Gamalinda, John Gabriel

BSN-2A0

CMCP

Data Gathering

Primary Source
- Client / Patient

Secondary Source
- Signi cant others

- Nursing and Medical Records

- Verbal and Written Consultations

- Diagnostic / Laboratory Works

Nursing Process in Action

Assessing Collect data

Organize data

Validate data

Document data

Diagnosing Analyze data

Identify health problems, risks and strengths

Formulate diagnostic statements

Planning Prioritize problems/diagnosis

Formulate goals/desired outcomes

Write nursing interventions

Implementing Reassess the client

Determine the nurses need for assistance

Supervise delegated care

Document nursing activities

Evaluating Collect data outcome

Compare data with outcomes

Relate nursing actions to client goals/outcomes

Draw conclusions about problem status

Continue, modify or terminate the clients care plan

Assessment Data
Objective Data
- Data obtained through observation and is veri able

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 Subjective Data
- Data obtained through collection of client’s symptoms, feelings or individual
perception of problems and needs. Can be only veri ed by the patient.

Patient Interview
- Establish good communication with the patient

- Select appropriate environment for the patient to loosen up

- Avoid using medical jargons

- Use proper body language

- Con rm patient statements to avoid misunderstanding

- Use open ended questions to allow patients provide general information on facts
and provide the client with a sense of control

Therapeutic / E ective Communication

- Actively listen to the patient not only what he / she is saying but also process the
information the patient is delivering

- Rephrase the information stated by the patient as it allows clari cation and focus to
provide further discussions, also encourage response

- Re ect on the information shared by patient, repeat questions to clarify and

eliminate misunderstanding if present

- Summarize information gathered to identify if there is any information omitted, you

may ask the patient if there is anything else he / she wants to add to the gathered
information

Components of a Complete Health History

- Biographic data

- Patients name

- Address

- Birth date

- Emergency contacts

- Chief complaint, Reason why patient seeks medical care ( Quote patient words )

- Medical History ( Past and current health care )

- Family History ( Family history of past diseases )

- Psychosocial History ( Feeling about self, place in society, and relationship with
others )

- Activities of daily living

High Risk Mother Complications with symptoms

First Trimester

• Abortion
• Threatened - vaginal bleeding during early pregnancy without cervical dilation

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 Causes:

• Small falls

• Injuries or stress during 1st trimester

Symptoms:
• Cramping in the abdominal area alongside with vaginal bleeding

• Dull but constant or sharp pain in the lower back or the abdominal region

• Clot or a tissue passing out of the vagina

• Mothers with multiple children has high chances of threatened miscarriage

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Bed rest

• Medicine

• Progesterone - female hormone that supports pregnancy

• Imminent - impending miscarriage indicated by bleeding and pain along with an

e aced cervix

Causes:

• Immunologic abnormalities

• Major trauma

• Uterine abnormalities

Symptoms:
• Vaginal bleeding

• Lower back discomfort

• Midline pelvic cramping

• Profuse bleeding

• Overt rupture of membranes

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• If products of conception are visible in the cervical os, gentle removal with ring
forceps may allow the cervix to close and may control bleeding

• Dilation and curettage

• Missed - dead embryo or fetus is retained in the womb for a period of time, during
which the usual symptoms of miscarriage may not occur

Causes:

• No probable cause

• Uterine problem (scarring)

Symptoms:
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 • hCG level doesn’t rise at a typical rate

• Vaginal bleeding

• Discharge of uid or tissue

• Rh incompatible

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Medicine

• Misoprostol - e ective medical method for completion of a missed abortion,

taken vaginally rather than orally

• Incomplete - miscarriage in which some fetal or Placental tissue remains in the

uterus

Causes:

• No probable cause

• Uterine problem (scarring)

Symptoms:
• Moderate to severe vaginal bleeding

• Lower abdominal and/or pain

• Pain in the back, buttocks, genitalia, and perineum

• Passing blood cloths

• Fever

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Frequent obstetrics follow-up

• Serial quantitative beta-hCG levels

• Expel fragments of conception on their own

• Complete - fetus parts have been expelled or removed from the uterus

Causes:

• Chromosomal abnormalities (hereditary or spontaneous)

Symptoms:
• Vaginal bleeding

• Abdominal pain

• Blood in the vaginal vault

• Closed cervical os

• No tenderness in the cervix, uterus, adnexa, or abdomen

• Ultrasound shows an empty uterus

Diagnostic test:
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 • Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Usually no further treatment is needed

• Septic Abortion - spontaneous or induced abortion associated with bacterial

infection

Causes:

• Retained products of conception

• Infection introduced into the uterus (normal vaginal ora and sexually transmitted
bacteria)

Symptoms:
• Chills

• Fever

• Vaginal discharge

• Peritonitis

• Septic shock

• Hypothermia

• Hypotension

• Oliguria

• Respiratory distress

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Medicine

• Clindamycin - 900 mg IV every 8 hrs

• Gentamicin - 5 mg/kg IV once a day

• Sepsis - body's response to an infection that damages its own tissues

Causes:

• Bacterial infections

• Viral infections

Symptoms:
• Thrombocytopenia

• Ecchymoses

• Intramuscular hemolysis

Treatment:

• Removal of tissue damaged by infection

• Antibiotics

• IV uids

• Vasopressors - given if bp remains too low

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 • Ectopic Pregnancy - fetus develops outside the uterus

Causes:

• In ammation and scarring of the fallopian tubes from a previous medical

condition, infection, or surgery

• Hormonal factors

• Genetic abnormalities

• Birth defects

Symptoms:
• In amed fallopian tube

• Fertilized egg gets stuck on the way to the uterus

• Hormonal imbalance

• Abnormal fertilized egg growth

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Expectant management - closely watching a patients condition but not giving any
treatment unless symptoms appear

• Medicine

• Methotrexate - used to stop pregnancy growing

• Surgery

• Used to remove the pregnancy, usually along with the a ected fallopian tube

Second Trimester

• H-Mole - rare mass or growth that forms inside the womb at the beginning of the
pregnancy

Causes:

• Two sperms fertilizing one normal ovum

Symptoms:
• Severe nausea and vomiting

• Sometimes vaginal passage of grape like cysts

• Pelvic pressure or pain

• Dark brown to red vaginal bleeding during the rst trimester

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Dilation and curettage

• Hysterectomy

• HCG monitoring

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• Incompetent Cervix ( Premature Cervical Dilation ) - cervix opens too early during
pregnancy

Causes:

• Uterine abnormalities

• Genetic disorders a ecting a brous type of protein that makes up the bodies
connective tissues exposure to diethylstilbestrol (DES), a synthetic form of the
hormone estrogen, before birth also has been linked to cervical insu ciency.

Symptoms:
• Mild discomfort or spotting when 14 to 20 weeks pregnant

• Feeling pressure in your pelvis

• Backache that you haven’t have before

• Abdominal cramps

• Light bleeding

• Change in vaginal discharge

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Cervical cerclage - doctor will sew a stitch around weakened cervix to make it
stronger. This may help pregnancy to last longer, usually done 12 to 14 weeks of
pregnancy

Third Trimester

• Placenta Previa - placenta is located over or near the cervix, in the lower part of the
fetus

Causes:

• Tumors in the uterus

• Past uterine surgeries or cesarean deliveries

• Woman who is older than 35

• Cigarette smoking

• Placenta previa in a past pregnancy

• Being pregnant with a boy

Symptoms:
• Bright red bleeding from vagina during the second half of the mothers pregnancy.
Ranges from light to heavy bleeding, often painless

• Has contractions along with the bleeding. Cramping or tightening alongside

contractions, can also feel pressure in your back

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

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 Treatment:

• Limit bleeding to get as close as possible to due date

• Medicine

• Tocolytic - given to prevent premature labor, also helps slow or stop

contractions

• Corticosteroid - given to help the baby’s lungs to develop faster

• Abruptio Placentae - placenta is partially or completely detaches itself from the

uterine wall before delivery

Causes:

• Placental abruptions in previous pregnancies

• Smoking

• Cocaine or other drug use

• High blood pressure

• Problems with the amniotic sac

• Getting pregnant later in life

• Carrying more than one baby

• Abdominal trauma

Symptoms:
• Abdominal pain

• Back pain

• Uterine tenderness or rigidity

• Uterine contractions, often come one right after another

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Medicine

• Corticosteroid - given to help the baby’s lungs to develop faster

• Analgesics - used to relief pain

• IV brinogen - Increases brinogen level

• Preterm Labor - labor that starts before 37 completed weeks of pregnancy

Causes:

• Problems with uterus or placenta

• Smoking

• Using illicit drugs

• Certain infections with the amniotic uid and lower genital tract

• High blood pressure

• Diabetes

• Autoimmune disease

• Depression

Symptoms:
• Regular or frequent sensations of abdominal tightening (Contractions)

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 • Constant low, backache

• Pelvic or lower abdominal pressure

• Mild abdominal cramps

• Vaginal spotting or light bleeding

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Bed rest

• Cervical cerclage - doctor will sew a stitch around weakened cervix to make it
stronger. This may help pregnancy to last longer, usually done 12 to 14 weeks of
pregnancy

• Medicine

• Tocolytic - given to prevent premature labor, also helps slow or stop

contractions

• Corticosteroid - given to help the baby’s lungs to develop faster

• Premature Rupture of Membranes - rupture of the amniotic sac before labor

begins

Causes:

• Low socioeconomic conditions

• Sti (chlamydia, gonorrhea)

• Previous preterm birth

• Vaginal bleeding

• Cigarette smoking

• Unknown causes

Symptoms:
• Sudden gush of uid from the vagina

• Leaking of uid from the vagina

• Feeling of wetness in the vagina or in the underwear

Diagnostic test:
• Ultrasound

• Sonogram

• HCG test

• Progesterone

Treatment:

• Expectant management - closely watching a patients condition but not giving any
treatment unless symptoms appear

• Medicines

• Corticosteroids - helps baby’s lungs to develop faster

• Tocolytic - given to prevent premature labor, also helps slow or stop

contractions

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 Hypovolemic Shock - A severe uid loss (blood or other uid) makes the heart unable
to pump blood to the body

Causes:

• Blood loss when a major blood vessel bursts or when you’re seriously injured

Symptoms:
• Anxiety or agitation

• Cool, clammy skin

• Confusion

• Decreased or no urine output

• Generalized weakness

• Pale skin color

• Rapid breathing

• Sweating, moist skin

Diagnostic test:
• Blood test

• Ct scan

• Ultrasound

• Echocardiogram

Treatment:

• Give uids or blood through IV line - Replenish the blood loss and improve
circulation

Medical Conditions During Pregnancy

• Gestational Hypertension - high blood pressure that is present before pregnancy

begins

Causes:

• Pre-existing hypertension

• Kidney disease

• Diabetes

• Hypertension with a previous pregnancy

• Mothers age is younger than 20 or older than 40

• Multiple fetuses

Symptoms:
• Headache that wont go away

• Edema (swelling)

• Sudden weight gain

• Vision changes (blurred or double vision)

• Nausea or vomiting

• Pain in the upper right side of the belly or around the stomach

• Making small amounts of urine

Diagnostic test:
• Blood pressure measurement

• Urine test

Treatment:

• Medicine

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 • IV labetalol

• Hydralazine

• Oral nifedipine

• Pre eclampsia without severe features - mothers high blood pressure reduces the
blood supply to the fetus which may get less oxygen and fewer nutrients

Causes:

• History of preeclampsia

• Chronic hypertension

• First pregnancy

• New paternity

• Age

• Obesity

• Multiple pregnancy

Symptoms:
• High blood pressure

• High levels of protein in urine

• Dark spots appearing in your vision

• Blurry vision or light sensitivity

• Shortness of breath

Diagnostic test:
• Urine test

Treatment:

• Bed rest

• Careful monitoring with a fetal heart monitor and frequent ultrasounds

• Medicine

• Labetalol or nifedipine - to lower blood pressure

• Pre eclampsia with severe features - mothers high blood pressure reduces the
blood supply to the fetus which may get less oxygen and fewer nutrients

Causes:

• History of preeclampsia

• Chronic hypertension

• First pregnancy

• New paternity

• Age

• Obesity

• Multiple pregnancy

Symptoms:
• High blood pressure

• High levels of protein in urine

• Signs of kidney or liver damage

• Low blood platelet levels

• Fluid in the lungs

Diagnostic test:
• Urine test

Treatment:

• Bed rest

• Careful monitoring with a fetal heart monitor and frequent ultrasounds

• Medicine

• Labetalol or nifedipine - to lower blood pressure

• Eclampsia - women who have preeclampsia develop seizures or coma

Causes:

• Gestational or chronic hypertension

• Being older than 35 years or younger than 20 years

• Pregnancy with twins or triplets

• First time pregnancy

• Diabetes or another condition that a ects blood vessels

• Kidney disease

Symptoms:
• High blood pressure

• High levels of protein in urine

• Signs of kidney or liver damage

• Seizures

• Coma

Diagnostic test:
• Complete blood count

Treatment:

• Bed rest

• Medicine

• Magnesium sulfate - helps prevention and control of maternal seizures

• Labetalol or nifedipine to lower blood pressure

• HELLP Syndrome - Pregnancy complication that a ects the blood and liver

Causes:

• Unknown

• Women with preeclampsia or eclampsia have a higher risk of HELLP syndrome

Symptoms:
• Blurry vision

• Chest pain

• Pain in the upper right or middle part of the belly

• Swelling

• Vomiting

Diagnostic test:
• D-dimer test

• Complete blood count

Treatment:

• Medicine

• Corticosteroids - improves platelet count and serum levels of LDH and ALT

• Dexamethasone - accelerates recovery from their platelet count

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• Gestational Diabetes Mellitus - condition in which a hormone made by the
placenta prevents the body from using insulin e ectively

Causes:

• Not enough insulin being produced

• Overweight

• Obese

• Gaining too much weight during pregnancy

Symptoms:
• Increased and frequent urination

• Increased thirst

• Fatique

• Nausea

• Vomiting

• Weight loss even with increased appetite

• Blurred vision

• Yeast infections

Diagnostic test:
• Fasting plasma glucose test

• A1C test

Treatment:

• Special meal plans

• Scheduled physical activity

• Daily blood glucose testing

• Insulin injections

Intrapartum Complications

• Hypotonic

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• Hypertonic

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• Uncoordinated

Postpartum Complications

• Postpartum Hemorrhages
Causes:

• Uterine Atony - failure of the uterus to contract su ciently during and after
childbirth

• Retained Placental Fragments - delayed post partum hemorrhage or prolonged

post partum spotting

• Trauma (Lacerations: All types, Hematomas, Uterine Inversion, Uterine Rupture)

Symptoms:

• Uncontrolled bleeding

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 • Decreased blood pressure

• Increased heart rate

• Decrease in the red blood cell count

• Swelling and pain in the vagina and nearby area if bleeding is from a hematoma

Treatment:

• Medication - to stimulate contractions

• Oxytocin

• Manual massage of the uterus - to stimulate contractions

• Removal of placental pieces that remain in the uterus

• Examination of the uterus and other pelvic tissues

• Puerperal Infections

• Endometritis - in ammation of the endometrial lining of the uterus

Causes:

• Infection in the uterus

• Sti (chlamydia, gonorrhea)

• More likely to occur after miscarriage or after childbirth

• Common after a long labor or C-section

Symptoms:

• Swelling of the abdomen

• Abnormal vaginal bleeding or discharge

• Discomfort with bowel movement

• Fever

• General discomfort, uneasiness, or ill feeling

• Pain in lower abdomen or pelvic region(uterine pain)

Treatment:

• Medicine

• Ampicillin

• Gentamicin

• Metronidazole

• Doxycycline

• Peritonitis - Redness and swelling of the that lines your belly or abdomen

Causes:

• A hole in the stomach, intestine, gallbladder, or bladder

• Infection during treatment for end stage kidney disease

• Infection of uid in the belly from end stage liver disease

• Pelvic in ammatory disease in woman

Symptoms:

• Severe belly pain that gets worst with any motion

• Nausea and vomiting

• Fever

• Sore or swollen belly

• Fluid in the belly

• Not being able to have a bowel movement or pass gas

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 • Less urine than normal

• Thirst

Treatment:

• Medicine

• Penicillin

• Cipro oxacin

• Thrombophlebitis - in ammatory process that causes a blood clot to form and

block one or more veins, usually in the legs

Causes:
• Injury to a vein

• Inherited blood clotting disorder

• Being immobile for long periods, such as during an injury or a hospital stay

Symptoms:
• Swelling of the leg or arm

• Pain or tenderness in the area of clot

• Feeling of increased warmth in the area of clot

• Red or discolored skin in the area of the clot

Treatment:
• Applying heat to the painful area

• Elevating the leg

• Using an over the counter non steroidal anti in ammatory drug

• Wearing compression stockings

High Risk Newborn:

• Preterm Infant

• SGA

• LGA

• Respiratory Distress Syndrome

• Meconium Aspiration Syndrome

• Hyperbilirubinemia: Rh Incompatibility / ABO Incompatibility

Review of Bodily structures and systems

• General

• Skin

• Head and Neck

• Eyes
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• Ears

• Nose and Sinuses

• Mouth and Throat

• Breasts

• Respiratory

• Cardiovascular

• Gastrointestinal

• Urinary

• Reproductive
• Female client

• Male client

• Peripheral Vascular

• Musculoskeletal

• Neurological

• Endocrine

• Hematologic

• Psychological