NCMA 219 RLE TASK 1

HELLO!

I am Andrea Autor

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CASE SCENARIO
Let’s start with the first set of slides
 CASE S CE NARIO

This is a case of a 39y/o G3P1 pregnant patient who was admitted with
chief complaint of headache and dizziness. The client weighs 73 kg and
has a height of 148cm. Patient claim to have complete childhood
immunization.
The patient has no known history of HPN, Asthma, DM, PTB, Thyroid
Disease, and malignancy. No known allergy to food and medications. No
history of blood transfusions and previous surgeries.

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 CASE S CE NARIO

Patient had her menarche at 13 years old occurring at regular interval, lasting for 3-5 days,
consuming 2-3 pads per day, moderately soaked with occasional dysmenorrhea. Subsequent
menses came in regularly with the same amount, flow and duration. Patient had her first child
in 2010 and delivered full term via normal spontaneous delivery. Her second pregnancy was a
missed miscarriage at 12 weeks AOG in 2012. Dilation and curettage were done in a
provincial hospital. Her current pregnancy is on her 28 weeks gestation. She had been on
antibiotic(prescribed) a month ago due to urinary tract infection. The patient has 2 siblings
and she is the eldest. She is a high school graduate, unemployed, single and currently living
in with her partner who works as construction worker. Patient is a non-smoker, occasional
alcohol beverage drinker.

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NURSING CARE PLAN

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ASSESSMENT DIAGNOSIS BACKGROUND PLANNING INTERVENTIO RATIONALE EVALUATION
KNOWLEDGE N

SUBJECTIVE Ineffective tissue Pre-eclampsia is a STG: Independent:

“Masakit po yung perfusion related medical condition After 3 hours of a. Create an a. Trust is an
ulo ko at nahihilo to in which nursing atmosphere essential first
ako.” vasoconstriction hypertension intervention, the to facilitate step in the
of blood vessels arises in pt will be able to: trust. therapeutic
OBJECTIVE as evidenced by pregnancy 1. Relieve from b. Monitor vital relationship.
• V/S: headache and (pregnancy headache and signs b. To identify
T – 37.3° dizziness, high induced dizziness. particularly physical
PR – 120bpm blood pressure, hypertension) in 2. Exhibit a blood responses
RR – 23cpm positive swelling association with normal blood pressure. associated
BP – of the upper and significant pressure of c. Place patient with medical
150/100mmHg lower extremities amounts of 120/80. on strict conditions.
• (+) pedal non (oedema), protein in the LTG: regimen of c. Lateral
pitting edema,
(+) edema on fatigue, and urine. After 48 hours of bedrest; recumbent
upper excess protein in 1. nursing encourage position
extremities the urine Vasoconstriction intervention, the lateral decreases
(Grade 1) (proteinuria). pt will be able to: position. pressure on
• (+) fatigability 1. Acquire the the vena cava,
• Warm to touch Hypertension absence of increasing
skin albumin in the venous return
• Labs: urine and
• Urinalysis (with circulatory
proteinuria) volume.

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with intravascular 2. Oedema This enhances
coagulation should be placental and
confined to the renal perfusion,
3. Endothelial lower extremities reduces adrenal
dysfunction only. activity, and may
lower BP

Oedema

4. Maternal
Plasma Volume
Contraction

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 REFERENCES

https://nurseslabs.com/pregnancy-induced-hypertension/
https://www.slideshare.net/abdullahkhamis777/pree-eclampsia
https://www.slideshare.net/iraqi4everm2/case-discussions
https://nurseslabs.com/pregnancy-induced-hypertension/
https://nurseslabs.com/ineffective-tissue-perfusion/
https://www.whattoexpect.com/pregnancy/symptoms-and-solutions/edema.aspx
https://www.youtube.com/watch?v=yta5RRJ-Mg8

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 THANKS!

Any questions?

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