Overview of the Case Study

Nursing Role
Registered nurses who care for new mothers and newborn infants in the hours and days following birth are known as postpartum nurses. In postpartum settings, nurses' primary responsibilities
are to assess postpartum patients, provide care and education, and, if necessary, report any significant findings. In addition to attending to their patients’ physical and emotional needs, they are
also trained to monitor carefully for issues of concern such as postpartum complications related to aberrant test results and signs & symptoms.
Background
Day 1 Postpartum
Client LL is a 23-year-old married female residing in Talisay City, Cebu. Client is 163 cm tall, weighs 45 kg, and has a BMI of 16.9 kg/m2 (underweight).
Client LL with a GTPAL of G2T1P1A0L2, is situated at bed #5 diagnosed with a Pregnant uterus full term (PUFT), 39 weeks AOG, delivered a live Baby Boy via Normal Spontaneous Vaginal
Delivery (NSVD). On day one postpartum, Client LL is administered with #4 D5LR 1L @ 30 gtts/min with remaining 800 ml by 7:30 am, infusing well over the right arm. Inserted with an
indwelling Foley Bag Catheter, the client is under Soft diet. At 9:00 am, 10U Oxytocin is added to the infusion at 30 gtts/min infusing well over the right arm, with 400 ml remaining. Client
expressed her concerns regarding the risk of triggering her hypertension during the long exhausting labor. Client further claims to have a pain score of 7/10, with presence of eye bags and
frequent yawning. Vital signs as follows: T= 37.50C, PR= 80 bpm, RR = 23 cpm, BP = 130/90 mmHg (120/80, hypertension, normal with chronic hpt). Heart sounds were normal. Lab results: >
310ml urine protein on Mrs. LL’s 24-hour urine sample. By 10:00 am, IV fluid level is noted, and the interview and physical assessment guided by the Maternal Assessment form is conducted.
Mrs. LL’s IVF is consumed and infused with the next IVF. Nurse explained the Doctor's order to Mrs LL, after sharing her inconvenience from the inserted catheter which limited her movements.
During the remaining time,the nurse formulates the NCP, monitors the patient's vital signs and I & O , ensures that the uterus is well-contracted, and accomplishes documentation.
Health History
At 20 weeks of pregnancy, she developed hypertension and proteinuria. She suffered preeclampsia with her first pregnancy, which was a year ago. She experienced high blood pressure,
proteinuria, disordered liver function, light sensitivity, and minor upper right abdomen pain during 39 weeks of pregnancy. On the maternal side, there is a positive (+) family history of
hypertension. She did not smoke or consume any alcoholic beverages. She didn't take any drugs, health supplements, or herbs on a daily basis.

Day 2 Postpartum
Endorsement at 8 am and the following vital signs are checked : Temperature: 37.3° C/axilla, Pulse: 73 beats/min, BP: 130/90 mmHg , Respirations: 23 cycles/min,
Pain score:7/10 (headache); but tolerable pain at the perineal area. Mrs. LL had her breakfast and the nurse educated the client regarding her medications and supplements with the following
information: classification, mechanisms of action, frequency as prescribed, indications, and possible side effects to be vigilant of. Nurse documented the taken medications in the medication
sheet. Nurse further coaches Mrs. LL on purpose of the Foley bag catheter and Magnesium Sulfate therapy for her superimposed severe preeclampsia. Mrs LL is evaluated after health
teaching. Client is informed for a modified hot sitz bath scheduled at 10:00 am, with the assistance of SO. Nurse advised Mrs. LL to do MHSB daily after her full bath in the morning or after
doing her perineal care until the wound is healed. At 10:00 am, the nurse then monitors the uterus for contraction, plots vital signs, and drafts the FDAR. Nurse accompanied the Resident on
Duty (ROD) at around 1:00 p.m during rounds. Mrs. LL was told that due to her medical condition, a subdermal implant is not an option for her. Vital signs are checked, noting Mrs. LL is afebrile
and nothing remarkable except for BP. Client complaint about the discomforts brought by intramuscular medication in her buttocks.

DAY 3 Postpartum
Mrs. LL is on status quo. Nurse checked vital signs showing no remarkable data except for BP, and administered medications and supplements after breakfast. Mrs. LL is exhibiting increased
energy in her regular activities. Client claims to have slept well but raises her concerns on the MgSO4 treatment. Nurse discussed and presented a drug study on MgSO4 treatment, sharing
with her the indications, mechanism of action, effects and possible side effects to watch for, including the importance of checking the parameters before she will receive the next dose.The
client positively responds to the health teaching. At around 11:30 am, nurse provides privacy to Mrs. LL and her husband after encouraging SO to immediately inform the Nurses on duty for
any unusualities experienced by the patient. During the remaining time,the nurse formulates the NCP, monitors the patient's vital signs and I & O , ensures that the uterus is well-contracted,
and accomplishes documentation.

Rationale

This case study is to help student nurses capable of providing entry level professional nursing care to promote, attain, maintain and restore the
health of clients in a variety of health care settings. Case study methodology serves to provide a framework for evaluation and analysis of complex
issues. Moreover, this will assist student nurses in performing nursing duties while also allowing them to obtain a better grasp of individualized patient
care. As their skills and experiences are applied to administering therapeutic interventions, the case study will assist nursing students in arranging data
essential for optimal supervision. Responsibilities such as Vital Signs Monitoring, Bedside Care, History Taking and Continuous Patient Assessment,
Administration of Medication, Intake and Output Monitoring (I&O), health teaching, Planning of Patient Care and Documentation of Care, will be
applied.

Statistical Data
Preeclampsia, a dangerous condition that may occur during pregnancy, can lead to serious complications for both mother and baby. Preeclampsia may result in seizures (or
eclampsia) and liver and kidney failure. Hypertensive disorders of pregnancy and the postnatal period can also lead to several long-term problems including complications in
future pregnancies and elevated lifetime risk of non-communicable diseases including cardiovascular disease, kidney disease, diabetes, obesity, and mental illness.
● Local
According to research data conducted by the Epidemiology Bureau Department of Health focusing on the ten leading causes of MORBIDITY in each region, hypertension is
Cebu's leading cause of death, with 61,792 instances out of a population of 100,000. This is the number within the span of 20 years, from 1998-2018.
● National
Identifying a high-risk pregnancy can be live-saving. One of these high-risk conditions is hypertension in pregnancy. In the Philippines, preeclampsia and eclampsia were the
cause of up to 30% of maternal deaths according to the Department of Health Philippine Health Statistics of 2017.
● Global
This disease encompasses 2% to 8% of pregnancy-related complications, greater than 50,000 maternal deaths, and over 500,000 fetal deaths worldwide.

Patient’s Profile

Name: LL
Sex: Female
Age: 23 years old
Civil Status: Married
Religion:
Occupation: (employed) .
Address: Talisay City
Highest Educational Attainment:
Date of Birth:
Height: 163 cm
Weight: 45 kg
BMI: 16.9 kg/m^2

VITAL SIGNS
Medication Sheet:
 Classification and Side Effects / Adverse
Name of Drug Indication and Dosage Contraindication Nursing Responsibilities
Mechanism of Action Reaction
 generic name: Therapeutic class: - Moderate to Contraindicated in patients Before giving the medication:
tramadol and - Analgesics Moderately severe hypersensitive to drug. Drug CNS: anxiety, fatigue, ➔ Perform hand washing
paracetamol pain can cause acute liver failure, headache, pyrexia. ➔ Verify the doctor’s order
Pharmacologic class: - 1 tab every 8 hours which may require a liver ➔ Check the medication thrice
synthetic centrally active
brand name: analgesics
x 3 doses, then PRN transplant or cause death. CV: HTN, hypotension, ➔ Check the right dose, right
for pain peripheral edema, route, and right patient
TDL plus tachycardia (IV). ➔ Check if patient is allergic to
MOA: the drug
thought to bind to opioid GI: nausea, vomiting,
receptors and inhibit reuptake abdominal pain, diarrhea, During:
of norepinephrine and - Monitor vital signs especially
serotonin the pain scale.
- Hematologic: hemolytic
Source: anemia, leukopenia, - Consider reducing total daily
Nursing2021 Drug neutropenia, pancytopenia, dose and increasing dosing
Handbook. anemia. intervals in patients with hepatic
(2021). Wolters or renal impairment.
Kluwer. Hepatic: jaundice.

Metabolic: hypoglycemia,
Tramadol + hypokalemia, hypervolemia,
paracetamol (TDL
plus) tab, 1 tab q 8 Musculoskeletal: muscle
hrs x 3 doses spasms, extremity pain
(24hrs) then PRN for
pain Respiratory: abnormal breath
sounds, dyspnea, hypoxia,
atelectasis, pleural effusion,
pulmonary edema, stridor,
Skin: rash, urticaria; pruritus.
Patient teaching:
- Advise patient that drug is only
for short-term use; long term
can result to liver damage.
- Warn patient that high doses or
unsupervised long-term use can
cause liver damage.
- Tell breastfeeding patient that
drug appears in human milk in
low levels. Drug may be used
safely if therapy is short-term
and doesn't exceed
recommended doses.

After:
- Evaluate the findings
- Document the procedure

Captopril 25 mg 1 tab OD
 Classification and
Name of Drug
Mechanism of Action
Generic name: Func. class:
captopril antihypertensive
Brand name: chem. class: angiostensin-
Capoten, converting enzyme (ACE)
Captoril inhibitor
Mode of Action:
Source: Inhibits ACE, preventing
Skidmore-roth, conversion of angiotensin I
L. (2021). to angiotensin II, a potent
Mosby’s 2021 vasoconstrictor.
Nursing Drug Less angiotensin II
Reference. decreases peripheral
Elsevier. arterial resistance,
decreasing aldosterone
secretion,
which reduces sodium and
water retention and lowers
BP.
Indication and Dosage Contraindication
Hypertensive Contraindication:
emergency/urgency
(Unlabeled) Contraindicated in patients
hypersensitive to drug or
● 25 mg, 1 tab once a other ACE inhibitors and in
day,  PO patients who
had angioedema related to
previous treatment with an
ACE inhibitor.
Side Effects/ Adverse
Nursing Responsibilities
Reaction
Before giving the medication:
CNS: Fever, chills, ● Perform hand washing
dizziness, drowsiness, ● Verify the doctor’s order
fatigue, headache, ● Check the medication thrice
insomnia, weakness  ● Check the right dose, right
route, and right patient
CV: Hypotension, ● Check if patient is allergic to
postural hypotension, the drug
tachycardia, angina  ● Assess hypertension and
renal studies.
GI: Loss of taste,
increased LFTs  During:
● Monitor AST< ALT alkaline
GU (Genitourinary):
phosphatase, glucose, urine
Impotence, dysuria,
protein bilirubin.
nocturia, proteinuria,
nephrotic syndrome,
Patient teaching:
acute reversible renal
● Take 1 hr before or 2 hrs
failure, polyuria,
after meals; not discontinue
oliguria, urinary
product abruptly
frequency 
● Not use OTC products
HEMA: Neutropenia, unless directed by
agranulocytosis, physician to avoid salt
pancytopenia, substitutes, high-potassium
thrombocytopenia, or high-sodium foods
anemia  ● To adhere to dosage
schedule even if feeling
INTEG: Rash, pruritus  better
● Notify prescriber of fever,
MISC: Angioedema, swelling of hand/feet,
hyperkalemia  irregular heartbeat, chest
pain, signs of angioedema,
RESP: Bronchospasm, rash, hoarseness, difficulty
dyspnea, cough breathing
● That dizziness, fainting may
 occur during first few days
of therapy; to avoid activities
that require concentration
After:
● Evaluate therapeutic
response: decrease in B/P
with hypertension
● Document the findings and
procedure

Magnesium sulfate 1g q 4h alternate buttocks after checking parameters x 6 doses -(24hrs) Magnesium sulfate is typically taken for 24 hours. 

Classification and Side Effects/ Adverse

Name of Drug Indication and Dosage Contraindication Nursing Responsibilities
Mechanism of Action Reaction

Generic name: Clinical class: Indications & Dosage Heart block, myocardial Before giving the medication:
Magnesium antacid, anticonvulsant, damage, IV use for pre- Magnesium toxicity ● Perform hand washing
sulfate electrolyte, laxative  Eclampsia/preeclampsia eclampsia/eclampsia during may cause loss of ● Verify the doctor’s order
deep tendon reflexes, ● Check the medication thrice
the 2 hrs prior to delivery. heart block, respiratory
Brand name: Mode of Action: ⮚ 1 gram every 4 ● Check the right dose, right
Mag-Ox 400, anticonvulsant, blocks hours IM, paralysis, cardiac route, and right patient
Uro-Mag neuromuscular alternating on arrest. Antidote: 10–20 ● Assess sensitivity to
transmission, amount of each buttock mL 10% calcium magnesium
Kizior, R & acetylcholine released at after checking gluconate
Hodgson, K. motor end plate. Produces parameters x 6 During:
(2021) seizure control. doses ● Monitor renal function (esp.
Saunders if dosing is long term or
Nursing frequent)
Drug
Handbook. ● Monitor fluid intake and
Elsevier. output.

● Monitor magnesium levels,

ECG for cardiac function

Patient teaching:
 ● Report symptoms of
hypermagnesemia (altered
mental status, difficulty
breathing, dizziness,
fatigue, palpitations,
weakness). 
After:
● Evaluate the findings
● Document the procedure

FLUID INTAKE AND OUTPUT

Last Name: L First Name: L Middle Name: Room # Case No. 2020-14344HN

Attending Physician: Dr. De los Santos Age: Sex: Civil Status: Religion: Roman Catholic
23 Female Married
INTAKE OUTPUT
ORAL INTRAVENOUS URINE Drainage BM Others TOTAL
Main Line Dilu Injectables Others TOTAL
ent
Date: 6AM 400 cc D5LR N/M Magnesiu N/M 1380 cc 600 cc N/M 1 N/M 600 cc
-2PM 950cc in m Sulfate
8hrs 1 gm q4h
04/18/22 20cc in
8hrs
2PM
-10PM
10PM
-6AM
DAILY TOTAL:
Nursing Care Plan

1ST PROBLEM
 SUBJECTIVE OBJECTIVE CUES NURSING SCIENTIFIC PLAN OF IMPLEMENTATIO RATIONALE EVALUATION
CUES DIAGNOSIS REFERENCE CARE/OBJECTIVE N
S

”Labad ako ulo pero BP: 130/90 mmHg Acute pain related An increase in Short term: After 8 Independent: 1. To help Short term:
ma agwanta ra man Pain scale: 7/10 to increased peripheral vascular hours of nursing 1. Assess for determine After 8 hours of
ma’am” as cerebral vascular resistance is a interventions, the referred pain, as possibility of nursing
verbalized by the pressure as hallmark of patient will be able appropriate and underlying interventions the
patient. evidenced by hypertension. to: evaluate pain condition or organ patient was able to:
Hypertension with Vascular resistance 1.Report pain is characteristics and dysfunction 1.Report pain is
BP of 130/90 can be increased by controlled. intensity requiring treatment controlled
mmHg, and pain reducing the lumen 2. Verbalize 2.Verbalized
scale of 7/10, diameter or the nonpharmac 2. Encourage the 2. Minimizes nonpharmacologica
“Labad ako ulo pero number of arteries ological methods patient to maintain stimulation and l methods that
ma agwanta ra man or by increasing the that provide relief. bed rest during the promotes provided relief. -
ma’am” as length of arteries. - acute phase. relaxation. Both goals were
verbalized by the National Center for Long term: partially met.
patient. Biotechnology After 1-2 days of 3. Provide/ 3. Measures that
Information, (2013) nursing recommend non reduce cerebral Long term:
interventions, the pharmacological vascular pressure After 1-2 days of
patient will be able measures for relief and that slow/block nursing
to: of headache, e.g., sympathetic interventions, the
1. Report pain is quiet, dimmed lit responses are patient was able to:
relieved. room; relaxation effective in relieving 1. Report pain is
2. Follow prescribed techniques (guided headache. relieved
pharmacological imagery) 2. Followed
regimen. 4. To demonstrate pharmacological
4. Perform pain improvement in regimen as
assessment each status or to identify prescribed.
time pain occurs. worsening of
Document and underlying -Goals were met.
investigate changes condition/developin
from previous g complications
reports and
evaluate results of Dependent
pain interventions 1.To maintain an
 “acceptable” level
Dependent: of pain. Notify the
physician if regimen
5. Administer is inadequate to
analgesics, as meet the pain
indicated, to control goal.
maximum dosage, Combinations of
as ordered: medications may be
● Tramadol + used on prescribed
Paracetamol (TDL intervals
Plus)
1 tab every 8 hours
x3 doses then PRN
for pain.

2ND PROBLEM
SUBJECTIVE OBJECTIVE CUES NURSING SCIENTIFIC PLAN OF IMPLEMENTATIO RATIONALE EVALUATION
CUES DIAGNOSIS REFERENCE CARE/OBJECTIVE N
S

Pt verbalized, Vital Signs Decreased cardiac Hemodynamic SHORT TERM INDEPENDENT 1. This provides a After 8 hours of
“Labad ako ulo pero Temp: 37.5 C output related to changes during After 8 hours of 1. Monitor vital baseline for holistic nursing
maagwanta ra man PR: 80 bpm increased systemic pregnancy include a holistic nursing signs q15 mins comparison to interventions, the
maam. Gipatumar RR: 23 cpm vascular resistance progressive interventions, the hourly until stable follow trends and goal was met as
man sad ko ug BP: 130/90 mmHg secondary to severe increase in CO and patient will be able evaluate response patient was able to:
tambal para pawala BMI: 16.9kg/m2 preeclampsia as a decrease in the to: 2. Assist patient in to interventions. - verbalize pain scale
sa sakit.” Pain score: 7/10 evidenced by systemic vascular - verbalize pain a semi-Fowler’s lower than 7/10 -
presence of protein resistance leading scale lower than position 2. This decreases demonstrate
With remaining in urine, to a high volume, 7/10 oxygen decreased episodes
400ml from her well headaches, low-resistance - demonstrate 3. Monitor the rate consumption and of dyspnea
infused in her right increased blood circulation. These decreased episodes of IV drugs closely, the risk of - The goal was met
arm D5LR 1 liter + pressure and changes peak in the of dyspnea using infusion decompensation
10U oxytocin respiratory rate mid third trimester pumps, as
running at 30 before CO falls, and LONG TERM appropriate 3. To prevent After 1 week of
gtts/min systemic vascular After 1 week of bolus or overdose holistic nursing
resistance increases holistic nursing 4. Assess urine interventions, the
Presence of >310m towards 40 weeks’ interventions, the output hourly or 4. To allow for goal was met as
urine protein on 24- gestation. The patient will be able periodically timely alterations patient was able to:
hour urine sample alteration in late to: DEPENDENT in therapeutic - display
pregnancy - display regimen hemodynamic
hemodynamics is hemodynamic 1. Administer fluids, stability (e.g., blood
biologically stability (e.g., blood medications such as 1. To support pressure, cardiac
paradoxical when pressure, cardiac Silgram, Captopril, systemic and output, urinary
considering that the output, urinary Magnesium sulfate, cardiac circulation output)
respiratory and output) ferrous sulfate, and - The goal was met
metabolic demands vitamin c and zinc,
of the maternal- as prescribed by -Goals were met.
fetal unit increases the physician
exponentially with
advancing 2. Administer
gestation. Tramadol + 2. To achieve the
Echocardiographic Paracetamol (TDL desired effect
studies of plus) analgesics without
uncomplicated with caution, as compromising
normal pregnancies prescribed by the hemodynamic
have demonstrated physician readingS
an excessive
increase in the left
ventricular mass
and remodeling
with associated
diastolic dysfunction
in a small but
significant
proportion of
women at term—
all of which revert
to normal
 postpartum. For
this reason,
pregnancy has been
described as a
stress test which
unmasks women
who have poor
cardiovascular
reserve or
dysfunction.
Thilaganathan, B.,
& Kalafat, E.
(2019).
Cardiovascular
system in
preeclampsia and
beyond.
Hypertension,
73(3), 522-531.

3rd problem
SUBJECTIVE OBJECTIVE CUES NURSING SCIENTIFIC PLAN OF IMPLEMENTATIO RATIONALE EVALUATION
CUES DIAGNOSIS REFERENCE CARE/OBJECTIVE N
S

Risk for Imbalanced Gestational Short Term: After 8 Independent: 1. Blood pressure Short Term:
Fluid Volume hypertension and hrs of nursing 1. Closely monitor and heart and After 8 hrs of
related to shifting pre‐eclampsia can interventions, the and document the respiratory rate nursing
of fluid to interstitial cause fluid shifts. patient will be able patient’s Vital signs. often increase interventions, the
space from Pulmonary edema to: initially when either patient was able to:
intravascular space and renal failure 1.Show willingness 2. Measure and fl uid defi cit or - Show willingness
and Hormonal can result from to adhere in record the patient’s excess is present. to adhere in
changes in these shifts. Fluid therapeutic intake and output, therapeutic
pregnancy management is activities by actively note the urine color 2. Monitor urine activities by actively
secondary to crucial in managing participating in the and specific gravity output hourly or as participating in the
preeclampsia. pre‐eclampsia, monitoring of the as required. Report needed. Report monitoring of the
especially in the therapeutic any imbalance in urine output less therapeutic
context of progress the intake and than 30 mL/hr or progress
pulmonary oedema 2.Will demonstrate output immediately. 0.5 mL/kg/hr,
and renal failure. understanding of because this may - Demonstrated
Pulmonary artery the need to closely 3.Determine if indicate deficient understanding of
catheterisation may monitor and how to there’s the fluid volume or the need to closely
be a method of properly obtain the presence of edema. cardiac or kidney monitor and how to
effectively Blood Pressure, and Assess if there is failure. properly obtain the
monitoring fluid signs of edema. pitting edema by Blood Pressure, and
status and thus aid applying pressure 3.Pitting edema of signs of edema.
in the management Long term: to the edematous the face, hands,
of renal failure and After 1 week of area, note its legs, sacral area, or - The goal was met
pulmonary oedema holistic nursing timing, exact abdominal wall
in the context of interventions, the location, and (moderate, 1+ to Long term:
pre‐eclampsia. patient will be able extent. 2+; severe, 3+ to After 1 week of
Davison, J. M. to: 4+) or edema that holistic nursing
(1984). Renal 1. Demonstrate 4.Engage and does not go away interventions, the
haemodynamics adequate fluid educate the client, after 12 hours of patient was able to:
and volume balance as family, and all bed rest is critical. - Demonstrated
homeostasis in evidenced by stable caregivers in a fluid adequate fluid
pregnancy. vital signs, management plan. 4. This enhances balance as
Scandinavian individual 5. Monitor urine cooperation with evidenced by stable
Journal of Clinical appropriate urinary output hourly or as the regimen and vital signs,
and Laboratory output, and no needed. Report achievement of individual
Investigation, edema present. urine output less goals. appropriate urinary
44(sup169), 15-27. than 30 ml/hr or output, and no
0.5 mL/kg/hr. 5.This may indicate edema present.
Dependent: deficient fluid - The goal was
volume or cardiac met
or kidney failure.

1. Administer IV
fluids, as 1. To deliver fluids
prescribed, using accurately and at
infusion pumps desired rates to
 prevent either
underfusion or
overinfusion

DISCHARGE PLAN
METHOD NURSING INTERVENTIONS RATIONALE
M (Medication) - Advise the patient and significant others to - This is to ensure optimum recovery.
continue the prescribed home medications .

- For iron-deficiency anemia or prevention of

- Ferrous fumarate (Beniforte) tab, 1 tab OD p.o. iron deficiency.
x 30 days

- For dietary supplement and it assists in

- Vitamin C + Zinc (Immunpro) tab, OD p.o. x 1 collagen formation, tissue repair, and is
month involved in oxidation reduction reactions, other
metabolic reactions

E (Environment) - Restrict environmental stimuli, especially during - Vivid lighting, noise, visitors, numerous
planned times for rest and sleep. distractions, and litter in the patient’s physical
surroundings can limit relaxation, disturb rest
or sleep, and contribute to fatigue.

- Provide comfort such as judicious touch or

- These may reduce nervous energy that lead to
massage, and cool showers
relaxation.

- Offer diversional activities that are soothing

- This method allows the use of nervous energy in
a positive manner and may lessen anxiety.

- Stay away from topics or people that annoy or - Increased irritability of the CNS can make the
disturb the patient. Converse ways to react to patient become easily excited, agitated, and
these feelings. prone to emotional outburst.
T (Treatment) - Instruct patients to increase fluid
intake.
H (Health Teaching) - Engage in regular aerobic physical activity for
30 minutes thrice every week.
- Proven nonpharmacological interventions for
hypertension include weight loss, dietary
modification, reduced sodium intake, potassium
supplementation, and increased physical activity.
- Monitor blood pressure regularly.
- Teach patient the proper principles of perineal
care
- Encourage SO to always be there for the patient.
O (Outpatient referral) - Instruct client for follow up check-up which
includes follow-up instructions and for the
schedule of the appointment.
- Likewise, instruct the SO or patient itself to seek
immediate medical care if the patient
experiences any problems.
D (Diet)
- Promote sufficient nutritional intake.
- Eat a variety of vegetables, fruits, whole grains,
fat-free or low-fat dairy products, and protein
foods. Choose foods and drinks with less added
sugars, saturated fats, and sodium (salt). Limit
refined grains and starches, which are in foods
like cookies, white bread, and some snack foods.
- Moderation of alcohol and caffeine consumption.
- Advice to increase fluid intake is a frequent
treatment recommendation. Attributed benefits
of fluids include replacing increased insensible
fluid losses, correcting dehydration from
reduced intake.
- These measures, constituting mainly lifestyle
modification, should be used to prevent HTN in
patients with elevated BP and hypertensive
patients.
- Monitoring the patient will allow you to
intervene if they show signs of deterioration,
which will aid in the healing process and make
the patient feel safer and more empowered in
managing her own recovery
- Timely follow-up with patients is vital for
ensuring they're moving forward with the
prescribed treatment plan, such as undergoing
testing and taking their medications. In
addition to increasing the likelihood of a
positive outcome, a medical follow-up is critical
for minimizing safety and liability concerns.
- The patient will need properly balanced intake
of fats, carbohydrates, proteins, vitamins, and
minerals to provide energy resources.
- Research shows that both alcohol and caffeine
can transfer from a mother’s bloodstream into
her breastmilk, and drinking too much of either
can affect a baby's health.
S(Spiritual)
- Encourage the patient to continue their belief in
God by going to church every Sunday and reading
the bible.
- It is important to know that without faith, your
life would mean nothing. You must have to
believe that in Him, everything impossible
became possible. Also, Believing in him will
bring you more peace in life.