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Mild Preeclampsia
Mild Preeclampsia
Mild Preeclampsia
General Appearance
A weight gain of more than 2 lb/wk in the second trimester Weight gain of more than 1lb/wk in the third trimester Edema begins to accumulate in the upper part of the body: slight pitting edema +1 Reflexes may be normal (using the reflex hammer, check the biceps, patellar, and ankle deep tendon reflexes.)
Neurologic
Patient may report for Headache Patient may report for dizziness
Head/Hair/Face
EENT Chloasma is present None Patient may report no visual disturbances at this stage None
No problems identified
Neck
Thorax/Lungs
none
none
Back
none
none
none
Cardiovascular/Peripheral Vascular
Blood reading of 140/90 mmHg x 2, 4-6 hr apart, no more than 1 wk apart CRT is > 3 seconds
GIT
none
GUT
Quantitative 24-hr urine analysis: Proteinuria of 0.3g in a 24-hr specimen Qualitative dipstick: 30 mg/dl (/+) on dipstick
Urine output: Output matching intake, 30 ml/hr or <650 ml/24hr Serum Creatinine: Normal
Musculoskeletal
Activity intolerance
Extremities
Edema begins to accumulate in the upper part of the body: slight pitting edema +1 CRT is > 3 seconds
Hematologic
None
No problems identified
VI. COURSE IN THE WARD A. Brief Description Of The Patient Stay From Admission Until Discharge B. Daily Enumeration of Physicians Order & Procedures Done
Date/Shift/Time June 5, 2012 7-3shift 7:10am Physicians Order Admit under Dr. Dazo/ Dr. Astillo/Dr. Ducducan Consent to Care Vital Signs every 1 hour NPO D5LR 1L at 30 gtts/min Labs: Complete Blood Count(CBC), Blood Typing (BT), Platelet Count(PC), Urinalysis(UA), HbsAg, Creatinine, Serum Urine Albumin(SUA), SGPT EFM Medications: Ampicillin 1gm every 6 hours ANST( ) Hydralazine 5gm PRN IVTT DBP110mmHg Methyldopa 250 mg every 6 hours FHT every hour Retain FBC Refer Dr. Astillo Procedures Done Dependent Nursing Functions: V/S Monitoring: BP RR PR Temp Secured consent for admission Instructed patient to take nothing by mouth Started venoclysis of #1 D5LR 1 Liter regulated at 30 gtts/minute. Follow-up laboratory results. Attached to Electronic Fetal Monitor (EFM). Monitored Fetal Heart Rate Inserted/maintain indwelling catheter, as indicated. Nurses Notes Independent Nsg. Functions Promote proper body positioning to promote comfort, such as semi fowlers position. Advise the patient to sleep 8 hours each night and to nap or rest for 2 hours in the afternoon. Instruct the patient in in basic deep chest breathing, which is similar to normal breathing but slower and deeper. Encourage client to acknowledge and express feelings. Promote bed rest Weigh daily at same time of day, on same scale, with same equipment and clothing.
Physicians Order For EFM Now Left Lateral Decubitus Position O2 at 2 Liters/minute Dr. Ducducan
9:00 pm
Postpartum Order: (PPO) DAT To HR II (High Risk 2) Incorporate 20 units of Oxytocin @ 30 gtts/minute Medications: Co-Amoxiclav 625 mg TID Ketorolac 10mg TID FeSO4 1 cap OD Nifedipine 5mg q 6 hrs Keep Uterus Well Contracted Perineal Care BID Dr. Dazo
Procedures Done VS Monitored: BP RR PR Temp Monitored EFM. Placed On Left Lateral Decubitus Position Oxygen Therapy Started And Regulated At 2 Liters/Minute. Maintain oxygen therapy as ordered. Delivered By Outlet Forcep Extraction Incorporated Intravenous Fluid With 20 Units Of Oxytocin Regulated At 30 Gtts/Minute Administered Medications Checked For Unusualities Kept Uterus Firm And Contracted Perineal Care Done
Nurses Notes Evaluate edematous extremities, change position frequently. Assess skin, face, and dependent areas for edema. Evaluate degree of edema (on scale of +1+4). Determine pain history, e.g. location of pain, frequency, duration, and intensity using pain scale and relief measures used. Place in comfortable position as appropriate Carefully monitor intake and output at least every 4 hours. Increased patients activity level as tolerated; for example, ambulate and increase self-care measures performed by patient.
Physicians Order Continue Meds Possible MGH tomorrow Refer for Hypertension/BP/Profuse Vaginal Bleeding Dr. Ducducan
Procedures Done IE Done BP 110/80 mmHg Medications given Checked For Unusualities VS monitored
Nurses Notes Inform patient about: Proper use of medication and possible adverse reactions.
Benefits of low-fat, lowcholesterol diet. Need to avoid straining with bowel movements. Date/Shift/Time June 7, 2012 7-3 shift 8:00 am Physicians Order MGH DAT Medications: Follow-up Check-up 6/13/12 @ OPD Advised Dr. Astillo Procedures Done VS Monitored Intake and output monitored. Nurses Notes Educate Patient regarding: Environmental safety measures. Fluid restriction and diet. Ways to prevent infection.