PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: JUANA DELA CRUZ
Age & Gender: 20, FEMALE
Birthday: MAY 27, 2000
Address: SAMAT ,BUGALLON PANGASINAN
Chief Complaint: PAIN IN ABDOMINAL AND SEVERE Name of Student Nurse: KAREN A. ABAD
HEADACHE
Admitting Diagnosis: ABDOMINAL PAIN Level/block/group: BLOCK 2
Hospital/area: OB WARD
Date of Confinement: 02/17/’21 Clinical Instructor: SIR JESUS RABE
Date: 02/16/’21

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Abdominal pain related to After 3 hours of nursing  Assess pain  In this data it can be After 3 hours of
“Masakit po ang aking epigastric pain due to intervention pain will characteristics used to identify the nursing
tiyan at ang sakit din abdominal pressure decrease and the (severity, location, onset, extent of pain and it interventions the
ng ulo ko” as patient report a relief duration, precipitating can served as a patient verbalized
verbalized by the within a day and rate it and relieving factors) baseline information relief from pain and
patient as 2/10 from 7/10 rated it as 2/10
 Attention to from 7/10
Objective: The patient will have  Monitor her vital signs associated signs may The patient’s VS are
-facial grimacing successful future and observe signs and help the nurse in as follows:
-abdominal guarding pregnancy symptoms that evaluating pain T: 36.7
below the ribs associated with pain BP: 130/80
-pain scale 7/10 PR: 80 bpm
 Some patient will feel RR: 19/min
VS:  Anticipate need for pain uncomfortable
T: 38°C relief exploring alternative
BP: 180/120 methods of pain relief
PR: 90bpm
RR: 20/min  Respond immediately to  One can most
complaint of pain effectively deal with
NURSING DIAGNOSIS pain by preventing it.
Altered comfort in
abdominal, lower of  Provide measures to
the ribs due to relieve pain before it  It is preferable to
increased abdominal becomes severe provide analgesic that
pressure and hormonal safe on the mother
changes that slow the and the baby before it
digestive process. becomes severe
 PHINMA University of Pangasinan
College of Health Sciences

Name of Student Nurse: KAREN A. ABAD Date: 02/16/’21

Level/block/group: 2ND YEAR ,BLOCK 2 Hospital/Area: Clinical Instructor: SIR JESUS RABE

NAME OF DRUG MECHANISM OF ACTION CONTRAINDICATIONS SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITIES
GENERIC NAME Direct vasodilator; dilates arterioles  Hypersensitivity  flushing Frequency Not  Advise them to check BP at
Hydralazine with little effect on vein; decreases to hydralazine  headache Defined least weekly and report
systemic resistance, which  upset stomach  Hypotension significant changes.
subsequently decreases blood  Coronary artery  vomiting  Palpitations  Patients should weigh
BRAND NAME pressure. disease  loss of  Conjunctivitis themselves twice weekly
Apresoline appetite  Tachycardia and assess feet and ankles
 Mitral valve  diarrhea  Headache for fluid retention.
rheumatic  constipation  Peripheral edema  May occasionally cause
heart disease  eye tearing  Vascular collapse drowsiness. Advise patient
CLASSIFICATION  stuffy nose  Peripheral to avoid driving or other
Vasodilators  rash neuropathy activities requiring
 Anorexia alertness until response to
 Diarrhea medication is known.
 Nausea  Advise patient to notify
 Vomiting health care professional if
 Psychotic reaction pregnancy is planned or
INDICATION  Agranulocytosis suspected or if breast
Hydralazine is used  Leukopenia feeding
with or without other  Hepatotoxicity
medications to treat  Chest pain
high blood pressure.  Dyspnea
Lowering high blood  Nasal congestion
pressure helps  Paralytic ileus
prevent strokes,  Dysuria
heart attacks, and  Thrombocytopenia
kidney problems.
Hydralazine is called a  Peripheral neuritis
vasodilator.  Rheumatoid
arthritis
DOSAGE &  Agranulocytosis
FREQUENCY  Arthralgia
injectable solution  SLE syndrome
-20mg/mL

tablets
-10mg
-25mg
-50mg
-100mg

Severe Essential
Hypertension
10 mg PO q6hr for 2-
4 days; 25 mg q6hr
daily for the first
week; increase to 50
mg q6hr from second
week on; adjust dose
to lowest effective
levels

20-40 mg IM/IV;
repeat as necessary

Dosing considerations
Change to oral
therapy as soon as
possible
Hypertension
(Chronic)
Initial: 10 mg PO q6hr
for 2-4 days; may
increase gradually by
10-25 mg/dose every
2-5 days up to 50 mg
PO q6hr (some
patients require 300
mg/day)

See also combo with

isosorbide dinitrate

Hypertensive Crisis
10-40 mg IV/IM; not
to exceed 20
mg/dose; repeat PRN

Pregnancy-associated
5-10 mg IV/IM
initially, THEN 5-10
mg q20-30min PRN,
OR
0.5-10 mg/hr IV
infusion

Congestive Heart
Failure
Initial dose: 10-25 mg
PO q6-8hr; titrate
dose q2-4weeks

Maintenance dose:
225-300 mg/day PO
divided q6-8hr

Dosing considerations
Adjust dose per
individual response