SISTER NIVEDITA GOVERNMENT NURSING COLLEGE

IGMC, SHIMLA

SUBJECT : OBSTETRICS AND GYNECOLOGICAL NURSING

CASE PRESENTATION : PREGNANCY INDUCED HYPERTENSION

SUBMITTED TO: SUBMITTED BY:

Mrs. Prema Negi Archita Sharma

Lecturer MSc. (N) 1st Year

Obstetrics and Gynaecological Nursing SNGNC, IGMC

SNGNC, IGMC Shimla

Shimla

SUBMITTED ON:
IDENTIFICATION DATA
Full Name : Mrs. Minakshi

Age (in years) : 28 years

Sex : Female Adult

Reg. No. : 310124103259

CR. No. : 310124103259

Marital status : Married

Religion : Hindu

Nationality : Indian

Education status : B.A., B.Ed

Occupation : Housemaker

Husband’s Name : Mr. Rakesh Kumar

Education Status : M.A., B.Ed

Occupation : Teacher

Type of family : Joint family

Income per month : 90,000/- month

Per capita income : 15,000/- month

Date of Admission : 20/12/2023

Ward : Antenatal ward

LMP : 15/04/2023

EDD : 22/01/2024

POG : 35 weeks+5 day

Obstetric score

 Gravida : 1
 Parity : 1
 Term : 0
 Abortion : 0
 Living : 0
  Still born : 0

Address - V.P.O Chapandli, Teh. Chopal, Distt. Shimla

Diagnosis – Pregnancy Induced Hypertension

Chief Complaints - Mrs. Minakshi, 28 years old admitted in Antenatal Ward of Kamla Nehru
State Hospital Mother and Child, Shimla with chief complaints of high blood pressure.

History of Present illness -

Mrs. Minakshi, 28 years old came to Kamla Nehru State Hospital Mother and Child,
Shimla for her routine check-up when her Blood pressure was 140/90. So, she is
admitted to Antenatal ward for safe confinement.

History of past illness-

Past Medical Illness history - There is no history of past illness.

Past surgical history - There is no past surgical history.
Allergy – Not known.

FAMILY HISTORY

History of Family Illness

History of chronic illness in family- Patient’s father-in-law and mother is having

Hypertension since last 5 years and 7 years respectively.
History of any communicable or hereditary disease- There is no history of
communicable or hereditary disease in family.
Family Tree – Key

Male

Mr. Suresh Mrs. Raksha

Female

Patient
Mr. Rakesh Mrs. Minakshi Ms. Srishti Ms. Sakshi
Type of Family – Joint Family.
Number of Family Members – 6

Sr. Name Age/Sex Relationship Education Occupation Marital Health Status

No. with patient Status
1. Mr. Suresh 66 yrs Father-in- Metric Farmer Married Healthy
/MA law

2. Mrs. Rekha 58 yrs Mother-in- 8th pass Housemaker Married Healthy

/FA law

3. Mr. Rakesh 30 yrs Husband M.A., Teacher Married Healthy

/MA B.Ed
4. Mrs. 28 yrs/ Patient B.A., Housemaker Married Pregnancy
Minakshi FA B.Ed induced
hypertension

5. Ms. Srishti 26 yrs/ Sister-in-law B.Sc., Private Job Unmarried Healthy

FA B.Ed
6. Ms. Sakshi 24 yrs/ Sister-in-law B.A Private Job Unmarried Healthy
FA

SEXUAL AND MARITAL HISTORY

Spouse general health- Spouse is healthy.

Spouse occupation- Teacher.
Relationship - The relationship between patient and her spouse is satisfactory.
No. of children – No Child.
Marriage- 3 years back.

MENSTRUAL HISTORY

Age at menarche- 14 years

Duration- 5-6 days.
Cycle- 28 days.
Regularity- Regular
 Flow- Normal
Clots- Absent
Any dysmenorrhea- Mild dysmenorrhea during menstruation period.

OBSTETRIC HISTORY

PRESENT OBSTETRIC HISTORY

 Is pregnancy confirmed? Yes.

 What test done for confirmation Pregnancy kit is used to confirm pregnancy.
 Quickening Felt at 5th month.
 Immunization Mother is immunized with two doses of tetanus
diphtheria.

PAST OBSTETRIC HISTORY:

Patient is primigravida.

Sr. Year of Place Preterm Method Labor Puerperium Baby

No. pregnancy of of
birth /Term delivery Sex Weight
delivery

Primary gravida with 35 weeks + 6 days POG.

HISTORY OF PRESENT PREGENANCY

Pregnancy confirmed by UPT after 1 month overdate.

USG done at 15/09/23, findings revealed:
 Single live fetus with cephalic presentation.

HISTORY OF FIRST TRIMESTER

No history of morning sickness present.

No history of excessive nausea and vomiting.
No history of fever.
No history of burning micturition.
HISTORY OF SECOND TRIMESTER
Quickening felt at 5th month.
Felt fetal movements regularly.
 Progressive enlargement of abdomen by growing fetus.
She is prescribed with iron, folic acid and calcium.

HISTORY OF THIRD TRIMSTER

Regular fetal movement present.

Progressive enlargement of abdomen by growing fetus.

ENVIRONMENTAL HISTORY

Environment hygiene Surrounding of the patient is hygienic.

Drinking Water Tap water
Environmental pollution Absent

NUTRITIONAL HISTORY

General Nutrition - Vegetarian

Appetite - Normal
Diet - Three times in a day along with mid-morning and evening snacks.

PSYCHOSOCIAL HISTORY

Language Known - Hindi, English

Social Support System - Social support is provided by family and relatives.

PERSONAL HISTORY

Habits - Patient is non-smoker and non-alcoholic.

Sleep pattern - Sleeping pattern is normal.
Nutritional pattern - Patient is vegetarian.
Work pattern - Housewife
Elimination - Bowel pattern is normal.
Personal hygiene - Patient maintain her personal hygiene by herself.

PHYSICAL EXAMINATION
GENERAL APPEARANCE:

 Sensorium Patient is Conscious, oriented to time place and person

and co-operative.
 General Appearance Patient looks normal.
  Nourishment Patient is well nourished
 Body Normal
 Built Normal
 Pallor Absent
 Clubbing Absent
 Icterus Absent
 Edema Absent
 Lymphadenopathy Absent
 Breast Normal
 Spine Lordosis of spine present.

ANTHROPOMETRIC MEASUREMENTS:
 Height - 156 cm
 Weight - 56 kg
 BMI - 56/(1.56)2
= 56/2.43 kg/m2
= 23.04 kg/m2 (Normal)

Vital signs: Date: 09-01-2024 Time: 10:00 AM

S. Vital Signs Patient’s Value Normal Value Remarks

No.

1. Temperature 98.40 F 98.60 F Normal

2. Pulse 76 beats/min 60-100 beats/min Normal

3. Respiration 18 breaths/min 16-20 breaths/min Normal

4. Blood pressure 140/90 mm of Hg 120/80 mm of Hg Elevated

HEAD TO TOE ASSESSMENT:

 SKIN-
 Colour : Colour of the skin is normal.
 Texture : Skin texture is normal.
 Temperature : Temperature is normal.
 Lesions : No lesions present.
  Edema : Edema is absent.
 Nails : No clubbing of nails present.
 Capillary refill time : Capillary refill time is normal i.e. 2 seconds.
 Skin turgor : Skin turgor is good.
 Chloasma : Present
 Nail colour : Pinkinsh
 HEAD-
 Hair : Well distributed
 Colour of Hair : Black in colour
 Symmetry of skull : Symmetrical
 Scalp : Oily
 Pediculosis : Absent
 FACE-
 Symmetry : Symmetrical
 Scar : Absent
 Facial puffiness : Present
 Facial expression : Normal
 Chloasma : Present
 EYES-
 Vision : Normal
 Visual Acuity : 6/6
 Eyelids : Normal
 Eyelashes : Equally distributed
 Eyebrows : Normal
 Conjunctiva : White in colour
 Sclera : Normal
 Discharge : Absent
 Peri-orbital edema : Absent
 EARS-
 Ear Symmetry : Symmetry of ear is proper.
 Swelling : No swelling in ears.
 Vertigo : Vertigo is absent.
 Discharge : No abnormal discharge from ears.
 NOSE-
  Symmetry : Symmetry of nose is proper.
 Deformity : No deformity in nose.
 Flaring : Nasal flaring is absent.
 Discharge : No abnormal discharge from nose.
 Any nose surgery : No history of nose surgery.
 MOUTH AND THROAT-
 Dental carries : Dental carries present in right and left molars.
 Oral hygiene : Oral hygiene is proper.
 Halitosis : Halitosis is absent.
 Tongue : Tongue is normal.
 Dentures : No use of dentures.
 Colour of lips : Lips are pink in colour.
 Moisture of Lips : Lips are moist.
 Tonsils : No inflammation of tonsils is present.
 NECK-

 Range of motion : Normal range of motion i.e extension, flexion,

 Nuchal rigidity
 Tracheal deviation
 Lymph Nodes
 Thyroid Gland
 CHEST/ BREAST:-
and neck rotation.
: Nuchal rigidity is absent.
: No tracheal deviation present.
: No lymph nodes enlargement present.
: Normal.

 Scar : No scar present on chest.

 Pain : No pain in chest/ breast.
 Rashes : Absent.
 Chest expansion : Proper chest expansion present.
 Breast : Breast is soft, no lumps present.
 Symmetry of breast : Breast is Symmetrical.
 Breast changes : Secondary areola present.
SYSTEMATIC EXAMINATION:

RESPIRATORY SYSTEM:

 Inspection:
 Nasal flaring or discharge : Absent
 Respiratory rate : 18 breaths/min i.e. Normal.
 Central cyanosis : Absent
 Shape and symmetry of thorax : Normal
 Chest scars : Absent
 Cough : Absent
 Sputum : Absent
 Dyspnea : Absent
 Hemoptysis : Absent
 Palpation:
 Sinuses lymph node palpation : Normal
 Trachea position : Normal
 Palpate apex beats : Normal
 Chest expansion : Normal
 Percussion:
 Fluid accumulation : Absent
 Auscultation:
 Breathe sound : Normal
 Assess vocal resonance : Normal

CARDIOVASCULAR SYSTEM:

 Pulse Rate : 76 beats/ min i.e. normal.

 Blood pressure : 140/90 mm of Hg i.e. High.

 Numbness : No numbness.

 Chest pain : Absent.

 Inspection:
 Shortness of breath : Absent
  Color of skin : Pink

 Cyanosis : Absent

 Clubbing : Absent

 Dyspnea : Absent
 Cough : Absent

 Palpation:
 Lump : Absent
 Auscultation:
 Heart sound : Normal S1 – S2 sound present.
 Blood pressure : 140/90 mm of Hg i.e. High.

GASTROINSTINAL SYSTEM:

 Appetite : Normal
 Nausea & vomiting : Absent
 Diarrhoea : Absent
 Constipation : Absent
 Inspection:
 Skin rashes : Absent
 Abdomen shape : Round
 Linea nigra : Present
 Striae gravidarum : Present
 Fetal movement : Present

 Umbilicus : Flat

 Auscultation:
 Bowel sound : Normal
 Palpation:
 Uterus : Firm

GENITOURINARY SYSTEM:

 Urination frequency : 5-6 times in a day

  Colour : Pale yellow
 Burning micturition : Absent
 Haematuria : Absent

REPRODUCTIVE SYSTEM:

 Inspection:
 Lesions : Absent
 Scar : Absent
 Inflammation : Absent
 Any discharge from vagina : Absent
 Palpation:
 Inguinal lymph node palpation for pain : No pain
 Swelling : Absent

MUSCULOSKLETAL SYSTEM:

 Posture : Normal
 Gait : Penguin gait present
 Movement weakness : Absent
 Range of motion : Absent
 Joint pain : Absent
Reflexes:

 Bicep reflexes : Normal

 Triceps reflexes : Normal
 Brachioradialis : Absent
 Patellar : Normal

NEUROLOGICAL EXAMINATION:

 Level of consciousness Conscious

 Headache Present
 Confusion Absent
 Weakness Absent
  Sensation Normal
 Memory Normal

CRANIAL NERVE FUNCTIONING:

 I Olfactory : Patient’s olfactory nerve is proper functioning and is able

distinguish various smells.
 II Optic : Patient optic nerve is functioning properly as vision is 6/6.
 III Oculomotor : Patient is able to move freely their eyelids and eyeballs.
Pupils are equally reactive towards light. Thus oculomotor
functioning is normal.
 IV Trochlear : Eye wall can move freely.
 V Trigeminal : Patient can chew the food easily.
 VI Abducens : Proper movements of eyeballs present.
 VII Facial : Sense of taste is proper as well as facial expression are also
proper.
 VIII Vestibulocochlear : Hearing is normal.
 IX Glossopharyngeal : Saliva formation is normal.
 X Vagus : Vagus nerve functioning is normal.
 XI Accessory : Normal extension, flexion and rotation of head present.
 XII Hypoglossal : Tongue movement and swallowing reflex is normal.

SENSORY SYSTEM:

All sensory organs are functioning properly.

 Vision - Vision of patient is normal.

 Hearing - Hearing of patient is normal.
 Taste - Patient is able to distinguish different tastes.
 Touch - Patient is able to distinguish between hot and cold objects.
 Smell - Patient is able to distinguish different kind of smells.
 DIAGNOSTIC EVALUATION
Sr. no. Diagnostic Test Remarks

1. History Collection Done properly

2. Physical Examination Done properly

3. Urine Analysis No protein present.

4. USG Single live fetus with cephalic

presentation present.

LAB INVESTIGATION
Sr. Investigation Patient Value Normal Value Remarks
No.

1. Hemoglobin 13 g/dl 12-15 g/dl Normal

2. RBC count 7.8 million/Mcl 6-10 million/Mcl Normal

3. WBC count 6.2 million/Mcl 5.5-19.5 million/Mcl Normal

4. Platelets 2.34 x 103 1.4-4.50 x 103 Normal

5. Sodium 165 mEq/L 135-145 mEq/L High

6. Calcium 8.8 mg/dl 8.6-10.3 mg/dl Normalsss

MEDICATION CHART

Sr. Drug Dose Route/ Action Indications Contraindicati Side Nursing

no. ons responsibility
Freque effects
ncy

1. Tab. Iron 100 Orally Acts as Nutritional Acute liver Nausea Advice patients
mg iron deficiency disease. to take citrus
BD suppleme anemia. Vomiting fruits while
nt Hypersensitivity taking iron
supplements to
 To maintain Hemochromatosi Constipati increase iron
iron load in s on absorption.
pregnancy for
hemoglobin Anemia not Diarrhoea

production. caused by iron

deficiency. Flatulence

Metallic
taste

2. Tab 500 Orally Effectivel Preventing Hypersensitivity Constipati Assess patient

Calcium mg y low level of on for appearance
OD improves calcium in Renal calculus of any side-
blood bone. Loss of effect.
High urine appetite
calcium
Weak bones. calcium levels Educate patient
levels in
Nausea/v to keep a gap in
pregnant Elevated serum omiting taking iron and
women. calcium levels
calcium tablets.
Muscle
Reduces
pain
parathyroi
d release Mood
and changes
intracellul
ar
calcium
and so
reduces
smooth
muscle
contractili
ty.

3. Tab. B 200 Orally Vitamin Fetal brain Hypersensitivity Vomiting/ Obtain

complex mg suppleme development nausea sensitivity
OD nt history before
Flushing administration.
 Prevents To maintain High Monitor for side
and treats proper nerve blood effects
low levels functions sugar
of vitamin level
B in body.

4. Cap. 200 Orally Reduces Infertility History of breast Breast Educate patient
Micronize mg risk of cancer pain to report side
d BD miscarria Prevention of effects and
progester ge miscarriage Liver disease Headache discontinue
one medication if
Thromboembolic Drowsine
severe side
disease ss
effects occur.

Dizziness

5. Inj. 6 mg IM Fetal lung Maturation of Systemic fungal Cushing Monitor

Dexameth maturity. fetal lungs infections syndrome Random blood
asone 4 doses sugar before
12 Decrease Cerebral malaria Weight administering
hourly. number of gain the drug.
neonates with High blood sugar

respiratory levels Hypertens

distress ion

syndrome Hypergly
cemia
Survival in
preterm
delivered
neonates

6. Tab. 5 mg Oral Calcium Hypertension Hypersensitivity Peripheral Monitor blood

Amlopres channel to amlodipine Edema pressure and
s5 OD blocker Chronic Heart pulse prior to
Stable Angina Cardiogenic Failure and during
shock Pulmonar therapy.
Vasospastic
y Edema Monitor intake
Angina
Flushing and output.
Severe aortic Dizziness Assess for signs
stenosis, Headache of CHF.
Unstable angina Drowsine
ss
Severe
hypotension Skin Rash
Heart failure

Hepatic
impairment
 DISEASE DESCRIPTION

PREGNANCY INDUCED HYPERTENSION

Hypertension is one of the common medical complications of pregnancy and contributes

significantly to maternal and perinatal morbidity and mortality. Hypertension is a sign of an
underlying pathology, which may be pre-existing or appears for the first-time during
pregnancy. The identification of this clinical entity and effective management plays a
significant role in the outcome of pregnancy, both for the mother and the baby. In developing
countries, with inadequately cared pregnancy, this entity on many occasions remains
undetected till major complications supervene.

Pregnancy induced hypertension is the development of new hypertension in a pregnant woman

after 20 weeks of gestation without the presence of protein in the urine or other signs of pre-
eclampsia.

Hypertension is defined as having blood pressure greater than 140/90 mmHg or higher.

The top number of blood pressure measurement is the systolic number, which measure the
pressure of blood against the wall of the arteries during heart contraction. The bottom number
is the diastolic pressure, a measurement of the pressure of blood when the heart relaxes and
fills with blood.

ANATOMY AND PHYSIOLOGY

The heart is a conical hollow muscular organ situated in the middle mediastinum and is
enclosed within the pericardium. It is positioned posteriorly to the body of the sternum with
one-third situated on the right and two-thirds on the left of the midline.

The heart measures 12 x 8.5 x 6 cm and weighs ~310 g (males) and ~255 g (females). The
human heart is about the size of a human fist and is divided into four chambers, namely two
ventricles and two atria. The ventricles are the chambers that pump blood and the atrium are
the chambers that receive blood. Among these both the right atrium and ventricle make up the
“right heart,” and the left atrium and ventricle make up the “left heart.” The structure of the
heart also houses the biggest artery in the body – the aorta.
 Fig. The Human Heart

Chambers of the Heart

Vertebrate hearts can be classified based on the number of chambers present. For instance, most
fish have two chambers, and reptiles and amphibians have three chambers. Avian and
mammalian hearts consists of four chambers. Humans are mammals; hence, we have four
chambers, namely:

 Left atrium

 Right atrium

 Left ventricle

 Right ventricle

Atria are thin and have less muscular walls and are smaller than ventricles. These are the
blood-receiving chambers that are fed by the large veins.
Ventricles are larger and more muscular chambers responsible for pumping and pushing blood
out into circulation. These are connected to larger arteries that deliver blood for circulation.

The right ventricle and right atrium are comparatively smaller than the left chambers. The walls
consist of fewer muscles compared to the left portion, and the size difference is based on their
functions. The blood originating from the right-side flows through the pulmonary circulation,
while blood arising from the left chambers is pumped throughout the body.

Functions of the Heart:

The function of the heart in any organism is to maintain a constant flow of blood throughout
the body. This replenishes oxygen and circulates nutrients among the cells and tissues.

Following are the main functions of the heart:

 One of the primary functions of the human heart is to pump blood throughout the body.

 Blood delivers oxygen, hormones, glucose and other components to various parts of the
body, including the human heart.

 The heart also ensures that adequate blood pressure is maintained in the body.

DEFINITION

 Pregnancy induced hypertension is a condition characterized by high blood pressure

during pregnancy. It can lead to condition like pre-eclampsia also referred to as toxemia
of pregnancy.
 Pregnancy induced hypertension is the development of new hypertension in a pregnant
woman after 20 weeks of gestation without the presence of protein in the urine or without
other signs of pre-eclampsia.

ETIOLOGY

BOOK PICTURE PATIENT PICTURE

 Family history of hypertension.  Family history.

 Obesity (BMI>35 kg/m2).
 Placental abnormalities.
 Coagulation abnormalities.
CLINICAL MANIFESTATIONS

BOOK PICTURE PATIENT PICTURE

 Increased Blood Pressure i.e.->  Headache.

140/90 mm of Hg.
 Swelling over the ankle, face,
abdominal wall.
 Headache.
 Nausea and vomiting.
 Epigastric pain.

Alarming Symptoms

 Headache.
 Disturbed sleep.
 Diminished urinary output.
 Epigastric pain.

DIAGNOSTIC EVALUATION

BOOK PICTURE PATIENT PICTURE

 History collection.  History collection.

 Physical examination.  Physical examination.
 Blood pressure monitoring.  Blood pressure monitoring.
 Ultrasonography.  Urine analysis.
 Urine analysis.

MANAGEMENT

BOOK PICTURE PATIENT PICTURE

 Initial hospitalization.  Initial hospitalization.

 Complete bed rest.  Complete bed rest.
 High protein diet.  Protein rich diet.
 Diuretics – Furosemide 40 mg  Tab. Amlopress 5 mg Orally/OD.
orally.  Daily clinical evaluation.
  Antihypertensive therapy –  Blood pressure monitoring- 6 times
-Tab. Amlodipine 5 Mg Orally a day.
-Labetalol (10-20 mg) IV  Daily weight monitoring.
-Hydralazine (10 mg) IV
 Eclampsia prevention – Magnesium
sulphate.
 Daily clinical evaluation for any
symptoms of eclampsia.
 Blood pressure monitoring 6 times a
day.
 State of edema and daily weight
recording.
 Urine examination for protein.

NURSING MANAGEMENT
NURSING ASSESSMENT-

 To assess general condition of the patient and history collection of patients.

 To perform head to toe examination of patient.

 To assess knowledge of patient regarding their health.

 To assess knowledge of patient regarding diet pattern

NURSING DIAGNOSIS-

1. Decreased cardiac output related to decreased venous return as evidenced by change

in blood pressure.
2. Deficit fluid volume related to excessive urination as evidenced by monitoring intake-
output chart.
3. Imbalanced nutritional pattern less than body demand related to intake of insufficient
diet as evidenced by intake-output chart.
4. Risk of maternal injury related to development of tonic-clonic seizures secondary to
complication of pregnancy induced hypertension.
5. Knowledge deficit related to disease as evidenced by frequent questioning.
GOALS

Short-term goals

 To improve the cardiac outflow of the patient.

 To encourage patient for complete bed rest.
 To maintain fluid and nutritional status.

Long -term goals

 To prevent further complications of disease condition.

 To provide health education to patient and family regarding patient condition, treatment
and prognosis.
 To provide psychological support to the patient and family members.
 To encourage patient for regular follow up.
Assessment Nursing Goal Planning Implementation Rationale Evaluation
diagnosis
Subjective Decreased To Assess the General To know the Patient
data: cardiac improve general condition of the general cardiac
output related cardiac condition of patient was condition of outflow is
Patient says
to decreased outflow patient. assessed. the patient. maintained to
that I am
venous return and some extent
having Strictly Vital signs of the
as evidenced maintain by using
extreme monitor the patient are
by change in blood these
Helps to
headache. vital signs of monitored.
blood pressure interventions
obtain
the patient.
pressure. within as evidenced
Objective Temp.- 98.40 F baseline data.
normal by
Data:
limit. H.R- 76 b/m monitoring
The nurse blood
P.R- 18 b/m
monitored pressure i.e.
the blood 128/86 mm of
B.P-140/90 mm
pressure of hg.
of hg.
the patient
i.e. 140/90 Provide Adequate rest is
To promote
mm of hg. adequate rest provided.
circulation.
to the patient.

To lower the
Provide anti-
Tab. Amlopress blood
hypertensive
5 mg is given. pressure.
medication as
prescribed by
the physician.
Assessment Nursing Goal Planning Implementation Rationale Evaluation
diagnosis

Subjective Deficit fluid To Assess the General condition To know the Fluid balance
data: volume improve general of the patient was general of the patient
related to the fluid condition of assessed. condition of is improved
Patient says
excessive balance patient. the patient. to some
that I am
urination as of the Assess skin Helps to extent by
having Skin turgor and
evidenced by patient. turgor and oral oral mucous obtain using these
excessive
monitoring mucous baseline data interventions
urine membrane
intake-output membranes regarding as evidenced
urgency. assessed.
chart. for signs of dehydration. by intake-

dehydration. output chart.

Objective To improve
Patient is
Data: Encourage the hydration
encouraged to
increased fluid status.
The nurse take plenty of
intake by
monitored fluids.
providing
the intake-
appealing
output chart
liquids.
of the To maintain
Monitor Intake-output
patient. the fluid
intake-output chart is
monitored. balance.
chart of the
patient.
Assessment Nursing Goal Planning Implementation Rationale Evaluation
diagnosis

Subjective Imbalanced To Assess the General condition To gather the Nutritional

data: nutritional maintain general of the patient was baseline data. pattern of the

Patient says pattern less nutritional condition of assessed. patient is

that I am not than body pattern. the patient. reduced to

having a demand Maintain the Intake output

some extent

good related to intake and chart by using

of the
intake of To maintain these
apettite. output chart patient is
insufficient the nutritional interventions
of the patient. maintained.
diet as status. as evidenced
evidenced by by intake-
Objective intake- To maintain output chart.
data: output chart. Provide small Small frequent the energy
Nurse frequent diet diet is provided.
stores and
observed to the patient.
nutritional
that patient requirement.
is lethargic Provide fresh
Fresh juice is To provide
and not juices to the
provided to the energy.
taking patient.
patient.
meals
properly.
 NURSING THEORY APPLICATION- VIRGINIA HENDERSON NEED THEORY

SR. HENDERSON’S 14 ASSESSMENT FINDINGS INTERVENTIONS

NO. CONCEPTS

1. Breathe normally. Patient has no difficulty in -

breathing.

2. Eat and drink adequately. Patient is not able to eat and Patient is encouraged to
drink adequately. take small frequent diets
and fresh juices.

3. Eliminate body waste. Elimination pattern is normal. -

4. Move and maintain desirable Patient is on complete bed rest. -

posture.

5. Sleep and rest. Sleeping pattern of the patient is -

normal.

6. Select suitable clothes- dress Patient is able to select suitable -

and undress. clothes- dress and undress.

7. Maintain body temperatures Body temperature of the patient -

within normal range by is normal.
adjusting clothing and
modifying environment.

8. Keep the body clean and well Patient is well groomed. -

groomed and protect the
integument.

9. Avoid dangers in the Patient is able to walk -

environment and avoid independently without any
injuring others. assistance.

10. Communicate with others in Patient expresses her needs and -

expressing emotions, needs, emotions.
fears, or opinions.

11. Worship according to one’s Patient is spiritual and worships -

faith. according to her faith.
12. Work in such a way that there Patient is able to perform her -
is sense of accomplishment. activities of daily living.

13. Play or participate in various Patient does not want to -

forms of recreation. participate in any form of
recreation.

14. Learn, discover, or satisfy the Patient has anxiety regarding Anxiety is reduced by
curiosity that leads to normal the present illness. answering every question,
development and health and the patient wants to know.
use the available health
facilities.
HEALTH EDUCATION
SR. TOPIC EDUCATION
NO.

1. Hygiene  I educated the patient regarding personal hygiene and

environmental hygiene.
 I educated the patient to do daily bathing, oral care and
hair care also.
 I educated the patient to keep the surrounding clean.
2. Nutritional diet  I educated patient to take limiting oral fat.
 I educated them eat more vegetable and fruits in diet.
 I educated them to take less sodium in diet.
 I educated patient to avoid fried food and processed foods.
 I educated patient to take low calories and rich in dietary
fiber.
3. Medication  I educated patient to take medication in time as prescribed
by doctor.
 Medication helps in early recovery.
4. Rest and sleep  I educated patient rest and sleep helps in maintaining
proper health.
 Rest and sleep can change body as well as mind.
 I educated his to take at least 6-8 hours rest at night and
1hours sleep in a day for better working.
5. Exercise  I educated patient exercise is also important for
maintaining good health.
 I educated patient to do deep breathing exercise.
 I educated patient to do aerobic exercises and meditation.

6. Follow up  I educated patient to come for follow up and checkup as

prescribed by doctors.
PROGNOSIS
1ST DAY:

Problem:

 The condition of the patient was not good due to increase in blood glucose level.
 Medications are provided to the patient.
 Continuous BP monitoring was done.
 Reassurance given.

Vital Signs:

 Temperature- 98.4 0 F
 Pulse- 76/ min.
 Respiration- 18/ min
 Blood Pressure- 140/90 mm hg.

2nd DAY:

Problem:

 The condition of the client is improved to some extent.

Care:

 Complete bed rest provided.

 Continuous BP monitoring done.
 Medications are provided to the patient.

Vital Signs:

 Temperature- 98.2 0 F

 Pulse- 80/ min.

 Respiration- 18/ min

 Blood Pressure- 130/90 mm hg.

3rd DAY:

Problem:

 The condition of the client is improved to some extent.

Care:

 Continuous BP monitoring done.

  Medications are provided to the patient.

Vital Signs:

 Temperature- 98.4 0 F

 Pulse- 78/ min.

 Respiration- 18/ min

 Blood Pressure- 128/88 mm hg.

SUMMARY
My patient (Mrs. Minakshi) was admitted in Antenatal ward of Kamla Nehru state Hospital for
Mother and Child, Shimla on 20/12/2023 with complaint of high blood pressure i.e. 140/90
mm of hg. After history collection, complete physical examination, viewing her investigations
and treatment regimen, I planned nursing interventions based on her priorities to provide better
nursing care. Then health education is provided which included important points like good self-
hygiene, therapeutic diet, exercise, medications and follow-up as advised by concerned
physician.

CONCLUSION
Patient’s condition was improved to some extent after following the treatment regimen and
providing priority-based nursing care for three days.
BIBLIOGRAPHY
 BOOK REFERENCES
 Dutta DC, Textbook of Obstetrics including Perinatology and Contraception, 9 th
Edition. New Delhi; Jaypee Brother’s Medical Publishers (P) Ltd. 2015. 224-226.
 Wolter Kluwer, Drug Book, 32th Edition; Lippincot William & Wilkinson
Publishers, London.
 NET REFERENCES
 https://byjus.com/biology/human-heart/
 https://www.istockphoto.com/vector/human-heart-circulatory-system-
gm598167278-102551837
 https://my.clevelandclinic.org/health/diseases/4497-gestational-hypertension