1.

Receiving the patient ✓what was the complaint ✓describe holistically: physical,
mental, emotional, etc

The patient arrived at the ER @ 10:30pm with a chief complaint of "nakafeel nako gamay nga
contractions, nya due date man gud nako gahapon" as verbalized by the client.

Client was awake and oriented and cooperative. She has an endomorph body type with the
height of 150 cm and a weight of 71.7 kilograms. The client was dressed appropriately. On
inspection the client skin is brown in color and is evenly toned. Skin is warm to touch and
capillary bed refill returns immediately within less than 2 seconds after release. Signs of edema
noted on the legs.

The client was able to answer the questions appropriately without any signs of confusions.
Client maintained eye contact and shows willingness to answers the questions asked. Client’s
thought are logical and well-organized.

The patient describes her general health as adequately active, she demonstrated feelings of
liveliness, nervousness and being talkative. This is normal in the latent phase in the first stage
of labor. She prefers standing and wanted to walk around the ER, however, she was restricted
by the NOD.

2. Ushered where? (Chair, wheelchair, stretcher) ✓what are the nursing actions (ideal
and actual) -was there a gap between ideal or actual? Ex: ideally: the nurse should get
the basic info and the complaints but in reality (actual scene) the clerk and the utility (IW)
were the ones first responded.

The patient was ushered to the bed of OB-Gyne Room by walking. The ideal nursing actions
include; monitoring blood pressure, assessing for edema, proteinuria, and weight gain,
Monitoring fetal well-being and status, instruct on diet recommendations. Monitor intake and
output. Position the patient comfortably on the left side-lying position. Administer oxygen as
prescribed. Administer antihypertensives. Restrict fluids as ordered. Encourage reduced activity.

There is a minimal gap between the actual nursing action, and ideal action. Monitoring of the
patient’s blood pressure was done, edema on the lower extremities were noted, however I
believe Urine testing to diagnose proteinuria is yet to be done, and base line data for weight
gain was obtained. The FHT was also monitored, however instructions for diet
recommendations were not given. I believe monitoring of the intake and output is mainly done at
the ward. The patient was also instructed by the nurse to a left side-lying positon to promote
adequate circulation. 2L of oxygen, along with antihypertensives was administered as
prescribed. The patient was also instructed not to stand and walk around to reduce activity as
physical activity diverts blood away from the placenta.

1
3. Quick assessment by the student nurse and refer the findings or results, giving the
baseline vital signs. ✓ how long it was seen by NOD? What was the nursing mgt based
on the symptoms/complaints? (Separate dependent, independent, collaborative)

3. Baseline Data: katong data kapoya type rawr rawr

Quick assessment: No airway obstruction noted. The patient can talk properly.

The patient is not using accessory muscles while breathing with an O2 of 97% and respiratory
rate of 19.

The pt. is experiencing hypertension with a BP of 150/96 mmHg.

Capillary refill is less than 2 seconds. Swelling of both legs are noted. Pulse rate of the mother
is 87, bpm within normal range. Weight is 71.7 kg. The fetal heart rate is 149bpm within normal
range.

The quick assessment was conducted approximately 5 to 10 mins.

For the signs and symptoms that the patient was manifesting, the dependent intervention was
the administration of medications and oxygen. For Antihypertensive, Methyldopa was
administered as the drug of choice for hypertensive pregnant mother. Hydralazine HCl is also
used for treating high blood pressure. Magnesium sulfate is used to prevent seizures due to
worsening pre-eclampsia.

Indepndent:

Provided patient privacy during the FHR monitoring and FBC insertion.

Promote aseptic technique during sterile procedure such as FBC insertion.

Instruct the patient to reduce activity and lie on the left side.

3. Medical mgt ✓when what the pt referred from the time the pt arrived? ✓how urgent is
the case? Triage: Color of the tag? Yellow? Red? Etc..

4. The patient was referred to the OB ward at 12:30am.

Yellow(Urgent) : The condition of the patient is stable but the blood pressure remains in high
value. Patient requires BP monitoring every 30 mins and also requires observed by professional
nurse and needs hospital care. Would receive immediate priority care under "normal"
circumstances.

4. Nursing mgt.. nurses' mgt based on the doctor's order? ✓step by step intervention
that was done (Ex: IV Line inserted, meds given, ecg, etc)

2
5. Disharge from ER ✓ going to which area? Ward ( pedia, medical, surgical, morgue) Note: pls
follow the steps in emergency room nursing.

Triage- (Yellow) The patient’s condition is stable for the moment, and there is no immediate
danger of death, however later triage is necessary. The patient still requires observation and
hospitalization.

Registration- The patient’s SO was interviewed for getting the necessary information needed for
admission.

Treatment- The patient was ushered to the bed of OB-Gyne Room,

-Monitor maternal BP and pulse, and FHR.

Inserted Foley catheter as indicated by the physician and too monitor urine output.

-Observe unusual adverse reactions to medication

-Ensured safety by putting the sidera ils up

Discharge

PART 2 Answer the following questions: With the case of the patient? 1 . What do you think is
the medical diagnosis Nursing Diagnosis 1. Discuss the pathophysiology ( both schematic and
narrative. 2. Short duiscussion on the drugs tha I

1. Preeclampsia

2. Decreased cardiac output related to increased systemic vascular resistance secondary

to preeclampsia, as evidenced by an average blood pressure level of 150/90 and edema
of the legs

3.

3
Schematic Diagram of Preeclampsia
Risk Factor: Precipitating Factor:
Age: 44 y.o Preeclampsia Increased Cardiac
Output

Spiral artery
remodeling

Fibrous
uteroplacental
arteries
Endothelial
Placental cell
Vascular Spasm
Insufficiency dysfunction

Hypoxia of
fetoplacental Formation of Increased
system thromboxane vascular
permeability

Complications: Hypertension Vasoconstriction

Fluid diffusion
Fetal Death into tissues
IUGR
Decreased
organ perfusion Edema

Kidneys Peripheral
Edema
Etiology
Sodium
Signs and symptoms Retention

Complications

4
Narrative Pathophysiology

The patient is at risk because she is 44 years old and has high blood pressure before

pregnancy. The pathophysiology of preeclampsia in this case starts from the development of

spiral artery remodeling. The spiral arteries dilate and develop into large uteroplacental arteries

capable of delivering large quantities of blood to the developing fetus. In preeclampsia, these

uteroplacental arteries become fibrous causing them to narrow, which means less blood gets to

the placenta, that leads to vascular spasm, in which may result to hypoxia of the fetoplacental

system, a poor perfused placenta can lead to intrauterine growth restriction and even fetal death

in severe cases. Also vascular spasm may lead to endothelial cell dysfunction of the arteries

and reduces the action of prostacyclin—a prostaglandin vasodilator—and causes formation of

thromboxane—a prostaglandin vasoconstrictor and stimulant of platelet aggregation.

Vasoconstriction occurs by narrowing of the blood vessels that may lead to increased blood

pressure, in which causes the heart to a forcefully pump against rising peripheral resistance.

This causes decreased organ perfusion, which affects the kidney, in a way that makes them

retain more salt which leads to edema. Endothelial cell dysfunction also leads to increased

vascular permeability allowing the fluid to diffuse out of blood vessels between neighboring

endothelial cells and get into the tissues, this causes generalized edema which is evident in the

legs based in this case.

5
 a. Drug Studies

DRUG THERAPEUTIC RECORD #1

Name: Reason for Admission: Labor pains and elevated blood pressure
Age/Sex: 44 years old/ F Medical Impression: PREECLAMPSIA
SIDE/ADVERSE NURSING
MECHANISM OF CONTRAINDICATI
DRUG NAME DRUG CLASS INDICATIONS EFFECTS RESPONSIBILITIES
ACTION ONS
(per body system) (5 each categories)
Generic Therapeutic: It is a central General: Side Effects: Before:
Name: nervous system -Renal failure  Assess the apical pulse
depressant that CNS: lethargy, rate and rhythm before
Magnesium Electrolyte acts to block -Hypomagnesemia -Hypermagnesemia weakness administering
sulfate supplement and neuromuscular appendicitis  Assess for allergy
Uterine relaxant transmission of -Preeclampsia and GI: nausea, history
acetylcholine to Eclampsia -Bowel diarrhea, vomiting,  Monitor the drug level
Brand Name: Pharmacologic halt convulsions. obstruction/perforat indicated
: -Uterine tetany ion Skin: Excessive  Assess for the
Concept Ob Anticonvulsants Sweating mentioned
; -Acute nephritis -Patients with heart contraindications to this
Antiarrhythmic block or myocardial Adverse drug to prevent further
Complete -Preterm labor damage Reactions: complication.
Rx:  Assess baseline status
CNS: coma, to determine any
4gmsIVTT Patient Pregnancy depressed deep potential adverse
very slow now indications: Category: tendon reflexes effects which includes
weight, and vital signs.
-Preeclampsia Pregnancy CV: decreased BP,  Prepare medications.
Date of Rx: category B heart block, During:
increased pulse,
Precautions: cardiac
 Administer medications,
Diarrhea, arrhythmias,
using rights of
digitalized patients, cardiac arrest
medication
impaired renal
administration
function
 Administer continuous
METAB:
infusion piggybacked
hypermagnesemia,

6
hypocalcemia, into a main IV line so it
hypothermia, can be discontinued
hypotension immediately without
interfering with fluid
GU: decreased administration.
urine output  Monitor intake and
output evry hourduring
RESP: respiratory continuous infusion
distress  Assess patients level of
consciousness every
hour.
 Educate client about
medications
 Administer and
document medications
given by parenteral
routes
 Educate the patient to
limit his fluid and salt
intake

After:
 Monitor patient’s
response to therapy by
blood pressure
monitoring.
 Monitor the adverse
effects mentioned to
this drug.
 Evaluate patient
teaching plan (patient
can name drug, its
indication, dosage and
adverse effects to
watch for).

7
  Monitor the patient
compliance to drug
therapy and the
effectiveness of comfort
measures.
 Document that drug has
been given.
 Dispose of unused
medications according
to facility/agency policy

Reference:

Faan, & Pnp, Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family, 2017, p.554

Magnesium sulfate | DrugBank Online. (n.d.). DrugBank. https://go.drugbank.com/drugs/DB00653

Magnesium Sulfate. (n.d.). Glowm. https://glowm.com/resources/glowm/cd/pages/resources/Pharmacy/magnesium_sulfate.htm

DRUG THERAPEUTIC RECORD #2

Name: Reason for Admission: Labor pains and elevated blood pressure
Age/Sex: 44 years old/ F Medical Impression: PREECLAMPSIA
SIDE/ADVERSE
MECHANISM OF CONTRAINDICATION NURSING RESPONSIBILITIES
DRUG NAME DRUG CLASS INDICATIONS EFFECTS
ACTION S (5 each categories)
(per body system)

8
Generic Therapeutic: Hydralazine is a General: Before:
Name: direct-acting Side Effects:
Vasodilators vasodilator which -Idiopathic systemic  Assess for the mentioned
Hydralazine acts predominantly Hypertension lupus erythematosus CNS: contraindications to this drug
on the arterioles. (SLE) and related Headache, to prevent further
Pharmacologi The exact diseases dizziness complication.
Brand Name: c: mechanism of  Assess baseline status to
action is unknown, -Severe tachycardia GI: nausea, determine any potential
Antihypertensiv but it is thought to diarrhea, vomiting adverse effects which
Apresoline e exert its Patient -Heart failure includes weight, vital signs
vasodilating effect indications: associated with high Adverse Effects: (blood pressure, body
through direct cardiac output(e.g. temperature, pulse,
Complete Rx: relaxation of Hypertension thyrotoxicosis) CNS: anxiety, respirations), overall skin
vascular smooth peripheral condition and color and
5mg IVTT q muscle by -Myocardial neuritis, psychotic laboratory tests like renal
20mins x 4 inhibition of Ca insufficiency reactions, tremor and hepatic function tests,
doses release from the serum electrolyte, and
sarcoplasmic CV: angina, complete blood count
reticulum and edema, flushing, (CBC). It also include
inhibition of myosin Pregnancy Category: hypotension, baseline electrocardiogram
phosphorylation in Pregnancy category C palpitations, (ECG), perfusion,
Date of Rx: the arterial smooth reflex tachycardia adventitious breath sounds,
muscle cells. bowel sounds and
Precautions: EENT: nasal abdominal examination.
congestion  Observe aseptic technique
Advanced renal  Prepare Medication
disease, children, GI: anorexia,  Administer undiluted. Use
pulmonary constipation, solution as quickly as
hypertension diarrhea, possible after drawing
hepatitis, paralytic through needle into syringe
ileus, nausea, During:
vomiting
 Verify order and patient
GU: urination identity.
difficulty
 Administer drug slowly to
avoid sudden fall in blood

9
HEME: pressure
agranulocytosis,  Maintain diastolic pressure
anemia, over 90 mmHG to ensure
eosinophilia, adequate placental filling.
leukopenia  Monitor patient in any
situation that might lead to
SKIN: pruritis, exacerbation due to the
rash, urticaria effect of the drug.
 Educate and encourage
MISC: lupus-like patient the importance of
syndrome, implementing healthy
arthralgia, muscle lifestyle choices which
cramps includes regular exercise,
weight loss, smoking
cessation and low-sodium
diet to maximize the effect
of antihypertensive therapy.
 Provide comfort measures
to the patient to help
tolerate drug effects,
including small and
frequent meals, access to
bathroom; safety
precautions if CNS effects
occur; environmental
control; appropriate skin
care as needed and
analgesic as needed.
 Provide thorough patient
teaching about the drug’s
effect to the body and
manifestations to enhance
patient knowledge on drug
therapy and promote
adherence.
 Offer support and

10
 encouragement to help the
patient deal with diagnosis
and the drug regimen.

After:

 Monitor patient’s response

to therapy by blood
pressure monitoring.
 Monitor the adverse
effects mentioned to this
drug.
 Evaluate patient teaching
plan (patient can name
drug, its indication,
dosage and adverse
effects to watch for).
 Monitor the patient
compliance to drug
therapy and the
effectiveness of comfort
measures.
 Document that drug has
been given.

Reference:

Hydralazine | DrugBank Online. (n.d.). DrugBank. https://go.drugbank.com/drugs/DB01275

Hydralazine: Indication, Dosage, Side Effect, Precaution | MIMS Philippines. (n.d.). MIMS.

https://www.mims.com/philippines/drug/info/hydralazine?mtype=generic

11
 Hydralazine. (n.d.). Glowm. https://glowm.com/resources/glowm/cd/pages/resources/Pharmacy/hydralazine.htm

DRUG THERAPEUTIC RECORD #3

Name: Reason for Admission: Labor pains and elevated blood pressure
Age/Sex: 44 years old/ F Medical Impression: PREECLAMPSIA
DRUG DRUG CLASS MECHANISM OF INDICATIONS CONTRAINDICATION SIDE/ADVERSE NURSING RESPONSIBILITIES

12
 EFFECTS
NAME ACTION S (5 each categories)
(per body system)
Generic Therapeutic: Mechanism of General: Contraindicate Side Effects: Before:
Name: Anti- action not d with hypersensitivity
hypertensive conclusively Drug of choice to methyldopa, active CNS: sedation,  Check doctor’s order.
Methyldopa demonstrated; for the hepatic disease, headache,  Assess sensitivity to
Pharmacologic probably due to treatment of previous methyldopa asthenia, methyldopa, hepatic
Brand Name: Sympatholytic drug’s metabolism, non-emergent therapy associated weakness disease, renal failure,
which lowers hypertension with liver disorders dialysis
arterial BP by during GI: bradycardia,  Assess weight, skin color,
stimulating the pregnancy lesions, mucous
alpha- adregenic Derm: rash seen membrane color,
Complete receptors, which in as eczema orientation
Rx: turn decreases Pregnancy Category:  Educate the client about
sympathetic Patient Pregnancy category A Endocrine: breast the drug, its purpose and
250 grams outflow from the indications: enlargemetnt importance
every 6 CNS Methyldopa is
hours given to Client Precautions: During
to treat Other: nasal
hypertension stuffiness, mild
 Check the label twice
arthralgia,
myalgia, septic  Administer the right dose
shock-like in the right time
Date of Rx: symptoms.  Do not crush nor chew
the tablets, swallow
whole
Adverse Effects:  Discontinue drug if fever,
abnormalities in liver
CV: myocarditis function tests, or jaundice
disorders
Derm: lichenoid  Discontinue drug if
eruption, toxic Coomb’s Postivie
epidermal haemolytic anemia
necrolysis fever occurs

Endocrine:

13
 gynecomastia,
lactation After:
 Monitor blood counts
Hemat: positive periodically to detect
Coomb’s test, haemolytic anemia
haemolytic  Monitor hepatic function,
anemia, bone especially in the first 6-8
marrow week of therapy or if
depression unexplained fever
appears
 Report unexplained
prolonged general
tiredness; yellowing of
the skin or eyes; fever;
bruising; rash
 Document that drug has
been given.

Reference:

14