BULACAN STATE UNIVERSITY CITY OF MALOLOS S.Y.

2011-2012 NCM102

A CASE PRESENTATION ON PRE-ECLAMPSIA

(Pregnancy Induced Hypertension)

SUBMITTED BY: GROUP 2 LEADER: MEMBER: De Jesus, Jade M. De Vera, Paula Marie E. Diaz, Elisha Rose C. Federis, Nerissa Joy Flores, Marjelene G. Garcia, Janette C. Jamakeo, Robheille Kathleen B. Junio, Ma. Jaecelyn S. Layug,. Jeremy R. Dela Cruz, Mary Grace C.

SUBMITTED TO: Maria Luisa C. De Jesus, RN, RM, MA

I.

INTRODUCTION A. INTRODUCTION ABOUT THE PATIENT Our client Mrs. M.S G4P2 (1301) is a 23 yrs. Old living in Frances, Calumpit, Bulacan. She was rushed to the hospital due to labor pain. A few hours prior to admission she delivered a fetal death (baby girl) on a tricycle on the way to the hospital. According to Mrs. M.S she felt pain on her lower back then goes to her abdomen. She decided to go to the hospital when there s a sudden gush of clear fluid coming from her vagina. Our patient was admitted last January 8, 2011 (10:00 am) at Calumpit District Hospital in Calumpit, Bulacan. She delivered a 26 weeks baby girl (death) by labor induction. Her blood pressure is 140/100mmHg with (+) edema on her upper and lower extremities, pulse rate of 80bpm and respiratory rate of 19cpm. As we go on monitoring her vital signs, her blood pressure reached up to 150/120mmHg. This was very alarming because this was an indication that she was having a condition called Pregnancy Induced Hypertension and on her clinical diagnosis, physician found out that there is a presence of protein in her urine. We conclude that Mrs. C.S experienced Pre-eclampsia. Her chart revealed that she has a history of Hypertension. Two of her sisters had this condition and her father too. It was so hard for her to cope up on this situation, she even cried to us when we asked her about her recent pregnancies. As we go further on this case presentation, we will be able to know the everyday lifestyle of Mrs. M.S but before that we must first to know some important information about Pre-eclampsia. DEFINITION OF THE CASE Pregnancy Induced Hypertension (PIH)
y y y y y

Pregnancy Induced Hypertension is a form of high blood pressure in pregnancy. It occurs in about 5 percent to 8 percent of all pregnancies. It is a condition in which vasospasm occurs during pregnancy in both small and large arteries. With high blood pressure, there is an increase in the resistance of blood vessels. This may hinder blood flow in many different organ systems in the expectant mother including the liver, kidneys, brain, uterus, and placenta. It occurs in about 5 percent to 8 percent of all pregnancies. Originally, it was called toxemia because researchers pictured a toxin of some kind being produced by woman in response to the foreign protein of the growing fetus, the toxin leading to the typical symptoms. No such toxin has ever been identified.

Possible causes may include:

y y y y y

Insufficient blood flow to the uterus Damage to the blood vessels A problem with the immune system Poor diet Genes

PREECLAMPSIA Preeclampsia is a medical condition that typically starts after the 20th week of pregnancy and is related to increased blood pressure and protein in the mother's urine (as a result of kidney problems). Preeclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. There s no known way to prevent preeclampsia. Eating less salt or changing your activities during pregnancy doesn t reduce the risk. The best way to take care of yourself and your baby is to seek early and regular prenatal care. If preeclampsia is detected early, you and your doctor can work together to prevent complications and make the best choices for you and your baby. The way to "cure" it is to deliver the baby. Risk factors of Pregnancy Induced Hypertension (PIH) Preeclampsia develops only during pregnancy. Risk factors include:
y y y y y y y

History of preeclampsia - A personal or family history of preeclampsia increases the risk of developing the condition. First pregnancy The risk of developing preeclampsia is highest during the first pregnancy or the first pregnancy with a new partner. Age The risk of preeclampsia is higher for pregnant women who are older than age 35. Obesity The risk of preeclampsia is higher if the pregnant woman is obese. Multiple pregnancies Preeclampsia is more common in women who are carrying twins, triplets or other multiples. Gestational diabetes Women who develop gestational diabetes have a higher risk of developing preeclampsia as the pregnancy progresses. History of certain conditions Having certain conditions before becoming pregnant such as chronic high blood pressure, diabetes, kidney disease or lupus.

Signs and Symptoms of Pregnancy Induced Hypertension (PIH)

y y y y y y y y y y y

Hypertension - Elevated blood pressure Proteinuria - presence of excess protein in the urine after 20 weeks of pregnancy. Severe headaches Changes in vision, including temporary loss of vision, blurred vision or light sensitivity Upper abdominal pain, usually under the ribs on the right side Nausea or vomiting Dizziness Decreased urine output Agitation Sudden weight gain, typically more than 2 pounds a week Edema swelling particularly in the face and hands, often accompanies preeclampsia as well. Swelling isn t considered a reliable sign of preeclampsia, however, because it also occurs in many normal pregnancies.

Nursing Intervention for a woman with severe PIH:

y y y y y

Support bed rest Monitor maternal and well being Monitor Fetal Well being Support a Nutritious Diet Administer medications to prevent eclampsia

STATISTICS: In the Philippines, according to Department of Health, Maternal Mortality Rate (MMR) is 162 out of 10,000 live births (Family Planning Survey 2006). Maternal deaths account for 14% of deaths among women. For the past five years all of the causes of maternal deaths exhibited an upward trend. Preeclampsia showed an increasing trend of 6.89%; 20%; 40%; and 100%. Ten women die every day in the Philippines from pregnancy and childbirth related causes but for every mother who dies, roughly 20 more suffer serious disease and disability. The UNFPA office in the Philippines declared that family planning can help prevent maternal deaths by 35%. B. OBJECTIVES Knowledge:  To acquire more knowledge about Pregnancy Induced Hypertension (Preeclampsia).  To identify the risk factors contributing to the occurrence of the disease.  To provide client education and involve in implementing therapeutic regimen to promote understanding and compliance. Skills:  To describe nursing care for the patient.  To apply nursing process in the case of the hospitalized patient.  To learn the pathophysiology and manifestations of preeclampsia. Attitude:  To support client and family and encouraged them to ask questions so that information could be clarified and understand.  To assess the health of the client.  To be more confident and independent in rendering nursing care to our client specifically pregnant woman with preeclampsia.

II.

NURSING ASSESSMENT A. y PERSONAL HISTORY Demographic Data of the Patient NAME: ADDRESS: AGE: SEX: STATUS: RELIGION: OCCUPATION: NATIONALITY: EDUCATIONAL ATTAINMENT: DATE OF ADMISSION: TIME: B. Mrs. M.S Frances, Calumpit, Bulacan 23 yrs. Old Female Married Catholic none Filipino High School Graduate January 08, 2012 11:00am

REASON FOR VISIT (CHIEF COMPLAIN) Our client felt labor pain, headache and blurring of her vision. Also her blood pressure started to rise from 140/100mmHg to 150/120mmHg.

C.

HISTORY OF PRESENT ILLNESS

Our client delivered spontaneously a P.U 26 weeks Intrauterine Fetal Death (baby girl) with birth weight of 300gms. Non-hystopathological, few hours prior to admission, on a tricycle on the way to the hospital. She experienced pain in the lower abdomen, dizziness and with blood pressure of 140/100mmHg. A few hours later her blood pressure reached up to 150/120mmHg with pulse rate of 80bpm, respiratory rate of 19cpm with presence of edema on her upper and lower extremities which shows signs and symptoms of Pregnancy Induced Hypertension (PIH). D. HISTORY OF PAST ILLNESS

Mrs. M.S told us that she never had illness during her childhood except for colds and flu but her mother always gave her over the counter medicine such as biogesic to cure those illnesses. She also stated that she was fully immunized; even on her recent and past pregnancy she received Tetanus Toxoid twice. Her medical record reveals that Mrs. M.S had Pregnancy Induced Hypertension which had been proven through her blood pressure and presence of protein in her urine.. Addition to that, our client experienced 3 spontaneous abortion (miscarriages) which lead to fetal death and we know that spontaneous abortion is one of the risk factors that would lead to another abortion on next pregnancies to occur.

E.

FAMILY HEALTH ILLNESS HISTORY (GENOGRAM)

LEGEND: - FEMALE - MALE - DEATH

Mrs. R.S 58 yrs. Old Cancer

Mr. H.S 66 yrs. Old +HPN

- DEATH A/W Alive & Well +HPN Hypertension S.B Still Birth

Mrs. L..M 38 yrs. Old +HPN

Mrs. M.M 36 yrs. Old A/W

Mr. R.S 34 yrs.old A/W

Mrs. D.A 32 yrs. Old A/W

Mr. J.S 30 yrs. Old A/W

Mrs. M.s Our client

23 yrs. Old +HPN

Ms. L.S 17 yrs. Old A/W

Our client s husband Mr. R.S 30 yrs. Old A/W

8 months S.B

R.S 4 yrs old A/W

6 months S.B

6 months S.B

F.

FUNCTIONAL HEALTH PATTERN (GORDON APPROACH) BEFORE HOSPITALIZATION Had a healthy lifestyle. Practiced hygienic measures such as taking a bath regularly, brushing the teeth, hand washing before and after meals and regular change of clothes. Usually seek a doctor if illness occurs. Easily follows order and suggestion of the doctor. She does not have regular dental check-up. Since she got pregnant she was regularly visiting her doctor for prenatal check-ups. Not smoking and even drinking liquor. Eats 3x a day with snacks in between meals. Food usually taken: Fish 4-5 servings a week. Second choice: vegetable 2-3 servings a week. Her diet usually high in Salts, had difficulty in tolerating certain foods such as noodles, dried fish and fish sauce. Soft drinks were usually taken even she got pregnant. Do not have difficulty in chewing and swallowing food. Do not take any vitamins or herbal supplements. Skin heals quickly. AFTER HOSPITALIZATION Became lazy doing hygienic measures. Still follows doctor s order.

FUNCTIONAL HEALTH PATTERN Health Perception Health Management Pattern

y y

y y

y y y y Nutritional Metabolic Pattern y y y y y

y y

Diet: Low Sodium intake But sometimes, still difficult to tolerate foods specifically noodles.

y y y y

24 HOUR DIETARY RECALL Date Noted Time of the Day Foods Taken January 8, Breakfast 2 packs of 2012 (morning) crackers (Sunday) 1 cup of coffee 1 glass of water

Lunch (noon time)

1 small bowl of kare-kare with one tsp. of bagoong 2 cups of rice 3 glasses of water

Dinner (evening)

1 small bowl of kare-kare 2 cups of rice 3 glasses of water

January 9, Breakfast 2012 (Monday (morning)

NPO

Lunch (noon)

bowl of menudo 1 cup of rice 2 glasses of water

Dinner (evening)

1 small bowl of chopseuy 1cup of rice 2 glasses of water

Elimination Pattern

Bowel Movement Urine Feces

Color

Frequency

Characteristic

Odor

Discomfort

No changes

Dark yellow brown

6-8 x a day Once a day

Slightly turbid firm

aromatic Foul odor

No discomfort No discomfort

y y

Activity Exercise Pattern

No voiding discomfort and bowel movements. Usually perspires when doing household chores but according to her simple chores makes her perspire that much on which she noticed that it was too different since she got pregnant. y Doing household chores and walking is her form of exercise. y Spends leisure time by watching television and doing household chores y As we assess our client s ADL, we noticed that she was fully independent, she can do all of that activities. Activities Score Criteria Feeding 0 Bathing Grooming 0 0 0 0 0 0
Level 0 Full Self-care Level 1 Requires the use of equipment or device Level 2 Requires assistance or supervision from another person Level 3 Requires assistance or supervision from another person or device Level 4 Dependent and doen not participate.

y Needs assistance when standing on bed and walking. y Wants only to rest the whole day. y As we assess our client s ADL, we notice that she was partially dependent with assistance from the nurse. Activities Feeding Bathing Grooming Ambulation Toileting Bed Mobility Dressing Score 0 3 2 2 1 0 2 No changes Criteria
Level 0 Full Self-care Level 1 Requires the use of equipment or device Level 2 Requires assistance or supervision from another person Level 3 Requires assistance or supervision from another person or device Level 4 Dependent and doen not participate.

Ambulation Toileting Bed Mobility Dressing Sexuality Reproductive Pattern y y y y

Menarche was in the age of 13. LMP: Sept. 10, 2011 Has regular menstrual cycle G4P2 (1301)

Sleep Rest Pattern

y y y y y y y y y y y

Cognitive Perceptual Pattern

Do not use any contraceptives. Sleeps 3-4 hrs. a day Have problem falling asleep. Feel fatigued after a sleep period Watching television is her form of relaxation when she had problem falling asleep. Takes a nap in the afternoon. No problems in her hearing abilities Has 20/20 vision, does not wear any eyeglasses Without memory problem Other senses are in good condition Has the ability to understand, communicate, remember and make decisions on her own. Feels good all the time Mood is affected which becomes irritable. Lives with family Handle and solve problems through communication Doesn t have problems dealing with her child Tensed sometimes and just takes rest to release it Her husband supports her all the time to provide emotional support for her condition Family is the most important thing in her life She s catholic and she deeply believes that God will always be there to keep her and her family safe, no matter what happens.

y Can now sleep 6-8 hrs. a day y Others no changes

y Has blurred vision because of her condition

Self-Perception and Self-Concept Pattern Role Relationship Pattern

Coping Stress Tolerance Pattern

y y y y y y y y y

y Sometimes she had headache and became dizzy. y Worry on her situation. No changes

y Tense a lot of times because she is worried about her condition No changes

Value Belief Pattern

G. GROWTH AND DEVELOPMENT MORAL Post conventional (universal ethical principle orientation) DEFINITION It is the final stage where The person lives it begins at the start of autonomously and defines puberty when sexual moral values and urges are once again principles that are distinct awakened. Adolescents from personal direct their sexual urges identification with group onto opposite sex peers, values. He or she lives with the primary focus according to principles that of pleasure is the are universally agreed on genitals. and that the person considers appropriate for life. FINDINGS Mrs. M.S personal lifestyle Our client uses rational Our client s energy is She is consistent on her develops, she establishes a thinking; her reasoning is directed toward full decision making. Her relationship with a significant deductive and futuristic. sexual maturity and conscience is working for others like her husband and function and her to do the right one. She had a meaningful social life development of skills makes an effort to define needed on which to cope valid values and principles with the environment. without regard to the expectation of others. REMARK/ANALYSIS We as a nurse must assist By this stage, the person We must encourage Our client s decisions and adult s chosen lifestyle and no longer requires separation from parents behaviors are based on assist with necessary concrete objects to make which lead to internalized rules, on adjustments relating to health. rational judgments. achievement of conscience rather than We must recognize the person s independence and social laws, and on selfcommitments and support decision making. chosen ethical and abstract change as necessary for health. principles that are universal, comprehensive, and consistent. THEORY STAGE COGNITIVE Formal operations stage (adolescence and adulthood) Occurring in this stage, they In this stage, intelligence begin to share their selves more is demonstrated through intimately with others. They the logical use of symbols explore relationships leading related to abstract toward longer term concept. He or she is commitments with someone capable of deductive and other than a family member. hypothetical reasoning. PSYCHOSOCIAL Young Adulthood ( Intimacy vs. Isolation ) PSYCHOSEXUAL Genital Stage ( puberty onward )

H.

THEORETICAL APPLICATION THEORY THEORIST Nola J. Pender Former professor of nursing at the University of Michigan, has developed a rational choice model of health care. DESCRIPTION Features: based on the idea that human beings are rational and will seek their advantage in health. It tightly bounded by things like self-esteem, perceived advantages of healthy behaviors, psychological states and previous behavior. Not merely to cure decease but to promote healthy lifestyle and choices that affect the health of individual. Function: To show the individual as selfdetermining but also determined by personal history and general personal characteristics. Health is a dynamic process not a static state health, to put it differently is a lifestyle conditioned by a number of choices made by individual to actually live a healthy lifestyle. Significance: Health is up to person. The significance here is that the medical profession is really not the main ingredient in living a healthy lifestyle. The health profession in other words is useless unless individual reform their own lives and perceptions of what is healthy. The major concepts and definitions of the health promotion model. y Individual characteristics and experience. APPLICATION OF THEORY TO THE PATIENT

Health Care and Promotion Theory

y Prior related behavior. y Frequency of the similar behavior in the past. Direct and indirect effects on the livelihood of engaging in health promoting behaviors.

III.

ANATOMY AND PHYSIOLOGY

I.

EXTERNAL PARTS:

1. Mons veneris / mons pubis a firm, cushion like elevation of adipose tissue over the symphysis pubis covered by curly hair or pubic hair forming escutcheon. In female, pubic hair tends to be triangular distribution, while in male, it tends to be diamond shaped. It serves to protect the junction of the pubic bone from trauma.

2. Labia majora

two rounded folds of adipose tissue with overlying skin; they extend from the mons pubis downward and backward to encircle the vestibule. The

outer surface are covered with hair, where as the inner surface contain sebaceous follicles which are smooth and moist. Their purpose is mainly to protect the inner delicate parts of the vulva. The labia majora are homologous of the scrotum in the male organ. At the same time, it is the frequent site of varicose vein in the vulva. The arterial blood is supplied by the internal and external pudendal arteries and a portion of the inferior rectus artery. It also shared an extensive lymphatic supply with the other structure of vulva, which facilitates the spread of cancer in female reproductive organ, and obstetric or sexual trauma may cause hematoma. Immediately under the skin is a sheet of dartos muscle, which is responsible for the wrinkled appearance as well as for their sensitivity to heat and cold. Ordinarily, these structures are 7 8 cm. in width and 1 1.5 cm. in thickness. 3. Labia minora - two thin, flat, reddish folds of tissue lying between the inner surfaces of the labia majora. Each labium minus consists of a thin fold of connective tissue which when protected, presents a moist, reddish appearance, similar to that of mucous membrane. The structure is covered by stratified squamous epithelium. It doesn t contain hair follicle but it contains many sebaceous follicles and occasionally a few sweat glands. y Functions:

a. To lubricate and waterproof the vulvar skin. b. To provide bactericidal secretion. The labia minora are classed among erectile structures. This structure is extremely sensitive and abundantly supplied with several varieties of nerve endings. Anteriorly, each divide into 2 parts; the upper pair merges into the prepuce and the lower one fuse to form the frenulum. Posteriorly, the labia minora fuse to form fourchette. The labia minora increase in size at puberty and decrease after menopause due to estrogen level changes. 4. Clitoris - a small, cylindrical highly sensitive erectile organ corresponding to the male penis. It is made up of erectile tissue which many large and small venous channels surrounded by large amount of involuntary muscle tissue, the ischiocarvernosa facilitate erection of the organ. y Functions :

a. Stimulate and elevate levels of sexual tension. b. Serve as a landmark in locating urethral opening during catheterization. The clitoris measures 5 6 mm. long and 6 8 mm. across. It has very rich blood and nerve supplies. It produces smegma, which along with other vulvar secretion has a unique odor that may be sexually stimulating to the male.

5. Vestibule

an almond

shaped area that is enclosed by the labia minora laterally and extends from the clitoris to the fourchette antero-posteriorly. The posterior

portion of the vestibule between the fourchette and the vaginal opening is called the fossa navicularis and is usually observed only in nulliparous women. The vestibular bulb is located beneath the mucous membrane of the vestibule on either side which are almond shaped aggregation of vein 3 4 cm. long, 1 2 cm. wide and 0.5 1 cm. thick. These bulbs lie in close opposition to the ischio-pubic rami and partially covered by the ischiocavernosus and constrictor vaginal muscles. These structures are liable to injury and rupture which may result in a vulvar hematoma or hemorrhage. It is perforated usually by 6 openings: urethra, vagina, and bartholin s gland (2) and paraurethral gland (2). 5.1. Urethral meatus / urethral orifice although not a true part, it is considered as part of the reproductive system because of its closeness and relationship to the vulva. It is situated in the middle of the vestibule and serves as an outlet for urine from the urinary bladder. 5.2. Vulvovaginal / bartholin s gland pair of small, pea sized glands located within the substances of the labia majora. They correspond to the bulbourethral of Cowper s gland in male. Often, they are sites of infection, abcess and cyst formation. Usually, the openings are not visible or palpable. The gland secretes a small amount of clear, viscid mucus during sexual excitement. 5.3. Paraurethral / skene s gland a pair of small glands lying on each side of the urethra. They produce a small amount of mucus and are especially susceptible to gonorrheal infection. It is homologous to male prostate. 5.4. Vaginal orifice / introitus occupies the lower portion of the vestibule and varies considerably in size and shape. The vagina has an abundantly vascular supply. Its upper third is supplied by the of the vesicovaginal branches uterine arteries. Its middle third by the inferior vesical arteries. Its lower third by the middle hemorrhoidal internal pudendal arteries. Anteriorly, the vagina is in contact with the bladder and urethra from which is separated by a connective tissue referred to vesicovaginal septum. Posteriorly between the lower portion and the rectum is the rectovaginal septum. Approximately, the upper of the vagina is separated from the rectum by the rectouterine or cul-de-sac of Douglas. The vagina varies in length. The anterior and posterior vaginal walls commonly measure 6 8 cm. and 7 10 cm. in length, respectively. The areas around the

cervix at the upper end of the vagina are called fornicles, right and left, anterior and posterior. The walls are lined with mucous membrane, which falls into folds, or corrugated formation called rugae. These are referred to the inner wall of vagina. It is smooth during labor and parturition. It is not present before menarche and gradually become obliterated after repeated childbirth and menopause. A healthy vagina has pH of 4.0 6.0.

Functions:

a. serves as excretory duct of the uterus b. female organ for copulation c. part of birth canal Hymen comprised mainly of connective tissue both elastic and collagen. Both surfaces are covered by stratified squamous epithelium. The hymen can be broken through strenous physical activities or masturbation. After childbirth, especially in multipara, the remnants of the hymen from several cicatrized nodules of varying size called myrtiform caruncles. 6. Perineum the area extending from the fourchette to the anus. The pelvic and urogenital diaphragm provides most of the support of the perineum. 6.1.Pelvic diaphragm consists of the levator ani muscles which is the principal muscle that is close to vagina and the coccygeus muscle posteriorly. The levator ani muscles form a broad muscular sling that originates from the posterior surface of the superior rami of the pubis, from the inner surface of the ischial spine and between the 2 sites from the obturator rami. 3 portion of levator ani muscle: a. iliococcygeus muscle b. pubococcygeus muscle c. puborectalis muscle The pubococcygeus and puborectalis constrict the vagina and rectum and form an efficient functional rectal sphincter. Their functions are as follows: a. play a role in sexual sensory function b. bladder control c. Control perineal relaxation during labor and in expulsion of the fetus during birth. located in the hollow of the pubic arch and consists of the transverse perineal muscles, constrictor of urethra and internal and

6.2.Urogenital diaphragm

external fascial covering. These muscles originate at the ischial tuberosities and insert into the perineal body. The strong muscle fibers provide support to the anal canal (sphincter muscle) during defication and to the lower vagina during delivery.

The perineal body is a wedge shaped between the vaginal and canal opening which serves as an anchor point for the muscles, fascia and ligament of the upper and lower pelvic diaphragm. The perineal body is about 4 cm. wide x 4 cm. deep and continuous with the septum between the rectum and vagina. This tissue is flattened and stretched as the fetus moves through the birth canal.

II .INTERNAL ORGAN :

1. Uterus a hollow pear shaped organ partialy covered by peritoneum or serosa. The posterior wall of the uterus is directly covered with peritoneum and the lower portion forms the anterior portion of the cul-de-sac of Douglas. The cavity of the uterus is lined by the endometrium. During pregnancy, the uterus serves for reception, implantation, retention and nutrition of the conceptus which then expels during labor. It undergoes remarkable growth due to hypertrophy of muscle fibers. Its size increases from 60 g. to about 1,100 g. at term and a total volume averages about 5 liters. A non pregnant uterus has an approximately measurement of 7.5 cm. long x 5 cm. wide x 2.5 cm thick, and during pregnancy, it is approximately measures 30 cm. x 30 cm. x 20 cm.

Two Major but unequal parts : 1. body or the corpus upper triangular portion which constitute the greater part.

a. Fundus the upper, rounded prominence above the insertion of the fallopian tube. b. Corpus - main portion encircling the intrauterine cavity. c. Isthmus - known as the lower uterine segment during pregnancy. It is slightly constricted portion that joins the corpus to the cervix. 2. Cervix the lowermost portion of the uterus. It is divided by the attachment of the vagina into vaginal and supravaginal portion. The supravaginal segment on its posterior surface is covered by peritoneum, laterally, it is attached to the cardinal ligament and anterior, it is separated from the overlying bladder by loose connective tissue. The cavity of the cervix is a narrow tube called cervical canal. a. Internal Os the narrowed opening between the uterine cavity and the endocervical canal. b. External Os small round opening at the lower end of the cavity and endocervical canal. y The corpus of the uterus is made up of 3 layers :

a. Serosal layer or perimetrium the outermost layer which is composed of peritoneum. b. Muscular uterine layer or myometrium the middle layer. This is continuous with the muscle layer of the fallopian tube and with that of the vagina. This helps the organ present a unified reaction to various stimuli ovulation and orgasm.


There are 3 distinct layers of uterine ( smooth ) involuntary muscles : b.1. The outer layer found mainly over the fundus, is made up of longitudinal muscles especially suited to expel the fetus during birth. b.2. The middle layers thick and made up of interlacing muscle fibers in figure of 8 patterns. These muscles fibers surround large old vessels and their

contraction produces a hemostatic action and control of blood loss after placental separation. The vaginal cervix appears pink and ends at the external Os. The cervical canal appears rosy red and is lined with columnar ciliated epithelium, which contains mucus secreting glands. Most cervical cancer begins at this squamocolumnar junction. Elasticity is the chief characteristics of the cervix. Its ability to stretch is due to the high fibrous and collagenous content of the supportive tissues and also to the vast number of folds in the cervical lining.  The cervical mucosa has 3 functions:

1. provide lubrication for the vaginal canal 2. act as a bacteriostatic agent 3. Provide an alkaline environment to shelter deposited sperm from the acidic vagina.

At ovulation, cervical mucus is clearer, thinner and more alkaline than at other times. b.3. The inner layer made up of circular fibers, which forms sphincter at the fallopian tube attachment sites and at the internal Os. The internal Os

sphincter inhibits the expulsion of the uterine contents during pregnancy but stretch in labor as cervical dilatation occurs. The sphincters at the fallopian tube prevent menstrual blood from flowing backward into the fallopian tube from the uterus. c. Mucosal layer or endometrium the innermost layer which composed of a single layer of columnar epithelium, glands and stroma.


The mucous membrane of endometrium composed of 3 layers :

C.1.compact surface layer C.2.spongy middle layer of loose connective tissue C.3. Dense inner layer From menarche to menopause, the endometrium undergoes monthly degeneration and renewal in the absence of pregnancy. During menstruation and following delivery, the compact surface and middle spongy layers slough off. Just after the menstrual flow ends, the endometrium is 0.5 mm thick; near the end of the endometrial cycle, just before menstruation begins again, it is about 5 mm thick. When pregnancy occurs, the endometrium undergoes changes and become decidua. Ligaments of uterus : 1. Broad ligament comprised of 2 wing like structures that extend from the lateral margins of the uterus to the pelvic walls and thereby divide the pelvic cavity into anterior and posterior compartments. Each broad ligament consists of a fold of peritoneum and these superior, lateral, inferior and medial margins. The inner 2/3 of the superior margin forms the mesosalphinx to which the fallopian tubes are attached. The outer third of the superior margin extends from the fimbriated end of the oviduct to the pelvic wall, forms the infundibulopelvic ligament. The broad ligament keeps the uterus centrally placed and provides stability within the pelvic cavity. 2. Round ligament composed of smooth muscle and connective tissue, and helps the broad ligament in keeping the uterus in place. It is capable of contraction on time of labor thereby, it steady the uterus, pulling downward and forward, so that the presenting part of the fetus is forced into the cervix.

3. Cardinal / transverse cervical ligament / Mackenrodt composed of the dense connective tissue that medially is united firmly to the supravaginal portion of the cervix. It serves as the chief uterine support and to upper part of the vagina thus to prevent uterine prolapsed.

4.Uterosacral ligament

a cordlike folds of peritoneum extending from the supravaginal cervical portion of the uterus. It provides support for the uterus at the

level of the ischial spine. They also contain sensory nerve fibers that contribute to dysmenorrhea. 5. Ovarian ligament anchor the lower pole of the ovary to the cornua of the uterus. They composed of muscle fibers that allow the ligament to contract. 6. Infundibulopelvic ligament the suspensory ligament of the ovary. It contains the ovarian vessels and nerves. 7. Position of uterus The position of the uterus varies depending on a woman s posture, number of children borne, bladder and rectal fullness and even normal respiratory pattern. 1. Anteverted the fundus is tilted forward. It is considered as the normal position. 2. Anteflexed slightly bend forward. 3. Retroverted tilted backward 4. Retroflexed bending backward

Blood supply is derived from : 1. Uterine artery which arise from the anterior branch of hypogastric artery passing towards the uterus through the parametrium. The hypogastric artery provides most of the blood supply to the pelvic viscera and the pelvic musculature. It is divided into 2 main branches: 1.1. Cervicovaginal artery which supplies blood to the lower portion of the cervix and the upper portion of the vagina. 1.2. Internal iliac artery a major portion of the blood supply to the Pelvis. This is commonly referred to as the hypogastric artery.

The internal iliac artery is divided into 2 divisions: 1.2.1. Anterior division includes the umbilical, middle and inferior vesicle, middle rectal, obturator, internal pudendal, middle hemorrhoidal,

vaginal and inferior gluteal arteries. 1.2.2. Posterior division includes the lateral, sacral, superior gluteal and iliolumbar arteries. 2. Ovarian artery a direct branch of the aorta enters the broad ligament through the infundibulopelvic ligament.

Nerve Supply : The nerve supply is derived principally from the sympathetic nervous system but partly from the cerebrospinal and parasympathetic system.  Functions of uterus : 1. organ for menstruation 2. organ for gestation

2. Fallopian tube membrane. Parts:

or oviduct, are 2 trumphet shaped about 8

14 cm. in length, 3

8 mm in diameter covered by peritoneum and their lumen lined by mucous

a. Interstitial the narrow portion contained in the muscular wall of the uterus approximately 1 cm. in length. b. Isthmus proximal to the ampulla. It is the narrow portion of the tube adjoining the uterus approximately 2 cm. in length. c. Ampulla the outer 3rd portion where fertilization occurs and considered as longest portion with approximately 5 cm. in length. d. Infundibulum ovulation. distal third. Its funnel shaped opening encircles with fimbrae approximately 2 cm. long. This fimbrae become swollen, almost erectile at

The wall of the fallopian tube is made up of 4 layers :

a. Peritoneal (serous) covers the tubes. b. subserous ( adventitial ) contains the blood and nerve supply c. Muscular - responsible for the peristaltic movement of the tube. d. Mucosal composed of ciliated and unciliated cells with the number of ciliated cells more abundant at the fimbria. Any malformation or malfunction of the tubes could result in infertility, ectopic pregnancy or even sterility. Each fallopian tube is richly supplied with blood by the uterine and ovarian arteries.  Functions :

1. site of fertilization 2. provide transport for the ovum from the ovary to the uterus 3. serve as a warm, moist, nourishing environment for the ovum or zygote 3. Ovaries 2 almond shaped organ situated in the upper part of the pelvic cavity. The size varies among women and according to the stage of the menstrual cycle. Each ovary weighs 6 10 g with 1.5 3 cm wide, 2 5 cm long and 1 1.5 cm thick. After menopause, ovarian size diminishes remarkably. The ovary is attached to the broad ligament by the mesovarium. They also changed in appearance from smooth surfaced, dull white organs to pitted gray organ. Scarring due to ovulation causes this pitting. There is no peritoneal covering for the ovaries. Although this lack of covering assists the mature ovum to erupt, it also allows easier spread of malignant cells from cancer of the ovaries. A single layer of cuboidal epithelial cells, called the germinal epithelium covers the ovaries. y Layers of ovaries :

a. Tunica albuginea - dense and dull white and serves as protective layer. b. Cortex main functional part because it contains ova, graafian follicles, corpora lutea, degenerated corpora lutea (corpora albicantia). c. Medulla or central portion of the ovary is composed of loose connective tissue. Both sympathetic and parasympathetic nerves supply the ovaries. These also a counterpart to the testes of male organ.

Functions :

a. ovulation b. hormone production

CARDIOVASCULAR SYSTEM
The cardiovascular/circulatory system transports food, hormones, metabolic wastes, and gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system include:
y y

blood: consisting of liquid plasma and cells blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange occurs.)

heart: a muscular pump to move the blood

There are two circulatory "circuits": Pulmonary circulation, involving the "right heart," delivers blood to and from the lungs. The pulmonary artery carries oxygen-poor blood from the "right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich blood from tbe lungs back to the "left heart." Systemic circulation, driven by the "left heart," carries blood to the rest of the body. Food products enter the sytem from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems ultimately return to the "right heart" via the inferior and superior vena cavae. A specialized component of the circulatory system is the lymphatic system, consisting of a moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymph nodes, and organs (bone marrow, liver, spleen, thymus). Through the flow of blood in and out of arteries, and into the veins, and through the lymph nodes and into the lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion.

Blood Components
Adults have up to ten pints of blood.
y

Forty-five percent (45%) consists of cells - platelets, red blood cells, and white blood cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white blood cells, neutrophils and lymphocytes are the most important. Fifty-five percent (55%) consists of plasma, the liquid component of blood

Major Blood Components

Modified from: Joel DeLisa and Walter C. Stolov, "Significant Body Systems," in: Handbook of Severe Disability, edited by Walter C. Stolov and Michael R. Clowers. US Department of Education, Rehabilitation Services Administration, 1981, p. 37.

Component Type Platelets, cell fragments

Source
Bone marrow life-span: 10 days

Function
Blood clotting

Lymphocytes (leukocytes)

Bone marrow, spleen, lymph nodes

Immunity T-cells attack cells containing viruses. B-cells produce antibodies.

Red blood cells (erythrocytes), Filled with hemoglobin, a compound of iron and protein

Bone marrow life-span: 120 days

Oxygen transport

Neutrophil (leukocyte)

Bone marrow

Phagocytosis

Plasma, consisting of 90% water and 10% dissolved materials -- nutrients (proteins, salts, glucose),
wastes (urea, creatinine), hormones, enzymes

1. Maintenance of pH level near 7.4 2. Transport of large molecules

(e.g. cholesterol)

3. Immunity (globulin) 4. Blood clotting (fibrinogen)

Vascular System - the Blood Vessels

Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run parallel throughout the body with a web-like network of capillaries connecting them. Arteries use vessel size, controlled by the sympathetic nervous system, to move blood by pressure; veins use one-way valves controlled by muscle contractions.

Arteries Arteries are strong, elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure. Arteries divide into progressively thinner tubes and eventually become fine branches called arterioles. Blood in arteries is oxygen-rich, with the exception of the pulmonary artery, which carries blood to the lungs to be oxygenated. The aorta is the largest artery in the body, the main artery for systemic circulation. The major branches of the aorta (aortic arch, ascending aorta, descending aorta) supply blood to the head, abdomen, and extremities. Of special importance are the right and left coronary arteries, that supply blood to the heart itself.
Major Branches of Systemic Circulation
Source: Joel DeLisa and Walter C. Stolov, "Significant Body Systems," in: Handbook of Severe Disability, edited by Walter C. Stolov and Michael R. Clowers. US Department of Education, Rehabilitation Services Administration, 1981, p. 40.

Name Head Abdomen

Carotid

Serves
Brain & skull

Mesenteric Celiac (Abdominal) Renal Iliac Brachial (axillary) Radial & Ulnar Dorsal Carpal

Intestines Stomach, liver, spleen Kidney Pelvis

Upper Extremity

Upper arm Forearm & hand Fingers

Lower Extremity

Femoral Popliteal Dorsal pedis

Thigh Leg Foot

Posterior tibial

Foot

Capillaries

Veins Blood leaving the capillary beds flows into a series of progressively larger vessels, called venules, which in turn unite to form veins. Veins are responsible for returning blood to the heart after the blood and the body cells exchange gases, nutrients, and wastes. Pressure in veins is low, so veins depend on nearby muscular contractions to move blood along. Veins have valves that prevent back-flow of blood. Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which carry oxygenated blood from the lungs back to the heart. The major veins, like their companion arteries, often take the name of the organ served. The exceptions are the superior vena cava and the inferior vena cava, which collect body from all parts of the body (except from the lungs) and channel it back to the heart. Artery/Vein Tissues

Arteries and veins have the same three tissue layers, but the proportions of these layers differ. The innermost is the intima; next comes the media; and the outermost is the adventitia. Arteries have thick media to absorb the pressure waves created by the heart's pumping. The smooth-muscle media walls expand when pressure surges, then snap back to push the blood forward when the heart rests. Valves in the arteries prevent back-flow. As blood enters the capillaries, the pressure falls off. By the time blood reaches the veins, there is little pressure. Thus, a thick media is no longer needed. Surrounding muscles act to squeeze the blood along veins. As with arteries, valves are again used to ensure flow in the right direction.

Anatomy of the Heart

The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies left of the chest midline The heart, along with the pulmonary (to and from the lungs) and systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated blood. Internally, the heart is divided into four hollow chambers, two on the left and two on the right. The upper chambers of the heart, the atria (singular: atrium), receive blood via veins. Passing through valves (atrioventricular (AV) valves), blood then enters the lower chambers, the ventricles. Ventricular contraction forces blood into the arteries.

Oxygen-poor blood empties into the right atrium via the superior and inferior vena cavae. Blood then passes through the tricuspid valve into the right ventricle which contracts, propelling the blood into the pulmonary artery. The pulmonary artery is the only artery that carries oxygen-poor blood. It branches to the right and left lungs. There, gas exchange occurs -- carbon dioxide diffuses out, oxygen diffuses in. Pulmonary veins, the only veins that carry oxygen-rich blood, now carry the oxygenated blood from lungs to the left atrium of the heart. Blood passes through the bicuspid (mitral) valve into the left ventricle. The ventricle contracts, sending blood under high pressure through the aorta, the main artery for systemic circulation. The ascending aorta carries blood to the upper body; the descending aorta, to the lower body.

Blood Pressure and Heart Rate

The heart beats or contracts around 70 times per minute.1 The human heart will undergo over 3 billion contraction/cardiac cycles during a normal lifetime. One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular contraction and relaxation, and a short pause. Atria contract while ventricles relax, and vice versa. Heart valves open and close to limit flow to a single direction. The sound of the heart contracting and the valves opening and closing produces a characteristic "lub-dub" sound. The cardiac cycle consists of two parts: systole (contraction of the heart muscle in the ventricles) and diastole (relaxation of the ventricular heart muscles). When the ventricles contract, they force the blood from their chambers into the arteries leaving the heart. The left ventricle empties into the aorta (systemic circuit) and the right ventricle into the pulmonary artery (pulmonary circuit). The increased pressure on the arteries due to the contraction of the ventricles (heart pumping) is called systolic pressure. When the ventricles relax, blood flows in from the atria. The decreased pressure due to the relaxation of the ventricles (heart resting) is called diastolic pressure. Blood pressure is measured in mm of mercury, with the systole in ratio to the diastole. Healthy young adults should have a ventricular systole of 120mm, and 80mm at ventricular diastole, or 120/80. Receptors in the arteries and atria sense systemic pressure. Nerve messages from these sensors communicate conditions to the medulla in the brain. Signals from the medulla regulate blood pressure.

EXCRETORY SYSTEM
The excretory system is an organ system that performs the function of excretion, the bodily process of discharging wastes. It is responsible for the elimination of the waste products of metabolism as well as other non-useful materials. The main components of the excretory system are your two kidneys, two tubes that carry urine called ureters, the bladder, and the urethra.

Kidney

The most important organs of the excretory system are the kidneys. The kidneys are placed on either side of the spinal column near the lower back. The kidneys are bean-shaped and they have an important job. They are responsible for removing wastes from the blood and they also keep your blood pressure in check and help with the making of red blood cells. The kidneys filter the blood and remove any wastes. The Kidney does this via its three lauers which are the Cortex, the medulla and the pelvis. In the Cortex and Medulla there are Nephrons. These Nephrons comprise of a Glomerulus (bundle of capilaries), a Bowman's Capsule, a Proximal Convoluted Tubuale, the decending and ascending Loop of Henle, the Distal Convoluted Tubual and Collecting Ducts. The collecting ducts come together in the Pelvis. When your body gets ready to pass waste products, it goes through the kidneys and mixes with water and urine. Then, the waste travels into the bladder through tubes. These tubes are called Ureters. Now, the bladder holds all of that urine until it feels so full that you need to get rid of it. That's called urination. When this happens, a tube called the Urethra takes the urine to the outside of the body.

Ureter

The ureters are muscular ducts that propel urine from the kidneys to the urinary bladder. In the adult, the ureters are usually 25-30cm (10-12 inches)long. In humans, the ureters arise from the renal pelvis on the medial aspect of each kidney before descending towards the bladder on the front of the psoas major muscle. The ureters cross the pelvic brim near the bifurcation of the iliac arteries (which they run over). This "pelviureteric junction" is a common site for the impaction of kidney stones (the other being the ureterovesical valve). The ureters run posteroinferiorly on the lateral walls of the pelvis. They then curve anteriormedially to enter the bladder through the back, at the vesicoureteric junction, running within the wall of the bladder for a few centimeters. The backflow of urine is prevented by valves known as ureterovesical valves, pressure from the filling of the bladder, and the tone of the muscle in the bladder wall.In the female, the ureters pass through the mesometrium on the way to the urinary bladder.

Urinary bladder

The urinary bladder is a hollow, muscular, and distensible (or elastic) organ that sits on the pelvic floor in mammals. It is the organ that collects urine excreted by the kidneys prior to disposal by urination. Urine enters the bladder via the ureters and exits via the urethra. In males, the bladder is superior to the prostate, and separated from the rectum by the rectovesical excavation. In females, the bladder is separated from the uterus by the vesicouterine excavation

Urethra
The urethra (from Greek - ourethra) is a tube which connects the urinary bladder to the outside of the body. The urethra has an excretory function in both

sexes to pass urine to the outside, and also a reproductive function in the male, as a passage for semen. The external urethral sphincter is a striated muscle that allows voluntary control over urination.

IV.

PATIENT AND HIS ILLNESS A. PATHOPHYSIOLOGY y SCHEMATIC DIAGRAM (CLIENT-CENTERED)

Modifiable: Diet ( Na intake)

RISK FACTOR

Non-modifiable: Pregnancy

Vascular Spasm

Decrease synthesis of potent vasodilators

Decrease circulating blood volume CLINICAL MANIFESTATIONS: Hypertension Proteinuria Edema Oliguria Cardiomegaly Increased sensitivity of the body to enzyme (Angiotensin II)

Cardiomegaly

Peripheral Arteriolar vasoconstrictor

HYPERTENSION

Decreased oxygen supply to the vital organs due to decrease oxygen perfusion

Vasopasm in the kidney

Placenta

Increased glomerular Permeability

Decreased glomerular Filtration

Tissue ischemia

Albumin/ globulin cross into the uterus

Increased tubular Na absorption

Release of thromboplastin like substance

Premature placental degeneration/ deterioration Proteinuria Water Retention Decrease fetal nutrient Edema Oliguria Fetal Distress Edema Generalized water retention
Premature labor and delivery

Fluid diffusion

PHYSICAL ASSESSMENT DATE OF PHYSICAL ASSESSMENT: January 10, 2011 BLOOD PRESSURE: 160/120mmHg PULSE RATE: 112bpm RESPIRATORY RATE: 37cpm TEMPERATURE: 35.3 C

AREAS TO BE ASSESSED GENERAL SURVEY Body built, height and weight in relation to the client s age Posture and Galt Overall hygiene and grooming Body and breath odor

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION/ANALYSIS

Inspection Inspection Inspection Inspection

Signs of distress Obvious sign of health or illness Client s attitude Mood and affect Quantity and quality of speech Relevance and organization of thoughts INTEGUMENTARY A. Skin Color

Inspection Inspection Inspection Inspection Inspection

Proportionate, varies with lifestyle Relaxed, erect Posture Clean, neat No body odor or minor odor relative to work or exercise; no breath odor No distress noted Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and inflection Logical sequence, makes sense; has sense of reality

Endomorph, height and weight proportion to her age. Relaxed and has erect posture Our client is neat and clean Poor Hygiene

Normal Normal Normal Deviation from Normal

No distress noted Looks weak Cooperative and can follow instructions Cooperative and pleasant, appropriate to situation She has a clear tone and understandable, moderate pace When she speaks it has sense of reality

Normal Normal Normal Normal Normal

Inspection

Normal

Inspection

Generally uniform in color

Her skin color is uniform

Normal

Presence of edema Temperature Skin Turgor Skin Intactness B. Hair Evenness of growth over the scalp Hair texture and oiliness Amount of body hair C. Nails Fingernail plate shape, toenail texture Tissues surrounding nails Perform blanch test of capillary refill D. Skull and face Skull size, shape and symmetry Presence of nodules, masses and depression Facial features Facial movements E. Eyes Eye brows for hair distribution Eyelashes for evenness of distribution and direction of curl

Inspection palpation palpation Inspection Inspection Inspection Inspection Inspection

except in the areas that are exposed to the sun No edema Uniform; within normal range Skin springs back to previous state No lesion, skin is intact Evenly distributed; thick or thin Silky, resilient hair Variable Convex curvature, angle of the nail plate about 160 ; smooth texture Intact epidermis Prompt return of pink or usual color

except in the areas that are exposed to the sun Has edema Normal and equally bilateral Poor skin turgor No lesion, skin is intact Has thick hair, evenly distributed, color black She has silky hair Variable Her nail shape is convex curvature. Has smooth texture. Has intact epidermis The usual color of nails returns to pink after 2-3 seconds. No nodules and masses, smooth No nodules and masses, smooth Facial features were slightly asymmetric Has symmetric facial movements Hair evenly distributed, eyebrows were evenly distributed. Eyelashes equally distributed; curled outward

Deviation from Normal Normal Deviation from Normal Normal Normal Normal Normal Normal

Inspection Inspection and palpation

Normal Normal

Inspection Palpation

Inspection Inspection

Rounded and smooth skull contour Smooth, uniform consistency; absence of nodules and masses Symmetric or slightly asymmetric facial features Symmetric facial movements

Normal Normal

Normal Normal

Inspection

Inspection

Hair evenly distributed, eyebrows symmetrically aligned. Equally distributed; curled slightly outward

Normal

Normal

Eyelids for surface characteristics, ability to blink and frequency of blinking

Inspection

Bulbar and palpebral conjunctiva for color, texture and presence of lesions

Inspection

Lacrimal gland Lacrimal sac and nasolacrimal duct Cornea for clarity and texture

Inspection and palpation Inspection and palpation Inspection

Skin intact; no discharge or discoloration; lids closed symmetrically approximate. Has the ability to blink about 15-20 involuntary blinks per minute Bulbar conjunctiva is transparent and capillaries sometimes evident. Palpebral conjunctiva is shiny, smooth and pink or red. No edema or tenderness over lacrimal gland No edema or tearing Transparent, shiny and smooth; details of the iris are visible Blinks when the cornea is touched Black in color, equal in size and smooth border Illuminated pupil constricts (direct response); Nonilluminated pupil constricts (consensual response) Pupils constrict when looking at near object; pupils dilate when looking at far; pupils converge when near object is moved towards the nose When looking straight ahead, client can see objects in periphery Both eyes coordinated, move in unison, with parallel

Skin intact; no discharge or discoloration; lids closed symmetrically. Has the ability to blink bilaterally.

Normal

Bulbar conjunctiva is transparent. Palpebral conjunctiva is shiny, smooth and pink. No edema or tenderness over lacrimal gland. No edema or tearing. Transparent, shiny and smooth; details of the iris are visible . Client blinks when the cornea is touched Her pupils are black, equal in size and has smooth borders Illuminated pupil constricts; Non-illuminated pupil constricts Her pupils constrict when looking at near object; pupils dilate when looking at far; pupils converge when near object is moved towards the nose. When looking straight ahead, client can see objects in periphery. Both eyes coordinated

Normal

Normal Normal Normal

Corneal sensitivity Pupils for color, shape and symmetry of size Pupil s depict and consensual reaction to light

Inspection Inspection Inspection

Normal Normal Normal

Pupil s reaction to accommodation

Inspection

Normal

Peripheral visual fields

Inspection

Normal

Six ocular movements

Inspection

Normal

Visual acuity F. Ears Auricles color, symmetry of size and position

Inspection

alignment Able to read newsprint

She was able to read newsprint Color same as facial skin, auricle aligned with the outer cantus of the eye. Mobile, firm and not tender; pinna recoils after being fold. Has dry light brown cerumen and grayish color She was able to hear ticking in both ears Symmetric and straight; no discharge or flaring; uniform in color Have no discharge and no lesions. Air moves freely as Mrs. C.S breathes through the nares Nasal septum is intact and in midline No tender, masses or displacement of bones and cartilage Maxillary and frontal sinuses are not tender Lips are color pink (uniform), moist soft and smooth, no lesions and she has the ability to purse her lips Moist, smooth, soft, glistening and elastic texture of buccal

Normal

Inspection

Texture, elasticity and areas of tenderness External ear canal for cerumen, skin lesions, pus and blood Watch tick test G. Nose Shape, size or color and flaring or discharge Nasal cavities Patency of both nasal cavities Nasal septum Tenderness, masses and displacement of bones and carriage Sinuses for tenderness H. MOUTH Lips for symmetry of contour, color and texture

Palpation Inspection

Inspection

Color same as facial skin, symmetrical; auricle aligned with the outer cantus of the eye Mobile, firm and not tender; pinna recoils after being fold. Dry cerumen, grayish-tan color, sticky or wet cerumen in various shades of brown Able to hear ticking in both ears Symmetric and straight; no discharge or flaring; uniform in color Mucosa is pink; clear watery discharge; no lesions. Air moves freely as the client breathes through the nares Nasal septum is intact and in midline Not tender

Normal

Normal Normal

Normal

Inspection

Normal

Inspection Inspection Inspection Palpation

Normal Normal Normal Normal

Palpation

Not tender

Normal

Inspection

Buccal mucosa for color, moisture, texture and

Inspection

Uniform pink color, soft, moist, smooth texture, symmetry of contour, ability to purse lips Moist, smooth, soft, glistening and elastic texture

Normal

Normal

presence of lesions Teeth for color, number, condition and presence of dentures Gums for color condition

Inspection

32 adult teeth, smooth white and shiny tooth enamel Pink gums, moist and firm texture to gums; no retractions. Central position, pink color, moist slightly rough, moves freely, no tenderness Smooth with no palpable nodules Light pink, smooth, soft palate; Lighter pink hard palate, more irregular Positioned in midline of soft palate Pink and smooth posterior wall Pink and smooth, no discharge Present Muscles equal in size; head centered Coordinated, smooth movements with no discomfort Not palpable Central placement in midline of neck; spaces are equal on both sides Not visible on inspection,

Inspection

Tongue for color, position, texture and movement Presence of nodules, lumps or excoriated areas Hard and soft palate for color, shape, texture and presence of bony prominences Position of the uvula and mobility while examining palates Oropharynx for color and texture Tonsils for color, discharge and size Elicit the gag reflex I.NECK Neck muscles Head movement

Inspection

Palpation Inspection

mucosa 32 adult teeth, smooth white and shiny tooth enamel. She has no dentures Pink gums, moist and firm texture to gums; no retractions. Tongue in the center, pink in color, moist and slightly rough without lesions, moves freely. It has no nodule She has light pink, smooth, soft palate. Hard palate is more irregular and lighter pink. Uvula is in the middle.

Normal

Normal

Normal

Normal Normal

Inspection

Normal

Inspection Inspection Perform test on gag reflex Inspection Inspection

Has pink and smooth posterior wall. Has pink and smooth tonsils; no discharge. Gag reflex is present. Muscles on the neck are equal in size; head centered. Head movement is coordinated, has smooth movements with no discomfort. No enlargement of lymph nodes Trachea is in central position in the midline of the neck; spaces are equal in both sides. Thyroid gland is not visible on

Normal Normal Normal Normal Normal

Entire neck for enlarged lymph nodes Trachea for lateral deviation

Palpation Inspection

Normal Normal

Thyroid Gland

Inspection and Palpation

Normal

ascends during swallowing but is not visible I.THORAX Posterior thorax Palpation Skin is intact; uniform in temperature, chest wall intact; no tenderness; no masses Anteroposterior to transverse diameter in ration of 1:2; chest is symmetric Spine vertically aligned Full and symmetric chest expansion

inspection; it ascends during swallowing but is not visible. Skin is intact; uniform in temperature, chest wall intact; no tenderness; no masses Anteroposterior to transverse diameter in ration of 1:2; chest is symmetric Her spine is vertically aligned When Mrs. C.S takes a deep breath, my thumb move apart an equal distance and at the same time. Bilateral symmetry of vocal fremitus; fremitus is heard most clearly at the apex of the lungs Percussion notes resonate, except over scapula; lowest point of resonance is at the diaphragm. Excursion is 3 to 5 cm. Diaphragm is usually slightly higher on the right side, Normal

Shape and symmetry of the thorax Spinal alignment for deformities Posterior chest for respiratory excursion

Inspection

Normal

Inspection Palpation

Normal Normal

Chest for vocal fremitus

Palpation

Thorax

Percussion

Bilateral symmetry of vocal fremitus; fremitus is heard most clearly at the apex of the lungs Percussion notes resonate, except over scapula

Normal

Normal

Diaphragm excursion

Percussion

Chest using the flat-disc diaphragm of the stethoscope J. ANTERIOR THORAX Breathing pattern Anterior chest for respiratory excursion

Auscultation

Excursion is 3 to 5 cm bilaterally in women and 5 to 6 cm in men; diaphragm is usually slightly higher on the right side, Vesicular and bronchovesicular breath sounds Quiet, rhythmic and effortless respirations Full symmetric excursion

Normal

Vesicular and bronchovesicular breathe sounds on the chest. Quiet, rhythmic and effortless respirations. Full symmetric excursion

Normal

Inspection Palpation

Normal Normal

Tactile fremitus

Palpation

Anterior chest

Percussion

Same as posterior vocal fremitus; fremitus is normally decreased over heart and breast tissue. Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over the areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach. Bronchial and tubular breath sounds

Bilateral symmetry of tactile fremitus; it decreased over heart and breast tissue. Percussion notes resonate down to the 6th rib at the level of the diaphragm but are flat over the areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach. Bronchial and tubular breath sounds

Normal

Normal

Auscultation K .BREAST AND AXILLAE Size, symmetry and contour or shape Skin of the breast Areola for size, shape, symmetry, color, surface characteristics and any masses or lesions Nipples for size, shape, position, color, discharge and lesions Axillary, subclavicular and supraclavicular lymph nodes J. ABDOMEN Skin integrity Contour and symmetry Abdomen for bowel sounds Inspection Inspection Inspection Rounded shape slightly unequal in size Uniform in color Oval and bilaterally the same; color varies widely Rounded shape slightly unequal in size Skin is uniform in color Oval and bilaterally same; color is dark-brown Normal Normal Normal

Inspection

Palpation

Round, inverted and equal in size; similar in color, soft and smooth; both nipples point in same direction No tenderness, masses or nodules Uniform in color, silver-white striae Flat, rounded or scaphoid Audible bowel sounds

Nipples are rounding, inverted and not equal in size.

Normal

Absence of nodules; not tender. Uniform in color, silver-white striae It is big and rounded because of her pregnancy There was a decrease in bowel sounds.

Normal

Inspection Inspection Auscultation

Normal Normal Normal

Liver K. MUSCULOSKELETAL Muscles for size Muscles and tendons for contractures and tremors Muscle tonicity Muscle strength Skeleton Joint

Palpation

May not be palpable; border feels smooth Equal size on both side of the body No contractures and tremors Normally firm Equal strength on each body side No deformities, tenderness or swelling No swelling and nodule, not tender

Liver is not palpable

Normal

Inspection Inspection Palpation Testing muscle strength Inspection Inspection

Muscles are equal in size on both side of the body. No contractures and tremors Normally firm Equal strength on each body side No deformities, tenderness or swelling No swelling and nodule, not tender

Normal Normal Normal Normal Normal Normal

DIAGNOSTIC PROCEDURE / LABORATORY Date ordered/ Date Result(s) in Indication(s)/ Purposes Actual Values Normal Values (Units used in Hospital) Analysis and interpretation of results Nursing Responsibilities ( prior, during, after )

Diagnostic/ Laboratory Procedures Blood Chemistry

RBS

Date ordered: 01/08/12 Date Results in: 01/08/12

To determine if the patient is in a hypoglycemic state, that may lead to convulsions.

5.60

3.83 mmol/L

9.0 RBS is within the normal Prior to: range indicating that the  Explain to the client client is not hypoglycemic. and significant others the purpose and indication of the

BUN

Date ordered: 01/08/12 Date Results in: 01/08/12

To measures the level of urea in the blood and is used to assess the glomerular function or how well the Kidneys are working.

4.6

1.7 8.3 mmol/L

The result is within normal range indicating that kidneys are functioning properly.

procedure.  Inform the client that the test requires blood sample.  Notify the laboratory

or

the

physician

about the drugs that client is taking that may affect the test results; it may be necessary to restrict y Uric Acid Date ordered: 01/08/12 Date Results in: 01/08/12 To evaluate the blood levels of uric acid for gout and to assess uric acid levels in the urine for kidney stone formation. 0.574 0.143 mmol/L them. 0.357 The result means there is Increased uric acid levels due to overproduction may also be caused by gout, by a genetic disorder During: of purine metabolism, or  Collect the sample in by metastatic cancer, destruction of red blood a proper container. cells, leukemia, or cancer chemotherapy.  Use aseptic technique when obtaining the sample.  Handle the sample properly to prevent y SGOT Date ordered: 01/08/12 Date Results in: 01/08/12 To determine if the heart or liver was being damage, this enzyme released into blood when the liver or heart are damaged. 59.5 10 40 U/L The SGOT is higher, so result means kidneys, heart, or liver are injured. hemolysis.

After:  Apply pressure on direct the

puncture site until

SGPT

Date ordered: 01/08/12 Date Results in: 01/08/12

To determine / evaluate patient who has symptoms of a liver disorder.

16.6

0 39 U/L

The result means is within the normal range. The SGPT are normally present in the liver but not so sensitive indicator like SGOT.

stop bleeding.  Watch out for edema formation.  Document procedure.  Secure the the results

ELECTROLYTES y Sodium Date ordered: 01/08/12 Date Results in: 01/08/12 This was done to determine the levels of sodium to detect whether there s the right balance of sodium and liquid in the blood to carry out those functions. To help evaluate fluid and electrolyte imbalance in terms of potassium component. 142.3 135 145 mmol/L The result is within the normal range. There is no imbalance of electrolytes within the client s body in relation to sodium.

and put it in the chart.  Refer the results to the physicians.

Potassium

Date ordered: 01/08/12 Date Results in: 01/08/12

3.3

3.5 5.0 mmol/L

The result means there is imbalance of potassium level in the client, it can increase the risk of an abnormal heart beat, it can also associated with muscle weakness. The result is within normal range. There is no imbalance of electrolyte within client s body in relation to chloride

Chloride

Date ordered: 01/08/12 Date Results in: 01/08/12

To determine the levels of chloride, can helps maintain a balance of fluids in the body to prevent certain chemical reactions from occurring in the body that are necessary it to keep working properly.

104.5

101 111 mmol/L

Diagnostic/ Laboratory Procedures

Date ordered/ Date Result(s)

Indication(s)/ Purposes

Actual Values

Normal Values (Units used in Hospital)

Analysis and interpretation of results

Nursing Responsibilities ( prior, during, after )

Urinalysis

Date ordered: 01/09/12 Date Results in: 01/09/12

For general health screening to detect renal Color: yellow and metabolic disease; diagnosis of disease or disorders of the kidney or Transparency: urinary tract; monitoring turbid patients with diabetes. Sugar: negative Albumin: positive Specific Gravity: 1.025 Pus cells: 5 8/ HPF TNTC/HPF Moderate.

The color, transparency , Color: Straw sugar, specific gravity, Pus cells, RBC, and epithelial yellow to amber. are all normal except to the albumin that means Transparency: Protein in the urine may transparent mean kidney damage, an infection, cancer, high Sugar: negative blood pressure, diabetes, Albumin: systemic lupus negative erythematosus (SLE), or glomerulonephritis is Specific Gravity: present. 1.015 1.025 Pus cells: 510/HPF TNTC/HPF cells: Moderate Albumin: negative The result is negative that indicating the glomerular membrane damaged. is not

Prior to:  Explain to the significant others the test, it s purpose and how it done.  Inform the significant others that the test will require a for urine clean the specimen.  Provide container specimen. During:  Collect the urine in a clean specimen cup.  Label the specimen properly. After:  The specimen should be delivered to the lab within 1 hour.  Obtain result and

Epithelial cells: Epithelial

Albumin

Date ordered: 01/09/12 Date Results in: 01/09/12 To determine the presence of glomerular damage.

Albumin: Negative

secure it to the chart  Refer result to the physician

Diagnostic/ Laboratory Procedures Blood test y Blood typing

Date ordered/ Date Result(s)

Indication(s)/ Purposes

Actual Values

Normal Values Analysis and Nursing Responsibilities (Units used in interpretation of results ( prior, during, after ) Hospital) Type A, B, AB, and The O result means the Prior to:  Explain procedures client to the the

Date ordered; 01/09/12 Date Results in: 01/09/12 Date ordered: 01/09/12 Date Results in: 01/09/12

To determine what type of blood the client has.

O+

client can donate blood to any kind of blood.

Hemoglobin

The

hemoglobin

test

124

115 155 g/L

The result is within the normal that sufficient level the indicating had that blood oxygen

 Explain the purpose and indication of the test

measures the amount of hemoglobin in blood and is a good indication of the blood's ability to carry oxygen throughout the body.

carrying protein.  Tell to the significant others or client that the test will not require restriction. feeding

Hematocrit

Date ordered: 01/09/12 Date Results in: 01/09/12

Evaluates fluid measures volume.

anemia

and and

38%

38 % 48 %

The result shows that the percentage of red blood cells in a given volume of the whole blood is normal.

balance

concentration

of RBC within the blood

During: y White cells Blood Date ordered: 01/09/12 Date Results in: 01/09/12 To evaluate presence of infection/ inflammation. 9.7 5
x 10 /L The result is within the normal indicating presence range there is that no  Use technique aseptic when

infection/

obtaining the sample  Label the container properly.

inflammation because of the actual number WBC per volume of blood. Date ordered: 01/09/12 Date Results in: 01/09/12 Neutrophils phagocytes bacteria products. primary during and It cell an are engulfing cellular evaluates response acute 0.74 0.45 0.85 The result is within that delayed of  Bring the collected sample laboratory to the

Neutrophils

normal suggests

range

participation infection.

neutrophils to presence of After:  Obtain results and secure it to the patients chart

inflammation process. Date ordered: 01/09/12 Date Results in: 01/09/12 Indicates the amount of lymphocytes participating local injury. with macrophages at a site of 0.26 0.20 0.35 Lymphocytes are within the normal range reduced antibiotic indicating continuous

Lymphocyte

infection as a result of treatment that does not require more lymphocytes to act upon it  Refer the results to the physician

Total Cholesterol

Date ordered: 01/09/12 Date Results in: 01/09/12

To determine the amount of cholesterol in our body that cause risk for heart and blood vessel disease.

6.58

3.45 6.35 mmol/L

The result is above the normal range. So does the possibility of plugging the arteries due to cholesterol plaque build-up.

HDL

Date ordered: 01/09/12 Date Results in: 01/09/12

HDL is good cholesterol as it protects against heart disease by helping remove the arteries. excess cholesterol deposited in

1.80

0 1.70 mmol/L

The result is above the normal range. It indicating High levels seems to be associated incidence heart disease. with of low coronary

LDL

Date Ordered: 01/09/12 Date Results in: 01/09/12

To determine the level of bad cholesterol in the body that cause coronary or vascular disease.

3.09

1.7 4.59 mmol/L

The

result

shows risk

the of or

normal range of LDL that indicates acquiring low coronary

vascular disease. Date ordered: 01/09/12 Date Results in: 01/09/12 Triglyceride is fat in the blood which, if elevated, has been associated with heart disease 3.72 0.11 2.09 mmol/L The result is above the normal level, this may indicate triglycerides associated pancreatitis and that are High also with also

Triglycerides

associated with problems other than heart disease

V.

THE PATIENT AND HIS CARE A. MEDICAL MANAGEMENT a. IVT, Blood Transfusion, Nebulization, Total Parenteral Nutrition, NGT, Oxygen Therapy etc. MEDICAL DATE ORDERED, GENERAL DESCRIPTION INDICATION/ PURPOSES MANAGAMENT DATE GIVEN/ CHANGED/ DISCONTINUE X 30-31 01/08/12 01/08/12 01/08/12 D5 water is an isotonic solution on initial administration, it provides free water when dextrose is metabolized, expanding intracellular and extracellular fluid volumes. It is used to supply water and calories to the body. It is also used as a fixing solution (diluents) for other IV medications. Dextrose is a natural sugar found in the body and serves as a major energy source. When used as energy source, dextrose allows the body to preserve its muscle mass. It is indicated as a source of water, electrolytes and calories or as an alkalinizing agent.

CLIENT S RESPONSE

NURSING RESPONSIBILITIES ( prior, during, after )

D5W 1L gtts./min.

Mrs. Preeclampsia complied that she has regained her strength and improved his hydration status gradually as evidence by regulated body temperature.

D5LRS 1L X 30 units 01/08/12 oxytocin at 30 31 01/08/12 gtts./min.

It is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration.

Prior to: 1. Check the Doctor s order 2. Check the expiration date of IVF. 3. Inform patient about the IVF to be given. 4. Explain the procedures to the patient or the patient s significant orders. During: 1. Clean the site of administration and observe aseptic technique. 2. Choose vein on the distal arm first. 3. Support patient hand and maintain aseptic technique. 4. Instruct the significant others to support the body of the patient

especially the while inserting the needle. 5. Once in the place regulate the IVF as ordered. 6. Label the IVF bottle properly. After: 1. Document the IVF properly on the chart. 2. Check for any sign of infection. 3. Monitor the rate flow every hour. 4. Monitor the patency of the tube and the IV site. B. DRUGS GENERIC/BRAND NAME/DRUG CLASSIFICATION Generic name: Cephalexin Brand name: Keflex Classification: Anti-infective DATE
ORDERED TAKEN/GIVEN CHANGED DISCONTINUED

01/08/12 (AM)

01/08/12 (AM)

----

01/09/12 (PM)

ROUTE OF MECHANISMS CLIENT S NURSING RESPONSIBILITIES ADMINISTRATION, OF ACTION RESPONSE PRIOR DURING AFTER DOSAGE, FREQUENCY P.O. (adults) 250- They stop or Nausea, -Assess the -observe for - monitor 500mg/kg q 6hr. patient for the s/sx. Of the v/s. slow the vomiting, infection. anaphylaxis. growth of diarrhea, P.O. (children) bacterial cells Rashes, 6.25-25 mg/kg q by preventing headaches. -obtain a -monitor 6hr. bacteria from history to the input determine and output. forming the if the pt. cell wall that surrounds have an allergic each cell. response.

GENERIC/BRAND NAME/DRUG CLASSIFICATION Generic name: Mefenamic acid Brand name: Ponstan,Ponstel Classification: Nonsteroidal anti -inflammatory drug.

DATE
ORDERED TAKEN/GIVEN CHANGED DISCONTINUED

01/08/12 (AM)

01/08/12 (AM)

----

01/09/12 (PM)

ROUTE OF MECHANISMS CLIENT S NURSING RESPONSIBILITIES ADMINISTRATION, OF ACTION RESPONSE PRIOR DURING AFTER DOSAGE, FREQUENCY P.O. (adult) 500mg the short- Chest pain, -Check for -Identify the -Document term q 6hr. dizziness, the right client. the given treatment of abdominal doctor s Medication. mild to pain order. -Administer moderate medication -Assess and pain from -check the on proper document various medication route. for conditions. It properly occurrence and read of adverse is also used to -Observe labels decrease pain for aseptic reaction. and blood carefully. technique. loss from menstrual - Know the -Administer periods. reason for the medication which client is slowly. receiving the medication.

GENERIC/BRAND NAME/DRUG CLASSIFICATION

DATE
ORDERED TAKEN/GIVEN CHANGED DISCONTINUED

Generic name: Ferrous sulfate Brand name: DLI-FERROUS SULFATE

01/08/12

01/08/12

----

----

ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY PO adult 5-10ml children 2.55ml,infant 0.2ml. to be taken tid-qid.

MECHANISMS OF ACTION

CLIENT S RESPONSE

NURSING RESPONSIBILITIES PRIOR DURING AFTER -asses the pt s nutritional status and dietary history to determine possible Asses the bowel function for constipation or diarrhea. Monitor the v/s.

Preventing or treating low levels of iron in the blood.

GI discomfort, stool darkening(nonpermanent)

Classification: Anti anemic

cause of anemia.

GENERIC/BRAND NAME/DRUG CLASSIFICATION

DATE
ORDERED TAKEN/GIVEN CHANGED DISCONTINUED

Generic name: Amlodipine besylate Brand name: Norvasc Classification: Antihypertensive, Antiarrhymics, antianginals

01/09/12

01/09/12

----

----

ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY PO (adults) 510mg q 4hr as a single dose.

MECHANISMS OF ACTION

CLIENT S RESPONSE

NURSING RESPONSIBILITIES PRIOR DURING AFTER -monitor the v/s specifically the blood pressure and pulse. -monitor the v/s specifically the blood pressure and pulse. Monitor the input and output. -monitor the v/s specifically the blood pressure and pulse.

-treatment and prevention of angina resulting from coronary spasm as well as from exertion. -is also used in the treatment of high blood pressure.

Head ache, edema, dizziness, fatigue, nausea

C. DIET TYPE OF DIET DATE ORDERED, DATE CHANGED NPO ( nothing per orem ) DO: 01/08/12 DC: 01/09/12

GENERAL DESCRIPTION Nothing per Orem or Nil per Os is a Latin word for a medical introduction meaning to

INDICATION/ PURPOSE This kind of diet is was ordered for the patient for various reasons such as for observation, for aspiration

SPECIFIC FOOD TAKEN All kinds of foods and fluids are restricted

CLIENT S RESPONSE Patient verbalized hunger but complied with the diet regimen.

NURSING RESPONSIBILITIES Prior to: 1. Check physician s order 2. Inform the patient s SO about the type of diet.

withhold oral foods and fluids from a patient for various reasons.

precaution due to tachypnea, vomiting and seizure.

3. Explain the purpose of the diet ordered the consequences of not following such diet and how it will be implemented.

DAT ( diet as tolerated)

DO: 01/09/12 DC: ---

The patient can eat rich foods in carbohydrate, protein, vitamin C, iron and drink fluids as tolerated.

Food rich in protein, carbohydrates, vitamin C adequate intake of fluids.

The patient complied with the diet regimen. She regained energy as evidenced by having slight increase in his muscle strength and can do simple activities of daily living with minimal assistance.

During: 1. Monitor if the patient complies with the given diet. 2. Monitor intake and output. After: 1. Document response of the patient.

D. ACTIVITY EXERCISE TYPE OF EXERCISE DATE ORDERED, DATE STARTED, DATE CHANGED Complete with privilege bed rest bathroom DO:01/08/12 DS:01/08/12

GENERAL DESCRIPTION

INDICATION/PURPOSES

CLIENT S RESPONSE

NURSING RESPONSIBILITIES (PRIOR,DURING,AFTER)

Confined in her bed to To promote rest to the The patient had rested Prior to: rest but can do some patient. well and improved her 1. Check physician s order light activities like condition. 2. Inform the patient s SO about the going to the bathroom and walking. type of activity. 3. Explain the purpose of the activity ordered the consequences of not following

such diet and how it will be implemented. 4. Provide proper positioning. During: 1. Assist the client in doing any activities. After: 1. Document response of the client.

B. NURSING PROBLEM PRIORITIZATION DATE IDENTIFIED JANUARY 09, 2012 CUES Elevated blood pressure Reading:140/100 160/120nnHg Edema on the lower and upper extremeties. PROBLEM/NURSING DIAGNOSIS Ineffective peripheral tissue perfusion related to hypertension due to elevated blood pressure. JUSTIFICATION Nature of the problem: 3/3 x 1 = 1 Modifiability of the problem: x 3 = 2.25 Preventive potential: 3/3 x 1 = 1 Salience: x 1 = 0.5 TOTAL: 4.75 Nature of the problem: 3/3 x 1 = 1 Modifiability of the problem: x 3 = 2.25 Preventive potential: 2/3 x 1 = 0.67 Salience:

Eyebags, tired, inability to restore energy even after sleep.

Fatigued related to Physiological factor specifically pregnancy.

 x 1 = 0.5 TOTAL: 4.42 Increased respiration: R.R = 37 cpm P.R = 12bpm Tingling in extremeties Abdominal pain Urinary frequency Nature of the problem: 3/3 x 1 = 1 Modifiability of the problem: x 3 = 2.25 Preventive potential: 2/3 x 1 = 0.67 Salience: 0/2 x 1 = 0 TOTAL: 3.92

Anxiety (moderate) related to two consecutive abortions/miscarriages

C. NURSING CARE PLAN

ASSESSMENT S:

DIAGNOSIS Ineffective peripheral tissue perfusion related to Hypertension due to elevated blood pressure

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

O:  Elevated blood pressure Reading: 140/100mmHg 160/120nnHg  Edema on the

After 2-3 hrs. of nsg. To maximize tissue Intervention, the client will be perfusion: able to:  Collaborate in  Demonstrate decrease treatment of underlying perfusion as conditions such as individually hypertension. appropriate.  Verbalize  Administer understanding of medication such as condition, therapy antibiotics. regimen, side effects of medications and when to contact health care provider.

After 2-3 hrs. of nsg. Intervention, the client was  To able to: maximize  Demonstrated systemic decreased perfusion as circulation individually and organ appropriate. perfusion.  Verbalized understanding of  To improve condition, therapy tissue regimen, side effects of perfusion medications and when or organ to contact health care function. provider.

upper and lower extremeties

 Demonstrate To evaluate degree of behaviors and lifestyle impairment. changes to improve  Assess presence, location and degree circulation. of swelling or  Promote wellness. edema formation.  Note client s nutritional and fluid status.

 Useful in identifying or quantifying edema in involved extremity.  Proteinenergy malnutritio n and weight loss make ischemic tissues more prone to breakdown .  It often accompany diminished peripheral circulation.

 Demonstrated behaviors and lifestyle changes to improve circulation.  Promoted wellness.  GOAL MET

 Inspect lower extremities for skin texture and skin breaks or ulceration.

ASSESSMENT S: hindi kumpleto tulog ko, para kong pagod pagkagising ko , as verbalized by the patient.

DIAGNOSIS Fatigued related to Physiological factor specifically pregnancy.

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION After 1-2 days of nsg. Intervention, the client was able to:  Identified basis of fatigue and individual areas of control.  Performed activities of daily living and participate in desired activities at level of ability.  Participated in recommended treatment program.  Promoted wellness.  GOAL MET

O:  Eyebags  Looks tired  Inability to restore energy even after sleep.

After 1-2 days of nsg. To assess Intervention, the client will causative/contributing be able to: factors:  Identify basis of  Note for the age, fatigue and individual gender, and areas of control. developmental stage.  Perform activities of daily living and participate in desired activities at level of ability.  Participate in recommended treatment program.  Promote wellness.  Review medication regimen/use.

 Although some studies show a prevalence of fatigue in adolescent girls, the condition may be present in any person at any age.  Certain medications, including prescription, OTC drugs, herbal supplements, and combination of the drugs are known to cause and/or exacerbate fatigue.  To evaluate fluid status and cardiopulmo nary

 Asses vital signs.

 Determine the presence/degree of sleep disturbances.

response to activity.  Fatigue can be a consequence of and/or exacerbated by, sleep deprivation.

ASSESSMENT S:

DIAGNOSIS Anxiety (moderate) related to two consecutive abortion/miscarriage.

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION After 1-2 days of nsg. Intervention, the client will be able to:  Verbalize awareness of feelings of anxiety.  Demonstrate problem-solving skills.  Identify health ways to deal with and expressing anxiety.  Promote wellness.  GOAL MET

O:  Tingling in extremities.  Abdominal pain  Sleep disturbance  Urinary frequency  Increased respiration: RR: 37 cpm PR: 112bpm

After 1-2 days of nsg. To assist client to identify Intervention, the client will feelings and begin to deal be able to: with problems:  Verbalize awareness  Establish of feelings of anxiety. therapeutic  Demonstrate relationship, problem-solving conveying skills. empathy and  Identify health ways unconditional to deal with and positive regard. expressing anxiety.  Promote wellness.  Provide accurate information about the situation.  Allow the behavior to belong to the client; do not respond personally.

 To avoid the contagious effect/transmis sion of anxiety.

 Helps client to identify what is realty based.  The nurse may respond inappropriately , escalating the situation to a

nontherapeutic interaction. VI. DISCHARGE PLANNING METHODS MEDICATION Advice the client to take her medication on time and with regular interval as indicated. ENVIRONMENTAL/ EXERCISE The client must be in complete bed rest with a non-stimulating room (darkened) Provide the client with a well ventilated room.

TREATMENT The presence of danger of convulsion until 48 hours post-partum, the patient will no longer have a problem after the pregnancy is completed that seizure will be intermittently. HEALTH TEACHING For seizure precaution, teach the significant others of the client that the bed must be padded in case of seizure attack. Provide the client with a room that is free of noise and with dimmed lights. Padded tongue depressor.

OUT-PATIENT APPOINTMENT Advice the client to follow check-up and return visit to the hospital as ordered. DIET High protein and calorie with moderate salt restriction. SPIRITUAL Impart to the client and significant others to attend in a counseling group or attend in a community religious activity.

VII.

CONCLUSION

Upon doing the case study our group gained a lot of information regarding the Pre-eclampsia (pregnancy-induced hypertension). From the above nursing problems perceived and presented through prioritization and analysis of the gathered data and proper assessment. Through the use of client focus nursing interventions and by following to nursing standards, the perceived problems were managed well. Truly, a clinical eye which is sensitive to client s need for care was established. Loyalty was observed in aiding the client s needs, managing andtaking a lead on advocating client s interest and creating ways on how to ensure a quality of care.

VIII.      

BIBLIOGRAPHY THEORETHICAL FOUNDATION OF NURSING, 1ST EDITION, Josie Quiambao-Udan,RN,MAN p. 327-332 ANATOMY AND PHYSIOLOGY,8th Edition,Seely,Stephens,Tate, p. 1049-1050 www.nurseslbs.org.com www.scrbd.com www.wikipedia.com www.mcnlabs.com