered to be raised if: the blood pressure is 140/90
mmHg or more, the systolic blood pressure has increased by 30 mmHg and the
diastolic blood pressure has increased by 15 mmHg. Usually, there are three
primary characteristics of this condition, including the following: high blood,
protein in the urine and edema or swelling. Eclampsia is defined as the onset of
convulsions in a woman with PIH that cannot be attributed to other causes. The
seizures are generalized and may appear before, during, or after labor. Eclampsia
is a severe form of pregnancy-induced hypertension. Women with eclampsia have
seizures resulting from the condition. Eclampsia occurs in about one in 1,600
pregnancies and develops near the end of pregnancy, in most cases. When the
blood pressure, or the force of blood against the walls of arteries, becomes high
enough to damage the arteries and other blood vessels. Damage to the arteries
may restrict blood flow. It can produce swelling in the blood vessels in the brain
and to the growing baby. If this abnormal blood flow through vessels interferes
with the brain’s ability to function, seizures may occur.

The clinical pathways to treat eclampsia address diverse components, such

as: screening, diagnosis, treatment at the different levels of care, medications,
monitoring, and criteria for referral and interruption of pregnancy (BMC Pregnancy
and Childbirth, 2003). Each pathway illustrates the different processes involved.
Eclampsia is a dynamic disease that can change rapidly, thus health outcomes
were considered the basis for making clinical decisions. It was assumed that the
pathways should be used as a guide and contributes to set standards of care, but
some flexibility should be given to individualize care for each patient.

A systematic review of data made available between 2002 and 2010

showed an incidence of eclampsia ranging from 0.1 to 2.7%, with higher rates
identified in regions of lesser socioeconomic development. It highlights the lack of
information on these important outcomes, especially in places where the disease
is more prevalent.

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 When evaluating the use of magnesium sulfate (MgSO4), a medication of
choice for the prevention or treatment of eclampsia, Sibai has demonstrated that
eclampsia occurred in between 2 and 3% of eclamptic women who developed
signs of severity and did not receive prophylaxis for seizures. In addition, 0.6% of
the patients with pre-eclampsia initially classified without signs of severity also
evolved to eclampsia. In Brazil, Giordano et al. evaluated 82,388 pregnant women
attended at 27 reference maternity hospitals. The general prevalence reported
was of 5.2 cases of eclampsia per 1,000 live births, ranging from 2.2:1000 in more
developed areas to 8.3:1000 in less developed areas. In that study, eclampsia
accounted for 20% of 910 cases classified as severe maternal outcomes.

According to the World Health Organization (WHO), hypertensive disorders

of gestation are an important cause of severe morbidity, long-term disability, and
both maternal and perinatal mortality. Although 10 to 15% of direct maternal
deaths are associated with eclampsia worldwide, 99% of these deaths occur in
low- and middle-income countries. Severe morbidities associated with eclampsia
can lead to death, such as renal failure, stroke, heart failure, pulmonary edema,
coagulopathy, and hepatic impairment. Fetal and neonatal complications result
mainly from placental insufficiency and the frequent need for premature delivery
that result in high rates of perinatal morbidity and mortality.

General Objective:

The main objective of this case study is establishing students to develop

knowledge regarding the normal human body system process, and skill practice in
providing nursing care, provide advices, health teaching to the patient and family
management of the pregnancy conditions. During the process we as future nurses
got the opportunities to learn about the condition, its complication and other
potential gynecological and obstetric abnormalities and complication that arise due
to the patient.

Page 5 of 62
Specific Objectives:

At the end of the case scenario study, we as future nurses in section C

second year students will be able to:

Knowledge:

• Determine the diagnosis of the client from the given scenario.

• Identify the possible cause of the client’s complication (Eclampsia).

• Formulate nursing care plans.

• Broaden the knowledge of the levels in relation to risk factors, signs and
symptoms, dangers, prevention and management of eclampsia.

• Understand nursing assessment in placement of the patient’s condition.

Skills

• Cultivate positive attitudes in dealing the health condition of a patient.

• Give right assessment and render quality and appropriate care to assigned
patient from the given scenario.

• Strengthen critical thinking for nursing care plan with right actions.

• Provide holistic nursing care to the patient in relation to her condition.

• Increase technology skills and develop interpersonal skills within the case
scenario.

Attitude:

• Provide Excellent Patient-Centered Care.

• Bound like other professionals to a shared set of behaviors, values and

attitudes.

• Build rapport to the client to develop trustworthiness with the student

nurses

• Creating a fully set of compassion in practice, courage, commitment, care

and courage in clinical setting.

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Health History

A. Biographical Data

Instructions: Kindly fill-out the forms with the necessary information of

the patient. Write legibly and accurately.
I. PATIENT’S
PROFILE
HRN : n/a Age :45 yrs old
Birth Date : November 21, 1979 Sex :Female
Civil Status : Married Religion :Iglesia Ni Cristo
Address : n/a Height: :160 cm
Educational Attainment : Highschool graduate Weight : 92 kg
Occupation : Sales lady Blood Type : AB (+)
Ethnic Group : n/a Vital signs
Date & Time of Admission : January 15, 2021, 9am Ward (Day 1)
Attending Physician : Dr. Adrian Higup BP :140/90 mmHg
Medical Diagnosis : Eclampsia PR : 90 bpm
RR : 20 bpm
History of Allergy/ies : n/a Temp : 36.2 C
o

Delivery Details : Emergency CS Ward (Day 2)

BP : 170/110 mmHg
Type of Delivery : Low segment transverse CS
Medications (if given) : Metoclopramide 10 mg/amp
IVTT PRN, Hydralazine 5 mg
IVTT q 15-30 mins,
Betamethason 12 mg, preop:
Betamethasone 12 mg IM,
Ampicillin 2 grams IVTT Q 6
hrs, postop: Ketorolac IV q 6
hrs for 24 hrs then shift to
ketorolac PO 1 tab q6 hrs
Date of Delivery: : January 16, 2021 Time : 9:00 am
Episiotomy type : n/a Estimated blood loss : n/a
Diagnose of Laceration : Bleeding Type of Placenta : n/a

B. Reason for Seeking Health Care / Chief Complaint

Pt presents increase blood pressure and advised for admission @ 30 weeks

pregnant. “Dili ko kasabot sa akong kundisyon, wala pud koy gibati karon,
natingala lang gyud ko kay pag homan nila ug kuha sa akong pressure health
center, ingon sa midwife magpa checkup daw ko sa hospital kay taas daw akong
BP” as verbalized by pt. Blood Pressure were recorded to be 140/90 mmHg and
was immediately admitted to the hospital.

History of Present Illness:

Page 7 of 62
 On June 2020 the pt visited the center for the first prenatal checkup and
had a regular check up every month. On her second trimester, quickening was felt
on Nov. 8, 2020 and continue to perceive fetal movements. 2 doses of tetanus
toxoid were administered. Anomaly scan was done at 12 weeks AOG. No history of
pedal edema, epigastric pain, blurring of vision and headache, no leaking or
bleeding per vagina and excessive weight gain of 1.5 lbs. per week was noted. On
the third trimester, the pt continued to perceive fetal movements. Calcium and
iron tablets administered. The pt failed to come to a regular antenatal check-up
and until her last check-up she was found to have high blood pressure.

On January 15, 2021 the pt was seen and examined and was advised for
admission @ 30 weeks pregnant for a high blood pressure rose to 140/90 mmHg
and suggestive of PIH. The pt works at Gaisano Mall as sales lady and married to
her husband Andrew for almost 6 yrs. now. Until January 16, 2021, the second
day of admission the pt experienced convulsion, eyes jerk from side to side and
then roll upward, tongue was bitten and bloody froth appears in the mouth. The
pt had 170/110 mmHg bp and the FHT dropped that allows for emergency CS
delivery.

C. OB History

LMP: June 8, 2020 G: 3 P: 1 (T:0 P:1 A:2 L: 1)

EDC: March 15, 2021
AOG: 30 WKS.
Age of Menarche: 10 yrs. old Menstrual Cycle: Irregular
Duration: 7 days

GRAVID PLACE OF AOG MANNER OF PRESENTATIO COMPLICATIONS

A CONFINEMENT DELIVERY N
G1 n/a 6 WKS Salpingostomy n/a Fetal death
G2 n/a 12 Incomplete abortion n/a Fetal death
WKS
G3 n/a 30 CS Normocephalic Premature birth
WKS
G4
G5
G6
G7

III. OBSTETRIC RISK FACTORS

() Age (below 18 and above 35) ( ) Multiple Pregnancy

( ) Ovarian Cyst ( ) Uterine Myoma ( ) Placenta Previa
( ) History of stillbirth ( ) History of 3 Miscarriages
( ) History of pre-eclampsia/eclampsia () Others: Measles, German
measles, mumps,

Page 8 of 62
rubella, ectopic pregnancy (2017) &

incomplete abortion (2019).

D. Antenatal History

1st Trimester: The patient had a regular prenatal check up every month.

2nd Trimester: Quickening was felt on Nov. 8, 2020 and continues to perceive fetal
movements. 2 doses of tetanus toxoid were administered. Anomaly scan was
done at 12 weeks AOG. No history of pedal edema, epigastric pain, blurring of
vision and headache, No leaking or bleeding per vagina; excessive weight gain of
1.5 lbs. per week was noted.

3rd Trimester: The patient continued to perceive fetal movements. Calcium and
iron tablets were taken. Patient failed to come to a regular antenatal check-up
and until her last check-up she was found to have high blood pressure.

D. FAMILY HISTORY

Family has no history of Hypertension, Diabetes Mellitus, and history of

Pregnancy induced Hypertension in mother or sister.

E. Family genogram

Page 9 of 62
F. All Content of Health History

Patient is female, 45 years old and at 30 weeks AOG. She was born on
November 21, 1979 and is an Iglesia ni Cristo. She is married for almost 6 years.
She weighs 92 kg and is 160 cm tall. Her vital signs are: PR is 90 bpm; RR is 20
breaths per minute; BP is 140/90 mmHg; temperature is 36.2 ꞏC; fundal height is
23 cm; and the FHR is 150 bpm.

She is gravida 3 para 1 with an LMP of June 8, 2020. Her attending

Physician is Dr. Adrian Higup, was admitted to the hospital on January 5, 2021
with high blood pressure and suggestive of Pregnancy induced hypertension thus
referred to a hospital, hence this admission. Past medical history shows no know
case of hypertension, diabetes mellitus, asthma, and thyroid disorder. Patient had
measles, German measles, mumps, and rubella. She also had a history of
hospitalization, surgery for ectopic pregnancy in 2017 @ 6 week AOG and D and C
in 2019 for incomplete abortion @12 weeks AOG. Her gravida 1 and 2 both
resulted in fetal death complications due to miscarriage and incomplete abortion.

She had a regular prenatal check-up until her third trimester. She was then
found to have pregnancy induced hypertension and was referred to the hospital
for admission. Her family history shows no signs of past health complications.

Page 10 of 62
Physical Assessment
Date: JANUARY 15, 2021
Time: 9 AM

System/Area Findings Implications

In general patient had NORMAL
GENERAL PHYSICAL no fever, (+) for
STATUS excessive weight gain
started @ 2nd trimester
of pregnancy and no
body malaise. Awake,
alert not in respiratory
distress, not in pain
Memory is intact.
Patient was negative for
bruisability. Client was
conscious, oriented to
time, date and place.
Skin color is even
without lesions. Client’s
posture is erect and
comfortable for age.
There were no eye, ear
and nose discharges. No
dyspnea was noted, no
cough and colds.
Client’s temperature is
36.2 degree Celsius.
Lesions observed in
both lower extremities.
Skin turgor is firm.
INTEGUMENTARY The patient has fair NORMAL
SYSTEM (Skin, Hair, complexion no rashes,
Nails, Appendages) and no jaundice. There
were no eye, ear and
nose discharges.

Breasts are symmetric,

no dimpling and
discoloration noted,
nipples and areolas are
dark in color; chloasma
is visible on face. No
heat and cold
intolerance

Patient was negative for

bruisability, Capillary
refill less than 2
seconds. Temp: 36.2
degrees Celsius

Page 11 of 62
HEENT (Head, Eyes, Head is normocephalic NORMAL
Ears, Nose & Throat) with anicteric sclera,pink
palpebral conjunctiva
Nasal septum in midline,
dry lips, moist oral
mucosa, tonsils non-
hyperemic ,non-
hypertrophic. The color
of the conjunctiva of the
client’s eyes were pink
and has no presence of
lesions. Neck had no
cervical
lymphadenopathy
There was no eye, ear
and nose discharges.

THORAX AND LUNGS No dyspnea was noted, NORMAL

no cough and colds.
Orthopnia, palpitations
and chest pain was not
noted, equally chest
expansion
BREASTS Breasts are symmetric, NORMAL
no dimpling and
discoloration noted,
nipples and areolas are
dark in color
Heart has a dynamic ABNORMAL
CARDIOVASCULAR precordium, normal rate
SYSTEM and regular rhythm with
clear breath sounds; BP:
140/90 mmHg
Abdomen The abdomen is Normal
globular upon
observation; presence
of Strae gravidarum ,
Linea negra on the
abdomen ; vomiting and
nausea noted. The
patient has a soft
tender abdomen upon
palpation. Abdomen had
audible bowel sounds
upon auscultation.
Fundic height: 23 cms
FHT: 150
Respiratory System Orthopnia, palpitations NORMAL
and chest pain was not
noted. Nasal flaring is
not observed and has
no trouble breathing.
The use of accessory
muscles was not

Page 12 of 62
 observed. No
adventitious sounds
were auscultated. RR:
20 cpm
MUSCULOSKELETAL Varicosities and edema ABNORMAL
SYSTEM was noted on lower
extremities. No
pathological reflexes,
Extremities have a good
range of motion;
Weight: 203 lbs
Height: 5 feet and 3
inches
NEUROLOGIC SYSTEM Patient has a GCS of 15. ABNORMAL
No pathological reflexes
There was headache
and seizure. Client was
oriented to time, date,
person and place.

REPRODUCTIVE Patient claimed that she ABNORMAL

SYSTEM experiences painless
vaginal bleeding and
cramping;

URINARY SYSTEM no dysuria, hematuria NORMAL

and frequency urgency
noted

Page 13 of 62
Anatomy & Physiology

ANATOMY AND PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM

The Circulatory (Cardiovascular) System

The Circulatory System is designed to deliver oxygen and nutrients to all
parts of the body and pick up waste materials and toxins for elimination.
This system is made up of the heart, the veins, the arteries, and the
capillaries.
Circulation is achieved by a continuous one-way movement of blood
throughout the body. The network of blood vessels that flow through the
body is so extensive that blood flows within close proximity to almost every
cell.

Heart
The heart is a muscular pump that
propels blood throughout the
body. The heart is located
between the lungs, slightly to the
left of center in the chest.

The heart is broken down into four chambers including:

• The right atrium, which is a chamber which receives oxygen- poor blood
from the veins.
• The right ventricle which pumps the oxygen-poor blood from the right
atrium to the lungs.
• The left atrium which receives the now oxygen-rich blood that is
returning from the lungs.
• The left ventricle, which pumps the oxygenated blood through the
arteries to the rest of the body.
Blood Vessels
Blood vessels are broken down into three groups: the arteries which carry
blood out of the heart to the capillaries, the veins which transport oxygen-
poor blood back to the heart, and the capillaries which transfer oxygen and
other nutrients into the cells and removes carbon dioxide and other
metabolic waste from these body tissues.

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Arterial Blood Pressure
A measure of the pressure exerted by the blood as it flows through the arteries.
The blood moves in waves, there are two blood pressure measurements.
 Systolic pressure is the pressure of the blood as a result of contraction
of the ventricles, that is, the pressure of the height of the blood wave.
 Diastolic pressure is the pressure when the ventricles are at rest

Blood Pressure Range

Blood Pressure Levels

Normal systolic: less than 120 mm Hg

diastolic: less than 80 mm Hg

At Risk (prehypertension) systolic: 120–139 mm Hg

diastolic: 80–89 mm Hg

High Blood Pressure (hypertension) Stage 1 Systolic 140-159 mm Hg

Diastolic 90-99 mm Hg

Hypertension , Stage 2 Systolic greater than 160 mm Hg

Diastolic greater than 100 mm Hg

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 Concept Map
(Etiology, Pathophysiology, Symptomatology & Prognosis)

A. Schematic Diagram
a. CONCEPT MAPPING
Biographical Data
B.
(Pt. Dolly, 45 y.o/female)
G3 P1 30wks AOG

Precipitating Factors
Etiology Predisposing Factors
 Stress
 Pain Pregnancy induced  Age
 High blood hypertension  Miscarriage
 Weight
Symptomatology  Ectopic pregnancy
 Stress Pathophysiology
 Pain (facial grimacing or Symptomatology
frown) Pregnancy Induced
hypertension  Age
 High blood pressure  Cramping and pain in
Diagnostic Tools your lower tummy.
 Numerical rating scale  Obesity (203 lbs)
 Sphygmomanometer  Severe abdominal or
 Stethoscope pelvic pain
accompanied by
Management
Preeclampsia vaginal bleeding
MEDICAL
1. Supportive counselling
2. Acupressure Diagnostic Tools
3. Heart healthy diet Eclampsia  Numerical rating scale
PHARMACOLOGIC  Weight scale
1. Antidepressants and  Urinalysis
antihistamines  Laparoscopy
2. Opioid analgesics, Anti-
depressants and Antianxiety
agents Management
3. Labetalol and nifedipine Medical
DIAGNOSIS
1. Anxiety related to situational Mifepristone, Diet, Methotroxate
crises as evidence by increased PHARMACOLOGIC
in blood pressure and Anxiety
related to unconscious conflict Metoclopramide, Hydralazine,
Disease
about physiological factors Betamethasone, Ampicillin, Ketorolac
Eclampsia
2. Risk for fluid Volume deficient
related to dehydration due to DIAGNOSIS
pain and hyperthermia as 1. Deficient knowledge, risk for
evidence by skin turgidity and spiritual distress and
dryness of oral mucosa, Acute situational low self-esteem
pain related to cephalgia and Page 16
2. Impaired of 62isolation,
social
imbalanced nutrition deficient knowledge and
3. Decreased cardiac output disturbed body image
related to increased systemic 3. Risk for Deficient Fluid
 Prognosis

a.

If treated If not treated

Eclampsia—the onset of seizures in a woman Left untreated, eclamptic
with preeclampsia—is considered a medical seizures can result in coma,
emergency. Immediate treatment, usually in a brain damage, and possibly
hospital, is needed to stop the mother's maternal or infant death
seizures, treat blood pressure levels that are
too high, and deliver the fetus.
Magnesium sulfate (a type of mineral) may be
given to treat active seizures and prevent
future seizures. Antihypertensive medications
may be given to lower the blood pressure.

Narrative Discussion
a. ETIOLOGY
Patient was found to have high blood pressure and suggestive of
Pregnancy induced-hypertension during her last check-up.
Hypertensive disorders of pregnancy, an umbrella term that includes
preexisting and gestational hypertension, preeclampsia, and
eclampsia, complicate up to 10% of pregnancies and represent a
significant cause of maternal and perinatal morbidity and mortality.
Pregnancy-induced hypertension (PIH) is a form of high blood
pressure in pregnancy. It occurs in about 7 to 10 percent of all
pregnancies.

Page 17 of 62
 Predisposing Present Absent Implication
Factors
Age / Older women (≥40
years old) had
increased odds for
mild preeclampsia,
fetal distress, and
poor fetal growth
(Yogev, et al, 2010)
Miscarriage / Women may
experience a roller
coaster of emotions
such as numbness,
disbelief, anger,
guilt, sadness,
depression, and
difficulty
concentrating.
(Friedman &
Gradstein, 2020)
Obesity / Increased risk of
maternal death and
complications
during pregnancy
and labor. (Lewis G,
2007)
Ectopic Pregnancy / An ectopic
pregnancy can
cause your fallopian
tube to burst or
rupture. (Johnson
T, 2020)
A family history of / The more family
hypertension members you have
with high blood
pressure before the
age of 60, the
stronger the family
history of high
blood pressure.
(Vasan R, 2002)
Personal/family / Patients who
history of chronic identified a relative
hypertension/diabetes as having diabetes
mellitus were almost three
times as likely to
have a plasma

Page 18 of 62
 glucose
determination when
compared with
individuals without
a family history.
(Coeytus et al,
2004)
gestational diabetes /
Precipitating Present Absent Implication
Factors
Stress / Stress can increase
the chances of
having a premature
baby (born before
37 weeks of
pregnancy) or a
low-birthweight
baby (weighing less
than 5 pounds, 8
ounces). Babies
born too soon or
too small are at
increased risk for
health problems.
(March D, 2019)

Pain / Over 85% of

women use some
medication during
pregnancy and
analgesics are the
most common
preparations used,
after vitamins, in all
trimesters of
pregnancy, with
over 50% of
women using
analgesics during
their pregnancy.
(Henry & Crother,
2000)
Highblood Pressure / It raises the risk of
heart attack and
stroke. High blood
pressure damages
the walls of the

Page 19 of 62
 arteries. This makes
them more likely to
develop deposits of
plaque that harden,
narrow or block
your arteries. These
deposits also can
lead to blood clots.
Blood clots can flow
through the
bloodstream and
block blood flow to
the heart or brain,
resulting in a heart
attack or stroke.
(UPMC, 2020)
Pregnancy induced / Higher incidences of
hypertension adverse perinatal
outcomes occurred
among women
pregnancy-induced
hypertension such
as low birth weight,
birth asphyxia,
small for gestational
age, preterm
delivery and
perinatal death.
(Berhe et al, 2019)
Alcohol intake / Binge drinking
(adjusted for
alcohol
consumption
frequency and other
covariates) was
associated with
increased risk of
preeclampsia (OR
1.8; 95% CI 1.16–
2.92) with an
especially strong
association noted
for preterm
preeclampsia (OR
3.7; 95% CI 1.25–
10.78). (Egeland et
al, 2016)
smoking / Smoking during
pregnancy

Page 20 of 62
 contributes to a
variety of infant
health problems
present at birth as
well as long lasting
behavioral and
neurodevelopmental
impairments, and
remains arguably
one of the most
important
modifiable risk
behaviors for child
and long-term
health and human
capital. (Buka &
Niaura, 2003)

b. PATHOPHYSIOLOGY
The pathophysiology of hypertension involves the impairment of
renal pressure natriuresis, the feedback system in which high blood
pressure induces an increase in sodium and water excretion by the
kidney that leads to a reduction of the blood pressure. Pressure
natriuresis can result from impaired renal function, inappropriate
activation of hormones that regulate salt and water excretion by the
kidney (such as those in the renin-angiotensin-aldosterone system),
or excessive activation of the sympathetic nervous system.
Pregnancy-induced hypertension (PIH), despite being one of the
leading causes of maternal death and a major contributor of
maternal and perinatal morbidity, the mechanisms responsible for
the pathogenesis of PIH are unclear. Hypertension associated with
preeclampsia develops during pregnancy and remits after delivery,
implicating the placenta as a central culprit in the disease. An
initiating event in PIH has been postulated to be reduced placental
perfusion that leads to widespread dysfunction of the maternal
vascular endothelium by mechanisms that remain to be defined. The
mechanisms leading to reduced placental perfusion in PIH may be
multiple, but most studies in humans suggest abnormal
cytotrophoblast invasion of spiral arterioles as an important factor.
c. SYMPTOMATOLOGY
Hypertension or high blood pressure is known as the silent killer
because in the majority of cases, there are very few or no symptoms
during the initial stages of disease. Symptoms may appear when
there is organ damage or the pressure has reached a very high level,
of around 180/110 mm of Hg. Long term high pressure against
arterial walls eventually damages and strains them. This may lead to

Page 21 of 62
several complications, the most well-known complication being
atherosclerosis which describes a build-up of fatty deposits or
plaques in the walls lining the arteries. As the walls thicken with the
deposits, they calcify and become brittle with a narrow lumen which
restricts the flow of blood.
Atherosclerosis is responsible for a host of other disease conditions
such as stroke and heart attacks. The formation of a blood clot at
the site of the plaque may block the artery completely and this leads
to ischemia or a lack of blood supply to the heart, a common cause
of heart attack.

Signs and Present Absent Implication

Symptoms
Stress / Stress can
increase the
chances of
having a
premature baby
(born before 37
weeks of
pregnancy) or a
low-birthweight
baby (weighing
less than 5
pounds, 8
ounces). Babies
born too soon or
too small are at
increased risk for
health problems.
(March D, 2019)
Pain / Over 85% of
women use some
medication
during pregnancy
and analgesics
are the most
common
preparations
used, after
vitamins, in all
trimesters of
pregnancy, with
over 50% of
women using
analgesics during
their pregnancy.
(Henry & Crother,

Page 22 of 62
 2000)
High Blood / It raises the risk
Pressure of heart attack
and stroke. High
blood pressure
damages the
walls of the
arteries. This
makes them
more likely to
develop deposits
of plaque that
harden, narrow
or block your
arteries. These
deposits also can
lead to blood
clots. Blood clots
can flow through
the bloodstream
and block blood
flow to the heart
or brain, resulting
in a heart attack
or stroke. (UPMC,
2020)
Age / Older women
(≥40 years old)
had increased
odds for mild
preeclampsia,
fetal distress, and
poor fetal growth
(Yogev, et al,
2010)
Cramping and / Women
pain in your experience more
lower tummy. gas during
pregnancy due to
increased
progesterone.
Progesterone
causes intestinal
muscles to relax
and extends the
time it takes food
to get through
the intestines.
Food remains in

Page 23 of 62
 the colon longer,
which allows
more gas to
develop.
(McDermotte,
2015)
Obesity / Increased risk of
maternal death
and
complications
during pregnancy
and labor. (Lewis
G, 2007)

High blood pressure in pregnancy may not cause signs or symptoms.

If protein is present in the mother's urine, then preeclampsia is
present. Other symptoms that can be associated with preeclampsia
include persistent headaches, blurred vision, sensitivity to light, and
abdominal pain.
d. PROGNOSIS
[CITATION DrA19 \l 13321 ] Hypertension Symptoms and Effects

[ CITATION Mel19 \l 13321 ] Pregnancy-Induced Hypertension:

Symptoms & Signs
[CITATION Joe01 \l 13321 ] Pathophysiology of pregnancy-induced
hypertension
[ CITATION Joh11 \l 13321 ] CHAPTER 24: PATHOPHYSIOLOGY OF
HYPERTENSION
[CITATION Hai18 \l 13321 ] Risk factors for hypertensive disorders
of pregnancy among mothers in Tigray region, Ethiopia:
matched case-control study
[ CITATION Ste19 \l 13321 ] Hypertension in pregnancy:
Pathophysiology and treatment

Laboratory & Diagnostic Tests

Laboratory & Indications & Results/ Normal Values Nursing Re
Diagnostic Purposes Interpretation
Procedure
Hemoglobin: Hemoglobin:  Asses for

Page 24 of 62
 Can help 90 120-140 g/L such as a
HEMATOLOGY diagnose Decreased  Instruct t
anemia, Hematocrit: Hematocrit: cooperat
infection, 0.37-0.45 follow dir
hemophilia, 0.31  Explain t
blood-clotting Deceased  Explain t
disorders, and Erythrocytes: discomfo
leukemia. Erythrocytes: 4.5-5.0 10^12/L when the
puncture
4.0 Leukocytes:  Encourag
Slightly Decreased 5.0-100 10^9/L stress if p
altered p
Leukocytes: influence
Thrombocytes: normal h
0.38 140-440 10^9/L values.
Decreased  Monitor t
for oozin
Thrombocytes: formation
 Neutrophil:  Instruct t
169.0 0.55-0.65 normal a
diet.
Within the normal  Lymphocytes:  Promptly
value 0.35-0.45 specimen
laborator
 Neutrophil:  Monocytes:  Educate
0.51 0.06-0.12 family ab
Slightly decreased condition
 Lymphocytes: suggestio
0.32 on how t
Slightly decreased  Eosinophils: condition
 Monocytes: 0.02-0.04
0.08
 Basophils:
Within the normal 0-0.02
value

 Eosinophils:
0.08 Absolute Neutrophil:
Elevated 1.8-7.8 10^9/L
 Basophils
0.01

Within the normal

value Absolute Lymphocytes
1.0-4.8 10^9/L
Absolute
Neutrophil:
2.74

Within the normal

value

Absolute
Lymphocytes
1.7

Page 25 of 62
 Within the normal
value

It gives SI SI  Ensure th
BLOOD important SGOT/AST: SGOT/AST: has had
CHEMISTRY information 75.00 preparati
about how well Elevated 14-54 u/L  Cleaning
a person's LDH: before an
kidneys, liver, 290 use to pr
and other Slightly Elevated LDH: spread o
organs are 140-280 U/L done by
working. CREATININE: staff.
150H CREATININE:  Assisting
Elevated 53-115 umol/L and othe
providers
Random Urine  diagnosti
Albumin:  Help pos
2.800 Random Urine  properly,
Within normal Albumin: patient o
range complete
1- 1.8 mg/dL diagnosti
Urine Creatinine  Monitorin
medical c
UACR= 9.4 mg/g must che
7557.73 vital sign
RANDOM URINE pressure,
SAMPLE breathing
physical
Urine protein ratio keep an
3.5 g Urine protein ratio monitors
Elevated <0.2 g needs to
up to dur
CONVENTIONAL such as a
SGOT/AST CONVENTIONAL or ventila
75.00 SGOT/AST
Elevated 15-41 u/L
CREATININE:
1.5 CREATININE:
Elevated 0.39-0.99 mg/dL

Random Urine 
Albumin: Random Urine 
2.008 Albumin:
Elevated
0-0.018 g/l
Urine Creatinine

85.49 mg/dL
Normal Urine Creatinine

Urine protein ratio 37-250 mg/dL in

females.
<.2 g

Page 26 of 62
Normal Urine protein ratio

<0.2 grams

Page 27 of 62
 Medical Management

A. Pharmacotherapy, Intravenous Fluids & Nursing Responsibilities

Drug Mechanism of Indications or Contraindications Side Effects Adverse Nursing Responsibilities

Action Purpose Reactions
Generic Name: Blocks dopamine To prevent  Hypersensitivity to Common side CNS: drowsiness, Monitor blood pressure
Metoclopramide receptors by chemotherapy- drug effects: restlessness, during IV administration.
disrupting CNS induced vomiting.  Pheochromocytom anxiety,
Brand Name: chemoreceptor a  decreased depression, Stay alert for depression
Apo-Metoclop, trigger zone, To facilitate small-  Parkinson’s energy irritability, fatigue, and other adverse CNS
gastrobid, increasing peristalsis bowel intubation; disease  tiredness lassitude, effects.
Gastromax, and promoting gastric radiologic  Suspected GI  diarrhea insomnia, tardive
Maxeran, emptying. examination when obstruction,  dizziness dyskinesia, Watch for extrapyramidal
Maxolon SR, delayed gastric perforation, or  drowsiness parkinsonian-like reactions, which usually
Nu- emptying haemorrhage  headache reactions, occur within first 24 to 48
Metoclopramide interferes.  History of seizures  nausea extrapyramidal hours of therapy.
, Paramax, disorders  vomiting reactions,
PMS- Diabetic  restlessness akathisia, dystonia Check for development of
Metoclopramide gastroparesis Use cautiously in:  malaise parkosonian-like symptoms,
, Reglan  Diabetes mellitus  trouble CV: hypertension, which may occur first 6
Classification: Gastroesophageal  History of sleeping hypotension, months of therapy and
Pharmacologic reflux depression (insomnia) arrhythmias, usually subside within 2 to 3
class: Dopamine  Elderly patients  breast neuroleptic months after withdrawal.
antagonist Prevention of  Pregnant or tenderness malignant
postoperative breastfeeding or swelling syndrome With long-term use, assess
Therapeutic nausea and patients  changes in patient for tardive
class; vomiting.  Children your GI: nausea, dyskinesia and discontinue
Antiemetic, GI menstrual constipation, drugs if signs or symptoms
stimulant period diarrhea, dry of tardive dyskinesia
Dose, Route & mouth develop.
Timing:

Dose:
10 mg/amp
Route: IVTT
Timing:
Immediately

Then;
Dose: 1 amp
Route: IVTT
Timing: PRN for
active vomiting
 urinating
more than GU: gynecomastia Monitor patients closely for
usual signs and symptoms of
neuroleptic malignant
syndrome.

In diabetic patients, stay

alert for gastric stasis.
Insulin dosage may need to
be adjusted.

Tell patient to take 30

minutes before meals.

Page 29 of 62
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Nursing Responsibilities
Action Purpose Reactions
Generic Name: Relaxes vascular Essential  Hypersensitivity Common side effects: CNS: dizziness, Monitor CBC, lupus
Hydralazine smooth muscles of hypertension to drug or drowsiness, erythematosus cell studies,
arteries and tartrazine.  Headache headache and antinuclear antibody
Brand Name: arterioles, causing Severe essential  Coronary artery  Pounding/fast peripheral neuritis titers before and periodically
Apo- peripheral hypertension disease. heartbeat during therapy.
Hydralazine, vasodilation and  Mitral valvular  Loss of appetite CV: tachycardia,
Apresoline, decreasing peripheral Heart failure rheumatic  Nausea angina, orthostatic Monitor blood pressure,
Novo-Hylazin, vascular resistance. heart disease.  Vomiting hypotension, pulse rate and regularity,
Nu-Hydral These actions  Diarrhea, arrhythmias and daily weight.
Classification: decrease blood Use cautiously in:  dizziness may
Pharmacologic pressure and  Suspected CV occur as your EENT: lacrimation, To avoid rapid blood
class: Peripheral increase heart rate, or body adjusts to nasal congestion pressure drop, taper dosage
vasodilator stroke volume, and cerebrovascular the medication. gradually before
cardiac output. disease, severe GI: nausea, discontinuing.
Therapeutic renal or hepatic Serious side effects: vomiting, diarrhea,
class: disease  Severe tiredness constipation, Watch for peripheral
Antihypertensiv  Pregnant or  Aching/swollen anorexia neuritis. If it occurs, expect
e breastfeeding joints to give pyridoxine.
Dose, Route & patients  Rash on nose Metabolic: sodium
Timing:  Children and cheeks retention Tell patient to take tablets
 Swollen glands with food.
Dose: 5 mg  Signs of kidney Musculoskeletal:
Route: IVTT problems (such joint pain, arthritis Instruct patient to move
Timing: q 15-30 as change in the slowly when rising
mins amount of urine, Skin: rash, blisters, (especially in morning on
bloody/pink flushing, pruritus, awakening), to avoid
urine) urticarial dizziness from sudden blood
 Signs of infection pressure decrease.
(such as fever, Other: chills, fever,
chills, persistent lymphadenopathy, Tell patient to report chest

Page 30 of 62
 sore throat) edema, lupuslike pain or numbness or tingling
 Easy syndrome hands or feet.
bruising/bleeding
.
To minimize GI upset,
advise patient to eat small,
frequent meals.

Caution patient not to

discontinue drug abruptly,
because severe
hypertension may result.

As appropriate, review other

significant and life-
threatening adverse
reactions and interactions,
especially those related to
the drug tests, and
behaviours mentioned
above.

Page 31 of 62
 Drug Mechanism of Indications or Contraindications Side Effects Adverse Nursing Responsibilities
Action Purpose Reactions
Generic Name: Stabilizes lysosomal Inflammatory,  Hypersensitivity Common side effects: CNS: headache, Monitor weight daily and
Betamethason neutrophils and allergic, to drug nervousness, report sudden increase,
e prevents their hematologic,  Breastfeeding  Increased blood depression, which suggests fluid
Brand Name: degranulation, inhibits neoplastic, euphoria, retention.
Betnelan, synthesis of autoimmune, and Use cautiously in: sugar level. psychoses,
Celestone lipoxygenase products respiratory  Systemic Symptoms may increased Monitor blood glucose level
Classification: and prostaglandins, diseases; infections, include: intracranial for hyperglycemia.
Pharmacologic activates anti- prevention of hypertension, pressure
inflammatory genes, organ rejection o confusio Assess serum electrolyte
class: osteoporosis,
Glucocorticoid and inhibits various after diabetes n CV: hypertension, levels for sodium and
(inhalation) cytokines. transplantation mellitus, o more thrombophlebitis, potassium imbalances.
surgery. glaucoma, renal thromboembolism
Therapeutic disease, frequent Watch for signs and
class: Bursitis or hypothyroidism, urges to EENT: cataracts, symptoms of infection.
Antiasthmatic. tenosynovitis cirrhosis, burning and
urinate
Anti- diverticulitis, dryness of eyes, Advise patient to report
inflammatory Rheumatoid thromboemboli o feeling rebound nasal signs and symptoms of
(steroidal) arthritis or c disorders, sleepy, congestion, infection.
Dose, Route & osteoarthritis seizures, sneezing, epistaxis,
thirsty,
Timing: myasthenia nasal septum Tell patient to report visual
Dose: 12 mg gravis, heart and perforation, disturbances.
Route: IM failure, ocular hungry difficulty speaking,
Timing: herpes simplex, oropharyngeal or Instruct patient to eat low-
 Trembling,
Immediately emotional nasopharyngeal sodium, high potassium diet.
instability dizziness, fungal infections.
 Patients weakness, Inform female patient that

Page 32 of 62
 receiving fatigue, and GI:nausea, drug may cause menstrual
systemic vomiting, anorexia, irregularities.
corticosteroids fast heartbeat dry mouth,
 Pregnant  Low potassium esophageal As appropriate, review all
patients level, which can candidiasis, peptic
other significant and life-
 Children ulcers threatening adverse
younger than cause muscle reactions and interactions,
age 6. pain and Metabolic: especially those related to
decreased growth, the drugs, tests, herbs, and
cramps
hyperglycemia, behaviours mentioned
 Skin changes, cushingoid above.
such as: appearance,
o pimples adrenal
insufficiency or
o stretch suppression
marks
o slow Musculoskeletal:
muscle wasting,
healing muscle pain,
o hair osteoporosis,
aseptic joint
growth
necrosis
 Signs of
infection, Respiratory: cough,
wheezing,
including:
bronchospasm
o fever
o chills Skin: facial edema,
rash, contact
o cough
dermatitis, acne,
o sore ecchymosis,
hirsutism,

Page 33 of 62
 throat petechiae,
urticarial,
 Mood and angioedema
behavior
changes Other: loss of taste,
bad taste, weight
 Menstrual gain or loss,
changes, such Churgg-Strauss
syndrome,
as spotting or
increased
skipping a susceptibility to
period infection,
hypersensitivity
 Vision changes,
reaction.
including
blurred vision
 Headaches
 Weight gain
 Sweating
 Restlessness
 Nausea

Serious side effects:

 Wheezing
 Chest tightness
 Fever
 Swelling of your

Page 34 of 62
 face, lips,
tongue, or
throat
 Seizure
 Blue skin color
 Infection. Signs
may include:
o cough
o fever
o chills

Drug Mechanism of Indications or Contraindications Side Effects Adverse Nursing Responsibilities

Action Purpose Reactions
Generic Name: Destroys bacteria by Respiratory tract,  Hypersensitivity Common side effects: CNS: lethargy, Watch for signs and
Ampicilin inhibiting bacteria skin, and soft to penicillins,  acute hallucinations, symptoms of
Brand Name: cell-wall synthesis tissue infections cephalosporins, inflammatory skin anxiety, confusion, hypersensitivity reaction.
Apo-Ampi, during microbial caused by imipenem, or eruption agitation,
Novo- multiplication. Haemophilus other beta- (erythema depression, fatigue Frequently measure
Ampicillin, Nu- influenza, lactamase multiforme) dizziness, seizures patient’s temperature, and
Ampi, staphylococci, and inhibitors  redness and check for signs and
Penbritin, streptococci peeling of the skin CV: vein, irritation, symptoms of super
Rimacillin Use cautiously in: (exfoliative thrombophlebitis, infection, especially oral or
Classification: Bacterial  Severe renal dermatitis) heart failure rectal candidiasis.
Pharmacologic meningitis caused insufficiency,  rash
class: by Neisseria infectious  hives GI: nausea, Monitor for bleeding
Aminopenicillin meningitis, mononucleosis  fever vomiting, diarrhea, tendency or haemorrhage.

Page 35 of 62
 Escherichia coli,  Pregnant or  seizure abdominal pain,
Therapeutic group b breastfeeding  black hairy tongue enterocolitis, Tell patient to take oral
class: Anti- streptococci, or patients  diarrhea gastritis, stomatitis, dose with 8 oz of water 1
infective Listeria  inflammation of glossitis, black hour before or 2 hours after
Dose, Route & monocytogenes; the small intestine tongue, furry a meal.
Timing: septicaemia and colon tongue, oral or
caused by  inflammation of rectal candidiasis, Inform patient that drug
Dose: 2 grams Streptococcus the tongue pseudomembranous lowers resistance to certain
Route: IVTT species, penicillin  nausea colitis other infections. Tell the
Timing: q 6 G-susceptible  yeast infection in patient to report new signs
hours staphylococci, the mouth (oral GU: vaginitis, or symptoms of infection,
enterococci, candidiasis/thrush nephropathy, especially in mouth or
E.coli, Proteus ) interstitial nephritis rectum.
mirabilis, or  swelling or
Salmonella inflammation of Hematologic: Advise patient to minimize
species the large anemia, GI upset by eating small,
intestine/colon eosinophilia, frequent servings of food
GI or urinary tract  inflammation of agranulocytosis, and drinking plenty of
infections the mouth haemolytic anemia, fluids.
 vomiting leukopenia,
Endocarditis  low white blood thrombocytopenic Tell patient to avoid
prophylaxis for cell count purpura, activities that can cause
dental, oral, or (agranulocytosis) thrombocytopenia, injury. Advise him to use
upper respiratory  anemia neutropenia soft toothbrush and electric
tract procedures  high white blood razor to avoid gum and skin
cell count Hepatic: nonspecific integrity.
Prevention of (eosinophilia) hepatitis
bacterial  reduction of white Inform patient taking
endocarditis blood cells Musculoskeletal: hormonal contraceptives
before GI or GU (leukopenia) arthritis that drug may reduce
surgery or  acute allergic exacerbation contraceptive efficacy.
instrumentation reaction Advise the patient to use

Page 36 of 62
 (anaphylaxis) Respiratory: alternative birth control
Prophylaxis for  elevated aspartate wheezing, dyspnea, method.
neonatal group B aminotransferase hypoxia, apnea
streptococcal (AST) As appropriate, review all
disease  inflammation in Skin: rash, other significant and life-
the kidney urticarial, fever, threatening adverse
N. gonorrhoeae  noisy breathing diaphoresis reactions and interactions,
infections  allergic reaction especially those related to
 headache Other: pain at the drugs, tests, and foods
Urehtritis caused  vaginal itching or injection site, mentioned above.
by N. discharge superinfections,
gonorrhoeae  dark urine hyperthermia,
 easy bruising or hypersensitivity
Prophylaxis bleeding reaction,
against sexually  persistent sore anaphylaxis serum
transmitted throat or fever sickness
disease in adult
rape victims

Drug Mechanism of Action Indications or Contraindications Side Effects Adverse Nursing Responsibilities
Purpose Reactions
Generic Interferes with Moderately severe  Hypersensitivity Common side CNS: drowsiness, Monitor for adverse reactions,
Name: prostaglandin acute pain to drug, its effects: headache, especially prolonged bleeding
Ketorolac biosynthesis by components,  Headache dizzinesss time and CNS reactions
Brand Name: inhibiting Ocular itching aspirin, or  Dizziness
Acular, Acular cyclooxygenase caused by other NSAIDs  Drowsiness CV: hypertension Check I.M. injection site for
LS, Apo- pathway of arachidonic seasonal allergic  Concurrent use  Diarrhea hematoma and bleeding.
Ketorolac acid metabolism, also conjuctivities of aspirin,  Constipation EENT: tinnitus
Classification: acts as potent inhibitor other NSAIDs,  Gas Monitor fluid intake and
Pharmacologi of platelet aggregation. Postoperative or probenecid  sores in the GI: nausea, output.
c class: ocular  Peptic ulcer vomiting, diarrhea,

Page 37 of 62
Nonsteroidal inflammation disease mouth constipation, Inform patient that drug is
anti- related to cataract  GI bleeding or  sweating flatulence, meant only for short-term
inflammatory extraction perforation  ringing in the dyspepsia, management.
drug (NSAID)  Advanced renal ears epigastric pain,
To reduce ocular impairment,  pain at stomatitis Advise patient to minimize HI
Therapeutic pain, burning, or risk of renal injection site upset by eating small, frequent
class: stinging after failure  small red or Hematologic: servings of healthy foods.
Analgesic, corneal refractive  Increased risk purple dots thrombocytopenia
anti-pyretic, surgery. of bleeding, on the skin Instruct patient to avoid
anti- suspected or Skin: rash, pruritus, aspirin products and herbs
inflammatory confirmed Serious side effects: diaphoresis during therapy.
Dose, Route cerebrovascular  yellowing of
& Timing: bleeding, the skin or Other: excessive Teach patient how to use eye
For 24 hours: hemorrhagic eyes thirst, edema, drops, if prescribed.
Route: IV diathesis,  excessive injection site pain
Timing: q 6 incomplete tiredness Caution female patient not
hours hemostasis  unusual take drug if she is
 Prophylactic bleeding or breastfeeding.
Shift to: use before bruising
Dose: 1 tab major surgery,  lack of Advise patient to avoid driving
Route: Orally intraoperative energy and other hazardous activities
Timing: q 6 use when  nausea until he knows how drug
hemostasis is  loss of affects concentration and
critical appetite alertness.
 Labor and  pain in the
delivery upper right As appropriate, review all
 Breastfeeding part of the other significant and life-
stomach threatening adverse reactions
Use cautiously in:  flu-like and interactions, especially
 Mild to symptoms those related to the drugs,
moderate renal  pale skin tests, and herbs mentioned
impairment,  fast above.

Page 38 of 62
 cardiovascular
disease
 Elderly patients
 Pregnant
patients
 Children.
Intravenous Fluid General Description
5% dextrose in lactated ringer’s (D5LR) Lactated Ringer’s and 5% Dextrose
Injection, USP is a sterile,
nonpyrogenic solution for fluid and
Electrolytes in 1000 ml electrolyte replenishment and
caloric supply in a single dose
container for intravenous
Sodium – 130 mmol administration. Each 100 mL
contains 5g Dextrose Hydrous,
Potassium- 4 mmol
USP*, 600 mg Sodium Chloride,
Calcium – 1.4 mmol USP (NaCI); 310 mg Sodium
lactate; 30 mg of Potassium
Chloride – 109 mmol
chloride, USP (KCI); and 20 mg
Lactate – 28 mmol Calcium chloride, USP (CaCI2-
2H20). It contains no antimicrobial
agents.
heartbeat
Indications or Purpose
 Replacement therapy
particularly in extracellular
fluid deficit accompanied by
acidosis.
 Treatment of shock.
 Persons needing extra
calories who cannot tolerate
fluid overload.
 To facilitate the flow of IV
medication during surgery
 To restore fluid balance after
significant blood loss or burns
 To keep vein with an IV
catheter open
Nursing Responsibilities
 Watch out for signs of
hypervolemia.
 Do not administer unless solution is
clear and container is undamaged.
 Never stop hypertonic solutions
abruptly.
 Don’t give concentrated solutions
IM or subcutaneously.
 Check vital signs frequently. Report
adverse reactions.
 Monitor fluid intake and output and
weight carefully.
 Watch carefully for signs and
symptoms of fluid overload.
 Monitor patients for signs of mental
confusion.
Page 39 of 62
  Lung sounds are frequently
auscultated to detect signs of fluid
accumulation.

A. Diet & Activity Management & Nursing Responsibilities

Type of Diet/Activity General Description Indication or Purposes Restricted Nursing Responsibilities

Foods/Activities
Nothing by mouth (NPO) It is a medical instruction Prevention of aspiration No foods allowed. 1. Observe intake
meaning to withhold food pneumonia, e.g. in those whenever possible to judge
and fluids. who will undergo accuracy
anesthesia, or those with
weak swallowing 2. Document appetite and
musculature, or in case of take action when the client
gastrointestinal bleeding, does not eat
gastrointestinal blockage, or
acute pancreatic. 3. Request a nutrional
consult
Before any surgery: to
prevent nausea and to keep 4. Assess tolerance
any food or liquid from
getting into the lungs. 5. Monitor weight

Having a cerebrovascular 6. Monitor progression of

accident, or stroke. restrictive diets

7. Monitor the client’s grasp

of the information and
motivation to change

Page 40 of 62

General liquids A general liquid diet is made
up only of fluids and foods
that are normally liquid and
foods that turn to liquid
when they are at room
temperature.
Full diet
8. Monitor input and output
for need for fluid restriction
This diet is used when a Foods to avoid: 1. Observe intake
patient is unable to chew or  Mashed fruits and whenever possible to judge
swallow solid food because vegetables, such as accuracy
of extensive oral surgery, mashed avocado
facial injuries, esophageal  Nuts and seeds 2. Document appetite and
strictures, and carcinomas  Hard and soft take action when the client
of the mouth and cheeses does not eat
esophagus. It may be used  Soup with noodles,
to transition between a rice, or other chunks 3. Request a nutrional
clear liquid and a regular in it consult
diet for the post-surgical  Ice cream with solids
patient. in it 4. Assess tolerance
 Bread
 Whole cereals and 5. Monitor weight
other grains
 Meats and meat 6. Monitor progression of
substitutes restrictive diets
 Carbonated
beverages, such as 7. Monitor the client’s grasp
sparkling water and of the information and
soda motivation to change
8. Monitor input and output
for need for fluid restriction
No foods are off-limits in 1. Observe intake
this diet, but think twice whenever possible to judge
before eating enriched accuracy
flour. Focus on fiber, lean
proteins like white-meat 2. Document appetite and
Page 41 of 62
chicken, and unsaturated take action when the client
fats like nuts and avocados. does not eat

3. Request a nutrional
consult

4. Assess tolerance

5. Monitor weight

6. Monitor progression of
restrictive diets

7. Monitor the client’s grasp

of the information and
motivation to change

8. Monitor input and output

for need for fluid restriction

Page 42 of 62
Summary of Medical Management
A. Pharmacotherapeutics
Date & Medication Classification Dosage Route
Time
1/16/21 Metoclopramide Antiemetic 10mg/amp IVTT
8am 1 amp PRN
1/16/21 Betamethasone Anti-inflammatory 12 mg NOW IM
8am
1/16/21 Hydralazine Antihypertensive 5 mg IVTT
8am
11/16/21 Ampicillin Anti-infective 2 g IVTT IVTT
8 am q6h
11/16/21 Ketorolac IV Analgesic, Anti- IV q6h for 24 IVTT
8am pyretic, anti- hours
inflammatory
11/17/21 Ketorolac Analgesic, Anti- 1 tab q6h PO
8am pyretic, anti-
inflammatory
B. Intravenous Fluids
Date & Bottle Type of IV Fluid & Rate Incorporation
Time No. Volume
1/15/202 1 D5LR 1L 30gtts/min
1 9am
1/16/202 2 D5LR 1L 120cc/hr Metoclopramide
1 10 mg/amp
8am IVTT STAT
Metoclopramide
1 amp IVTT
PRN (for active
vomiting)

MEDS:
Hydralazine 5
mg IVTT q 15-
30 (BP of 160 or
greater than
110 mmHg)

PRE-OPERATIVE
ORDER:
Ampicillin 2
grams IVTT Q 6
hours (ANST)
Nursing Care Plan
A. Problem List (Summary)

Cues Nursing Diagnosis Definition

The face becomes Risk for Maternal Injury At risk of injury as a result
fixed, the eyes jerk related to tonic-clonic of the interaction of
from side to side convulsions environmental conditions
and then roll interacting with the
upward, the mouth individual’s adaptive and
twitches and then defensive resources.
the convulsion
becomes general.
Tongue was caught
between the teeth,
all the muscles
including the
diaphragm
becomes rigid.
Following the tonic
stage, the arm and
legs begin to jerk
(the clonic stage),
the tongue was
bitten, and a bloody
froth appears in the
mouth. Breathing
now begins again
but is stertorous
and labored.
 Had Risk for Self-care deficit Inability to independently
measles, related to eclampsia as perform or complete
german evidenced by somnolence, cleansing activities; to put
measles, hyperemesis gravidarum, on or remove clothing; to
mumps, & and epigastric pain eat; or to perform tasks
rubella. associated with bowel and
 Surgery in bladder elimination.
2017 for
ectopic
pregnancy @
6 week AOG
and D and C
in 2019 for
inc abortion
@ 12 weeks
AOG
 Feeling of
uneasiness

She stated “Sa una Risk for Surgical Infection Susceptible to invasion of
2017 wala pay duha related to ectopic pregnancy; pathogenic organisms at

Page 44 of 62
ka bulan mikalit lang Insufficient knowledge surgical site, which may
ug  sakit akong tiyan related to childbearing compromise health.
unya dili daw sa process A pattern of preparing for
matress mi tubo ang and maintaining a healthy
akong bata kun dili sa
pregnancy, childbirth
fallopian tube daw  ug
process.
kinahanglan pa
operahan. Ang
ikaduha nako gi buros
2019, nakwaan napud
ko pag ika tulo  ka
bulan human nako ug
german measles. Ug
ang ika tulo mao ni
karon akong gi buros”
 BP: 140/90 Decreased cardiac output Decreased cardiac output
mmHg related to decreased venous is an often-serious medical
return. condition that occurs
Varicosities in lower when the heart does not
extremities. pump enough blood to
meet the needs of the
body. It can be caused by
multiple factors, some of
which include heart
disease, congenital heart
defects, and high blood
pressure.
Tongue was caught Risk for fetal injury related Inadequate blood pumped
between the teeth, to fetal distress as evidence by the heart to meet the
all the muscles by maternal eclamptic metabolic demands of the
including the seizures. body.
diaphragm becomes
rigid.  The arm
and legs begin to
jerk (the clonic
stage), the tongue
was bitten, and a
bloody froth
appears in the
mouth. 
Breathing now
begins again but is
stertorous and
labored. After a few
minutes the
breathing becomes
deeper and easier
and the cyanosis
disappears. 
Jerking of the
muscles ceases and
following a period of
restlessness the pt.
lies inert
“Pagmata nako ganina, Deficient Fluid Volume Decreased intravascular,
sakit kaayo akong ulo

Page 45 of 62
ug na lipong ko; lain interstitial, and/or
kayo akong gibati, dili intracellular fluid. This
ko kasabot ky mura kog
kasuka-on hangtud
refers to dehydration,
naka suka gyud ko. Ug water loss alone without
lain kayo akong panan- change in sodium.
aw ky mura kog malibat
ug ga kipat-kipat akong
mata nga silaw kaayo.
Nabantayan pud nako
nga gamay
lang akong gina ihi ug
balason pa.”

Patient verbalized: Decreased cardiac output Inadequate blood pumped

related to by the heart to meet the
“Dili ko kasabot sa hypovolemia/decreased metabolic demands of the
akong kundisyon, wala venous return secondary to body.
pud koy gibati karon, preeclampsia as evidenced
natingala lang gyud ko by high in blood
kay pag homan nila ug pressure/hemodynamic
kuha sa akong pressure
readings and alteration in
health center, ingon sa
mental status.
midwife magpa checkup
daw ko sa hospital kay
taas daw akong BP.”
- Nausea and
vomiting
- Decreased
urine output
- Sensitivity to
light
- Blurred vision

Increased blood Decreased cardiac output When blood pressure

pressure 140/90 related to decreased venous readings are higher than
return 140/90 mm Hg in a
Dizziness woman who had normal
blood pressure prior to 20
Weaklessness weeks and has no
proteinuria.
The face becomes Impaired Urinary Elimination Disturbance in urine
fixed, the eyes jerk related to hypertension as elimination
from side to side evidenced by decreased
and then roll urine output
upward, the mouth
twitches and then
the convulsion
becomes general.
Tongue was caught
between the teeth,
all the muscles
including the
diaphragm
becomes rigid.

Page 46 of 62
Following the tonic
stage, the arm and
legs begin to jerk
(the clonic stage),
the tongue was
bitten, and a bloody
froth appears in the
mouth. Breathing
now begins again
but is stertorous
and labored.

Page 47 of 62
 Nursing Care Plan

Patient’s Code: __________________ Age: _______ Sex: _________ Civil Status: ___________ Religion: ___________ Date & Time of Admission: ________________ Room: _______________
Attending Physician: ___________________________ Chief Complaints: ____________________________________________________________________________________________________

Nursing Diagnosis (PES): (Emphasize if this is an actual, risk or potential or even wellness nursing diagnosis)

Definition:

Assessment/ Cues Planning Interventions Rationale Evaluation

(Subjective/ Objective) (Goals and Objectives)
Subjective Data At the end of my 8 hours Independent The planned care was…
of nursing care, the  MET
patient will be able to…..  PARTIALLY MET
 NOT MET

Dependent Supporting Data

Objective Data

Collaborative

Specify your interventions accordingly.

References: (APA Format, 7th Edition)

Name of Student: ____________________________________ Yr/Crs/Sec: ________________ RLE Group: __________ CI: ____________________________
 Nursing Care Plan

Patient’s Code: Patient Dolly Age: 45 Sex: F Civil Status: Married Religion: Iglesia ni Cristo Date & Time of Admission: January 15, 2021, 9am
Room: n/a Attending Physician: Dr. Adrian Higup
Chief Complaints: Pt presents increase blood pressure and advised for admission @ 30 weeks pregnant. “Dili ko kasabot sa akong kundisyon, wala pud koy gibati karon,
natingala lang gyud ko kay pag homan nila ug kuha sa akong pressure health center, ingon sa midwife magpa checkup daw ko sa hospital kay taas daw akong BP” as
verbalized by pt.

Nursing Diagnosis (PES):

Risk for Maternal Injury related to tonic-clonic convulsions

Impaired Urinary Elimination related to hypertension as evidenced by decreased urine output

Definition:
At risk of injury as a result of the interaction of environmental conditions interacting with the individual’s adaptive and defensive resources.
Disturbance in urine elimination

Assessment/ Cues Planning Interventions Rationale Evaluation

(Subjective/ Objective) (Goals and Objectives)
Subjective Data After the nursing Assess voiding pattern (frequency Identifies characteristics of bladder After the nursing
intervention, the patient and amount). Compare urine output function (effectiveness of bladder intervention, the patient

Page 49 of 62
 would be able to: with fluid intake. Note specific emptying, renal function, and fluid was able to:
gravity. balance). Note: Urinary
In the interview conducted with
complications are a major cause of
the patient, she said: “Dili ko
Demonstrate behaviors mortality. Demonstrate behaviors
kasabot sa akong kundisyon,
and techniques to and techniques to
wala pud koy gibati karon,
prevent prevent urinary
natingala lang gyud ko kay pag
retention/urinary This provides information about retention.
homan nila ug kuha sa akong
infection. Note reports of urinary frequency, degree of interference with
pressure health center, ingon sa
urgency, burning, incontinence, elimination or may indicate bladder
midwife magpa checkup daw ko
nocturia, and size or force of urinary infection. Fullness over bladder Display balanced I&O
sa hospital kay taas daw akong
Maintain balanced I&O stream. Palpate bladder after following void is indicative of with normal urine.
BP.”
with clear, odor-free voiding. inadequate emptying or retention
urine, free of bladder and requires intervention.
distension/urinary Display normal levels of
leakage. blood pressure.
“Pagmata nako ganina, sakit Many patients are incontinent only in
kaayo akong ulo ug na lipong the early morning when the bladder
ko; lain kayo akong gibati, dili Display normal levels of Assess the patient’s usual pattern of has stored a large urine volume
ko kasabot ky mura kog kasuka- blood pressure. urination and occurrence of during sleep.
on hangtud naka suka gyud ko. incontinence.
Ug lain kayo akong panan-aw
ky mura kog malibat ug ga Sufficient hydration promotes
kipat-kipat akong mata nga silaw urinary output and aids in
kaayo. Nabantayan pud nako preventing infection.
Encourage adequate fluid intake (2–
nga gamay lang akong gina ihi
4 L per day), avoiding caffeine and
ug balason pa.” as stated by the
use of aspartame, and limiting
patient.
intake during late evening and at
bedtime. Recommend use of
cranberry juice/vitamin C.

Page 50 of 62
While she is talking, suddenly
she ceases to talk, the face
becomes fixed, the eyes jerk
from side to side and then roll
upward, the mouth twitches and
then the convulsion becomes
general.
Objective Data
Vital Signs:
● BP: 140/90 mmHg
● Temp: 36.2 degrees Celsius
● PR: 90 bpm
● RR: 20 cpm
● Weight: 203 lbs
● Height: 5 feet and 3 inches
● Blood type: AB (+)
● Fundic height: 23 cms
● FHT: 150
Refer to urinary continence specialist Collaboration with specialists is
as indicated.
Check for alterations in level of
consciousness.
Assess for signs of impending
eclampsia: hyperactivity of deep
tendon reflexes (3+ to 4+), ankle
clonus, decreased pulse and
respirations, epigastric pain, and
oliguria (less than 50 ml/hr).
Establish measures to lessen
likelihood of seizures; i.e., keep
room quiet and dimly lit, limit
helpful for developing individual plan
of care to meet patient’s specific
needs using the latest techniques,
continence products.
In progressive PIH, vasoconstriction
and vasospasms of cerebral blood
vessels reduce oxygen consumption
by 20% and result in cerebral
ischemia.
Generalized edema/vasoconstriction,
manifested by severe CNS, kidney,
liver, cardiovascular, and respiratory
involvement, precede convulsive
state.
Lessens environmental factors that
may stimulate irritable cerebrum and
cause a convulsive state.
Page 51 of 62

There are hyperactive reflexes
(sustained ankle clonus) noted.
Tongue was caught between the
teeth, all the muscles including
the diaphragm becomes rigid.
Following the tonic stage, the
arm and legs begin to jerk (the
clonic stage), the tongue was
bitten, and a bloody froth
appears in the mouth. Breathing
now begins again but is
stertorous and labored.
After a few minutes the
breathing becomes deeper and
easier and the cyanosis
disappears. The jerking of the
muscles ceases and following a
period of restlessness the pt. lies
inert.
visitors, plan and coordinate care,
and promote rest.
Enforce seizure precautions per
protocol.
In the event of a seizure:
Position patient on side; insert
airway/bite block only if mouth is
relaxed; suction nasopharynx, as
indicated; administer oxygen; avoid
restrictive clothing; do not restrict
movement. Document motor
involvement, duration of seizure,
and postseizure behavior.
Palpate for uterine tenderness or
rigidity; check for vaginal bleeding.
Review history of other medical
problems.
If seizure does occur, reduces risk of
injury.
Maintains airway by reducing risk of
aspiration and preventing tongue
from occluding airway. Maximizes
oxygenation. Note: Be cautious with
use of airway/bite block, because
attempts to insert when jaws are set
may result in injury.
These signs may indicate abruptio
placentae, especially if there is a
preexisting medical problem, such as
diabetes mellitus, or a renal or
cardiac disorder causing vascular
involvement.
During seizure activity, fetal
bradycardia may occur.
Page 52 of 62
 Assess fetal well-being, noting FHR. MgSO4 a CNS depressant, decreases
acetylcholine release, blocks
neuromuscular transmission, and
prevents seizures.

Give MgSO 4 IM or IV using infusion

pump.
When fetal oxygenation is severely
reduced owing to vasoconstriction
within malfunctioning placenta,
immediate delivery may be
necessary to save the fetus.

Prepare for cesarean birth if PIH is

severe, placental functioning is
compromised, and cervix is not ripe
or is not responsive to induction.
References:

Wayne, G. (2019, June 1). 6 pregnancy induced hypertension nursing care plans. Nurseslabs. https://nurseslabs.com/pregnancy-induced-hypertension-nursing-
care-plans/4/
Wayne, G. (2017, September 23). Impaired urinary elimination – Nursing diagnosis & care plan. Nurseslabs. https://nurseslabs.com/impaired-urinary-elimination/

Name of Student: Arcaya, Ilert Kliene T. Yr/Crs/Sec: BSN2C RLE Group: Group 3
CI: Jainah Rose Gubac, RN

Page 53 of 62
 Nursing Care Plan

Patient’s Code: PX. D Age: 45-year-old Sex: F Civil Status: Married Religion: Iglesia ni Cristo Date & Time of Admission: January 15, 2021, 9am Room: Ward
Attending Physician: Dr. Adrian Higup Chief Complaints:  Increase in blood pressure

Nursing Diagnosis (PES): Risk for Maternal Injury related to Tonic-clonic convulsions

Definition: Susceptible to a disruption of the symbiotic mother-fetal relationship as a result of comorbid
health.
Assessment/ Cues
(Subjective/ Objective)
Subjective Data
In the interview conducted with
the patient, she said: “Dili ko
kasabot sa akong kundisyon, wala
pud koy gibati karon, natingala  Patient will participates
lang gyud ko kay pag homan nila
ug kuha sa akong pressure health
center, ingon sa midwife magpa
checkup daw ko sa hospital kay
taas daw akong BP.” 
“Pagmata nako ganina, sakit kaayo
akong ulo ug na lipong ko; lain
kayo akong gibati, dili ko kasabot  Patient will be able to
ky mura kog kasuka-on hangtud
naka suka gyud ko. Ug lain kayo
akong panan-aw ky mura kog
Planning Interventions
(Goals and Objectives)
At the end of the nursing  Check for CNS involvement (i.e.,
care, the patient will be headache, irritability, visual
able to: disturbances or changes on
funduscopic examination).
 Check for alterations in level of
in treatment and/or consciousness.
environmental  Assess for signs of impending
modifications to eclampsia: hyperactivity of deep
protect self and tendon reflexes (3+ to 4+), ankle
enhance safety. clonus, decreased pulse and
 Patient will be free of respirations, epigastric pain, and
signs of visual oliguria (less than 50 ml/hr).
disturbances,  Establish measures to lessen
headache, and likelihood of seizures
changes in mentation.  Enforce seizure precautions per
protocol.
have a successful  Position patient on side; insert
cesarean delivery. airway/bite block only if mouth is
relaxed; suction nasopharynx,
as indicated; administer oxygen;
or pregnancy-related conditions, which may compromise
Rationale Evaluation
 Cerebral edema and After the nursing
vasoconstriction can be intervention, the patient
evaluated in terms of was able to participate in
symptoms, behaviors, or the treatment and
retinal changes. delivered the baby
 In progressive PIH, successfully through
vasoconstriction and cesarean delivery. The
vasospasms of cerebral blood patient recovered
vessels reduce oxygen successfully.
consumption by 20% and
result in cerebral ischemia.
 Generalized
edema/vasoconstriction,
manifested by severe CNS,
kidney, liver, cardiovascular,
and respiratory involvement,
precede convulsive state.
 Lessens environmental
factors that may stimulate
irritable cerebrum and cause

Page 54 of 62
 avoid restrictive clothing; do not a convulsive state.
malibat ug ga kipat-kipat akong restrict movement. Document motor  If seizure does occur,
mata nga silaw kaayo.  involvement, duration of seizure, reduces risk of injury.
Nabantayan pud nako nga gamay and postseizure behavior.  Maintains airway by reducing
lang akong gina ihi ug balason risk of aspiration and
 Palpate for uterine tenderness or
pa.”, verbalized by the patient. preventing tongue from
rigidity; check for vaginal bleeding.
Review history of other medical occluding airway. Maximizes
problems. oxygenation. Note: Be
 Observe for signs and symptoms of cautious with use of
Objective Data
labor or uterine contractions. airway/bite block, because
 Vital Signs
 Assess fetal well-being, noting FHR. attempts to insert when jaws
BP: 140/90 mmHg 
 Perform funduscopic examination are set may result in injury.
regularly.  These signs may indicate
Temp: 36.2 degrees Celsius 
 Review test results of clotting time, abruptio placentae, especially
PT, PTT, fibrinogen levels, and if there is a preexisting
PR: 90 bpm 
FPS/FDP. medical problem, such as
 Prepare for cesarean birth if PIH is diabetes mellitus, or a renal
RR: 20 cpm 
severe, placental functioning is or cardiac disorder causing
Weight: 203 lbs compromised, and cervix is not ripe vascular involvement.
or is not responsive to induction.  Convulsions increase uterine
Height: 5 feet and 3 inches 
irritability; labor may ensue.
Blood type: AB (+)   During seizure activity, fetal
bradycardia may occur.
Fundic height: 23 cms   Helps to evaluate changes or
severity of retinal
FHT: 150 involvement.
 Such tests can indicate
While she is talking, suddenly she depletion of coagulation
ceases to talk, the face becomes factors and fibrinolysis, which
fixed, the eyes jerk from side to suggests DIC.
side and then roll upward, the  When fetal oxygenation is
severely reduced owing to

Page 55 of 62
mouth twitches and then vasoconstriction within
the convulsion becomes general. malfunctioning placenta,
immediate delivery may be
necessary to save the fetus.

References:
 Wayne, G. (2019) 6 pregnancy induced hypertension nursing care plans. https://nurseslabs.com/pregnancy-induced-hypertension-nursing-care-plans/6/
 Herdman, T.H. & NANDA International (2018-2020) NANDA International Nursing diagnoses

Name of Student: Sanchez, Mae Elaisa C. Yr/Crs/Sec: BSN2C RLE Group: 3 CI: Jainah Rose Gubac, RN

Page 56 of 62
 Nursing Care Plan

Patient’s Code: Patient S Age: 45 year old Sex: F Civil Status: Married Religion: Iglesia ni Cristo Date & Time of Admission: 01-15-21 / 9:00am Room:
Ward
Attending Physician: Dr. Adrian Higup Chief Complaints: Increased blood pressure ; “Dili ko kasabot sa akong kundisyon, wala pud koy gibati karon, natingala lang
gyud ko kay pag human nila ug kuha sa akong pressure sa health center, ingon sa midwife magpa checkup daw ko sa hospital kay taas daw akong BP.”

Nursing Diagnosis (PES): Decreased cardiac output related to decreased venous return.
Definition: Decreased cardiac output is an often-serious medical condition that occurs when the heart does not pump enough blood to meet the needs of the body. It c
be caused by multiple factors, some of which include heart disease, congenital heart defects, and high blood pressure.
Assessment/ Cues Planning Interventions Rationale Evaluation
(Subjective/ Objective) (Goals and Objectives)
Upon admission: At the end of the nursing Independent: The goal was met
care, the patient will evidenced by the patie
“Dili ko kasabot sa akong •Monitor blood pressure of the patient. •Comparison of pressures provides a
participate in activities was able to participate
kundisyon, wala pud koy gibati Measure in both arms or thighs three more complete picture of vascular
that reduce blood activities that redu
karon, natingala lang gyud ko kay times, 3-5 minutes apart while patient involvement or scope of the problem.
pressure or cardiac work blood pressure or card
pag human nila ug kuha sa akong is at rest, then sitting, then standing •Presence of pallor, cool, moist skin
load. work load.
pressure sa health center, ingon sa for initial evaluation. and delayed capillary refill time may be
midwife magpa checkup daw ko sa due to peripheral vasoconstriction
•Observe skin color, moisture,
hospital kay taas daw akong BP.”
temperature and capillary refill time. •May indicate heart failure, renal or
As verbalized by the patient
vascular impairment.
• Note dependent or general edema.
•Help reduce sympathetic stimulation,
• Provide calm, restful surroundings,
 BP: 140/90 mmHg promotes relaxation.
minimize environmental activity or
 Temp: 36.2 C
 PR: 90 bpm noise. • Reduces physical stress and tension
 RR: 20 bpm •Maintain activity restrictions that affect blood pressure and course
 Weight: 203 lbs of hypertension.
 Height: 5”3 in •Instruct in relaxation techniques, and
 Blood type: AB (+) guided imagery. •Can reduce stressful stimuli, produce
 Fundic height: 23 cms calming effect, and thereby reduce
 FHT: 150 blood pressure.
 Gravida 3 para 1 w/ AOG of
30 weeks
 LMP: June 8, 2020
 (-) case of hypertension,
•These restrictions can help manage
DM, asthma, & thyroid
disorder Collaborative: fluid retention and with associated
 Had measles, german hypertensive response, which decrease
measles, mumps, & rubella. cardiac workload.
 Surgery in 2017 for ectopic •Implement dietary sodium, fat, and
pregnancy @ 6 week AOG cholesterol restrictions as indicated.
and D and C in 2019 for inc
abortion @ 12 weeks AOG
 Regular check up on 1st and
2nd tri
 (-) fever
 (+) for excessive weigt gain
started @ 2nd tri w/ no body
malaise
 LOC: 10/10
 GCS: 15
 (+) vomiting & nausea
 (+) varicosities & edema on
lower extremities
 (+) hematuria and
frequency urgency

Page 58 of 62
  (+) vaginal bleeding and
cramping at times

Progress:

“Pagmata nako gaina, sakit kaayo

akong ulo ug na lipong ko; lain
kayo akong gibati, dili ko kasabot
ky mura kog kasuka-on hangtud
naka suka gyud ko. Ug lain kayo
akong panan-aw ky mura kog
malibat ug ga kipat-kipat akong
mata nga silaw kaayo. Nabantayan
pud nako nga gamay lang akong
ihi ug balason pa.” as verbalized
by the patient.

 Grade 1 : low-lying placenta

 (+) severe headache,
persistent vomiting,
epigastric pain
 (+) somnolence
 (+) double vision
 (+) scotoma
 (+) oliguria (less than 30 cc
of urine per hour)
 (+) hyperactive reflexes
 (+) cyanosis

Page 59 of 62
References:
Doenges (2007) 11th Edition, Nurse’s Pocket Guide
Doenges (et al.) (2019) 15th Edition, Nurse’s Pocket Guide, diagnosis, prioritized interventions, and rationales
Wayne (2016) Self-Care Deficit Nursing Care Plan, Nurseslabs

Name of Student: LAGURA, CHRISJAY MAE R. Yr/Crs/Sec: BSN 2C RLE Group: 3 CI: Ma’am Jainah Rose Gubac

Page 60 of 62
References

Akaishi R, Yamada T, Morikawa M, et al (2014). Clinical features of isolated

gestational proteinuria progressing to pre-eclampsia: Retrospective observational
study. Retrieved from
Berman, A., Snyde, S. Frandsen, G. 2018. Fundamentals of Nursing Concepts,
Process and Practice (10th Edition). Ph: PEARSON EDUCATION SOUTH ASIA PTE.
LTD
Bodnar, L. M., Catov, J. M., & Roberts, J. M. (2007). Racial/ethnic differences in
the monthly variation of preeclampsia incidence. American Journal of Obstetrics
and Gynecology, 196(4), 324–326.
Cantey, J. B., Tecklenburg, F. W., & Titus, M. O. (2007). Late postpartum
eclampsia in adolescents. Pediatric Emergency Care, 23(6), 401–403.Doenges
(2007) 11th Edition, Nurse’s Pocket Guide
Clark, E. A. S., Silver, R. M., & Branch, D. W. (2007). Do antiphospholipid
antibodies cause preeclampsia and HELLP syndrome? Current Rheumatology
Reports, 9(3), 219–225.
Doenges (et al.) (2019) 15th Edition, Nurse’s Pocket Guide, diagnosis, prioritized
interventions, and rationales
[CITATION DrA19 \l 13321 ] Hypertension Symptoms and Effects

Herdman, T.H. & NANDA International (2018-2020) NANDA International Nursing

diagnoses
[CITATION Hai18 \l 13321 ] Risk factors for hypertensive disorders of pregnancy
among mothers in Tigray region, Ethiopia: matched case-control study
[CITATION Joe01 \l 13321 ] Pathophysiology of pregnancy-induced hypertension

[ CITATION Joh11 \l 13321 ] CHAPTER 24: PATHOPHYSIOLOGY OF HYPERTENSION

Kluwer, W. (2020) Nursing 2020 Drug Handbook Schull, P. (2011) McGraw-Hill

Nurse’s Drug Handbook 6th Edition
[ CITATION Mel19 \l 13321 ] Pregnancy-Induced Hypertension: Symptoms & Signs

Shilva, S. C., Kalra, J., & Prasad, R. (2007). Safety and efficacy of low-dose
MgSO4 in the treatment of eclampsia. International Journal of Gynaecology and
Obstetrics, 97(2), 150–151.
[ CITATION Ste19 \l 13321 ] Hypertension in pregnancy: Pathophysiology and
treatment

Wayne (2016) Self-Care Deficit Nursing Care Plan, Nurseslabs

Wayne, G. (2017, September 23). Impaired urinary elimination – Nursing
diagnosis & care plan. Nurseslabs. https://nurseslabs.com/impaired-urinary-
elimination/
Wayne, G. (2019, June 1). 6 pregnancy induced hypertension nursing care plans.
Nurseslabs. https://nurseslabs.com/pregnancy-induced-hypertension-nursing-care-
plans/4/
http://www.thieme.com/images/emails/NANDA_Preview.pdf
https://www.ncbi.nlm.nih.gov/books/NBK447469/

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