University of Cebu Lapu-Lapu and Mandaue

A.C. Cortes Ave., Looc, Mandaue City

COLLEGE OF NURSING

CASE STUDY & NURSING CARE PLAN

Submitted by: Devanni Shane D. Hiyas

BSN 4-B
Submitted to: Beverly B. Po, RN, MAN
Clinical Instructor
 CASE STUDY

Name: L.S.G. Date of Submission: May 7, 2023

Age: 23 y/o Room Number: LR/DR Hospital Number: 3****5

Impression/s: Gestational Hypertension, Pre-eclampsia Attending Physician/s:

Diagnosis: Gestational Hypertension, Pre-eclampsia Student nurse’s Signature:

CLINICAL PORTRAIT PERTINENT DATA

ASSESSMENT: Chief complaint:
G1P0 L.S.G., a 23-year-old pregnant woman present in the hospital with gestational
LMP: July 21, 2022 hypertension and pre-eclampsia. Her blood pressure is elevated at 150/100
EDC: April 28, 2023 mmHg, and her fetal heart rate has been fluctuating between 94-120 bpm. Her
AOG: 41 weeks chief complaint is not explicitly stated, but it can be inferred that she is
DX: Gestational Hypertension, Pre-eclampsia experiencing symptoms related to her hypertensive disorder, such as headache.

SIGNIFICANT FINDINGS: History of present illness:

L.S.G. is a 23-years old pregnant woman with a diagnosis of Gestational
Hypertension and Pre-eclampsia at 41 weeks of gestation. Her blood pressure is
elevated at a hundred and fifty/a hundred mmHg, and she is in active labor with
cervical dilation of 8cm for 2 hours. The fetal heart rate changes from regular to
irregular. There is mild tenderness on palpation of the abdomen, with no
vaginal bleeding or discharge. The patient is a G1P0 with a LMP of July 21,
2022, and an EDC of April 28, 2023.
Based on the given information, the patient is diagnosed with gestational
hypertension and pre-eclampsia. These conditions are serious and can cause
complications for both the mother and the baby. Gestational hypertension is
high blood pressure that occurs after the 20th week of pregnancy, while pre-
eclampsia is a condition that occurs after 20 weeks of pregnancy and is
characterized by high blood pressure and damage to organs such as the liver
and kidneys. It can also affect the baby's growth and development.

VITAL SIGNS (during first contact with the patient): BP:150/100 mmHg Health history relevant to present illness:
Temp: 36.6 HR/PR: 98 bpm RR: 20 cpm It is not stated in the information given.
Diagnostic procedure/s done: Not stated.
 V/S during admission: BP: 150/100 mmHg Temp: 36.6 HR/PR: 98
PATHOPHYSIOLOGY: bpm RR : 20 cpm
Gestational hypertension is a circumstance wherein excessive blood pressure
develops after 20 weeks of pregnancy and resolves inside 12 weeks after
shipping. The genuine purpose is unknown, however it's far idea to be
associated with adjustments inside the blood vessels that deliver the placenta. PHYSICAL EXAMINATION:
The placenta releases substances that constrict blood vessels, main to extended
blood strain. PARTS RESULTS
Head and neck: Normocephalic, no loads or
Preeclampsia is a extra severe form of gestational high blood pressure, which is tenderness. Neck supple with out a
characterized by using excessive blood stress and damage to organs which lymphadenopathy.
includes the liver and kidneys. It also can affect the child's boom and Chest and lungs: Clear to auscultation bilaterally, no
improvement. The actual purpose of preeclampsia is not recognized, but it is wheezing or crackles cited.
idea to be related to issues with the blood vessels that deliver the placenta. Heart: Regular rhythm and not using a
These problems can lead to reduced blood drift and damage to the placenta, that murmurs or gallops
can launch substances that purpose high blood strain and organ harm. Abdomen: Fundal peak corresponds to AOG.
Mild tenderness cited on palpation,
with out a guarding or rebound
tenderness. Fetal heart rate changes
from regular to irregular.
Extremities: Mild Edema cited on lower
extremities. Pulses palpable and
identical bilaterally.
Pelvic exam: Cervix dilated to 8 cm, 100%
effaced, vertex presenting at station
+2. No vaginal bleeding or discharge
noted.
Neurologic exam: Restless but was able to cooperate.
 NURSING CARE PLAN
CUES/EVIDENCES NURSING SCIENTIFIC GOAL & NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS OUTCOME INTERVENTIONS
CRITERIA
SUBJECTIVE Ineffective Maternal Pre-eclampsia, Short-term Goals: Independent: Short-term Goals:
DATA: No shown Tissue Perfusion involves
data Related to vasoconstriction of >After 20 minutes of >Monitor fetal >Continuous fetal >After 20 minutes of
Gestational the maternal blood Nursing coronary heart fee monitoring allows Nursing
hypertension and vessels, main to Intervention, the constantly to detect for early detection Intervention, the
Pre-eclampsia as decreased blood drift fetus will be able to any adjustments. and intervention in fetus was able to
evidenced by to crucial organs maintain case of fetal misery. maintain
elevated blood which include the oxygenation within oxygenation within
pressure. kidneys, liver, and regular limits. >Encourage the >The left lateral regular limits.
OBJECTIVE DATA: mind. This can result mother to lie on her position helps to
in elevated blood >After 30 minutes of left facet to improve improve uterine and >After 30 minutes of
V.S. 150/ 100 strain, proteinuria, Nursing uterine and placental placental perfusion, Nursing
FHR- changes from edema, and other Intervention, the perfusion. which could enhance Intervention, the
94-120 bpm headaches. patient will be able fetal oxygenation. patient was able to
Headache The impaired to reduce blood reduce blood stress
perfusion of stress to prevent >Administer oxygen >Oxygen to prevent further
maternal organs due further at 6 lpm to improve administration can complications.
to hypertension and complications. fetal oxygenation. help improve fetal
pre-eclampsia can oxygenation and > After 30 minutes
cause serious > After 30 minutes decrease fetal of Nursing
maternal headaches of Nursing distress. Intervention, the
including eclampsia, Intervention, the patient was able to
stroke, and organ patient will deliver a >Encourage the >Relaxation and deliver a healthy
failure. Therefore, it healthy infant thru mom to relax and respiration strategies infant thru vaginal
is essential to reveal vaginal shipping or use respiratory can assist to reduce shipping or cesarean
and manage cesarean section if strategies to reduce anxiety, that may section if vital.
maternal blood vital. anxiety. cause advanced
pressure to prevent maternal and fetal GOAL WAS MET
those complications consequences.
and make certain a Collaborative:
safe shipping. >Administer >Medications can be
medicines to control used to govern
References: maternal blood strain maternal blood
American College of as ordered with the pressure and save
Obstetricians and aid of the medical you similarly
Gynecologists. doctor. headaches.
(2020).
Hypertension in >Prepare for a
Pregnancy. ACOG possible emergency
Practice Bulletin, cesarean section if
222. fetal distress is
present. >Preparation for
Magee, L. A., Pels, emergency cesarean
A., Helewa, M., section may be
Rey, E., von >Continuously finished in case fetal
Dadelszen, P., & screen maternal misery is gift, and
Canadian blood pressure, urine the doctor's
Hypertensive output, and different instantaneous
Disorders of important signs. notification of any
Pregnancy (HDP) changes in repute
Working Group. >Notify the can result in set off
(2014). Diagnosis, physician right now intervention.
evaluation, and of any changes in
control of the maternal or fetal
hypertensive issues status.
of pregnancy:
executive precis.
Journal of obstetrics
and gynaecology
Canada, 36(five),
416-441.