Cebu Institute of Technology

University
N. Bacalso Ave., Cebu City Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

PREGNANCY – INDUCED HYPERTENSION

IN PARTIAL FULFILLMENT OF THE COURSE

RLE 204

Submitted by:

Regulacion, Yobel
Ricafort, Ronna Mae F.
Rio, Ariane Grace
Roma, Kimberly Angel
Sario, Nichole
Sente, Cris Clayian
Sequillo, Khin Jarryl
Sigue, Margot Isabel
Toledo, Marie Blanch
Vercide, Jeivey

Submitted to:

Mrs. Mary Jean L. Siase, RN, MAN

Clinical Instructor
 INTRODUCTION

Pregnancy-induced hypertension (PIH) is a form of high blood pressure in pregnancy.

It occurs in about 7 to 10 percent of all pregnancies. Another type of high blood pressure is
chronic hypertension - high blood pressure that is present before pregnancy begins.
Pregnancy-induced hypertension is also called toxemia or gestational hypertension. It
occurs most often in young women with a first pregnancy. It is more common in twin
pregnancies, and in women who had PIH in a previous pregnancy. Usually, there are three
primary characteristics of this condition, including the following: high blood pressure (a
blood pressure reading higher than 140/90 mmHg or a significant increase in one or both
pressures), protein in the urine, edema (swelling). Eclampsia is a severe form of pregnancy-
induced hypertension. Women with eclampsia have seizures resulting from the condition.
Eclampsia occurs in about one in 1,600 pregnancies and develops near the end of pregnancy,
in most cases. HELLP syndrome is a complication of severe preeclampsia or eclampsia.
HELLP syndrome is a group of physical changes including the breakdown of red blood cells,
changes in the liver, and low platelets (cells found in the blood that are needed to help the
blood to clot to control bleeding).

Pregnancy induced hypertension (PIH) is one of the most common causes of both
maternal and neonatal morbidity, affecting about 5 – 8 % of pregnant women. It is associated
with adverse pregnancy outcomes as well as maternal morbidity and mortality. Harare City
experienced an increase in referrals due to PIH to central hospitals from 2009 to 2011.
Worldwide, 10 % of all pregnancies are complicated by hypertension, with pre-eclampsia
and eclampsia being the major causes of maternal and prenatal morbidity and mortality. It
is also estimated that pregnancy induced hypertension (PIH), one of the hypertensive
disorders of pregnancy, affects about 5 – 8 % of all pregnant women worldwide. Pregnancy
induced hypertension (PIH) is defined as BP ≥ 140/90 mmHg, taken after a period of rest on
two occasions or ≥160/110 mmHg on one occasion in a previously normotensive woman.

Pre-eclampsia affects 5-7 % of all pregnancies. It is broadly defined by hypertension

and proteinuria. Eclampsia includes pre-eclampsia with the presence of convulsions not
attributable to other neurologic disease.

CHRONIC HYPERTENSION GESTATIONAL HYPERTENSION

20TH WEEK

BEFORE AFTER
PREGNANCY DURING PREGNANCY PREGNANCY

PREECLAMSIA

1. Chronic Hypertension - Chronic hypertension means having high blood pressure

before you get pregnant or before 20 weeks of pregnancy. Women who have chronic
hypertension can also get preeclampsia in the second or third trimester of pregnancy.
2. Gestational Hypertension - is a form of high blood pressure in pregnancy. It occurs
in about 6 percent of all pregnancies. Another type of high blood pressure is chronic
hypertension--high blood pressure that is present before pregnancy begins.
Gestational hypertension can develop into preeclampsia.
3. Pre-eclampsia—this is the non-convulsive form of PIH. This affects 7% of all
pregnant women. Its incidence is higher in lower socio-economic groups. It may be
classified either mild or severe.
 4. Eclampsia—this is the convulsive form of PIH. It occurs with 5% of all pre-eclampsia
cases. The mortality rate among mothers is nearly 20% and fetal mortality is also high
due to premature delivery.

Based on the severity of the PIH present to a person or the extent of damage
left/occurred, a list of possible complications can be drawn.

1. Abruption placenta
2. Disseminated intravascular coagulation (DIC)
3. Prematurity
4. Intrauterine growth retardation (IUGR)
5. HELLP syndrome
6. Maternal and/or fetal death

At the Medical City’s Institute for Women’s Health, the Section of Maternal Fetal
Medicine has a comprehensive predictive, preventive, and precise approach for pre-
eclampsia detection and prevention that follows international recommendation. This
comprehensive screening is most accurate primarily because it combines the woman’s own
risk factors with findings on ultrasound and the levels of biochemical markers in the
mother’s blood. The accuracy of TMC’s first trimester prenatal screening program is
documented in a study by Javier and Gonzaga published in the Philippine Journal of
Obstetrics and Gynecology. Compared with the UK and US screening recommendation using
the mother’s risk factors alone, TMC’s combined first trimester screening is able to detect
more women who are at risk for preeclampsia, either early or late during their pregnancy.
This means the TMC preeclampsia screening can identify 9 out of 10 women who will
eventually develop hypertension in pregnancy.

One of these high-risk conditions is hypertension in pregnancy. In the Philippines,

preeclampsia and eclampsia were the cause of up to 30% of maternal deaths according to
the Department of Health Philippine Health Statistics of 2017. Hypertensive disorders of
pregnancy account for 36.7% of all maternal deaths in the Philippines, which is much higher
than the worldwide rate of 18%. Included among these hypertensive diseases affecting
pregnant women is preeclampsia, a severe and diverse disorder that is associated with life-
threatening multi-organ maternal complications and which causes serious feto-placental
problems. It accounted for 22.5% of hypertensive patient admissions at the hospital where
this study was conducted. Preeclampsia is a multifactorial disease, with both genetic and
environmental factors contributing to its development. Multiple interrelated pathways have
been suggested to contribute to its pathogenesis. Previous studies have tested genes with
potential biological relevance in specific pathways to ascertain whether certain variants
influence the disease process. The biological pathways impacted by preeclampsia include
but are not limited to aberrant placental development and dysfunctional hemodynamic and
renal functions, impaired immune function, free radical dysregulation and lipid
peroxidation, and defects in coagulation and fibrinolysis.
 NURSING HISTORY

BED NO.: 8 CASE NO.: 008

NAME: M.M. AGE: 30-year-old DATE OF BIRTH: September 19,1991

SEX: Female
RELIGION: Roman Catholic
OCCUPATION: Housewife
HEIGHT: 5’5”
WEIGHT: 73 kg
BMI: 26.6 (OVERWEIGHT)
LMP: 11/18/21
GESTATIONAL AGE: 23rd week
GRAVIDA: 1 PARITY: 0 (0-0-0-0-0)
T-P-A-L-M

CHIEF COMPLAINT/S: Headache; Nausea and vomiting

DIAGNOSIS: Pregnancy-Induced Hypertension
HISTORY OF PRESENT ILLNESS:
Prior to admission, patient experienced visual changes such as blurred or double vision due
to elevated blood pressure.

PAST MEDICAL HISTORY: None

SURGICAL HISTORY: No known surgical history
FAMILY HISTORY: Mother (+) HPN (+) DM; Father (+) HPN
ALLEGIC REACTIONS: Allergy to seafood; No known allergy in medications
LABORATORY: Urinalysis, CBC
DIAGNOSTIC: Fetal Ultrasound

BIOGRAPHIC DATA

A case study of patient MM, a 30-years-old, a 23rd week pregnant woman, and a
housewife, from Maria Luisa Estate Park, Barangay Banilad, Cebu City 6000 Cebu. She is a
Filipino citizen and a Roman Catholic. Patient weighed 73kg with a height of 5’5’’. The
patient’s BMI is 26.6 which is categorized as overweight. The patient was born on September
19, 1991

On March 14, 2022 at 8:00 o’clock in the morning, patient MM was quickly brought
by her husband at Allegiant Regional Care Hospital (ARC-Hospital) due to the following
complaints of the patient: (1) persistent headache; (2) nausea and excessive vomiting; and
(3) blurred or doubled vision. After several assessments done by Doctor Park, patient was
immediately admitted after being diagnosed with Pregnancy – Induced Hypertension. The
above-stated information was being obtained from the patient (primary) and S.O.
(secondary).
 CHIEF COMPLAINTS

Patient MM was admitted at Allegiant Regional Care Hospital (ARC-Hospital) with a

chief complaint of experiencing persistent headache, and nausea and excessive vomiting.

HISTORY OF PRESENT ILLNESS

Prior to admission, the patient said that she is experiencing persistent headache;
nausea and vomiting. Also claimed that she experienced blurred or doubled vision. Patient’s
vital signs during admission were as follows: T-36.8, PR- 91bpm, RR-21cpm, BP- 140/100
mmHg, O2-92 with a pain score of 8/10. Patient appears lethargic and weak. Also, she
showed a grimace expression.

PAST MEDICAL HISTORY

As patient stated, she has seafood allergies like shrimps and crabs. But she has no
known allergies in medications. She also claims that before her pregnancy happened, she has
no history of elevated blood pressure and blood sugar.

Patient’s SO claimed that before patient MM’s pregnancy, she was living with a good
lifestyle and also, she was very conscious with her weight that leads her to have a healthy
body. Moreover, the only medication she took before was Tylenol for fever and OTC
medications.

FAMILY HEALTH HISTORY

Family history is a contributory factor to one’s present health condition. Patient MM

has a family history of hypertension and Diabetes Mellitus on her mother's side and
hypertension on the father side.

FAMILY GENOGRAM
 MENSTRUAL AND OBSTETRIC HISTORY

The patient's menarche started at age 13 and as far as she can remember the duration
lasted for 6 days, the menstrual cycle is regular. According to her, she usually experiences
dysmenorrhea during her period which she relieves by taking OTC pain relievers. Patient
verbalized that she first had her sexual intercourse with her husband at the age of 28 and
has no children. She also stated that she has been taking oral contraceptives way back 3 years
ago for family planning.

LIFESTYLE/ACTIVITIES OF DAILY LIVING

Patient MM enjoys undertaking everyday tasks such as cleaning the house or

participating in leisure activities. She exercises to keep her body in shape and maintain a
healthy lifestyle during her pregnancy. She tries to stroll around the home or in plaza in order
to maintain mobility. She ate a healthy, balanced diet and supplemented with vitamins but
she didn’t drink enough water. She enjoys spending quality time with her family at the beach
or the shopping, as well as dining out with her spouse. Patient is not a fussy eater, but she
has a seafood allergy, so she avoids shrimp and crabs. She also likes fruits and vegetables.
She has never undergone any type of surgery.

SOCIAL DATA

According to the patient, she has been living for about 10 years with her family and is
happily married to her husband. She stated that there are no problems with her relationship
towards her family and husband. She stated that although both their income is enough
throughout pregnancy, her husband still does his best to provide more financial support.
Patient verbalized that she belongs to a social group consist of mothers.

PSYCHOLOGICAL DATA

Psychologically, the patient is conscious and coherent, she looks weak, and lethargic
due to vomiting. Patient’s family have a history of hypertension and diabetes.

GORDON’S FUNCTIONAL HEALTH PATTERN and REVIEW SYSTEMS

GORDON’S
FUNCTIONAL
BEFORE AFTER
HEALTH
PATTERN

1. Health
Perception/Health The patient stated that she had a
Management healthy lifestyle and was mindful of her
weight. She ate healthy meals including
fruits and vegetables, which helped her
stay in shape during her pregnancy, but
she didn’t drink enough water. When
she's sick, she only takes Tylenol and
over-the-counter medications. She
appears to have vices and allergies that
she is aware of, such as a seafood allergy
to crab and shrimp. She has never
undergone any type of surgery.
During her stay in the hospital, the
patient complained of a severe headache,
nausea and vomiting, and impaired vision,
leading to a diagnosis of Pregnancy -
Induced Hypertension. She stated that she
will adjust and be more conscious of her
lifestyle now that she is expecting a child.
She will be more aware of the benefits and
drawbacks to her health, as well as the
things she should avoid.
2. Nutritional-
Metabolic Eats 3 times daily. The usual food Same amount and quality of food is
intake would be composed of fish and taken. Coffee was eliminated.
vegetables, seldom eats meat. Drinks 5 Discontinued taking vitamins. Pale color
glasses of water and 2 cups of coffee a of skin, height still proportional to the
day. Takes vitamins as a supplement. Skin body weight.
color was fair, height was proportional to
the body weight.

3. Elimination
Pale color of skin, height still
proportional to the body weight. Soft firm
stool. Voids fair amount of urine without
difficulty, in normal frequency. Clear,
yellow urine.
Same bowel movement frequency.
Difficulty moving bowels, stool quality is
hard. More frequency in voiding urine in
the lesser amount and same quality.
Bowel movement was affected because
patient cannot exert enough effort to
expel stool. Hard stool due to fluid
deficiency

4. Activity
Exercise Prior to her admission, patient During admission, patient appears to
verbalized has enough energy to do her be weak and lethargic. She cannot be able
desired or required activities. She can do to do her desired or required activities.
actively her duties as a wife and a worker. Patient does not do activity at all. Patient
Patient is living with a healthy lifestyle. is always lying on her bed due to her
She does exercise regularly because she current condition and a must to take a
is a type of person who is weight rest. She cannot be able to do things on her
conscious, which lead her to have a nice own and verbalized that she is very tired.
and healthy body. She verbalized that she
walked and jogged every morning around Level 0: Full self-care
the village to promote good mobility and Level 1: requires use of equipment or device
it also promotes better progression for Level 2: requires assistance or supervision
her pregnancy. Patient’s leisure time was from another person
Level 3: requires assistance or supervision
doing household chores. She also loves
from another person and equipment or device
reading books during her spare-time. Level 4: is dependent and does not
participate
Level 0: Full self-care
Level 1: requires use of equipment or Criteria Before Criteria Before
device Feeding 3 Grooming 3
Level 2: requires assistance or supervision
from another person
Level 3: requires assistance or supervision Bathing 4 General 3
from another person and equipment or Mobility
device
Level 4: is dependent and does not Toileting 2 Cooking 4
participate
Home 4 Shopping 4
Criteria Before Criteria Before
Maintenance
Feeding 0 Grooming 0
Dressing 4 Bed 2
Mobility
Bathing 0 General 0
Mobility
Gait 3 Posture 2
Toileting 0 Cooking 1
ROM 2 Hand 0
Grip
Home 1 Shopping 0
Maintenance

Dressing 0 Bed 0 According to the functional codes

Mobility presented above, the patient appears to be
73% dependent during her admission
Gait 0 Posture 0 here in ARC-Hospital. Mostly of her
 activities and routines are dependent with
the devices and assistant of another
ROM 0 Hand 0
Grip
person. The patient appears to be weak
and lethargic which makes her impossibly
do such activities on her own.
According to the functional codes
listed above, the patient appears to be
99.96% independent before her
admission and has full capacity of self-
care. The patient appears to be finely
groomed and neat. She is always
practicing proper hygienic procedures.

5. Sleep-Rest
Patient is quickly weary due to
household tasks and has expressed
trouble sleeping at night because she’s
able to nap during the day (afternoon),
which acts as a respite from the chores.
Despite her difficulty sleeping, she did
not use any medication to aid her sleep;
instead, she used her phone and browse
on the internet until she fell asleep. She
sleeps around 10 p.m. and wakes up
around 6 a.m. as a result, the patient
obtains about 8-9 hours of sleep. In
addition, the patient said that she does
not have nightmares.
Patient complains difficulties sleeping
during hospitalization, despite the fact
that she is weary. She’s just not used to
sleeping a new environment, and which is
why she wakes up early. In another story,
she can sleep again after getting the
prescriptions prescribed due to its side
effects. The patient added that she
sometimes experienced nightmares and
wakes up in the middle of her sleep cycles.

6. Cognitive
Perceptual Patient stated that she is currently
having trouble seeing due to blurred
vision. Patient do not have any history of
visual difficulty; patient do not use
eyeglasses and she like to read books and
newspapers. Her last eye checkup was
before pregnancy, Patient can still clearly
remember memories either short or long
term. Patient often have difficulties
bringing matters on her own hands.
patient also stated that she and her
partner find a way to deal with the
situation.
7. Self-Perception/
Self-Concept Patient manages to practice healthy
lifestyle so as not to seek medical
assistance. When asked what her
perception about herself is, she answered
“I’m self-conscious especially now that I
am pregnant. I always ensure that I feed
myself with a healthy and balanced diet.”
Patient also said that after the signs and
symptoms onset, she started to question
herself, she is saddened about the
physical changes she felt. Yet she is
positive and hopeful to be relieved and
treated. Recently, she believed that
admission will be helpful to assist her in
her needs, to alleviate the pain she felt.
During, confinement the patient stated
that she does not have any blurred vision
and is more cooperative when
interviewed by the doctor or the nurses.
Patient is coordinating with her partner if
there is any procedures or medications
that is needed to be done.
Though patient feels sick, she still
manages to appear calm and relaxed.
Patient verbalized that she is grateful for
her decision to be admitted and it help her
calm her mind and promised herself to
follow what the nurses and doctors will
tell her to do. She desires that no
complications will arise especially on her
first pregnancy. The patient also added
that her major concern is her recovery.
She believed on herself that she will
recover from the illness.
8. Role-
Relationship She patient is living with her husband. Patient is still living with his family and
She stated that there is no any problems became much closer with them especially
with her relationship towards to her during his time of illness.
family. Her husband is taking the
responsibilities and she stated that her
partner is doing his best to sustain and
provide the needs throughout the
pregnancy. The patient belongs to one
social group a group in social media in
which all the members are mothers. The
patient verbalized that her income and
his husband’s income is enough for them
especially in her child- bearing because
they have savings.

FAMILY GENOGRAM

9. Sexuality -
Reproductive She was accompanied by his husband
She has a husband and in a loving
on the course of treatment. At the time
marriage. Patient verbalized that even
she was hospitalize they were no longer
though she is pregnant at the moment,
sexually active due to complications on
they are still sexually active. She also
her pregnancy specifically Pregnancy
stated that she has been taking oral
induced hypertension. She has no
contraceptives way back 3 years ago for
reproductive problem and currently she
family planning. The patient's menarche
is 21 weeks pregnant.
started at age 13 and as far as she can
remember the duration lasted for 6
G 1T 0 P 0 A 0 L 0 M 0
days, the menstrual cycle is regular.
According to her, she usually
experiences dysmenorrhea during her
period which she relieves by taking OTC
pain relievers. She had her last
menstrual period on November 18,2021
and currently 23 weeks pregnant.

G 1T 0 P 0 A 0 L 0 M 0
10. Coping/Stress Patient said that at 23, When it comes
Tolerance to being stressed, the patient often thinks
and re-thinks of all the things that
stresses her and has always seem to come
up with a solution for it. Since it is her
During confinement, the patient said
that she is not scaredanymore about
injection and the doctor and nurses
understands the way the patient responds
to it.
 first hospitalization, the patient expects
that this would not be so traumatic to her.
She admits that she’s scared of injection
or its any form and expects the doctors
and nurses to understand the way she
might react and respond to it.
11. Value-Belief Patient mentioned that right now God During confinement patient stated that
is her source of strength and meaning. she entrusted all things to God with her
Patient said that relationship with God is present condition
very essential and with her present
condition and with the previous
decisions that she made.

SUMMARY

Before:

Prior to admission, patient M.M. is showing signs and symptoms of Pregnancy induced
hypertension. The patient stated that her health status was deteriorating. She verbalized that she was
also experiencing blurred vision and skin pallor. In her current state, God is her source of strength
and gave meaning to her endeavors. To cope up with the stress building up, she took courage to admit
herself to the hospital although she was afraid of injection. This was her first time admitting to the
hospital as she practices a healthy lifestyle. As she had a healthy lifestyle, she maintained it through
having a healthy diet and exercise regularly. She ate 3 times a day which usually consist of fish and
vegetables, and sometimes meat as well. As patient M.M always maintained her wellness, when she
gets sick, instead of going to the hospital, she takes on OTC medication. Patient M.M quickly wears
out due to excessive physical activities which in result to the patient sleeping on the afternoons giving
her difficulty sleep at night.

During:

Patient M.M, after admission to the hospital, stated that she will adjust and be more conscious
of her lifestyle as she now is expecting a child. She is now more aware of the benefits and drawback
to her health. She still ate the same amount of food and coffee was eliminated. She stops on taking
vitamins and she have skin pallor. She still had the same bowel movement, only difference is that she
is having difficulty in defecating. She has been instructed to minimize her physical activities as to it
will strain herself and the child. She had let go her habits of taking on everything, now she is having
adequate bed rest. After her admission, she does not experience blurred vision and is now more
cooperative with the doctors and nurses. Though patient feels sick, she still manages to appear calm
and relaxed. Patient verbalized that she is grateful for her decision to be admitted and it help her
calm her mind and promised herself to follow what the nurses and doctors will tell her to do. She is
still living with her family and became much closer to them. As she was accompanied by her husband,
they no longer have sexual activity due to her pregnancy, she does not have reproductive problems.
She had stated that she is not scared anymore about injection and the doctor and nurses understands
the way the patient responds to it. She had entrusted her faith to God and entrusted all things to the
will of God.
 PHYSICAL ASSESSMENT (Head to Toe) and REVIEW OF SYSTEMS

Vital Signs: T - 36.8, P – 91, R – 21, BP – 140/100 mmHg

PHYSICAL
FINDINGS REVIEW OF SYSTEMS
ASSESSMENT

SKIN Inspection:

Skin is slightly pale and yellowish in color; “maka bati kog kainit ug
erythema is present on skin of hips. Skin is kauga sako panit”
intact, moles and warts are normal, and no
variation in pigmentation and texture.

Palpation:

Skin is warm, firm and slightly dry – no “pag tan-aw nako sako tiil,
excessive moisture or dryness. Skin turgor nag burot na sha”
is poor, it takes 2 seconds to return to its
previous state when skin is pinched. There
is a sign of dehydration. Presence of
pitting edema in ankle.

HAIR Inspection:

Hair black in color, has a fine texture, wavy

hair, neatly arranged, there’s no indication
of alopecia but hair is dry and brittle. Scalp
has no lumps, lesions, and nevi but has
shown minimal amount of dandruff.

HEAD Inspection:

Head is generally round, normocephalic,

with symmetrical nasolabial folds and
palpebral fissures. Scalp is lighter in color,
no scars noted, anchariids free from lice
and nits but has minimal amount of
dandruffs. Hair is black, evenly
distributed, covers the whole scalp (no
evidence of alopecia), but hair is brittle
and dry.
Palpation:
No alopecia noted but take
note that alopecia can be
associated to some medical
conditions like
hypertension, hormonal
changes, and can be side-
effects of certain drugs.

Symmetrical head, non-tender, scalp

freely movable. No nodule, masses and
deviation of the head structure noted and
palpated.

FACE Inspection:

Shape of the face is oval, symmetrical, no No Involuntary muscle

involuntary muscle movements, can move
facial muscles at will, intact cranial nerve
V and VII.
movements/Hemifacial
spasm noted. Just take note
that Hemifacial spasm is a
nervous system disorder in
which the muscles on one
side of your face twitch
involuntarily. Hemifacial
 Palpation:

Facial bones are smooth, intact, spasm is most often caused

symmetrical, and non-tender. Temporal
artery is tender, no swelling, and
crepitation with movement was noted
when the temporomandibular joint is
palpated.
by a blood vessel touching
or pulsating against a facial
nerve.

EARS Inspection:
Both ears are located at the top of pinna
cross the occiput line. Equal size
bilaterally. There is no presence of lump or
lesion on pinna. No discharge, redness,
masses or foreign body, small amount of
cerumen present in external auditory. No
pain while moving pinna or palpating
mastoid process.

Weber Test – sound hear equally on both

ear
Rinne Test – Air conduction of sound is
greater than bone conduction

EYES Inspection:

Eyes alignment/position have shown no

signs of deviation from normal condition.
Uniform distribution of eyebrows and no
scaliness present. No infection or sty
present on eyelashes. No redness,
paleness, discharge, foreign body, dryness
or tearing. Slightly yellowish sclera.
Cornea is transparent, no abrasion or
white spots. Pupil is round, symmetrical
and uniform. Good eye movement and
coordination. Normal papillary lens
transparent. Convergence test result is
normal.

NOSE Inspection:

The nose looked to be symmetrical,

straight, and of a consistent tint. There
was no discharge or flaring present.

Palpation:

There was no pain or lesions when softly

palpated.

MOUTH Inspection:

The lips are a consistent shade of pink,

moist, symmetrical, and silky. When
requested to whistle, the patient was able
to pucker his lips. There is no yellowing of
the enamels, no retraction of the gums,
and the gums are pinkish in color. The
buccal mucosa was consistently pink,
moist, soft, shiny, and elastic in texture.
 The client's tongue is in the center of the
picture. It has a pink tint, is wet, and has a
rough texture. There is a thin yellowish
covering present. The smooth palates are
light pink and silky, but the hard palates
have a rougher texture. The uvula is
positioned in the soft palate's midline.

NECK Inspection:

Patient’s neck is symmetric with the head

centered, there is no prescience of bulging
masses or lumps. The patient showed a
coordinated head movement without
discomfort. patient’s thyroid cartilage and
cricoid cartilage move upward
symmetrically as the client swallows.
There is no resistance during range of
motion upon head and neck movement. no
enlargement found on the patients’ neck,
no prescience of discoloration.

Palpation:

When palpated there is no presence of

masses, or lumps and is warm to touch.

Auscultation:

No bruits auscultation.

CHEST AND Inspection:

LUNGS
Clients has proportional breast, saggy and
with the same color as the skin. No sign of
redness. The areola is rounded with the
same color (dark brown). No discharges
from nipple, breathing pattern with RR
21cpm

Palpation:

Ribs can be slightly palpable. Absence of

masses and lesions. Smooth texture when
touched. Not fixated and moves bilaterally
when hands are abducted overhead, or is
leaning forward

ABDOMEN Inspection:
Round shape, no presence of distention,
lesions, and previous incisional scars or
dilated abdominal veins. Linea nigra and
striae gravidarum present.

Auscultation:

Bowel sound present in all areas in

every 20 seconds. Gurgling sound
present
 Percussion:

Tympanic sounds heard over gas filled

viscera and dull sound over fluid filled
viscera.

Palpation:

No abdominal masses and tenderness.

Liver not palpable, no tenderness or
enlargement. Spleen not palpable, no
enlargement or tenderness. Kidneys
not palpable and no tenderness.

UPPER Inspection: “Kapoy and poypoy akong

EXTREMITIES kamot ma’am, sakit jud
Patient’s skin and nails in upper kaayo labi nas abaga padung
extremities have pallor appearance. No sa ako kamot.”
presence of lesions and scars on upper
extremities. Nails are clubbing and has an
excessive thickness texture. Also,
hypertrophy has been observed in the left
portion of the arm of the patient and
slightly on the right side. Muscles appears
to be asymmetrical. Swelling and puffiness
in hands were being observed also. Muscle
strength is 2/5.

Palpation: “Dili nako kalihok tarung sa

mga buhatonon kay dali
Upon palpating, flaccidity of the muscles rako kapuyon. Poypoy and
has been obtained because muscles are bug-at ako ma feel nagsukad
weak. Hypothermia on the hands and nails sa bukton og kamot.”
was being felt during palpation. Delayed
return of usual color during capillary refill
test.

LOWER Inspection: “Mura feel nako na ni dako

EXTREMITIES ko, feel nako puno ko“
Maintains posture flexion. Patient Able to
walk slowly. Good range of motion in all
joint.

Palpation:

Presence of edema or swelling on patient’s

feet and legs.
 LABORATORY AND DIAGNOSTIC RESULT

LABORATORY RESULTS:

COMPLETE BLOOF COUNT (CBC) - A CBC is a commonly performed blood test that is often
included as part of a routine checkup. This can be used to help detect a variety of disorder
including infections, anemia, and diseases of the immune system.

Date Taken: 03/15/2022

REFERENCE /
Nursing
TESTS RESULTS UNITS NORMAL SIGNIFICANCE
Responsibilities
FINDINGS
CBC with
Differential/Platelet Before:
WBC 1. Informed the
X10E/ patient this test can
20.69 4.10 – 10.9 Infection
uL assist in evaluating
Lymphocytes general health and
9.0 % 14 - 46 Lymphocytopenia the body’s response
to illness and
Monocytes explained that a
2.3 % 4 - 13 Monocytopenia blood sample is
needed for the test
procedure.
Neutrophils
2. Explained that
91.9 % 40 - 74 Acute Infection
slight discomfort
may be felt when the
RBC
X10E/ skin is punctured.
4.15 4.10 – 5.60 Normal
uL 3. Explained that
there is no food, fluid
Hemoglobin
activity or
13.5 g/ dL 12.5 – 17.0 Normal
medication
restriction unless by
Hematocrit
medical direction.
45.0 % 36.0 – 46.0 Normal
After:
MCV 4. Monitored the
96.0 fL 80 - 98 Normal puncture site for
oozing or hematoma
MCH formation.
30.0 pg 27.0 – 34.0 Normal 5. Informed patient
for possible
MCHC repetition of the
33.9 g/dL 32.0 – 36.0 Normal laboratory
examinations.
RDW 6. Documented
14.6 % 11.7 – 15.0 Normal laboratory results.
URINALYSIS

URINALYSIS- a type of test that screens the urine. It is used to detect and manage a wide
range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis
involves checking the appearance, concentration, and content of urine.

Date Taken: 03/15/2022

TEST NORMAL URINE Reference Nursing responsibility

SAMPLE A
PHYSICAL Before-
COLOR Pale Yellow – Amber No significance 1. instruct to use cotton
dark Amber ball tissue paper or
APEARANCE clear clear No significance towelette to clean the
urethral area to
MUSCUS No No No significance prevent external
bacteria from
CHEMICAL entering the urine
LEUKOCYTES Negative Negative No significance specimen.
NUTRITE Negative Negative No significance
2. Inform the patient
UROBILIN 3.2 mol/L 3.2 mol/L No significance that the test result of
the urine screening
PROTEIN <10 mg/dl 13 mg/dl Presence of protein will inform us the
in the urine current condition of
indicates that the the urinary system.
kidney is damaged
or impaired. During-
pH 4.5-8.0 4.9 No significance 1. Instruct and allow the
patient to void into
BLOOD Negative Negative No significance
the container.
SPECIFIC .010 – 1.025 0.012 No significance
GRAVITY
After-
KETONE <6 mg/dl No No significance
1. Label the specimen
presence
container with the
client’s identifying
information and send
BILIRUBIN 0.2 – 1.2 0.2 mg/dl No significance to the lab
mg/dl immediately.
GLUOSE <130 mg/dl 113mg/dl No significance
 ANATOMY AND PHYSIOLOGY

NORMAL ANATOMY AND PHYSIOLOGY

Anatomy
There are a lot of bodily changes that happen during a normal pregnancy. There are
external changes that are noticeable, and there are internal changes that can only be appreciated
through thorough clinical examinations. Most of the changes are the body’s response to the
changes in levels of hormones and the growing demands of the fetus.
The two dominant female hormones, estrogen and progesterone, change in a normal level.
Along with this, a significant rise/appearance of 4 more major hormones take place; these are:
1. human chorionic gonadotropin (HCG),
2. human placental lactogen,
3. prolactin, and
4. oxytocin.

All these 6 hormones interact with each other simultaneously to maintain a normal
pregnancy as it progresses.
The following are the major effects of these hormones in the body:

• BREAST - enlarged; dark end areola; production of colostrum milk (first milk)
• OVARIES - ovum production stops; corpus luteum continues production of
hormones up to 10-12 weeks of gestation, or until the placenta takes over.
• UTERUS - amenorrhea (absence of menstruation; Hegar’s Sign (Increased
vascularity of the lower segment of the uterus); there is growth due to
hypertrophy and hyperplasia of muscles and connective tissues; there is
continuous rise of the fundal height
• CERVIX - Goodell’s sign (softening); Chadwick’s sign (blue-purple discoloration);
edema; hyperplasia; thickening of mucous lining; increase mucous production;
(+) mucus plug by the end of the 2nd month; shorter; more elastic; thicker
• VAGINA - Chadwick’s sign (deeper color); hypertrophy; hyperplasia; acidity: pH
4.0-6.0
• PERINEUM - Increased in size, deepened color
Physiology
 PREGNANCY-INDUCED HYPERTENSION: PATHOPHYSIOLOGY

PLACENTA

TROPHOBLASTIC CELLS

SPINAL ATRIOLES

TROPHOBLASTIC INVASION TROPHOBLASTIC INVASION

achieved not achieved

LUMEN WIDE LUMEN NARROW

LOW LOW HIGH VOLUME HIGH HIGH LOW VOLUME

PRESSURE RESISTANCE VESSELS PRESSURE RESISTANCE VESSELS

INCREASE BLOOD SUPPLY DECREASE BLOOD SUPPLY

TO PLACENTA & FETUS TO PLACENTA & FETUS

ISCHEMIA IN THE PLACENTA

PRO-INFLAMMATORY PROTEINS
RELEASED IN MOTHER’S CIRCULATION

ENDOTHELIAL DYSFUNCTION

VASOCONSTRICTION KIDNEYS RETAIN MORE SALT CAPILLARY LEAKING

MOVEMENT OF FLUID IN EXTRAVASCULAR SPACE

HYPERTENSION

EDEMA HEMOCONCENTRATION

PLATELET DYSFUCNTION DECREASE VOLUME OF BLOOD

END ORGAN DAMAGE

KIDNEY BRAIN LUNGS OCCIPITAL LOBE

PROTEINURIA
SEIZURE PULMONARY EDEMA TEMPORARY BLINDNESS
OLIGURIA (ECLAMPSIA)
 MEDICAL MANAGEMENT

MEDICAL IDEAL ACTUAL (Done or Not Done)

MEDICATIONS MAGNESIUM SULFATE

Purpose: DONE
Magnesium Sulfate is the Magnesium Sulfate 10ml
drug of choice of PIH. It is IVTT
used to prevent seizures in BID
women with preeclampsia.
It can also help prolong a
pregnancy for up to two
days. This allows drugs that
speed up your baby’s lung
development to be
administered.

METHYLDOPA
Purpose: DONE
Methyldopa can prevent Methyldopa 250mg
the complications caused PO
by hypertension (high BID
blood pressure) in
pregnancy, and a related
condition called pre-
eclampsia. These
complications include
preterm birth, low birth
weight in the baby, and
illness in both the mother
and baby which is
sometimes serious.

MULTIVITAMINS WITH
FOLIC ACID
Purpose: DONE
Folic acid before and Multivitamins with Folic Acid
during pregnancy can help 10mg
prevent birth defects of PO
your baby's brain and BID
spinal cord.

CLONIDINE
Purpose: DONE
Clonidine tablets Clonidine 0.1mg
(Catapres) are used alone PO
or in combination with OD
other medications to treat
high blood pressure.
LABORATORY URINALYSIS
Purpose:
A urinalysis is a test of your
urine. DONE
In PIH, it screens for high
levels of sugars, proteins,
ketones, and bacteria. High
levels of sugars may
suggest Gestational
Diabetes, which may
develop around the 20th
week of pregnancy.

COMPLETE BLOOD
COUNT (CBC)
Purpose:
A CBC is a commonly
performed blood test that
is often included as part of DONE
a routine checkup. This can
be used to help detect a
variety of disorder
including infections,
anemia, and diseases of the
immune system.

DIAGNOSTICS Fetal ultrasound

Purpose: DONE
For close monitoring of
your baby's growth,
typically through
ultrasound. The images of
your baby created during
the ultrasound exam allow
your doctor to estimate
fetal weight and the
amount of fluid in the
uterus (amniotic fluid).

Nonstress test or
biophysical profile
Purpose:
A procedure that checks
how your baby's heart rate
DONE
reacts when your baby
moves. A biophysical
profile uses an ultrasound
to measure your baby's
breathing, muscle tone,
movement and the volume
 of amniotic fluid in your
uterus.

Recommended Foods to
DIET Eat:

HIGH PROTEIN
Purpose: DONE
Helps baby’s growth and
repair of new and
damaged tissues. Making
antibodies for their
immune system. Making
hormones and enzymes.

CALCIUM RICH FOODS

Purpose:
Calcium intake may DONE
regulate blood pressure
by increasing
intracellular calcium in
vascular smooth muscle
cells leading to
vasoconstriction, and by
increasing vascular volume
through the renin–
angiotensin–aldosterone
system (RAAS).

POTASSIUM RICH FOODS DONE

Purpose:
The more potassium you
eat, the more sodium you
lose through urine.
Potassium also helps to
ease tension in your
blood vessel walls, which
helps further lower blood
pressure.

IRON and FOLIC ACID

RICH FOODS
Purpose: DONE
So, you would not develop
iron deficiency anemia and
help prevent some major
birth defects of the baby’s
brain.
TREATMENT Medication therapy
Purpose: DONE
Medications to lower
blood pressure. These
medications, called
antihypertensives, are used
to lower your blood
pressure if it's dangerously
high.
Drug of choice of PIH is
Magnesium Sulfate.
Magnesium sulfate may
attenuate blood pressure
by decreasing the vascular
response to pressor
substances.

Lifestyle Modification for

Managing PIH
Purpose: DONE
Lifestyle measures can
improve the way the
immune system functions.
And that can help ease the
symptoms of PIH. Healthy
living can also prevent or
control other health
problems.

HOSPITALIZATION
Purpose: DONE
PIH may require that you
be hospitalized. In the
hospital, your doctor may
perform regular nonstress
tests or biophysical profiles
to monitor your baby's
well-being and measure
the volume of amniotic
fluid. A lack of amniotic
fluid is a sign of poor blood
supply to the baby.

DELIVERY
Purpose:
(If treatments do not NOT YET
control PIH or if the fetus or
mother is in danger).
Cesarean delivery may be
recommended, in some
cases.
 OUTLINE OF NURSING MANAGEMENT

GOAL FOCUS NURSING INTERVENTIONS

HEALTH PROMOTION Physical - set a goal of 5-10 mins per day of

activities aerobic exercise such as walking.
- advise patient to have a regular rest
breaks per day but avoid lengthy naps.
- create a regular sleep schedule and aim
for 8 hrs of sleep every night.
- create a restful environment such as
cool, quiet and dark-lighted room to
induce sleep
- encourage patient to manage worries
and avoid stress

Patient and - educate and assist family members in

Family learning the procedure for home
Education monitoring of bp, as indicated
- provide information of the nutritional
diet indicated for the patient to consume
(protein, calcium, potassium, vitamin a,
iron, magnesium and folic acid rich
foods)
- inform to drink sufficient water during
the day when drug is administered orally
to prevent net loss of body water
- do not breast feed while taking this drug
without consulting physician
(postpartum)

DISEASE PREVENTION Screening - identify risk factors of the patient

- perform health history / health and risk
assessments
- utilize appropriate procedure and
interviewing techniques when taking the
client health history
- follow up the patient frequently

Patient/Couple - assess patient’s/couple’s knowledge of

Education the disease process. provide information
about pathophysiology of pih,
implications for mother and fetus; and
the rationale for interventions,
procedures, and tests, as needed.
- provide information about
signs/symptoms indicating worsening of
condition, and instruct patient when to
notify healthcare provider
- have patient informed of health status,
results of when tests, and fetal well-being
- review techniques for stress
management and diet restriction

- position patient on her left side to

maximize oxygenation to the placenta
Seizure and maternal organs and avoiding
compressing the inferior vena cava
 -keep side rails up and padded to prevent
injury if seizure occurs
-administer magnesium sulfate as
ordered

- monitor for signs of magnesium toxicity

Magnesium - notify physician if signs of toxicity occur
Toxicity - have calcium gluconate readily
available in case of magnesium sulfate
toxicity.
- if toxicity is suspected – discontinue
infusion and notify provider

CURATIVE Medication - administer magnesium sulfate

administration according to protocol; all infusions
should be prepared by the facility
pharmacy or the facility should use
commercially prepared solutions
- establish primary iv line and administer
magnesium sulfate piggyback by means
of a controlled-infusion device
- infuse via a separate line and do not mix
with other iv drugs unless compatibility
has been established
- avoid administration of any solution of
magnesium sulfate if particulate matter,
cloudiness, or discoloration is noted
- continuous fetal assessment
- keep calcium gluconate (1 g of a 10%
solution) immediately available in a
secure medication area on the unit 9
drug
dispenser system or locked emergency
medication area.
- caution with concurrent administration
of narcotics, cns depressants, calcium
channel blockers. magnesium sulfate
dose may need to be adjusted or
discontinued.
- educate patient about the other drug for
PIH, methyldopa, which can prevent the
complications caused by hypertension
(high blood pressure) in pregnancy, and
a related condition called pre-eclampsia,
and clonidine which is also an
antihypertensive drug.
- administer methyldopa tablet
(antihypertensive drug) 250 mg PO two
times a day.
- administer clonidine tablet 0.1 mg PO
once a day.

Dietary - provide information of taking

Supplements multivitamin with folic acid as a dietary
supplement 10 mg PO twice a day.
 - provide information about ensuring
REHABILITATION Nutrition enough protein in diet.
- plan for a balanced diet with optimal
calories including good quality protein,
calcium, potassium, vitamin a, iron and
folic acid rich foods.
- instruct patient to avoid foods that
contains salt/sodium, processed foods
with trans or saturated fat.
- recommended daily allowances of
magnesium are obtained in a normal
diet. rich sources are whole-grain
cereals, legumes, nuts, meats, seafood,
milk, most green leafy vegetables, and
bananas.
- providing nutritional rehabilitation
especially in households.
NAME OF DRUG DOSAGE/ FREQ/ CLASSIFICATION MECHANISM OF INDICATIONS/ SIDE EFFECTS ADVERSE NURSING
ROUTE/ ACTION CONTRAINDICATIONS EFFECTS RESPONSIBILITES
SUPPLIED

GENERIC NAME: 1 g IM an anticonvulsant, and May decrease INDICATIONS: CNS: sweating,

CNS: drowsiness, BEFORE:
Magnesium q 4-6 hrs. an electrolyte acetylcholine 1. To prevent or control drowsiness, depressed 1. Check doctor’s order
Sulfate replenisher released by nerve seizures in preeclampsia or depressed reflexes, flaccid 2. Apply patients 10
impulses but its eclampsia reflexes, flaccid
paralysis, rights of drug
2. Hypomagnesemia paralysis, administration
anticonvulsant hypothermia.
3. Seizures, hypotension and hypothermia. 3. Determine patients’
mechanism is CV: hypotension,
REFERENCE: encephalopathy with acute history to the drug
unknown. flushing,
Nurses nephritis in children CV: hypotension, 4. Check for patients’
bradycardia,
Reference 4. To manage paroxysmal flushing, chart and assess patient
circulatory
Library; Drugs atrial tachycardia circulatory for all RX and OTC
collapse,
BRAND NAME: pp 416-417 collapse,
5. To manage pre-term labor medications, including
depressed cardiac
Magnesium depressed cardiac to patients’ vitamins,
function
sulfate function, heart herbal products that she
REFERNCE: EENT: diplopia
block is taking.
Nursing2005 Metabolic:
REFERENCE: CONTRAINDICATIONS: hypocalcemia 5. Monitor patients vital
Drug Handbook
Nursing2005 1. Parenteral administration Others: Respiratory: signs especially patients
25 Anniversary
th
Drug Handbook contraindicated in patients respiratory respiratory BP.
Edition pp 429-
25th Anniversary with heart block or paralysis, paralysis 6. Wash hands
430 hypocalcemia.
Edition pp 429- myocardial damage Skin: diaphoresis
430 2. Contraindicated in patients DURING:
with toxemia of pregnancy 1. Introduce yourself to
during 2 hours preceding REFERENCE: the patient
delivery Nurses 2. Verify patients’
3. Use cautiously in patients Reference REFERENCE: identity through the
with impaired renal function Library; Drugs Nursing2005 patients’ tag
4. Use cautiously in pregnant pp 416-417 Drug Handbook 3. Explain the need to
woman during labor 25th Anniversary give the medication.
Edition pp 429- 4. Administer the
430 medication, right dose
and the right time,
5. Ensure that the
patient has taken the
medicine
6. Monitor changes in
the patients’ vital signs.
AFTER:
1. Encourage patient to
notify if there is any
sensitivity or reactions
present
2. Advise patient to
follow the medication
given by the doctor.
3. Document
administration
NAME OF DRUG DOSAGE/ FREQ/ CLASSIFICATION MECHANISM OF INDICATIONS/ SIDE EFFECTS ADVERSE NURSING
ROUTE/ ACTION CONTRAINDICATIONS EFFECTS RESPONSIBILITES
SUPPLIED

GENERIC NAME: 250 mg/5ml antihypertensives Unknown. INDICATIONS: Blood: hemolytic EENT- dry mouth, BEFORE:
Methyldopa Tablets 125 mg Thought to inhibit
1. Hypertension, hypertensive anemia, reversible nasal stuffiness 1. Check doctor’s order
PO the central
crisis granulocytopenia, GI: diarrhea 2. Apply patients 10
vasomotor thrombocytopenia Hepatic: hepatic rights of drug
centers thereby CNS: sedation, necrosis administration
BRAND NAME: decreasing CONTRAINDICATIONS: headache, Other: 3. Determine patients’
Aldomet REFERENCE: sympathetic 1. Contraindicated in patients asthenia, gynecomastia, history to the drug
Nursing2005 outflow to the hypersensitive to drug and in weakness, lactation, skin 4. Check for patients’
DRUG heart, kidneys
those with active hepatic dizziness, rush, drug- chart and assess patient
REFERENCE: HANDBOOK 25th and peripheral
disease such as acute hepatitis decreased mental induced fever, for all RX and OTC
Nursing2005 Anniversary vasculature. or active cirrhosis acuity, impotence. medications, including
DRUG Edition pp 300- 2. Contraindicated in those involuntary to patients’ vitamins,
HANDBOOK 25th 301 whose previous methyldopa choreoathetotic herbal products that she
Anniversary therapy caused by liver movements is taking.
Edition pp 300- REFERNCE: problems and in those taking CV: bradycardia, 5. Monitor patients vital
301 Nursing2005 MAO inhibitors. orthostatic signs especially patients
DRUG 3. Use cautiously in patients hypotension, REFERENCE BP.
HANDBOOK 25th with history of impaired aggravated NURSES 6. Wash hands
Anniversary hepatic function or sulfate angina, REFERENCE
Edition pp 300- sensitivity and in breast- myocarditis, LIBRARY DRUGS DURING:
301 feeding women. edema and weight pp 304-305 1. Introduce yourself to
gain the patient
2. Verify patients’
REFERENCE: identity through the
NURSES patients’ tag
REFERENCE 3. Explain the need to
LIBRARY DRUGS give the medication.
pp 304-305 4. Administer the
medication, right dose
and the right time,
5. Ensure that the
patient has taken the
medicine
6. Monitor changes in
the patients’ vital signs.
AFTER:
1. Encourage patient to
notify if there is any
sensitivity or reactions
present
2. Advise patient to
follow the medication
given by the doctor.
3. Document
administration
 NAME OF DOSAGE/FREQ CLASSIFICATION MECHANISM OF INDICATIONS/ SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITIES
DRUG / ACTION CONTRAINDICA
ROUTE/SUPPL TIONS
IED
GENERIC Adult and Vitamin b complex Increases red Indications Side Effects: 1. Bronchospasm 1. Assess for fatigue, dyspnea,
NAME child >14 years group blood cells, white Folic acid is 1. Nausea 2. Erythema weakness, dyspnea that are
Folic Acid old: PO 400 mcg Water-soluble blood cells, and effective in the 2. Gas or bloating 3. Malaise signs of megaloblastic anemia
AdGenericult Vitamin platelets treatment of 3. Poor appetite 4. Pruritus 2. Assess for hgb, hct, and
(Pregnant/Lac formation in megaloblastic 4. Funny taste in 5. Rash reticulocyte count
BRAND NAME tating): PO 600 megaloblastic anemias due to a your mouth 6. Slight flushing 3. Assess for nutritional status:
Folvite mcg/day anemias. Elevates deficiency of folic 5. Trouble bran, yeast, dried beans, nuts,
Children the serum iron acid as may be sleeping fruits, fresh vegetables,
9-13 years old: concentration seen in tropical 6. Feeling asparagus
PO 300 mcg which then helps or non-tropical depressed or 4. Assess for products currently
Children to form High or sprue, in anemias overly excited taken: estrogen,
4-8 years old: trapped in the of nutritional carbamazepine,
PO 200 mcg reticuloendotheli origin, glucocorticoids, hydantoins;
Child al cells for storage pregnancy, these products may increase
1-3 years old: and eventual infancy, or folic acid use by the body and
PO 150 mcg conversion to a childhood. contribute to a deficiency if
Infants usable form of taking other neurotoxic
<6mo-1 yr: PO iron. Contraindicatio products
80 mcg ns 5. Evaluate therapeutic response:
Neonates and Hypersensitivity, increased weight, orientation,
Infants anemias other wellbeing, absence of fatigue;
<6mo: PO 65 than increase in reticulocyte count
mcg megaloblastic/m within 5 days of beginning
acrocytic anemia, treatment, absence of neural
Reference: vit B12 tube defect
Folic Acid: deficiency 6. Teach patient to take product
Mechanism of anemia, exactly as prescribed
Action (2014). uncorrected 7. Teach patient that urine will
Retrieved from pernicious turn bright yellow
https://www.rxli anemia 8. Teach patient to notify the
st.com/folic_acid/ physician if any allergic
supplements.htm reaction occurs
#Interactions
 NAME OF DOSAGE/FREQ CLASSIFICATION MECHANISM INDICATIONS/ SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITIES
DRUG / OF ACTION CONTRAINDICATIO
ROUTE/ NS
SUPPLIED
GENERIC 0.2 mg Antihypertensive Stimulates Indications Side Effects: 1. Vomiting 1. Monitor BP carefully when
NAME BID alpha- It is indicated in the 1. Dry mouth 2. Loss of appetite discontinuing clonidine;
Clonidine PO adrenergic treatment of 2. Drowsiness 3. Malaise (a general ill hypertension usually returns within
1 tablet receptors in hypertension. 3. Dizziness feeling) 48 hr
BRAND NAME the CNS; 4. Constipation 4. Elevated liver 2. Advise patient to take the drug
Catapres which Contraindications 5. Sedation enzymes (found exactly as prescribed and not to stop
results in Hypersensitivity. using a blood test) abruptly because withdrawal
decreased Disorders of cardiac 5. Weight gain symptoms and severe hypertension
sympathetic pacemaker activity 6. Rash may occur.
outflow and conduction. 3. Instruct patient to consult
inhibiting Pregnancy and prescriber if dry mouth or
cardio lactation. drowsiness becomes a problem.
acceleration 4. During oral clonidine therapy. To
and minimize these effects, the
vasoconstricti prescriber may suggest taking most
on centers of the dosage at bedtime.
5. Instruct the patient to report chest
pain, dizziness with position
changes, excessive drowsiness, rash,
urine retention, and vision changes.
As needed, tell the patient to rise
slowly to avoid hypotensive effects.

Reference:
Yasaei, R.
(2021, August
6). Clonidine.
StatPearls
from
https://www.
ncbi.nlm.nih.g
ov/books/NB
K459124/
ASSESSMENT NURSING DIAGNOSIS PLANNING/ INTERVENTIONS AND RATIONALE EVALUATION
GOAL OF CARE RATIONALE
SUBJECTIVE: After 8 hrs. of thorough INDEPENDENT After 8 hrs. of
Deficient Fluid Volume rt. nursing intervention the thorough nursing
“ Natingala ko kay osmotic pressure secondary patient will be able to: 1. Monitor patient’s V/S 1. To determine any intervention the goal
dako akong BP ‘ron ug to pregnancy induced especially BP and I/O. underlying condition was met as evidence
sige lang ga labad hypertension, as evidenced -Patient is normovolemic, by:
akong ulo, by an average blood as demonstrated by a 2. Observe and check the 2. To monitor hydration
magpanglipong pressure level of 140/100, systolic blood pressure of amount of oral fluid intake status. -Displayed core V/S
, ‘nya mo doble akong persistent headaches, and 120 mmHg (or the based on individual needs. including BP and I/O
panan- aw ug mag epigastric pain by nausea patient's baseline), the within normal range.
sakit nalang akong and vomiting. absence of orthostasis, a 3. Stress the importance of 3. A lack of hydration might
tiyan kay mag suka- heart rate of 60 to 100 good dental result in a dry, sticky -Verbalized an
suka man ko” as beats per minute, a urine hygiene. mouth. Attention to oral understanding of
verbalized output of greater than 30 hygiene encourages specific interventions to
by the patient. mL/hr, and normal skin drinking and alleviates the prevent deficient fluid
turgor. discomfort of dry mucous volume.
membranes.
OBJECTIVE: -Patient verbalizes -Demonstrated
-Variations in blood awareness of the variables 4. Enumerate and emphasize 4. To be educated enough. behaviors and practices
pressure that cause fluid deficiency the relevance of maintaining to monitor and promote
- V/S Taken as follows: and the activities that are proper nutrition and relevance of maintaining
required to correct it. hydration. proper hydration and
T-36.70C nutrition.
P-86 bpm -The patient describes 5. Provide a comfortable 5. Comfortable
R-21 cpm what steps can be taken environment and plan daily environment and planning
BP-140/100 mmHg to treat or avoid fluid activities. conserves the patient’s
volume loss. energy.

-The patient makes lifestyle 6. Determine an emergency 6. Some effects of low fluid
modifications to prevent plan, including when to seek volume are life- threatening
dehydration from assistance. and cannot be corrected at
worsening. home. Patients who’s in
verge will require
-The patient discusses the immediate medical
symptoms that indicate the attention.
need for a doctor's visit.
ASSESSMENT NURSING DIAGNOSIS PLANNING/ INTERVENTIONS AND RATIONALE EVALUATION
GOAL OF CARE RATIONALE
DEPENDENT
1. Aid the patient if they cannot 1. Dehydrated patients may
eat without assistance and be weak and unable to meet
encourage the family or SO to prescribed intake
assist with feedings as necessary. independently.

2. Administer medicine as 2. Taking medication as

SCIENTIFIC BASIS
Deficient Fluid Volume (also
known as Fluid Volume
Deficit (FVD), hypovolemia)
is a state or condition where
the fluid output exceeds the
fluid intake. It occurs when
the body loses both water
and electrolytes from the
ECF in similar proportions.
Common sources of fluid
loss are the
gastrointestinal tract,
polyuria, and increased
perspiration.
Source: Wayne, G. (2021)
DEFICIENT Fluid Volume
(Dehydration)
https://nurseslabs.com/defic
ien t-fluid-
volume/#goals_and_outcome
s hypoperfusion; insufficient
OUTCOME
IDENTIFICATION / control certain conditions.
EXPECTED OUTCOME
After 8 hrs. of nursing
care intervention, the
patient will be able to
display vital signs within
the normal range,
including urine output
and is now fully aware
and practices the
variables needed to be
improved that cause fluid
deficiency.
prescribed by the doctor prescribed is important to
3. Evaluate the client nutrition 3. Low calories and
status refer to dietician if needed protein in diet may
for proper monitoring of salt worsen PIH and indirectly
caloric and protein intake. cause edema formation.
Low salt intake may
increase hydration while
high salt intake may
cause edema formation.
4. An accurate measure of
4. Teach family members how to fluid intake and output is an
monitor output in the home. important indicator of a
Instruct them to monitor both patient’s fluid status.
intake and output
COLLABORATI VE 1.Nutritional consult may
1. Check on dietary intake of be beneficial in
proteins and calories. determining individual
Collaborate with dietitian as needs/dietary plan. Proper
indicated. nutrition decreases
incidence of prenatal
hypovolemia and
protein/calories increase
the risk of edema formation
and PIH. Intake of 80–100 g
ASSESSMENT NURSING DIAGNOSIS PLANNING/ INTERVENTIONS AND RATIONALE EVALUATION
GOAL OF CARE RATIONALE
of protein may be required
daily to replace losses.
ASSESSMENT NURSING DIAGNOSIS PLANNING/ INTERVENTIONS AND RATIONALE EVALUATION
GOAL OF CARE RATIONALE
SUBJECTIVE CUES Decreased cardiac output related to After 8 hours of nursing INDEPENDENT After 8 hours of
“Huot ako dughan hypovolemia as evidenced by change in intervention the patient 1. Record and graph vital signs 1. The patient with PIH nursing intervention
ma’am and lipong ako blood pressure/hemodynamic will: especially BP and pulse. does not display the the patient:
pamati” readings normal cardiovascular
- remain normotensive response to pregnancy (left - remained
throughout the ventricular hypertrophy, normotensive
OBJECTIVE CUES remainder of the increase in plasma volume, throughout the
T - 36.8 C
o pregnancy. vascular relaxation with remainder of the
P – 91 bpm decreased peripheral pregnancy.
R – 21 cpm - report absence and/or resistance). Hypertension
BP – 140/100 mmHg decreased episodes of (the second manifestation - reported absence
dyspnea. of PIH after edema) occurs and/or decreased
-Change in blood owing to increased episodes of dyspnea.
pressure/hemodynamic - alter activity level as sensitization to
readings the condition warrants. angiotensin II, which - altered activity
-Edema increases BP, promotes level as the condition
-Shortness of breath aldosterone release to warrants.
-Alteration in mental OUTCOME increase sodium/water
status SCIENTIFIC BASIS IDENTIFICATION / reabsorption from the
EXPECTED OUTCOME renal tubules, and
A decrease in circulating blood volume After 8hrs of nursing constricts blood vessels.
due to the shifting of fluid from the intervention the patient
intravascular to the interstitial spaces will be able to improve 2. Assess MAP at 22 weeks’ 2. Pulmonary edema may
occurs in a pregnant client with a her respiratory status gestation. A pressure of 90 mm transpire, with
hypertensive disorder due to the and will lessen the Hg is considered predictive of modification in peripheral
decrease of the circulating blood feeling of discomfort PIH. Assess for crackles, vascular resistance and
volume and the total vascular volume and the formation of wheezes, and dyspnea; note drop in plasma colloid
and an increase in the systemic edema. respiratory rate/effort. osmotic pressure.
vascular resistance, the heart rate
decreases as well as the stroke volume.
These mechanisms lead to a decrease 3. Institute bedrest with 3. Improves venous return,
in cardiac output seen among clients patient in lateral position. cardiac output, and
with hypertensive disorders in renal/placental perfusion.
pregnancy.

4. Check for invasive 4. Provides precise picture

Source: hemodynamic parameters. of vascular changes and
ASSESSMENT NURSING DIAGNOSIS PLANNING/ INTERVENTIONS AND RATIONALE EVALUATION
GOAL OF CARE RATIONALE
Gil, W., (2022). Risk for Decrease fluid volume. Prolonged
Cardiac Output. Nurseslabs. Retrieved vascular constriction,
from: increased
https://nurseslabs.com/preeclampsia- hemoconcentration, and
gestional-hypertensive-disorders- fluid shifts decrease
nursing-care-plans/2/ cardiac output.

5. Check on BP and side effects 5. Side effects such as

of antihypertensive drugs. tachycardia, headache,
Administer propranolol nausea, and vomiting, and
(Inderal), as appropriate. palpitations may be treated
with propranolol.

DEPENDENT:
1. Give antihypertensive drug 1. If BP does not respond to
such as hydralazine conservative measures,
(Apresoline) PO/IV (as short-term medication may
prescribed by the physician), be needed in conjunction
so that diastolic readings are with other therapies, e.g.,
between 90 and 105mmHg. fluid replacement and
Begin maintenance therapy as MgSO4. Antihypertensive
needed, e.g., methyldopa drugs work directly on
(Aldomet) or nifedipine arterioles to promote
(Procardia). relaxation of
cardiovascular smooth
muscle and help increase
blood supply to cerebrum,
kidneys, uterus, and
placenta. Hydralazine is the
drug of choice because it
does not produce effects on
the fetus. Sodium
nitroprusside is being used
with some success to lower
BP (especially in HELLP
syndrome).
ASSESSMENT NURSING DIAGNOSIS PLANNING/ INTERVENTIONS AND RATIONALE EVALUATION
GOAL OF CARE RATIONALE
Subjective: After 8 hours of nursing INDEPENDENT After the nursing intervention,
Risk for Falls related to intervention, the patient 1. Identify factors that affect 1. To know the goal was met.
“mura man feel nako body weakness will be able to; safety needs. intervention that will be
mitumba ko” established. - increased
-increase strength of strength of affected and
affected and 2. Assess the patient ability to 2. It is helpful to determine compensatory body parts.
compensatory body ambulate safely with or without the client’s functional
Objective: parts. assistive devices. abilities to plan for ways of - Patient or SO was able to
improving the problem verbalize the importance of
v/s taken as; - Patient or SO will be areas having safety measurement s.
BP: 150/110 able to verbalized the
T: 36.5 importance of having 3. Thoroughly orient the patient 3. For the client to -Patient was able to rejuvenate
RR: 17bpm safety measurement s. to environment. familiarize the physical mobility impairment.
PR: 89bpm surroundings.
O2sat: 98% -Patient will be able to
rejuvenate physical 4. Assess vision and provide 4. To provide well- lighted
mobility impairment. adequate lighting to clearly see environment and avoid
the pathway. the occurrence of injury.
OUTCOME To ensure clients safety.
SCIENTIFIC BASIS IDENTIFICATION /
EXPECTED OUTCOME 5. Ask the significant others to 5. To prevent the patient
Within 8 hours of always stay with the client. - from falling on bed.
Increased susceptibility rendering proper Instruct the patient to call for
to falling that may cause nursing intervention, assistance when moving.
physical harm. the patient will be free
from fall. Patient will be 6. Put side rails. 6. To reduce the risk of
Reference: able to impart health falling.
teaching about risk of
Admin. (2017, June 13). falls related to body
Assessing your patients' weakness.
ASSESSMENT NURSING DIAGNOSIS PLANNING/ INTERVENTIONS AND RATIONALE EVALUATION
GOAL OF CARE RATIONALE
risk for falling. American 7. Provide assistive devices for 7. For the client’s support.
Nurse. Retrieved walking such as cane, crutches
November 20, 2021, from and/o wheelchairs.
https://www.m
yamericannur 8. Ensure that the patient wears 8. To prevent from
se.com/asses sing- proper shoes slippering.
patients- risk-
falling/amp/. DEPENDENT
1. Administered medications as 1. To facilitate
prescribed by the physician. management.

COLLABORATI VE
1. Referred to the dietitian for 1. These restrictions can
the nutritional consultation and help manage fluid
institution of dietary retention and with
supplement. associated hypertensive
response, which decrease
cardiac workload.

2. Referred to the physical 2. These management

therapist for further prescribed develops a treatment plan
exercise. to improve the ability to
move, restore function
and prevent disability.
DISCHARGE PLANNING

Instructed the patient not to skip the

MEDICATION medications that the doctor ordered.

EXERCISE/ENVIRONMENT Advised the patient to have adequate rest.

Encourage SO to provide adequate lighting.

Secure laboratory tests such as Complete

TREATMENT Blood Sugar (CBC), Fasting Blood Sugar
(FBS), and Urinalysis.

HEALTH TEACHING • Encourage patient for sodium

restriction.
• Encourage patient to have a proper
hygiene.
• Encourage the patient to limit her
daily activities and exercise.
• Encourage to avoid a Salty, high-fat
diet; instead, eat healthy foods.
• Advise to continue medicine as
prescribed by the doctor.

• Observe carefully for symptoms.

OPD Follow up • Advice patient to have follow-up
check-up after 1 week.

• Adequate fluid intake

DIET • Eat fresh green healthy leafy
vegetables and fresh fruits

• Limit sexual activity

SPIRITUAL/SEX • Provide spiritual and emotional
support
REFERENCES

5 deficient fluid volume nursing care plans. NurseStudy.Net. (2021, December 3). Retrieved
March 18, 2022, from https://nursestudy.net/deficient-fluid-volume-nursing-care-plans/

Assessing your patients' risk for falling. American Nurse. (2017, June 13). Retrieved March 18,
2022, from https://www.myamericannurse.com/assessing-patients-risk-falling/

Folvite (folic acid) dosing, indications, interactions, adverse effects, and more. (2019, September
28). Retrieved March 18, 2022, from https://reference.medscape.com/drug/folvite-folic-
acid-344419#10

Muti, M., Tshimanga, M., Notion, G. T., Bangure, D., & Chonzi, P. (2015, October 2).
Prevalence of pregnancy induced hypertension and pregnancy outcomes among women
seeking maternity services in Harare, Zimbabwe - BMC Cardiovascular Disorders I'm.
BioMed Central. Retrieved March 18, 2022, from
https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-015-0110-5

Preeclampsia Screening: New Studies Document Its Effectiveness and Cost Benefits. (n.d.).
Retrieved March 18, 2022, from https://www.themedicalcity.com/index.php/news/pre-
eclampsia-screening-new-
studies#:~:text=One%20of%20these%20high%2Drisk,Philippine%20Health%20Statistics
%20of%202017.

Pregnancy induced hypertension. Pregnancy induced hypertension | Children's Wisconsin. (n.d.).

Retrieved March 18, 2022, from https://childrenswi.org/medical-care/fetal-concerns-
center/conditions/pregnancy-complications/pregnancy-induced-
hypertension#:~:text=Pregnancy%2Dinduced%20hypertension%20(PIH),is%20present%2
0before%20pregnancy%20begins.

RxList. (2021, June 11). Folic acid: Health benefits, side effects, uses, Dose & precautions.
RxList. Retrieved March 18, 2022, from
https://www.rxlist.com/folic_acid/supplements.htm#Interactions

U.S. National Library of Medicine. (n.d.). Pregnancy-induced hypertension. Hormones (Athens,

Greece). Retrieved March 18, 2022, from https://pubmed.ncbi.nlm.nih.gov/26158653/

Wayne, G., GLORIA, Jonathan marcel, says:, P., & says:, K. (2021, October 3). Fluid volume
deficit (dehydration) nursing care plans. Nurseslabs. Retrieved March 18, 2022, from
https://nurseslabs.com/deficient-fluid-volume/