Maternal and Child Health Care Nursing:

Eclampsia

Presented By:
Mendoza, Rolland Ray D.

Level 2 – BS Nursing

Presented To:

Batch 2025

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 TABLE OF CONTENTS

I.Introduction
A. Background of the study
B. Biographical data
C. Genogram
D. History of past illnesses
E. History of present illnesses

II. Assessment
A. Vital Signs
B. Review of Systems
C. Gordons Functional Pattern of Assessment
D. Diagnostic and Laboratory

III. Anatomy and Physiology

IV. Pathophysiology
V. Drug Study

V. Nursing Care Plan

A. Prioritization
B. Actual Problems
C. Risk/ Potential Problems
D. Pomotional

VII.Discharge Plan
A. Health Teaching
B. Anticipatory Guidance and Teaching
C. Spirituality
D. Medication
E. Nutrition and DIet
F. Exercise

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 I. Introduction

A. Background of the Study

Eclampsia is a serious medical condition that can occur during pregnancy, typically in the third trimester or shortly
after childbirth. It is characterized by the development of seizures and high blood pressure (hypertension) in a
woman who previously had preeclampsia, a condition marked by elevated blood pressure and signs of organ damage.
Eclampsia is a life-threatening emergency that requires prompt medical attention and intervention to ensure the
well-being of both the mother and the baby.The exact cause of eclampsia is not fully understood, but it is believed to
be related to abnormalities in the placenta and blood vessels supplying the placenta. These abnormalities can lead to
restricted blood flow, reduced oxygen supply, and the release of harmful substances into the mother's bloodstream.
As a result, the mother's blood pressure rises, and her organs, such as the liver, kidneys, and brain, can become
damaged.The most prominent and alarming symptom of eclampsia is the occurrence of seizures. These seizures are
typically generalized and can be accompanied by loss of consciousness, convulsions, and muscle rigidity. Other
symptoms of eclampsia may include severe headaches, visual disturbances (such as blurred vision or flashing lights),
abdominal pain, swelling (edema), and changes in urine output. If left untreated, eclampsia can have serious
complications.

I selected 28 years old female for me to conduct an interview for my case study presentation. Before the
interview started, I ensured that all information and data gathered will be treated with utmost discretion and
confidentiality so that the patient’s safety is ensured. She has a GPTPAL of 1001. She appears lively and is very active
in answering to my questions and is always willing to participate on to what data the study needed to gather. This is
a case of a 28 years old female who had delivered her first baby and has no body image disturbance as stated that
She was shocked by the change in her body but she had no choice but to accept it and she believed that her body
would return to the way it was before.

The purpose of this case is to understand what eclampsia really is. Our understanding of the
technique and management, as well as the similarities and differences among the suitable nursing
interventions that may be provided to clients, will be aided by this experience for nursing students.

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A. Patient's Data

A. Primary Information

Name: E.Y

Age: 28 years old

Date Of Birth: October 30, 1994

Address: Brgy Sampaloc V, Dasmarinas , Cavite

Religion: Iglesia ni Cristo

Civil Status: Married

Educational Attainment: Graduated / College

LMP: August 30, 2022

Date & Time Admitted: 06/02/2023 & 10:00 AM

Chief Complaint: Stiffness of all extremities, +seizure

Admitting Diagnosis: G1P1 (1001) S/P VSD (CHO1) Eclampsia

Final Diagnosis:

Source of Information:

A. Primary Informant: Relative ( R. Y. )

B. Secondary Informant: Relative ( T.Y. )

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C. GENOGRAM

Paternal Maternal

Analysis: The genogram reveals that Grandmother E has diabetes

mellitus and that Grandfather R, Father R's grandfather, has hypertension.
Mother E, who is the wife of Father R, on the other hand, has high blood
pressure. The father of Mother E is in good physical condition.
Grandmother S, mother of Mother E, has diabetes mellitus as well.On the
other side, the newborn child was healthy and did not have any diseases
or abnormalities.

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HISTORY OF PAST AND PRESENT ILLNESS

A. PAST ILLNESS
As previously stated, the patient has hypertension, but all other findings are in the
normal range. Client E.Y. Apparently became pregnant for the first time at the age of 28.
Prior to this, his only significant issue was the occasional rise in blood pressure.
Additionally, client E.Y has never had an abortion or miscarriage in the past.
B. PRESENT ILLNESS

Client E.Y.  chief complaint of a 28-year-old patient who visited Pagamutan ng Dasmarinas
on June 2, 2023 at 10:00 in the morning was stiffness in all extremities. She is already 39 weeks
pregnant. Her last period was on August 30, 2022, and her due date is scheduled for June 6, 2023.
The fetus had a cephalic presentation. The married couple had planned the pregnancy.
Additionally, it was noticed through the urine test that the patient had a UTI.
II. GENERAL HEALTH ASSESSMENT

A. VITAL SIGNS

December 5, 2022
TEMPERATURE 36.6 NORMAL

PULSE RATE 76 NORMAL

RESPIRATORY RATE 25 NORMAL

O2 SATURATION 98% NORMAL

BLOOD PRESSURE 90/60 NOT NORMAL

CAPILLARY REFILL
<1 seconds NORMAL
TEST

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 B. REVIEW OF SYSTEM-PHYSICAL
EXAMINATION
SYSTEM FINDINGS NORMAL FINDINGS
SKIN Varicose, stretch The abdominal wall must stretch to
marks, scars, linea accommodate it. This
nigra, and barely stretching(plus possibly
visible signs of skin increased adrenal cortex activity)
condition can all be can cause rupture and atrophy of
seen on the small segments of the connective
patient's skin. layer of the skin, leading to
Positive dry skin streaks (striae gravidarum) on
the sides of the abdominal wall
and sometimes on the thighs
(Pillitteri 8th edition)
ANALYSIS
The abdominal wall has difficulty stretching
enough to accommodate the growing fetus,
causing the rectus muscles underneath the
skin to actually separate, a condition known
as diastasis. If this happens, after
pregnancy, the separation can be assessed
through
physical exam, and physical therapy can be
offered for persistent diastasis. The
umbilicus is stretched by pregnancy to such
an extent that by the 28th week, its
depression becomes obliterated and it is
pushed.
so far outward in some women, it appears as
if it has turned inside out, protruding as a
round bump at the center of the abdominal
wall.(Pillitteri 8th edition)
HEAD Skull is normocephalic,
symmetrical, features appropriate
for the size). Hair must be
moisturized and evenly
distributed. No masses (Pillitteri
8th edition)
Assess facial sensation and motor function.
Lightly touch the forehead of the patient on
both sides and the upper and lower areas of
the
cheek with the index finger.
(Amboss, 2022)

Medium-length,
softly thin, equally
distributed, and
louse-free hair. . No
masses were felt
when the head and
neck were palpated.
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EYES The patient's vision Increased pigmentations around

is 20/20, however the eye. Cornea may show The ocular effect of pregnancy involves a
there is more changes in sensitivity, thicknesswide spectrum of physiologic and pathologic
pigmentation in the or curvature. Transient loss of changes. The latter might be presenting for
patient's eyes. accommodation has been the firsttime during pregnancy such as corneal
reported previously both with melting and corneal ectasia, or an already
pregnancy and lactation. existing ocular pathologies that are modified
by pregnancy such as diabetic retinopathy
Wide speculation exists about the and glaucoma. In addition,
degree and mechanism of these pregnancy can affect vision through systemic
changes. (Qureshi IA, disease that are either specific to the pregnant
2006) state itself. (Imre J. 2010).
Lips are moist, red and smooth,
gums are pink, tongue is at the
The mouth, teeth, tongue and salivary glands
center and slightly rough on top, it
need to function before the food can travel
moves freely, teeth are not yet
MOUTH down the esophagus to get to the stomach. If
completely erupting, soft palate is
AND the
color pink and hard palate is
TEETH mouth is compromised, with bad teeth or gum
lighter in color and positioned in
Gums are pink, lips disease or other medical problems, things
the midline. Pink and soothing
are smooth, red, can go wrong. (Pillitteri 8th edition)
and no discharge; Consistency is
and moist.
even. (Pillitteri 8th edition)
 10

Equal chest
CHEST motions are seen. Changes in the circulatory system
AND Normal respiration are extremely significant to the
LUNGS rate health of a fetus because
(25bpm) they determine whether there will
be adequate placental and fetal
No crackles or other circulation for oxygenation and Because the uterus enlarges so much during
hollow odd noises nutrition. (Pillitteri 8th edition) pregnancy, the diaphragm, and ultimately, the
are heard when lungs, receive an increasing amount of
breathing in any pressure. Toward the end of pregnancy, this
orientation. can actually displace the diaphragm by as
much as 4 cm upward. Even with all this
crowding, however, a woman’s vital capacity
(the maximum Volume exhaled after a
maximum inspiration) does not decreas during
pregnancy because, although the lungs are
crowded in the vertical dimension, they can
still expand horizontally. (Pipkin, 2012).
BREAST The nipple's areola The areola of the nipple
darkens, and the darkens, and its diameter
breasts get bigger. increases from about 3.5 cm
(1.5 in.) to 5 cm or 7.5 cm (2 or
3 in.). There is additional
darkening of the skin
surrounding the areola in some
women, forming a
secondary areola. (Pratts &
Lawson, 2015)
Early in pregnancy, the breasts begin readying
themselves for the secretion of milk. By the16th
week, colostrum—the thin, watery,high-protein
fluid that is the precursor of breast milk can be
expelled from the nipples. As vascularity of the
breasts increases, blue veins may become
prominent over the surface of the breasts.
The sebaceous glands of the areola
Montgomery’s tubercles), which keep the nipple
supple and help to prevent nipples from
cracking and drying during lactation, enlarge
and become protuberant.
(Pratts & Lawson, 2015).
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ABDOMEN A nigral line and The umbilicus is stretched by A narrow, brown line (linea nigra) may
stretchmarks pregnancy to such an form, running from the umbilicus to the
can be seen. extent that by the 28th symphysis pubis and separating the
No masses are week, its depression abdomen into right and left halves .
present, and becomes obliterated and it Darkened or reddened areas may appear
there is no on the face as well, particularly on the
is pushed so far outward in
abdominal pain. cheeks and across the nose. This is known
some women, it appears as if it
During as melasma (chloasma) or the “mask of
has turned inside out,
the auscultation, pregnancy.” With the decrease in the level
the bowel sound protruding as a round bump at
of melanocyte- stimulating hormone after
was normal. the center of the
pregnancy, these areas lighten but do not
abdominal wall. Extra
always disappear.(Pillitteri 8th edition) and
+ Linea Nigra pigmentation generally swelling is fine. The wound may manifest
+Striae appears on the abdominal warm to touch, and pain around the
Gravidarum wall because of melanocyte- incision site.
stimulating hormone from the
pituitary. (Pillitteri 8th
edition)

EXTREMITIES The nail isn't Number of fingers per each hand Upon assessing the extremities, the
overly long, and is five. patient
the capillary refill Symmetrical, equal in length, manifested difficulty in lifting
test result was pinkish in color. on her right leg. According to her with a
normal (2 Capillary refill; prompt return of pain scale of 7/10. Pain in the lower
seconds). pink (less than 3 sec. extremities after surgery is common and
(Pillitteri 8th edition) may be caused by general anesthesia,
it increases the risk of DVT formation.
Extremities are without swelling or
erythema. Full
range of motion is noted to all joints.
(ThriveAP, 2016)

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GENITAL
Vaginal discharge An increase in the vascularity of the
is present, and vagina parallels the vascular
the vagina's color changes in the uterus.
darkens.
The resulting increase in circulation
changes the color of the vaginal
walls from their normal light pink to
a deep violet (Chadwick’s sign).
Under the influence of estrogen, the
vaginal epithelium and underlying
tissues increase in size as they become
enriched with glycogen. This occurs
because of the action of
Lactobacillus acidophilus, a bacteria that
grows freely in the increased glycogen
environment

RECTAL No lesions are According to Peri, Rectal examination was found to have a
visible, and the C. (2020), a swollen vein 94.3% accuracy in determining
anal skin is causes pregnancy when
intact. Hemorrhoid in the carried out between 30 and 60 days
rectum. Getting gestation. Rectal
them during examination was also found to be a suitable
pregnancy is method of
detecting the onset of oestrus in the sow.
normal, especially in
(Pillitteri 8th edition)
the third trimester

NEUROLOGICAL The patient has According to thriveap.com

the ability of (2016), patient
responding with should be alert and Patient was interviewed to gather data
adequate oriented to person, about her
responses and place, and time with normal demographic data, history of
communicating speech. past and present illness, and data
clearly. She is Memory should be about genograms. By that, her
also aware of normal and thought cognitive or
time and process is intact. thinking skills were tested. It proves that
surroundings. she is oriented and alert. Upon
She considers answering
everything the interview, the patient did not stutter
throughout and she can talk
before making a normally and it shows the willingness
statement. during the interview.

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 C. GORDON’S FUNCTIONAL ASSESSMENT

GORDON’S BEFORE DURING ANALYSIS

ASSESSMENT PREGNANCY PREGNANCY

Health Perception- “Maingat na ako sa “Netong nagbubuntis na The study results showed that
Health Management kinakain ko dati ako ganun parin naman pregnant women should be
dahil mabilis mas nagingat lang ako motivated to modify their
tumaas ang aking dahil hindi lang
dugo. Kaya
lifestyle andadopt healthy
kalusugan ko ang dapat
sobrang ingatan pati sa anak ko”
lifestyles. Pregnant women seek
importante ng As to modify their lifestyle because
kalusugan para sa verbalized by the of motherhood responsibility
aming magasawa” patient and and having a healthy baby.
As verbalized by Access to information and
the patient supports from various sources
promote a mother’s inner
decision to change, leading to
modifying different aspects of
life. However, these
modifications often shift to the
pre-pregnancy lifestyle due to
cessation of supports and care,
despite reminding the benefits of
the lifestyle change.
Health care providers should
consider supportive measures
during pregnancy and
postpartum. ( Biomed)

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 Nutritional “Mahilig kaming “Nitong nagbubuntis The client expressed verbally that her diet
Metabolic Pattern kumaing magasawa ng na ako puro gulay at has changed.. Although she now eats
mga matatabang prutas nalang healthier foods, it is unavoidable that she
pagkain, madalas din kinakain ko pero di ko won't consume any fatty foods.
kaming kumain sa maiwasan kumain ng
labas mga matatabang
.” As verbalized by the pagkain” as
patient. verbalized by the Fruits and vegetables are
patient. nutrient-dense foods and key
sources of a number of
essential nutrients, including
potassium, magnesium,
dietary fiber, folate, and
vitamins A and C; fruits and
vegetables also contain a
variety of other bioactive
substances that may play a
role in health. Studies have
shown that consuming a diet
high in fat during pregnancy
can affect the taste
preferences and metabolism
of the offspring. (Int J Womens
Health. 2014)

ELIMINATION “Napapadalas na ang The client states that she is urinating

PATTERN aking pag ihi siguro frequently and defecating everyday.
“2-6 na beses akong mga 9 Frequent urination is a common early
umihi dati sa loob ng times a day na tapos pregnancy symptom, but it can also
isang araw at madalas masakit ang aking reappear later on during pregnancy as
ay light yellow ang pagihi tapos your uterus and baby grow, putting
kulay. Sa pagdumi araw araw na rin akong pressure on your bladder.
naman ay mga 4 dumudumi" verbalized
times a week lang" by the patient. Although it can definitely be annoying, it's
as verbalized by nothing to worry about” as stated by Lauren
the patient. Jimeson.
Activity-Exercise “Naglalakad lakad According to the client, she had trouble
Pattern naman na ako ngayon finding the time to exercise when she
sa umaga madalas na
“Hindi na ako wasn't pregnant but was able to stretch
rin akong magunat ng
nakakapagexercise sa katawan.” as and go for a morning walk when she got
umaga kasi may verbalized by the pregnant.
trabaho paguwi ko client.
naman mag gagawa ng Observational studies of
gawaingbahay tapo
women who exercise during
magpapahinga nalang ”
as verbalized by the pregnancy have shown
patient. benefits such as decreased
GDM(American College of
Obstetricians and Gynecologists)
1
5

SLEEP-REST “Nakakatulog naman ako “Hindi na ako

PATTERN ng maayos kahit hindi makatulog ng maayos
According to the client, she never had
sapat yung oras dahil sa pagihi ko ng
trouble falling asleep before being
masasabi ko naman na madalas.” as verbalized
by the patient. pregnant
nakakatulog ako sa gabi
ng mapayapa.” as
According to Benjamin JS In the first
verbalized by the
trimester period of pregnancy, night
patient.
urination, shortness of breath,
heartburn, forced body position in bed,
breast tenderness, and itching are the
physiological changes affecting sleep .
Quality of sleep is essential for the
physical and mental health of both the
mother and fetus.

Cognitive “Masaya ako sa

Perception Pattern pangyayari dahil dumatig
“Plinano naman namin ng na yung araw na
nagdadalang tao na ako.
After realizing that she is pregnant, the
aking asawa ang
Natatandaan ko pa lahat client experience satisfied as well. The client
pagbubuntis at kung ilan
ang aming dapat na ng mga plano namin sa was capable of comprehending all of the
magiging anak.” As buhay.” As verbalized questions and provide excellent answers.
verbalized by the patient. by the patient.
Self-Perception/ “Hindi naman ako “Nagulat ako sa The client was anxious because of her
Self-Concept mahilig magmake up pinagbago ng aking body's substantial change.
Pattern pero paglalabas ako katawan dahil sobra
gusto ko palagi lang ang pinagbago nito” According to Padmanabhan,U.,
maayos ang ,itsura ko As stated by the Summerbell,C.D.& Heslehurst,N, due to
lalo na ang buhok ko” patient. difficulties in altering diet and
As verbalized by the physical activity behaviors directly,
client. influencing the choices that people
make is an appropriate strategy for the
modification of behaviors and convection
beliefs can limit pregnant women.

16

Role-Relationship Her bond with her partner remained the

Pattern same, as the client observed. Their
relationship strengthens as a result of her
pregnancy as well.

According to the study of Asres

“Okay naman kami ng “Wala namang
nagbago ganun parin Bedaso around one in four pregnant
asawa ko parehas
kaming nagtutulungan mas inintindi ako ng women in Australia suffer symptoms of
pero madalas ako yung aking asawa lalo na depression and one in five report
nagdedesisyon sa mga nung nagmomodd symptoms of anxiety, new research
bagay bagay lalo na swing ako.” as shows, and those with low social
pagdating sa pera” as verbalized by the support are at higher risk of these
verbalized by the patient. patient. mental health problems.

Sexually “Active kami sa ganyang “Nung buntis na

According to the customer, they used to
Reproductive bagay pero gumagamit ako sa unang
be sexually active, but when she
naman kami ng trimester activer
became pregnant, they
contraceptives kasi may parin pero nung
continue throughout the first trimester
family planning kami.” nagtagal nawala
As verbalized by the but stop after that. Mother previously
na rin” as
used contraception to prevent
patient verbalized by the pregnancy.
patient
Effective contraception benefits both
mother and baby by decreasing
morbidity and mortality, improving the
 social and economic status of the
mother. (Andrew M. Kaunitz,MD)

Coping Stress The patient claimed that although she is

Tolerance Pattern still stressed, her primary way of dealing
is her close relationship to his husband.

Stress may lead to high blood pressure

“SIguro yung
“Madami din kaming nakakatulong nalang during pregnancy. This puts you at risk
nagiging problema kapag sakin is yung
ganon nangyayari samin pagintindi ng mister ko of a serious high blood pressure
nagluluto nalang ang sa akin at yung hindi condition called
aking asawa at niya pagiwan kapag preeclampsia, premature birth and
nagbobonding nalang kailangan ko siya” as
kami” as verbalized by verbalized by the having a low-birthweight infant.
the patient patient (2023 March of Dimes)
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7

Values-Belief “Ako at aking asawa “Kapag kaya ko pang The patient stated that she used to
Pattern ay INC kaming sumamba nagsasamba frequently attend services and
dalawa ay active talaga ako pero nung participate in chapel activities. She
lalo na sa lumaki na tyan ko hindi entirely worshiped when she could,
pagsamba. ” As na ako nakakapunta ng regardless of being pregnant.
verbalized by the Kapilya ” As
patient verbalized by the Filipino beliefs and culture is sometimes
patient affect the pregnancy and the recovery
of the patient
According to Aziato,L., Odai, P.N.A &
Omenyo,C.N, during pregnancy,
women intensify their prayers to God for
protection, safe delivery and
blessings. Some women panic at the
mention of cesarean section for fear of
death during surgery and others who
undergo cesarean section are
stigmatized. Themes generated
revealed religious beliefs and practices
such as prayer, singing, thanksgiving at
church, fellowship and emotional
support.
 VII. LABORATORY AND DIAGNOSTIC EXAMINATIONS

RELATED TESTS PRIOR TO HOSPITALIZATION.

UNIT ANALYSIS
TEST RESULT REFERENCE

White Blood Cell is elevated, WBC count is

White Blood Cells usually elevated during pregnancy. The WBC are
12.1 10^/uL 5.0-10 commonly measured to investigate suspected
Red Blood Cells infection and inflammation in pregnant women,
3.5 10^6/uL M 4.6-6.2 F 4.2-5.4
but the pregnancy-specific reference interval is
Hemoglobin 108 6/L M 135-180 F 120-160 variably reported, increasing diagnostic
uncertainty in this high-risk population. It is
0.30 % fL M 0.40-0.54 F 0.38-0.47
Hematocrit essential that clinicians can interpret WBC results
in the context of normal pregnant physiology,
MCV given the huge global burden of infection on
28.4 pg g/dL 81.5-99 maternal mortality.
MCH 30.8 10^3/uL 28.0 – 33.0
Red blood Cells count is not normal, You
352 320 – 360
MCHC may have anemia during
14.8 11 - 16% pregnancy if a complete
RDW
blood count (CBC) shows that
Neutrophil (%)
83 % 50.0 – 70.0 your red blood cells, which
Lymphocyte (%) 09 25.0 – 40.0 carry oxygen through your
%
% 3.0 – 8.0 body, are low. This can make
06
Monocyte (%)
1.0 – 4.0
you feel fatigued, dizzy, cold
02 %
Eosinophils (%) and out of breath. In most
cases of anemia during
Basophils (%) 0.0 – 1.O
pregnancy, tweaks to your
150-450
Platelet 176 diet can put you on the right
path.
The result shows low hemoglobin and
hematocrit, low hemoglobin and hematocrit
values, together with higher gravidity at the time
of admission, may indicate an increased risk of
tubal rupture.

MCV is an unreliable marker

 of iron deficiency in
pregnancy. Stimulation of
erythropoiesis leads to a
physiologic increase in MCV
during gestation that
counterbalances the
microcytosis of iron
deficiency. A low MCV,
defined as an MCV <80 fL,
is highly sensitive,26 but not
specific, for iron-deficiency
anemia.

The MCH of the patient is normal. A low MCH

value typically indicates the presence of iron

deficiency anemia. Iron is important for the

production of hemoglobin. Your body absorbs a
small amount of iron that you eat in order to
produce hemoglobin.

The total white cell count will

frequently be elevated in
pregnancy due to increased
numbers of neutrophils.
Neutrophils can also
demonstrate a “left shift”
(increased number of band
neutrophils). However, this
neutrophilia is not usually
associated with infection or
inflammation.

These cells have a potential role in

immunological tolerance
development, and their presence
during pregnancy might be necessary
for pregnancy protection. During
pregnancy, B10 lymphocytes inhibit
TNF secretion from T
CD4+ cells [205], which may lead to
the regulation of pre-labor
inflammatory conditions [3]
The patient Monocyte count is within the normal.
Monocytes are short lived cells that
mature in the circulation and invade
into tissues upon an inflammatory
stimulus and develop into
macrophages. Macrophages are
abundantly present in the
endometrium and play a role in
implantation and placentation in
normal pregnancy.

Eosinophils are one of several white

blood cells that support your immune
system. They're part of your body's
defense system against allergens and
help protect your body from fungal
and parasitic infections.
Analysis:

As the patient's body won't generate antibodies against her baby's, there is no chance of blood
incompatibility even when the patient's Rh blood is positive. A individual who has the Rh-positive
factor will also not produce anti-Rh antibodies. A person with Rh+ blood can accept transfusions of
both Rh+ and Rh- blood, whereas a person with Rh- blood can only receive transfusions of Rh- blood
since they will create the antibodies.

The most typical blood type is Rh positive, according to Mayo Clinic (2020). A Rh-negative blood type
is not a disease, and it typically has no harmful effects on your health. But it can have an impact on
your pregnancy. If you are Rh negative and your baby is Rh positive (Rh-incompatibility), you need
take extra precautions during your pregnancy.

URINALYSIS
COLOR: DARK YELLOW Urine color and transparency is not normal.
Dark yellow urine might indicate
 that you have a severe infection,
an underlying kidney condition
or it could additionally mean that
you are dehydrated: Temporary
conditions or medication
affecting the liver and kidneys
can also sometimes cause this
effect.
Transparency: TURBID Cloudy urine can be caused by
many different medical
conditions, ranging from
relatively benign to severe.
These conditions can include
dehydration, a urinary tract
infection, sexually transmitted
infections, kidney stones,
diabetes, and others.

PH: 5.0 pH is normal, pH is a measure of how

acidic/basic water is. The range goes from 0 -
14, with 7 being neutral. pHs of less than 7
indicate acidity, whereas a pH of greater than
7 indicates a base.

Reaction: ACIDIC Acidic urine can also create an environment

where kidney stones can form. If a person has
low urine pH, meaning that it is more acidic, it
might indicate a medical condition, such as:
diabetic ketoacidosis, which is a complication
of diabetes. diarrhea. starvation.

Specific Gravity: 1.030 The Urine color and transparency is

normal, Specific gravity is usually 1.030(normal
range: 1.003-1.030) and highest in the
morning. A value >1.030 indicates normal
concentrating ability. A value >1.035- 1.040
suggests possible contamination, very high
levels of glucose, or recently received
lowmolecular-weight dextran or high-density
radiopaque dyes.

Protein: 1+(30mg/dL) If you have one + or more of

protein and high blood
Sugar: NEGATIVE pressure, you may have pre-
eclampsia and will need extra
medical care. Your urine may be
checked for other causes of
protein, such as an infection but
it is unlikely unless you also
have symptoms.

MICROSCOPIC FINDINGS

WBC / Pus Cells: 10-25 / HPF The normal range of pus cells in
urine is 0-5/hpf , however up to
10 pus cells may be present
without any definite infection. If
you have any symptoms of a
urine infection, you should get a
urine culture done.
Red Blood Cells: 0-2 / HPF Urine dipsticks can detect low levels
of blood in urine (correlates with > 1-4
RBC/high- power field). Red Blood
Cells (RBCs) Urinary tract
inflammation or glomerular
bleeding (0-2 RBC/high power field
(hpf) normal value, ≥3 RBC/hpf
significant for microscopic hematuria).
Epithelial Cells: FEW / LPF A normal range is less than 15 to 20
per HPF; therefore, more than 15 to
20 squamous epithelial cells per HPF
indicate contamination in the urine
sample. More than five squamous
epithelial cells in a single field of view
can be considered an increased
number that may indicate an infection
or other health condition.
Amorphous Urates /
Phosphates / LPF

Mucus Threads: FEW / LPF There is a rare mucus thread and urates
found in the result

Bacteria: MANY

Crystals:

Casts: 5-10/LPF

Others:
 III. ANATOMY AND PHYSIOLOGY

The Female Reproductive System

There are significant anatomical and physiological changes during pregnancy. Along with the
reproductive organs, all maternal reproductive systems adjust to accommodate the growing fetus while
also preserving homeostasis. For nurses and midwives who care for women throughout pregnancy, a
thorough awareness of these changes is a crucial starting point. This chapter gives a general summary
of the changes that occur in the reproductive organs, the impact of the pregnancy's key hormones,
fetal development, and maternal adaptations.

The Female Reproductive Organ

Ovaries
Ovaries act as the main female sex organs that produce the female gamete and
various hormones. These organs are situated one on both the side of the lower abdomen.
Each ovary measures about 2 to 4 cm in length which is then connected to the uterus and
pelvic wall through ligaments. The ovary is surrounded by a thin covering of epithelium,
encloses the ovarian stroma and is divided into two zones – outer cortex and the inner medulla.
The cortex consists of various ovarian follicles in different stages of development. The ovarian
follicle is called the basic unit of the female reproductive system. Each oviduct is divided into
three anatomical regions- ampulla, isthmus, and infundibulum.
Uterus
A uterus is also called the womb. It is a muscular, inverted pear-shaped organ of the female
reproductive system. The walls of the uterus consist of three layers- the inner glandular layer,
the middle thick layer, and the outer thin layer. These three layers are maintained by ligaments
which are attached to the pelvic wall which then opens into the vagina from a narrow cervix.
The cervical canal along with the vagina creates the birth canal. The vagina is a muscular tube
which starts at the lower end of the uterus to the outside.
Fallopian Tubes
Fallopian tubes are a pair of muscular tubes and funnel-shaped structures, extend from the
right and left of the superior corners of the uterus to the edge of the ovaries. These tubes are
enclosed in small projections called fimbriae that swipe over the ovaries to pick up released
ova and deliver them to the infundibulum for supplying the uterus. Each fallopian tube is
covered by cilia that functions by carrying the ovum to the uterus.
Vagina
The vagina is a muscular and elastic tube that connects the cervix to the external body. It
functions as the receptacle for the penis in sexual intercourse and delivers sperm to the
fallopian tubes and uterus. It also acts as a birth canal by expanding to allow delivery of the
fetus during childbirth.
The external genitalia comprises the labia minora, labia majora and clitoris
Ovulation 
Ovulation is the process of releasing the eggs from the ovaries. This process takes place as
soon as the follicle is fully grown and reaches its size along with the accumulation of liquid in
the follicle without a significant rise in pressure. As the follicle swells out, a small oval-shaped
area, the stigma or macula pellucida appears sticking outward as a clear cone area and later
undergoes localized changes in colour, integrity, and translucency. The secretion of estrogen
hormones reaches the maximum level before the ovulation. After the surge of luteinizing
hormone, ovulation occurs at the site of the stigma. This surge is essential for ovulation.
Ovulation is the process in which the follicle is separated by releasing of follicular fluid along
with the ovum surrounded by the corona radiata. The cells of the corona radiata will separate
later in the presence of spermatozoa. In ruminants, the oocytes have already lost their corona
at the time of ovulation. The very active fimbriae, end of the oviduct picks up the ovum. If
fertilized ovum or zygote undergoes cleavage and makes its way to the uterus for implantation.
If not fertilized, it degenerates within 24 hours.
Menstrual Cycle
All females, after reaching their puberty produce mature egg cell every month during a process
called the menstrual cycle.  During this period, an ovary discharges a mature egg, which
travels to the uterus. In the uterus, if the egg is not fertilized, the lining in the uterine sheds
away and a new cycle begins. Overall a menstrual cycle lasts for 28 days, in some cases,
these cycles may either last for 21 days or as long as 35 days in some individuals. The entire
process of the menstrual cycle is controlled by the endocrine system and the hormones
involved are FSH, LH, estrogen, and progesterone. Both FSH and LH hormones are produced
by the pituitary gland,  whereas estrogen and progesterone hormones are produced by the
ovaries.
Alon with the hormonal disorders, there are many other factors, which are responsible for the
disturbance in the menstrual cycle. The responsible factors include diet, exercise, stress and
weight gain or loss affects the menstrual cycle. The cycle may be irregular at times, especially
during puberty.  The menstrual cycles occur every month from the time of puberty up to the age
of 45 to 55, except during pregnancy. After the age of 55 ovaries slows down their production
of hormone and release of mature eggs. Progressively, the menstrual cycle stops, therefore,
the woman is no longer able to become pregnant.
Fertilization and Pregnancy
Following implantation, the placenta originates from maternal and fetal tissues, producing
human chorionic gonadotropin (HCG) that helps in maintaining the level of corpus luteum in the
ovary until the placenta begins synthesizing its own progesterone and estrogen hormones.
Estrogen and Progesterone
Estrogen and progesterone hormones are produced by the ovaries that foster the development
of reproductive organs by maintaining the proper uterine cycle and by developing female
secondary sex characteristics. During menopause, usually between age 45 and 55, the uterine
cycle stops, and the ovaries are no longer produce estrogen and progesterone hormones.
Infertility
 In general, infertility can be defined as the failure in couples of not getting pregnant, despite
having carefully timed, unprotected sex for one year. It is estimated to be around 15% of all
couples undergo infertility. The reasons behind this infertility in males and females.
The Male Reproductive Organ
Penis
The penis is the male organ for sexual intercourse. It contains many sensitive nerve endings,
and it has three parts:
Root. The root is the base of your penis. It attaches to the wall of your abdomen.
Body (shaft). The body has a shape like a tube or cylinder. It consists of three internal
chambers: the two larger chambers are the corpora cavernosa, and the third chamber is the
corpus spongiosum. The corpora cavernosa run side by side, while the corpus spongiosum
surrounds your urethra. There’s a special, sponge-like erectile tissue inside these chambers.
The erectile tissue contains thousands of spaces. During sexual arousal, the spaces fill with
blood, and your penis becomes hard and rigid (erection). An erection allows you to have
penetrative sex. The skin of the penis is loose and stretchy, which lets it change size when you
have an erection.
Glans (head). The glans is the cone-shaped tip of the penis. A loose layer of skin (foreskin)
covers the glans. Healthcare providers sometimes surgically remove the foreskin
(circumcision).
In most people, the opening of the urethra is at the tip of the glans. The urethra transports pee
and semen out of your body. Semen contains sperm. You expel (ejaculate) semen through the
end of your penis when you reach sexual climax (orgasm).
When your penis is erect, your corpora cavernosa press against the part of your urethra where
pee flows. This blocks your pee flow so that only semen ejaculates when you orgasm.

Scrotum
The scrotum is the loose, pouch-like sac of skin that hangs behind the penis. It holds the
testicles (testes) as well as nerves and blood vessels.
The scrotum protects your testicles and provides a sort of “climate-control system.” For normal
sperm development, the testes must be at a temperature that’s slightly cooler than body
temperature (between 97 and 99 degrees Fahrenheit or 36 and 37 degrees Celsius). Special
muscles in the wall of the scrotum let it contract (tighten) and relax. Your scrotum contracts to
move your testicles closer to your body for warmth and protection. It relaxes away from your
body to cool them.
Testicles
The testicles (testes) are oval-shaped organs that lie in your scrotum. They’re about the size of
two large olives. The spermatic cord holds the testicles in place and supplies them with blood.
Most people AMAB have two testicles, on the left and right side of the scrotum. The testicles
make testosterone and produce sperm. Within the testicles are coiled masses of tubes. These
are the seminiferous tubules. The seminiferous tubules produce sperm cells through
spermatogenesis.
Epididymis
The epididymis is a long, coiled tube that rests on the back of each testicle. It carries and
stores the sperm cells that your testicles create. The epididymis also brings the sperm to
maturity — the sperm that emerge from the testicles are immature and incapable of fertilization.
During sexual arousal, muscle contractions force the sperm into the vas deferens.
Vas deferens
The vas deferens is a long, muscular tube that travels from the epididymis into the pelvic
cavity, just behind the urinary bladder. The vas deferens transports mature sperm to the
urethra in preparation for ejaculation.
Ejaculatory ducts
Each testicle has a vas deferens that joins with seminal vesicle ducts to form ejaculatory ducts.
The ejaculatory ducts move through your prostate, where they collect fluid to add to semen.
They empty into your urethra.
Urethra
The urethra is the tube that carries pee from your bladder outside of your body. If you have a
penis, it also ejaculates semen when you reach orgasm.
Seminal vesicles
The seminal vesicles are sac-like pouches that attach to the vas deferens near the base of the
bladder. Seminal vesicles make up to 80% of your ejaculatory fluid, including fructose.
Fructose is an energy source for sperm and helps them move (motility).
Prostate gland
The prostate is a walnut-sized gland that rests below your bladder, in front of your rectum. The
prostate adds additional fluid to ejaculate, which helps nourish sperm. The urethra runs through
the center of the prostate gland.
Bulbourethral (Cowper) glands
The bulbourethral glands are pea-sized structures on the sides of your urethra, just below your
prostate. They create a clear, slippery fluid that empties directly into the urethra. This fluid
lubricates the urethra and neutralizes any acids that may remain from your pee.
V. PHATOPHYSIOLOGY

29
 VI. Drug Study

DRUG NAME MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING

OF ACTION ATION EFFECTS
RESPONSIBILITI
ES

Generic name: Essential - Iron deficiency - - Metallic taste - Hypotension  Lab tests:
component in anemia - Temporary Monitor
Ferrous sulfate Hemochromatos staining of teeth Hgb and
formation of
is enamel - GI irritation
Hgb, myoglobin, reticulocyte
- Prophylaxis of - Nausea
enzymes. iron deficiency - Thalassemia values
Brand name: - Vomiting
in low birth - Abdominal
during
Slow FE, Promotes
effective weight and pain therapy.
Fer-In-Sol, - Hemolytic
breast-fed babies - Flatulence Investigate
erythropoiesis anemia
Feratab, Iron, and transport, - Constipation the absence
Mol-Iron, utilization of - Dark, tarry of
Feosol, and oxygen. It stool satisfactory
- Peptic ulcer
Mykidz Iron 10 prevents iron response
disease
deficiency. after 3 wk of
- Gastritis
drug
treatment.
- Inflammatory  Continue
iron therapy
for 2–3 mo
after the
hemoglobin
level has
returned to
normal
(roughly
twice the
period
 required to
normalize
hemoglobin
concentratio
n).
 Monitor
bowel
movements
as
constipation
is a common
adverse
effect.

31
DRUG NAME MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING
OF ACTION ATION EFFECTS
RESPONSIBILI
TIES

Generic name: Mefena mic Mefenamic - Mefenamic acid - Increase BP - CNS:

acid binds the acid is is
Mefenamic Acid contraindicated Drowsiness,
prostaglandin a non- ).
insomnia,
- Skin Rash
 synthetase steroidal anti- in patients with  Assess
receptor s inflammat ory salicylate patients who
Brand name: COX- drug (NSAID hypersensi ti - Blood yurine dizziness, develop
vity or blood y, black, nervousness, severe
Ponstel or tarry stools confusion,
1 and It is most often NSAID diarrhea and
used decre a sed headache.
COX-2, inhibitin hypersensi ti vomiting for
frequ e ncy or
g for treating pain vity who have amount of urine dehydration
Route:
of dysmenor experience d and
the asthma, EENT:
P.O rhoea in electrolyte
action urticaria, or - heart burn Blurred vision, imbalance.
the short term other allergic eye irritation
of prostagl  Lab tests:
(seven days reactions after
Classification: andin synthet taking aspirin With long-
or term therapy
non-steroidal ase. or other
NSAIDs. CV: Edema (not
anti- less), as
inflammatory well as recommended
drugs ) obtain
mild to periodic
moderate
GI: Severe complete
pain
Frequency: diarrhea, blood counts,
ulceration and Hct and Hgb,
Q8 bleeding; and kidney
nausea. function tests.
vomiting.
DRUG NAME MECHANISM OF INDICATION CONTRAINDIC SIDE ADVERSE NURSING
ACTION ATION EFFECTS
EFFECTS RESPONSIBILI
TIES

Generic Ciprofloxacin is - Nausea - Arthralgia  Monitori

name: Ciprofloxacin Ciprofloxacin is contraindicated in - Redness or ng the
acts on bacterial only indicated persons with discomfort Pseudomemb infant for
Ciprofloxacin a
in infections history in the eye ranous
topoisomerase II of possible
caused by - Diarrhea colitis
(DNA gyrase) hypersensitivity to effects
susceptible - Muscle Erythema
Brand name: and ciprofloxacin or on the
bacteria. weakness nodosum
topoisomerase any of the - Tinnitus gastroint
 Cipro, Cipr IV.12 Ciprofloxac estinal
quinolones. Stevens-
o XR, in's targeting of JOhnson flora,
and ProQui the alpha syndrome such as
n XR. subunits of DNA diarrhea
Concomitant Reversible
gyrase prevents administration with haematologi or
it from tizanidine is cal candidias
supercoiling the contraindicated. disorders is.
bacterial DNA
 Ensure
which prevents
that
DNA replication
patient is
Route: well
IV hydrated
 Advice
Frequency: patient to
Q12 report
rash,
visual
changes,
severe GI
problems
,
weakness
, tremors.
DRUG NAME MECHANISM INDICATION CONTRAINDIC SIDE EFFECTS ADVERSE NURSING
OF ACTION ATION EFFECTS
RESPONSIBILITI
ES

Generic name: - Diazepam is a -  Light  Drowsiness  Asses blood

Diazepam is a benzodiazepine headedness pressure,
 Vertigo
Diazepam benzodiazepine medication that - Valium is  
Rash
Constipatio
pulse and
tranquilliser with is FDA  Hypotension respiration
also n
anticonvulsant, approved for  Tachycardia  Provide
Brand name: sedative, muscle the contraindic  Nausea
 Vommiting  Ataxia frequent sip
relaxant and management of ated in  Blurred of water for
Valium  Chest pain
amnesic anxiety patients vision dry mouth
Diastat properties 15,16,6.disorders, with myast  Provide fluids
short-term
Valtoco
Benzodiazepine relief of henia and fibre for
constipation
s, such as anxiety gravis,
 Evaluate
diazepam, bind symptoms, severe therapeutic
to receptors in spasticity respiratory
associated with response,
various regions
of the brain and upper motor insufficien mental state
spinal cord. This neuron cy, severe and physical
binding disorders, hepatic dependency.
increases the adjunct therapy insufficien
inhibitory effects for muscle
of gamma- spasms, cy, and
aminobutyric preoperative sleep
acid anxiety relief, apnea
(GABA) 15,16,6. management of syndrome.
GABAs functions certain
include CNS refractory
involvement in epilepsy
sleep induction. patients, and
Also involved in adjunct in
the control of severe
hypnosis, recurrent
memory, convulsive
anxiety, epilepsy seizures, and
and neuronal an adjunct in
excitability  status
epilepticus.
 V. NURSING
CARE PLAN

A. PRIORITIZATION ACTUAL PROBLEMS

NURSING DIAGNOSIS RANK

Decrease cardiac output 1st

related to decrease venous
return secondary to
eclampsia
 Acute pain related to 2nd
urinary tract infection

Disturbed sleeping pattern 3rd

related to frequent urination

Knowledge deficit related to 4th

proper position of
breastfeeding
 Disturbed body image related 5th
to temporarily physiological
changes during pregnancy as
evidence by irritability due
frequently looking in the mirror
to see changes in hour body.

POTENTIAL PROBLEMS

NURSING DIAGNOSIS RANK

Risk for unstable blood pressure 1st

related to unhealthy diet

Risk for impaired skin 2nd

integrity as evidenced by
dry skin

42
 PROMOTIONAL
PROBLEMS

NURSING DIAGNOSIS RANK

Readiness for enhance parenting as 1st

evidenced by expresses desire to
enhance parenting
Readiness for enhaned 2nd
parenting
Readiness for enhance sleep 3rd
related to discomfort due to
frequent urination

Readiness for enhance 4th

knowledge of breastfeeding

Readiness foe enhance 5th

knowledge: Health
 ACTUAL PROBLEMS
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Disturbed Short term: Independent: Short term:

sleeping pattern
"Paputol-putol ang After 3 hours •Encouraged •L- trytophan is a The goal met, After 3
related to
tulog ko dahil sa of rendered patient to component of hours of rendered nursing
madalas na pagihi frequent nursing drink milk milk that intervention patient was
ko sa gabi.” as urination intervention before going promotes sleep. be able to take an
verbalized by the patient will be to bed. adequate hours of sleep
patient. able to identify and reduces the frequent
at least one •To reduce the urination.
Objective data: individual amount of urine
 Easy appropriate n the bladder
intervention to •Encourage therefore
fatigability.
promote rest. patient to void decreasing the
 Sleepy before going number of Long term:
appearance to sleep
 Urinary output voiding at night.. Goal partially met after 3
Reduce the days of rendered nursing
4-6 times/
voiding at intervention the patient
night
night • To compensate increases the duration of
•Advised the lack of sleep. her sleep.
patient to take
Long term: a nap.

After 3 days of •Drinking fluids

at night increases
rendered
the chance to
nursing
•Advise void since the
intervention
patient to limit bladder will be
the patient will full
fluid intake
have enough
especially
rest and sleep.
 during night.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Disturbed body Short term: •Provide •To help the Short term:
image related to health
"Nagulat lang ako After 3 client Goal met, after 3
temporarily
dahil ang laki ng hours teaching in hours nursing
physiological nursing understand
pagabago sa aking terms of intervention the
changes during intervention the different
katawan." As patient was be able
pregnancy as the patient different
verbalized by the physical to understand the
evidence by will be able physiological
patient. relationship of
irritability due to changes during
changes during pregnancy towards
frequently understand
pregnancy pregnancy. physiological physical
looking in the the
Objective data: changes. Long term:
mirror to see relationship
Irritability due changes in hour of pregnancy Goal met, After a week
frequently looking in towards •Encouraged of nursing intervention
body.
the mirror to see physiological the pregnant •To help the the patient was be
changes in the body. physical women to client to able to accept the
changes. share her reduce her physical changes
concerns. irritability. happened during her
Enlargement of the Changing her
pregnancy journey
abdomen due the Long term: concerns may
help her relax.
pregnancy After a week
physiological. of nursing
intervention • To help the
the patient client
will be able •Provided understand
to accept health the different
the physical teaching in physical
changes terms of changes
happened different during
during her physiological pregnancy.
pregnancy changes during
journey. pregnancy.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Short term: Independent: •To gain Short term:

patients trust
"PAkiramdam ko After 6 hours of •Establish and After 2 hours of rendered
sobrang pagod ako nursing rapport cooperation nursing
at parang intervention the Monitored BP intervention, the patient
hinahabol ko ang patient will display Determine To obtain displayed hemodynamic
hinga ko” as blood pressure baseline vs. baseline stability.
verbalized by the within her normal Review signs of Provides
patient Decrease range shock opportunities Long Term:
cardiac output Promote to track The patient shall have
Objective Data: related to Long Term: adequate rest changes demonstrated activities that
decrease After 3 days of by decreasing reduce the workload of the
To prevent
Restlessness venous return nursing stimuli heart.
hypovolimic
BP: 160/100 secondary to intervention the shock
eclampsia patient will sustain Dependent:
normal range of Administered To maximize
sleep periods
blood pressure hypertensive
and demonstrate drugs as
activities that ordered by the
reduce the doctor.
workload of the
heart.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Short term: After 4 and a half
SUBJECTIVE DATA: After 4 and a half Provided health hours of nursing
Knowledge For effective
“ Unang hours of nursing teachings about intervention the
deficit related to breastfeeding
breastfeeding ko intervention the breastfeeding patient
proper position
ito diko alam paano patient will at performed the
of breastfeeding.
yung tamang pag least perform 1 first breast
breastfeed “.” as breastfeeding Proper positioning feeding position
verbalized by the position. Soap will remove that we discuss.
patient. (Hold baby - tummy
the natural oils
to tummy, baby's
Long term: that are present
OBJECTIVE DATA: nose and chin
After 48 hours of on your breasts
Temp 36 should be placed
nursing and nipples and
BP 160/100 against the breast) After 48 hours of
intervention, the will contribute to
78 Bpm nursing
Breastfeed every 23 drying and
Mother will be intervention the
19 Rpm hours, 8-10 times cracking,
able to: mother was able
daily
. to gain
• Express
How to get good knowledge
physical and To be able to
attachment (Make about the proper
psychological breastfeed
sure baby sucks the way to hold her
comfort in
areola, not just the properly and for baby, breastfeed
breastfeeding
nipple. Baby's top the safety of the her baby and
practice and
and bottom lip baby. clean her breasts
techniques
should be turned
out. Baby's chin • To
should be pressed obscure any
• State at
into the breast) distractions that
least one resource
for breastfeeding may interfere
support. with the feeding
Clean breasts only
And the infant with water and • To find
will be cotton, don't use an easier and
 soap or lotion more efficient
feeding pattern
Support baby's
suitable for the
head.
infant
neck and back.

• To increase the
parents'
understanding on
the nutritional
needs of their infant
and promote strict
compliance to the
correct feeding
patters

-Explain to the
parents the
importance of
proper nutrition
among infants by
following the
prescribed feeding
pattem

Assessment Diagnosis Planning Intervention Rationale

Evaluation
 .
Acute pain Short Term: Independent  Provides
related to 1. Assessed information to
After 6 hours of
urinary tract pain, noting aid in Short Term Goal:
nursing intervention
infection location and determining Evaluation After 6
the patient’s
intensity. choice or hours of nursing
Subjective data: painscale will be
2. Encouraged effectiveness of interventions, the
“Masakit ang reduce to at leat
pagihi ko” as increase fluid interventions patients pain is
4/10
verbalized by the intake  Increase tolerable.
client. Long term: 3. Monitored hydration
report of bladder flushes bacteria Long term Goal:
After 7 days of
fullness and toxins Evaluation After 7
effective nursing
intervention the 4. Provided  Urinary days of Nursing
patient’s pain will comfort measer retention may Intervention,the
Objective data: patient’s pain is
be relieved or like back rub, develop,
-Facial grimace controlled helping patient causing tissue relieved.
assume position distention.
-Restlessness
of comfort  Promotes
-Painscale of 7/10 relaxation,
Dependent: refocuses
Laboratory:
Administered attention and
Urinalysis
medication as may enhance
prescribed y the coping ailities
medical
practitioner.
 Promotional Problem
ASSESSME DIAGNOSI PLANNING INTERVENTIO RATIONAL EVALUATIO N
NT S N E
Subjectivedata: Readiness Short term: Independent: -To Short term: The
for After 2 hours determine goal was met after
“Dahil unang baby enhance of nursing -Established need/motiva 2 hours of nursing
nga namin to parenting intervention, rapport. tion for intervention, the
walapa akong as the patient will improvemen patient was able to
masyadong idea evidenced be able to: -Ascertained t. Identify their own
sa pagaalaga sa by motivation and strengths,
bata kaya ready expresses -Identify own expectation for -To foster individual needs,
naman kaming desire to strengths, a change. and methods and
improvemen
matuto” as enhance individual resources.
t of
evidenced by the parenting. needs, and -Make time for parenting Long term: The
patient methods and listening to skills. goal was met after
resources to concerns of the
Objective data: meet them. parents. 3 days of nursing
-To intervention, the
Parents expresses
- promote patient was able
desire to enhance -Involved all
optimal demonstrate
parenting members of the
Long term: family in wellness. improved parenting
After 3 days learning. behaviors and
of nursing verbalize realistic
intervention -Encouraged information and
, the patient parents to expectations of
will be able identify positive parenting role.
to: outlets for
meeting their
- own needs.
Demonstrate
improved -
 ASSESSME DIAGNOSI PLANNING INTERVENTI RATIONAL EVALUATIO
NT S ON E N
Subjective data: Readine Short term: Independent: -To improve Short term:
ss for After 7 hours patient’s The goal
ASSESSME DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
“Tuwing gabi enhance - motivations. was met
NT After 7
dahil sa pagihi ko sleep as of nursing Establish
Subjective Data:hindi
ng madalas Readiness
parenting for After 8 hours of ed Independent
rapport.
 To
-The patient hours Afterof8 hours of
Ano po bang related
enhanced to intervention,
nursing promote nursing
na ako makatulog behaviors. willhave a nursing
maadvice niyo discom the patient will
intervention the -Established parents interventio
ng maayos kayaparenting -Assessed intervention the
knowledg n, goal
fort due to
para sa pagaalaga -Verbalize client willto:
be able be able rapport. the was met
gagawin ko lahat the patients stronge of
sa aking baby” as realistic
frequent to enumerate patient wasactively
parents
g sasabihin ng ascertain motivation
infant
verbalized by the urination. concepts and Performed
-Discuss how to expectation s physical able to
assume
doctor para hindiinformation
mother clarify roles of and high
physical
and achieve optimal andassessment
motivatiwith diiscu ssed
responsibility
na ako parenting and expectations
characteri
sleep. parents
on for and show howfor emotional
mahirapan” as expectations of
Objective: express typical newborn to improve
stics and
improveme nt. herself to and physical
 verbalized
Shows by theparenting role. confidence in characteristics. behavior
to a
patient -Discuss  To achieve
care and well
manifestatio taking care of Point out state traitsgood optimal
dietary
their newborn such as quiet awakelifestyl
promote being of
n of -Assured sleep
matters, such familiarity newborn and
eagerness and cues to feedinge.
patientthat . expresses
Objective data: as limiting with
and readiness
occasional
intake of behaviors
willingness sleeplessne confidence.
chocolate and and
to Encouraged
ss should not parent decrease Long term:
caffeine or participation
threaten. in care
cooperate parental The goal was
 Easy fatigability. alcoholic behaviors such as met
anxiety
 Sleepy beverages. diapering,
-Encouraged formula and to After 12
appearance feeding
regular and bathing enhance hours of
Urinary output 4-6 exercise parental nursing
\
times/ night Encouraged feeling of intervention,
Long term: during the
visitation and contributi the patient
After 12 hours day toaid
access in
to health on as was able to
of nursing stress
servicescontrol
and newborns Show
intervention, and release
provides primary personal
the patient will of energy. caretaker concerns of
be able to: s. sleep quality
 To
and quantity.
-Express promote
\
personal continued
proper
concerns of
parenting
sleep quantity
and
and quantity. ongoing
To promote learning
optimum sleep applied at
and home
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Readiness Short term: Independent: -To help Short term: The
data: for After 1 hour the baby to goal was met
enhance of nursing - suck after 1 hour of
“Pangunang knowledge intervention, Established properly nursing
anak ko ito of the patient rapport and intervention, the
kaya gusto breastfeedi will be able prevent patient
kong to: -Assessed the aspiration. understand the
ng
malaman mother’s importance of
kung ano an -Understand desiresfor proper breast
tamang the - feeding.
feeding infant.
pagbreast importance of
feeding” as proper breast -Provide
verbalized feeding. Long term: The
health
by the goal was met
Long term: teaching
patient” after 12 hours of
After 12 aboutthe
benefits of nursing
Objective hours of intervention, the
nursing breast
data: feeding. patient verbalize
intervention,
understanding
-Mother the patient
will be able -Demonstrate of the benefits
Expresses how to support of breast milk
desire to to:
and position and aplied the
enhance theinfant.
-Verbalize different
ability to
understandin techniques of
exclusively -
g of the breastfeeding.
breastfeed. Encourage
benefits of
breast milk. dskin-to-
skin
-Apply contact.
different
 breastfeeding
positions.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Subjective data: Readiness for Short term: Independent:  Indicates Short term:
enhanced After 6 hours deficient The goal was
“Ano bang knowledge of nursing  Established knowledge or met after 4
pwede kong health interventio n, rapport. misinformatio hours of
gawin para the patient will n nursing
maging maayos be able to  Assessed  To develop intervention,
ang aking verbalize clients plan for the patient had
kalusugan at understanding perceptions of learning been able to
hindi na ako of information their current  To facilitate verbalize
atakihin ng gained learning
understanding
health
higblood ko”. as of information
problems process
verbalized by Long term: gained
 To promote
the patient After 4 days
 Determine wellness
of nursing -
motivation/
Objective data: interventio
n,the patient expectations
The client manifested Long term:
will be able to for learning The goal was
cooperative,follows
instruction, active use met after 4
 Review
and asking about information to days of nursing
develop specific
normal condition of dietary intervention the
his health
individual client had been
plan to meet changes/
restrictions able to use
health care
needs. with client information to
develop
individual plan
to meet health
care needs.
pregnancy. such as ruits,
proper nutrition vegetables,
for the diet of fat-free and
pregnancy such protein
as fruits, foods.
vegetables,
fatfree and -Engage in the
protein foods. proper decision
– making by
-Engage in identify,
the proper assess,
decision – consider,
making by Implement, and
identify, evaluate the
assess, situations.
consider,
Implement,
and
evaluate
the
situations
 RISK POTENTIAL
ASSESSM DIAGNO PLANNING IMPLEMENTATIO RATIONALE EVALUATION
ENT SIS N
Subjective Risk for Within 3 hours of ● Establish   Building up trust GOAL MET.
: unstable rendering nursing helps nurse-patient
rapport. After 3 hours of
blood interventions the interaction more
The patient rendering the
pressure patient will be ● Monitor effective.
stated that nursing
related to able to recognize  To have a baseline
“hindi ko the interventions the
unhealthy that our body is data
maiwasan patient’s patient was able
diet profoundly
kumain ng vital signs.  This will allow the to understand the
affected by the
matatabang patient to gain importance of
food we  Educated the
pagkain”. knowledge in the nutritious food to
consume. patient on the
area of how to our body and the
bodys nutrional
independently care patients vital
needs
Objective: for oneself upon signs are also
Long term:  Provided good
BP: discharge stable
160/100 Within 5 days of oral hygiene  Good oral hygiene
rendering nursing can increase an
interventions the individual’s
patient will be Collaborative appetite. The oral
able to display a mucosa is also a
● Discussed
stable blood vital part of salvia
pressure reading MD the production which
and increase their potential will further aid in
intake of need for the digestion of
nutritious foods. refferal to a food.
dietitian  Utilizing
. appropriate
resources is a vital
 part of being a
nurse. The dietitian
will be able to
appropriately
assess the patient
and individualize
the patient’s plan
of care regarding
nutrition.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATI RATIONALE EVALUATION

ON
Subjective: Risk For After 4 hours >Establish rapport >To gain the client Goal met client were
Naglolotion Impaired skin of nursing >Monitor VS trust able to verbalize
ako palagi integrity as intervention .>Note age and .>To obtain data individual factors
dahil parang evidenced by client will be sex forcomparison. that causes skin
nagddry ang dry skin able to >Assess mood, >to
impairment
ang balat ko verbalize abilities,and evaluatedegree/source
kahit marami understandin personal styles. of riskinherent in
akong uminom g of individual >Provide theindividual situation
ng tubig” as factors that healthteachings .>to evaluate Goal met the patient
verbalized by contribute to regarding pt.’sattitude which were able to
the patient possibility of theimportance of maycontribute to demonstrate
skin maintaining an skinbreakdown behaviors to prevent
Objective: impairment. intact andmoist .>To increase the dry skin.
Dry skin skin patients knowledge
Long Term: .>Adviced the thus,prevention of
After 3 days clien a balance, skinbreakdown is
of nursing and nutritious realizedand taken
intervention food intoconsideration
the client will especiallyfoods .> To improve
be able to rich in Iron clientsimmune system
demonstrate andvitamin
behaviors to
prevent dry
skin.
 children in the home. overcome parenting
Determine
barriers.
challenges in the
Observe the parent’s
parent’s
attitude toward the Parent were able to
capabilities.
infant. Monitor participate in classes
interactions when
to promote effective
feeding and changing
parenting.
the infant or a
reluctance or
indifference in
parenting.

Young parents with an

unplanned or
unwanted pregnancy
may lack the skills and
knowledge for
parenting. Consider the
parent’s intellectual
and emotional level as
well as any physical
weaknesses.
VII. DISCHARGE PLAN
A. Health Teaching

The following set of guidelines for at-home care must be followed:

l Patients diagnosed eclampsia during pregnancy, as well as their family members, need to be educated on
the signs and symptoms of eclampsia. They need to be instructed to call emergency services immediately and
should bring the patient to the hospital as soon as possible.
l Patients should be counseled about the importance of their hypertensive medication and should regularly follow up with their
obstetrician.
 Keep follow-up appointments with your doctor. These may be very frequent and are very important for

 your health.

 • Take all medications prescribed for you exactly as ordered.

 • Weigh yourself at the same time each day. Write down your weight and take this record with you to your

 doctor visits.

 • If ordered by your doctor, monitor your blood pressure at home.

 • Ask your doctor if you need to check your urine at home for protein.

 • Eat a healthy, balanced diet. Your doctor will tell you if you need to follow any special restrictions in

 what you eat.

 • Don’t smoke.

 • Don’t drink alcohol or use any drugs not prescribed to you.

  • Ask your
doctor before
taking any
medications that he or she didn’t prescribe for you. This includes any

B. Anticipatory Guidance & Teachings l As instructed by your doctor, keep your follow-up
appointments.
l If your blood pressure at or exceeding 140/90, let your doctor know right away.
l If you experience severe headache,stomach pain, and vision changes let someone know right away.

C. Exercise
l Encourage deep breathing exercise.
l Educate client on proper mechanics to prevent strain and enable client to relax.
l Begin range of motion exercises
l Walking is the best exercise, bed rest may slow your recovery.

D. Spiritually

l To feel comforted and encouraged, family members or relatives should continue to communicate well with one
another.
 To maintain a happy marriage, maintain a close bond with your partner.
l For problem-solving concerns, always cooperate. Through idea sharing, you will receive actual solutions.
E. Medication
l Describe the importance of regularly taking of prescribed medications including potential12` unpleasant effects of
non compliance.
l Advise client no to miss the intake of medications given by her physician upon discharge.
l Take diazepam to prevent or treat seizure.
l If you experiencing pain take mefenamic acid.
l Take ferrous sulfate to treat prevent or treat iron deficiency anemia..
.

F. Treatment
l Have enough time to rest and sleep while you're recovering.
l Allowing oneself to move more will help in your recovery.
l Encourage the client to keep doing deep breathing exercises, and give the family
instructions on the necessary exercise. Blood circulation and relaxation are both promoted
by doing this.

G. Nutrition and Diet

l Eat a well- balanced diet. No dieting or junk food.
l Eat foods that are high in vegetables, olive oil, fruits and poultry
l Continue to take vitamins and iron tablets as ordered.
l Maintain hydration by consuming 6 to 8 glasses of water per day.
l Restrict eating fatty foods.