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نسخة case study
نسخة case study
1. Personal information:
(2 Marks)
Patient initials:
Mrs H, she is primigravida mother (G1, P0, L0, A0) diagnosed with pregnancy-induced
hypertension.
4. Obstetrical History (Fill for ANC/PNC cases. If newborn case fills for the
newborn’s mother): (2 Marks)
Died: 0 Alive: 0
L.M.P: 5/8/2020 EDD (Scan): 13/5/2021 EDD (history): 13/5/2021
Primigravida mother, G1, P0, L0, A0, 31 weeks and 5 days of gestation with PIH.
6. Chief Complaint:
(Admission and present complain with duration) (2 Marks)
The mother admitted to Royal hospital in 15/3/2021 due to high blood pressure during pregnancy.
When I was assessing her she told me “I feel headache, dizziness and imbalance sometimes. I also
suffer from low back pain, especially when I sit or stand for a long period.
A mother is primigravida G1, P0, L0, A0, 31 weeks and 5 days of gestation with PIH. PIH is
pregnancy- induced hypertension which is a condition in which vasospasm occurs during pregnancy
in both small and large arteries. It is unique to pregnancy and occurs in 5% to 7% of pregnancies.
8. Etiology of the disease: (4 Marks)
(Example: A mother is G4, P3, L3, A0, 39 weeks with PIH, Oligohydramnios,
delivered by LSCS. In this case write the etiology for PIH, Oligohydramnios and
LSCS)
- Proteinuria. - Proteinuria.
- Edema. - Edema in the lower extremities.
- Hypertension. - Hypertension.
- Vision changes. - Dizziness.
- Dizziness. - Headache.
- Headache.
Causes
Clinical manifestation
Headache and Edema and
dizziness. Vision changes Proteinuria. high blood
pressure.
Pregnancy – induced
hypertension
Cardiovascular Client verbalized “ both When I assessed her legs, she has edema in her feet. The edema of the patient’s feet
assessment of my legs are indicates pregnancy induced
edematous “ hypertension.
Abdominal Client verbalized “ I a. Inspection: -All of the changes in the
assessment have this brown line Gestational age: 31 weeks. abdomen it’s physiological
from the umbilicus tell Size: appropriate for gestational age. changes happens during
near the bladder” Shape: round. pregnancy.
Skin changes: there are linea nigra and striae -The fundal height is appropriate
gravedarum. for the gestational age.
Fetal movement: visible
b. palpation:
fundal height:29cm
fundal: buttocks (irregular, soft and broad)
lateral:
right: extremities (irregular and I felt gabs in
between)
left: back (smooth, firm and regular)
position: LOA
lie: longitudinal
pelvic:
presentation: cephalic (round, smooth, firm and hard)
engagement: not engaged
c. Auscultation:
fetal heart rate: 142 beats/minutes and it’s regular.
Drug Dose Route Freque Indicatio Classificati Action Side Nursing responsibility
name ncy n on effect
Heparin 4000unit Inj OD To Anticoagul Promotes the Injection 1-Instruct patients to report any blood in urine
low mol wt prevent ant inactivation of site or stools or bleeding from gums, nose, vagina,
clixane blood factor X, reactions or wounds.
clots Category B which, in turn, such as 2--Check concentration of heparin carefully (-
prevents the redness, Use of the wrong concentration for the route of
conversion of irritation administration is a common medication error
prothrombin and with serious/potentially life-threatening
to thrombin. bruising. ramifications).
Also has an
effect on
fibrin, limiting
the formation
of a stable
clot.
Paracetamo 1000mg Inj STAT To reduce Non obioid Inhibits the Nausea 1-Assess patient for medical conditions that
l pain. analgesics synthesis of Rash contradict the use of acetaminophen.
prostaglandins Urticarial 2-Remind patient that the maximum adult dose
Category A that may serve is 4g in 1 day, and that exceeding this dose may
as mediators cause acute liver disease or kidney disease.
of pain and
fever,
primarily in
the CNS.
Nifedipine 20mg Tab BID Treat Antihyperte Inhibits the Headache 1-Check BP before administering the
hypertensi nsive movement of Fatigue medication.
on during calcium ions Nausea 2-Inspect gums visually. Changes in gingivae
pregnancy Category C across the Diarrhea may be gradual, and bleeding may be exhibited
membranes of only with probing.
cardiac and
arterial muscle
cells.
Labetalol 200mg Tab TID Treat Antihyperte Competitively Depressio 1- Do not administer the dose if the patient is
hypertensi nsive blocks alpha1, n bradycardic or hypotensive.
on during beta1 and Nausea 2-Teach the patient not to stop taking her
pregnancy Category C beta2. Alpha Vomiting medication on her own and to be certain not to
and beta allow her prescriptions to run out.
bloking actions 3-Teach the patient or her family how to check
contribute to her pulse and blood pressure at home, and what
the blood to do if there is a problem.
pressure
lowering effect.
Fefol 1cap Capsul OD It’s iron Vitamin Elevates the Nausea 1-Instruct the patient to take the drug at bed
capsule e supplemen serum iron Vomiting time and with empty stomach.
t, to Category A concentration Anorexia 2-Teach the patient strategies to deal with
prevent or which then Constipati constipation.
treat Iron helps to form on 3-Instruct the patient to take the drug with fresh
deficiency hemoglobin. fruit juice especially with fruit with vitamin C.
anemia.
16. List of all nursing diagnosis with prioritization use PES format: (4 Marks) Note: Include appropriate nursing
diagnosis for the mother and newborn in case of postnatal case study.
Problem Etiology Signs and symptoms
Ineffective tissue perfusion Related to vasoconstriction of Edema, Skin temperature
blood vessels changes, Skin discolorations,
Bp changes, Positive
Homans’ sign.
Deficient fluid volume Related to fluid loss to Dry skin, increase body
subcutaneous tissue temperature (T=37.9), thirst,
alteration in skin turgor,
decrease in urine output (3-4
times).
Risk for fetal injury Related to reduced placental There were no signs and
perfusion secondary to symptoms in the risk
vasospasm diagnosis.
Social isolation Related to prescribed bed rest Patient verbalized “I’m bored
here, all the time I’m in this
bed”.
Include health teaching points under heading which is appropriate for all the needs of the mother and newborn with
rational.
Priority topic for health teaching: control or lower the high blood pressure during pregnancy.
Rationale: the patient is hypertensive patient so she needs to know the measurements of reducing blood pressure
during pregnancy.
Summary points Scientific rational / explanation
Decrease the salt in your diet. Even a small reduction in the sodium in your diet can
improve your heart health and reduce blood pressure about
5 to 6 mmHg. The effect of sodium intake on blood
pressure varies among groups of people. In general, limit
sodium to 2300 mg a day or less. However, a lower sodium
intake 1500 mg a day or less is ideal for most adults.
Eat healthy food. Eat fruits, vegetables, whole grains, poultry, fish and low
fat dairy foods. Also, get plenty of potassium, which can
help prevent and control high blood pressure. Eat less
saturated and trans fat.
Reduces the amount of caffeine drinking Caffeine may cause a small rise in blood pressure.
per day. Drinking a moderate amount of caffeine (less than 2 cups
of coffee per day) does not increase the risk of high blood
pressure in most people.
Maintain healthy weight. Keeping a healthy weight and losing weight if you are
overweight or obese can help control the high blood
pressure.
19. Reflection: (Use Gibbs reflective cycle) (3 Marks)
Introduction:
On Wednesday, March 17th, I was in the maternity ward 4. The teacher chose one patient for me to
do the antenatal assessment and to be my patient for the case study. I went to the patient and asked
her permission that I would like to ask her some questions and I want to see her breast and abdomen.
At first, I was worried that she would not agree because in the day before I looked for more than one
patient, and all of them did not agree, but I was very happy because she agreed and did not say no
and did not refuse my request. At the beginning I asked her some questions and she answered all the
questions well. It is true that she was feeling a little tired, but that did not prevent her from allocating
some time to me. This patient was cooperative with me and did not refuse to answer any questions
or refuse the examination that I did for her.
Through this situation I was very happy because the patient agreed, as in such situations and
requests most of the patients do not allow as to do so, we may face some difficulties in convincing
the patient. This patient was cooperative and understanding me. I felt happy and reassured about her
and I did the antenatal assessment well with my teacher.
Evaluation:
In my opinion, that situation happened well, as I did not take mush time to convince the patient to
agree. When I took permission from her, she quickly agreed and did not hesitate to do so. She is
very good at dealing and her approval made me feel happy because I tried a lot before to convince
more than one patient, but all of them refused. On the other hand, it can be said that there are some
things that happened a little wrongly, I did my job completely in about 10 to 15 minutes. The patient
was cooperative and responsive to me, and when I asked her, for example, to lift her clothes, she
does that quickly and does not ask questions. In the end, I thanked her for her approval.
Analysis:
Surely, this situation happened very well. Why? Because the patient helped me a lot in doing
antenatal assessment, as she understood that must of the patients do not agree to my request, so I
will lose my time convincing a patient. This patient agreed quickly because I mentioned to her that
yesterday I searched for more than one patient to do this assessment but all of them refused. I think
what made this situation go well was that I used good therapeutic communication and techniques
which made the patient agree to my request. In the end, I can improve such situations like this with
patients through the use of therapeutic communication skills, and to speak with the patient clearly
with a smile. Also, an explanation of what I will do must be provided to the patient because the
patient deserves to know about the procedure will be done for her.
Conclusion:
I learned from this situation that not all patients will refuse if we ask them for something. I learned
positively from my experience that I can persuade the patient to do a procedure for her by using
therapeutic communication and explaining the procedure to the patient, so that she is understood of
what I will do. My strengths are that I was able to convince the patient in a simple and fast way. I
was able to achieve some of my goals as I was able to do the antenatal assessment.
Reflection on action:
Through this experience, I see that as student, we will encounter many patients who may reject our
request in making a procedure for them so we must know and understand all the strategies that we
can use in convince the patient. For example, we must be calm and avoid negative language by
talking to the patient calmly and not raising our voice. Also, we should avoid arguing with the
patient and talk to her with respect. In the end, I felt that I did a good job and that I was able to
achieve my goals. I felt happy in doing the procedure after many attempts with more than one
patient.
20. References: (3
Marks)
- Pillitteri A (2010) Maternal & Child Health Nursing: Care of the Childbearing &
childrearing family (6th edn) Philadelphia: Lippincott Williams and Wilkins
- Hinkle ,J.L,&Checver, K.H. (2012). Brunner and Suddarth’s text book of Medical Surgical
Nursing (13 ed). Philadelphia, PA: J.B.Lippincott Williams & Wilkins, pp,862-863.
- Karen J.& Linda K.(2007), Nursing Diagnosis Reference Manual, 7th Edition, Philadelphia:
Judith A, Chapter5(369 370), (394-397).4
- 10 ways to control high blood pressure without medication. (2021). Retrieved 31 March 2021, from
https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-
20046974
- Patange, R., V. Rokadhe, A., R. Shinde, G., N. Jadhav, S., & Bahulekar, A. (2020). ORAL NIFEDIPINE
VERSUS ORAL LABETALOL IN THE TREATMENT OF PREGNANCY INDUCED
HYPERTENSION. Retrieved 31 March 2021, from https://ejmcm.com/article_5748.html
- 6 Preterm Labor Nursing Care Plans. (2021). Retrieved 31 March 2021, from
https://nurseslabs.com/preterm-labor-nursing-care-plans/4/
21. Organization of case study: (2 Marks)
Marks obtained = X 35
100
Teacher’s Signature:
Date: