Level & Section: BSN 3-C Time: 6:15 am

Name of Patiet: Patient Z Area of Exposure: Delivery Room

Attending Physician: Dr. Ariel Labus Chief Complaints: Increased BP and painless vaginal @ 30 weeks pregnancy

ASSESSMENT
DIAGNOSIS PLANNING / DESIRED INTERVENTION /
RATIONALE EVALUATION
OUTCOME IMPLEMENTATION

September 18, 2023; 6:15 
am
Subjective data:
Patient verbalized:
“Nagmata ko karong
buntag nga sakit akong ulo
nag dulom ako panan-aw
tapos kalit lang ko nalipong
ganiha maayo nalang naa
akong bana. Naka suka ko
ganiha.Ug Nabantayan pud
nako nga gamay ra kaayo
ang akong ihi. Nagpadayon
gihapon ang akong manas.”
Demographic data:
 Age: 26 yrs. old
 Gender: Female
 Marital Status: Married
 Occupation: Housewife
Previous Medical History:
 (-) previous
hospitalization history
 (+) family history of
hypertension
 1st Prenatal Visit:
 BP: 120/80 mmHg
 2nd Prenatal Visit:
Decreased cardiac output Short-term goal:
related to increased After 8 hours span of care the
systemic vascular patient will have an improved 1. Assess the gestational Age, 1. To identify the growth &
resistance secondary to cardiac output as manifested
disease process by:
(Pregnancy Induced
Hypertension) as a. Patient will show a slight
evidenced by BP of decrease in BP (120/80- 2. Assess and conduct physical
170/100 mmHg, +2 135/110 mmHg) and retain
Edema, a severe normal temperature (36-
headache and visual 37.5 degrees Celsius) RR
blurring. (12-20 cpm) PR (60-100
bpm).Patient will appear to
have small signs of
progress with her edema
and an adequate urinary
output (>30 cc/hr).
b. Patient will appear to have
small signs of progress
with her edema and an 3. Monitor and record TPR every 3. TPR stands for Temperature,
adequate urinary output
(>30 cc/hr).
c. Patient will remain free of
side effects from the
medications used the
magnesium to achieve
adequate cardiac output.
Independent: September 18, 2023;
pm
maternal factors & monitor the condition of the fetus. Short Term Goal Mee
fundal height, fetal After 8 hours span of c
movements & fetal heart rate. patient had an imp
cardiac output as man
by:
examination and commence 2. Edema, headaches, visual
daily weight monitoring. disturbances, and nausea and a. Patient showed a
vomiting are associated with the decrease in BP (13
patient’s high blood pressure mmHg) and re
level. Weight gain is an normal temperatur
important symptom of PIH. degrees Celsius) R
Fluid retention may be evident cpm) PR (95 bpm).
if the mother has a weight gain
of more than 1.5kg/month b. Patient appeared to
during the 2nd trimester, or more small signs of pr
than 0.5 kg/week during the 3rd with her edema a
trimester. adequate urinary
(>30 cc/hr).
4 hours and blood pressure Pulse, and Respiration. To c. Patient remained f
every one (1) hour or as obtain baseline data and side effects from
indicated. monitor condition of patient medications used
until stable. Monitoring the achieve adequate c
blood pressure hourly will help output.
give baseline data for patients
with hypertension and give d. Patient demon
interventions to control the activities that redu
condition. workload of the
 BP: 110/70 mmHg
 3rd Prenatal Visit:
 BP: 140/90 mmHg
Past Health History
 History of Allergies:
None
 Current Medication:
Ferrovit
 Smoking: None
 Food allergy: Shrimp
Objective data:
 (+2) Edema swelling
was noted on lower
extremities
 Cold
 Clammy skin
 Capillary refill within 6
 Dizziness
 seconds
 Severe headache
 Visual blurring
 Nausea and vomiting
General State of health:
 Pt. was well groomed
with cleanness of the
body, conscious and
aware.
Mental Status:
 Pt is alert, conscious and
aware.
VS taken as follows:
such as rela
Long-term goal: 4. In PIH, the kidneys respond to techniques
4. Monitor and measure the reduced cardiac output by therapeutic med
d. Patient will demonstrate client’s urine output as per retaining water and sodium. regimen. (The
activities that reduce the protocol. Maintain strict intake Intrarenal vasospasms cause stated that she will
workload of the heart such and output. oliguria in severe preeclampsia the advices given
as relaxation techniques due to a reduction in glomerular like practicing
and therapeutic medication filtration rate. To monitor breathing techniqu
regimen. circulatory blood volume. And by taking the pres
to ensure that the mother has medications).
adequate oral hydration or if
there is a need to commence IV
hydration therapy. Hypovolemia
and oliguria suggest renal
hypoperfusion.
5. Tachycardia may be present
when the body compensates for
the decrease in circulating
 The patient will be able to volume that can hardly reach
maintain fluid volume at a 5. Auscultate for the apical pulse the peripheries and distant
functional level. and assess the client’s heart tissues. Pulmonary edema may
rate and rhythm. And assess transpire, with modification in
 Client will be able to know also the lungs for crackles, peripheral vascular resistance
and perform activities that wheezes, and dyspnea, note and drop in plasma colloid
do not only provide relief respiratory rate/effort. osmotic pressure.
from pain but are helpful in
dealing with the disease 6. Cardiotocography (CTG)
condition measures your baby's heart rate.
At the same time, it also
 Patient provide rationale monitors the contractions in the
for treatment 6. Attach CTG and monitor fetal womb (uterus). Observe for
heart rate. signs and symptoms of fetal
 Patient verbalizes distress due to maternal blood
understanding of the pressure, decreased placental
condition. blood flow and lack of
 Temp: 37.5 0C (axillary) oxygenation.
 PR: 85 bpm  Patient will express
 RR: 21 cpm awareness, knowledgeable 7. Some swelling is normal in
 BP: 170/100 mmHg and verbalize pregnancy, but pitting edema is
 Pain scale: 6 out of 10 understanding and different and can be a
 SpO2: 97% monitoring of reducing significant sign of decreased
cholesterol through cardiac output. Elevation
lifestyle changes / 7. Check and monitor the edema, increases venous return to the
 Height: 165 cm
adjustment, acute pain r/t note location and determine heart and, in turn, decreases
 Weight: 187 lbs.
decreased myocardial flow degree of pitting. Elevate edema.
 BMI: 31.2 (Overweight) edematous extremities, and
disease management,
 AOG: 30 weeks prescribed medication, diet handle with care. 8. Helps reduce sympathetic
 GTPAL: G1T0P0A0L0 plan as well as the stimulation and promotes
treatment plan. relaxation. Reduces physical
Allergy skin test: stress and tension that affect BP
 MgS04: Negative  Patient will demonstrate and the course of hypertension.
the proper administration 8. Provide calm, restful
LABORATORY TEST: of nitroglycerin as first aid surroundings, minimize 9. Lateral recumbent position
Blood Test: and atorvastatin environmental activity and decreases pressure on the vena
 Hemoglobin: 100 g/dl medication as maintenance noise. cava, to lower blood pressure
 Platelets: <100,000/mm3 in safest as per physician levels, improves venous return,
 Bilirubin: 3mg/dl ordered to her, including cardiac output, and
the dosage, route, renal/placental perfusion.
Urine analysis: frequency, timing, 9. Instruct the patient to have
 (+2) Dipstick expiration and can bedrest with patient in lateral 10. To asse the probability of
Proteinuria verbalize the important position. developing toxemia.
 Creatinine: 1.2 mg/dl indication for,
 Decreased urine output contraindication, caution, 11. To prevent in changes in cardiac
less than 30 cc adverse effect, and pressures or impede blood flow.
interaction.
Ultrasound: 12. To relieve edema & improve
 FHR: 132 bpm  Patient will participate in 10. Perform roll over test. venous return.
 Fetal weight: 1.8 kg 30 minutes of exercise 3-4
 Adequate amniotic fluid days per week to be able to
achieve the ideal weight 11. Encourage breathing exercise.
(BMI) from 26.4 decrease 13. To prevent seizures at an early
 to 18.5-24.9 within the stage.
normal range. 12. Provide range of motion &
passive exercise to the
 Patient including the family extremities & elevate the
member will perform extremities with pillows.
independently at home the 14. To help diagnose whether you
vital sign including the 13. Monitor the mother have allergies and to find out
blood pressure, pulse rate, continuously for the root cause of the symptoms.
respiration rate and complications of Seizures.
glucometer.
Dependent:
 Patient will apply the 15. PLR helps to aid in balancing
nutrional dietary plan as 14. Perform skin test to determine fluid and electrolyte levels.
per recommended by the if the patient has any allergic PNSS + MgSO4 helps to
dietician. reaction on that certain drug control life-threatening
being order by the physician. convulsions and works as a
 Patient will implement the treatment in preeclampsia and
financial budget or petty 15. Administer IV fluids (Start eclampsia during the pregnancy.
management including venoclysis with PLR 1L at Monitor parameter q 4 hours,
investing of sufficient KVO rate at right hand and urine output less than 30 cc per
medical care and life start another line at left hand hour, RR less than 12, PR less
insurance. PNSS + 10 grams MgSO4 at than 50 bpm and absent deep
100 cc/hour) and tendon reflexes since these
 The patient will become antihypertensive drug such as indicate magnesium sulfate
educator in her family and Hydralazine IVTT for systolic toxicities. Antihypertensive
share with her family and BP of 160 or greater than 160 drugs work directly on
community about the and for Diastolic BP of equal arterioles to promote relaxation
importance of health to or greater than110 mmHg. of cardiovascular smooth
promotion and disease And monitor the patient for muscle and help increase blood
prevention similar to what any side effects. And prepare supply to cerebrum, kidneys,
her disease currently antidote calcium gluconate at uterus, and placenta. Monitor
experience. bedside for magnesium sulfate the patient for any side effects
overload. such as tachycardia, headache,
nausea, and vomiting, and
palpitations to give immediate
interventions.

16. Administer oxygen as 17. Low calories and protein in the
necessary.
Collaborative/Interdependent:
17. Refer the patient to a dietitian
for proper monitoring and
advice of salt, caloric and
protein intake.
18. Establish a therapeutic
connection between the patient
and his family members.
16. Oxygen supplementation may
be given to relieve dyspnea and
improve maternal-fetal
oxygenation and tissue
perfusion.
diet may worsen PIH, some
sodium intake is necessary
because levels below 2–4 g/day
result in greater dehydration in
some patients. However, excess
sodium may increase edema
formation. So that’s why
nutritional consult is important
in determining individual
needs/dietary plan.
18. Establishing a healthy nurse-
patient relationship.
19. To help the patient about
seeking or utilizing resources
they have and government
agency.
 Including spiritual,
psychological support and
diversional therapy in the form
of mild music, tv, reading
magazine, bible and etc.

19. Discuss about financial

management support on how
to pay and lessen medical bills 20. Providing the most education to
in the hospital, and on how to patients gives them more power
adapt behavior of seeking and control over their health
health care and allocate
medical care insurance and
store medicine at home for
emergency.

20. Educate the patient about the

right administration of
medication when she’s in her
home, including the dosage,
route, frequency, timing,
expiration, indication,
contraindication and drug food
interaction.
.