Jose Rizal University

80 Shaw Boulevard, Mandaluyong City

College of Nursing and Health Sciences

Nursing Care Management of a Client with Eclampsia

A Case Study

Presented to:

The Faculty of the College of Nursing and Health Sciences

In Partial Fulfillment of

The Requirements for The

Bachelor of Science in Nursing

Presented by

BSN- 201N

Group 1

Allas, Sheryl Mae D.

Benavidez, Mark Adrian M.

Bernardino, Justin Timberlake M.

Bunquin, Myrene C.

Daza, Mauren D.

S.Y 2017-2018
 CHAPTER I

INTRODUCTION

Eclampsia is the most severe classification of gestational hypertension. A woman

has passed into this stage when cerebral edema is so acute a grand mal (tonic-clonic) seizure or

coma has occurred. With eclampsia, the maternal mortality can be as high as 20% from causes

such as cerebral hemorrhage, circulatory collapse, or renal failure (Liu, Joseph, Liston, et al.,

2011).

Eclampsia often follows preeclampsia, which is characterized by high blood

pressure after the 20th week of pregnancy and protein in the urine. If your preeclampsia worsens

and affects your brain, causing seizures, you have developed eclampsia. No one knows what

exactly causes preeclampsia or eclampsia, although abnormalities in the endothelium (the inner

layer of blood vessel walls) have been considered as a potential cause. Since the exact cause of

preeclampsia or eclampsia is poorly understood, it is not possible to effectively predict when

preeclampsia or eclampsia will occur, or to enact any preventative measures that might prevent

these problems from developing. Preeclampsia usually occurs during an initial (first) pregnancy.

In addition to swelling, protein in the urine, and high blood pressure, preeclampsia symptoms

can include rapid weight gain caused by a significant increase in bodily fluid, abdominal pain,

severe headaches, change in reflexes, reduced urine or no urine output, dizziness, excessive

vomiting and nausea, vision changes. Risk factors are identified and includes hypertension (high

blood pressure), headaches, being older than 35 years or younger than 20 years, pregnancy

with twins, first-time pregnancy, history of poor diet or malnutrition, diabetes or another

condition that affects your blood vessels

 Eclampsia is a condition that only occurs during pregnancy and causes seizures,

usually late in the pregnancy. It is a rare condition, affecting 1 in every 2,000-3,000 pregnancies

every year. Many of the pregnancies affected by eclampsia or preeclampsia are first

pregnancies. Around 70 percent of cases in the United States are in first-time pregnancies.

While eclampsia can be fatal if untreated, it is very rare for pregnant women to

die from the condition in developed countries. Globally, eclampsia accounts for

approximately 14 percent of maternal deaths. In the majority of cases, preeclampsia symptoms

are mild and do not require any intervention other than monitoring and possibly diet change.
General Objective:

The group would like to study this case (Eclampsia) because we have observed that this case is

rarely happening in delivery of pregnancy, we would like to identify the nursing problems and

corresponding nursing considerations and managements involved for promotion and

maintenance of the client’s health and of course, this case will allow us students to enhance our

nursing skills and application of nursing interventions for patient’s health recovery and wellness.

Specific objectives:

Students:

1. To Discuss and elaborate actual signs and symptoms of the disease exhibited by the

client.

2. To Discuss, explain, and elaborate the nature of the disease of the process.

3. To Know the significance of client’s response to the rendered nursing interventions.

4. To Efficiently provide appropriate and proper nursing diagnosis in line with the client’s

medical condition.

5. To Efficiently apply the learned concepts and theory of the disease.

Patients:

1. To be able to uunderstand awareness of the patient’s disease.

2. To be able to learn and gain knowledge from the patient’s condition.

Scope and Limitations

Our study focuses on the nursing care to our patient with eclampsia and the main

purpose of this study is to regain the patient's optimum level of functioning, We've gathered all

of our information from our primary source which is our client by interviewing, using her chart

and physical assessment by using inspection, palpation, percussion and auscultation. For our

limitations, we handle our patient for 3 consecutive days that's why we have limited information

about the condition of our patient.

Nursing Theoretical Framework

Health as Expanding Consciousness by Margaret A. Newman

Newman emphasizes the primacy of relationship as a focus of nursing, both the nurse-client

relationship and relationships within clients' lives. Clients get in touch with the meaning of their

lives through identification of meanings in the process of their evolving patterns of relating “The

emphasis of this process is on knowing/caring through pattern recognition” which is applicable

to our client to help her became knowledgeable about the health especially on the second time

around that she will get pregnant and for the overall well-being of our client.
 CHAPTER II

ASSESSMENT

A. Nursing Health History

1. Demographic Data

Ms. J is a 25-year-old, female, who works as a call center agent in one of the BPO

company's around Taguig. She is not married but currently living in with her partner for a year

now together with the sibling and a cousin. Client was born in Manila on August 3, 1992 but

originally from Bicol. She finished college majoring in Bachelor in Science in Psychology in

RTU and currently resides at Baranka Ibaba, Mandaluyong City. She is a Filipino citizen and a

Christian who attends service every Sunday. She was admitted in Mandaluyong City Medical

Hospital this 11th day of December 2017 at 2:22AM

2. Chief Complaint

Loss of consciousness

“Nasa banyo lang ako umiihi, bigla ko nalang naramdaman na nahihilo ako, next

thing I know nasa stretcher na ako, binuhat nila palabas ng apartment” as verbalized by the

patient.

As we interviewed the client, she stated that she already filed for leave of absence

from work due to the environment of her job.

 3. Medical Diagnosis

6
Admitting diagnosis: G1P0 22 7 weeks AOG NIL; Eclampsia rule out

Hypertension

4. History of Present Illness

Client was uncertain about her medical diagnosis since it was her first time having

it and felt scared about it. Upon interviewing she stated that neither of her parents had any

incidence of such. But stated that her father has a history of hypertension and manageable.

She was admitted due to loss of consciousness while using the bathroom. No part

of the body was hit because her partner’s cousin rescued her right away. She has been feeling

weak since it was stressful at work. Mild headache at times with no fever, but manageable with

over the counter pain relievers like biogesic and aleve. Stated that she had observed edema from

upper and lower extremities few months after getting pregnant.

On our first day handling the client (December 13, 2017), she shows no signs of

pain, with blood pressure of 110/80mmHg in the morning but spiked up to 150/100mmHg after

lunch and informed our Clinical instructor. She has some PRN medications for her blood

pressure. Temperature 36.6°𝐶, cardiac rate of 74bpm, and respiration of 53bpm, her blood

pressure rises on various time. Client was put on restricted diet and later on turn to NPO for the

preparation of luminaria insertion.

 During the second day of handling the client, we did our morning vital signs

check at 8:00AM, noted the blood pressure of 110/80mmHg, pulse rate of 74bpm, respirations

rate of 14bpm and temperature of 36.6°𝐶. Administered Hydralazine 5mg via IV. Client’s

contractions started and began moaning and crying because of the severe pain (9/10). At exactly

11:40AM, client was transferred to DR for the delivery of the fetus.

5. Past Medical History

According to client, she is the only daughter of her parents then they separated

when she was young. She stayed with her mother with little information about her father’s

whereabouts. She stated that her father as a history of hypertension as per her mother. She has

few siblings on her father side but unsure of how many they were. She is the oldest daughter and

has 4 more siblings on her mother’s side. Both grandparents has history of diabetes and

hypertension.

She completed her immunization when she was young and no knowledge of

getting any surgical hospitalizations. Her blood pressure was stable before current

hospitalizations. No drug and food allergies, but just recently she had experienced rashes on her

palms while cutting and preparing squid for dinner. She then, seek medical attention was given

proper care. No other severe incidence occurred.

6. Socio Economic

As per client, she graduated college with the degree in Psychology. She works as

a call center agent on a 9PM to 5AM shift five days a week. Lives with partner and partner’s
sibling and cousin. She stated that she used to contribute extra earnings to her mother for her

stepsiblings, but discontinued it because of getting pregnant.

Ms. J enjoys spending time out watching movies and travelling with her friends

when she’s off from work. She insisted that she does not smoke and just drink occasionally. She

is a Christian and goes to service every Sunday. She is not involved in any community

organizations at this time.

7. Family Health History

Ms. J

LEGEND:

Male

Female

Hypertension

Diabetes

Deceased

The grandparents of Ms. J on her father side has both history of hypertension as well as his

father, while on her mother side her grandmother has a hypertension and diabetes and her

grandfather died due to drowning. She has 4 siblings on her mother side and all of them are

healthy.
B. REVIEW OF SYSTEM

1. Subjective Data

• REVIEW OF SYSTEMS GORDON'S PATTERN OF FUNCTIONING

GORDON'S PATTERN OF FUNCTIONING

PATTERN BEFORE DURING INTERPRETATI IMPLICATION

HOSPITALIZATI HOSPITALIZATI ON OF CARE
ON ON
1. HEALTH “Umiinom ako ng “Since na Before According to Role
PERCEPTION/ pain medication pag hospitalized ako, hospitalization, Performance Model,
HEALTH hindi ko na kaya wala naman akong client shows an people who can
MANAGEMENT yung sakit ng ulo nararamdaman na active lifestyle but fulfill their roles are
ko, pero most of the kakaiba, hindi lacking of healthy even if they
time itinutulog ko naman ako nahihilo knowledge when it have clinical illness.
lang sya at or nasusuka” as comes to breast (Fundamentals of
nawawala naman” verbalized by the examining since she Nursing Kozier and
as verbalized by the client was not educated ERB'S pg. 297)
client /knowledgeable
properly.
“Hindi ako
naninigarilyo,
nagagalit pa nga
ako sa partner ko
kapag nakikita ko
syang naninigarilyo
pinapalabas ko sya
ng bahay. Umiinom
din ako pero
occasional lang,
mga dalawang bote
lang ” as verbalized
by the client

“Sa tingin ko active

naman ako, ako pa
nga nagyayaya sa
mga kaibigan ko na
umalis at gumala”
as verbalized by the
client

“Pagdating sa self
examination ng
 breast ko, di ko sya
nagagawa monthly,
kasi di naman din
ako aware and wala
naman akong
nararamdaman na
abnormal” as
verbalized by the
client
2. We asked the client “More on sabaw Before People who spend
NUTRITIONAL/ about what food she muna daw ako hospitalization, many hours at home
METABOLIC eats then she ngayon, kasi naka client has big may take time to
MANAGEMENT replied, restrict yun salt appetite on foods prepare more meals
intake ko” especially on meat “from starch”
“Madami eh, pero verbalized by client. but put on restricted Individual
minsan lang kami diet with low salt differences also
mag gulay, mga and sodium. influence lifestyle
once a week minsan patterns eg. cooking
nga wala pa eh, skills.
pero usually mga (Fundamentals of
pritong manok, Nursing Kozier and
baboy, lalo na kapag ERBS pg. 1238)
nagluluto yung
pinsan ng partner ko
kasi chef yun eh.”

3. ELIMINATION “Everyday naman “Wala naman Client shows Maintaining Normal

PATTERN akong dumudumi, pagbabago sa healthy urinary and Urinary Elimination
my times na pagdumi at pag ihi bowel movement. by promoting
malambot meron ko, ganun pa din, Voids and urinate adequate fluid
din naman times na medyo mas madalas frequently as soon intake and
medyo constipated nga ang pag ihi ko after drinking water maintaining normal
ako kasi siguro puro pa” as verbalized by and juices. voiding habits.
meat at wala the client. (Fundamentals of
masyadong gulay Nursing Kozier and
yung kinakain ko.” ERB'S pg. 1297)

“Sa pag ihi naman,

madalas akong
umihi kasi panay
panay ang pag inom
ko ng tubig. Siguro
sa isang araw
nakaka 5-6 na beses
 ako kung umihi”
stated by the client.
4. ACTIVITY- “Di ako “Di ako Client does not Positive effects of
EXERCISE nageexercise eh, nakakaexercise practice nor have exercise on
PATTERN usually yung nung naconfine akoany exercise routine cognitive
pagbaba ko lang ng dito kasi lagi lang
due to her hectic functioning,
hagdan kasi sa 5th akong nakahiga schedule at work Individuals who
floor yung naglalakad lang ako
even before have inactive
apartment namin papuntang CR nung hospitalization. lifestyles or who are
pati yung sa office tinanggalan ako ng faced with inactivity
namin kasi nasa 2nd catheter” as because of illness or
floor yun eh” as verbalized by the injury are at risk for
verbalized by the patient many problems that
patient can affect major
body
systems.(Fundamen
tals of Nursing
Kozier and ERB'S
pg. 1117)
5. SLEEP-REST “Ang uwi ko kasi sa “Okay naman yung Since our client Following an
PATTERN bahay 7am dahil tulog ko sa hospital works overnight irregular morning
inaantay ko pa yung pagising-gising lang shift, her sleeping and nighttime
partner ko tapos dahil sa mga test na pattern is altered but schedule can affect
matutulog nako ginagawa sakin o she made sure that sleep. The person's
hanggang 1 or 2 pm kaya kapag may she sleeps 6-7hrs a ability to relax
tapos kung may bisita meron may day after work. But before retiring is an
time pa bago ako oras naman ng during important factor
pumasok matutulog dalaw eh” as hospitalization, her affecting ability to
pako ulit” as verbalized by the sleeping pattern is fall asleep. Night
verbalized by the client. disturbed because shift workers
client. of the frequent frequently obtain
medical less sleep than other
we've asked if she interventions. workers and have
has a trouble in difficulty falling
sleeping and if she asleep after getting
takes sleeping pills off work.
then replied; (Fundamentals of
Nursing Kozier and
“May times na ERB'S pg. 1170)
ganun kasi dahil sa
internet sa bahay
pero wala naman
akong iniinom na
sleeping pills”
6. COGNITIVE- We asked the client “Wala naman Client responds and According to
PERCEPTUAL if she can hear nagbago nung answers questions Piaget's cognitive
PATTERN clearly and if she naconfine ako.” as clearly and theory it is refers to
has a trouble in verbalized by the appropriately. Full manner in which
visual acuity then client consciousness is people learn to
she said; seen present to the think,reason and use
client. language. It
“hindi naman ako involves a person's
nahihirapan intelligence,
makarinig, pero perceptual ability,
recently lumalabo and ability to
yung paningin ko, progress
hindi din naman ako information.
nagsusuot ng (Fundamentals of
eyeglasses o kaya Nursing Kozier and
contact lenses” ERB'S pg. 356)

We asked the client

if she have any
difficulty in
remembering things
then she said;

“Hindi, madali
akong makaalala”
7. SELF- We asked the client “Ngayong nandito The disease or According to
PERCEPTION- regarding the ako sa hospital condition that the Erikson, throughout
SELF-CONCEPT activities that she nalulungkot ako lalo client has had life people face
PATTERN cannot do starting na ngayon na slightly affects her developmental tasks
from when she got pinalilibutan ako ng perception about the associated with 8
pregnant then she mga babies, na sana self and psychological
said; ako din” as environment. stages that provide
verbalized by the theoretical
“Kumain lang ng client. framework. The
madami yung di ko success with which
magawa simula a person copes with
nung nagbuntis ako, these developmental
yun kasi sinabi ng taks largely
OB ko eh.” determines the
development of
We also asked if she self-concept.
easily gets angry, (Fundamentals of
cry or if she worries Nursing Kozier and
on simple things, ERB'S pg. 1004)
afraid of something
and how she can
cope up with this
then she said;
 “hindi naman ako
madaling magalit
pero mababa yung
luha ko”
8. ROLE “Nag iisang anak “Nung nalaman ni The client shows Family roles are
RELATIONSHIP lang ako and may 4 Mama na wala na eagerness on especially important
pa akong kapatid sa yung bata sa tiyan commiting her role to people because
side ni Mama, pag ko, nalungkot siya as a daughter to her family relationships
sumusweldo ako, at nag alalala sa mother and are particularly
nagbibigay ako sitwasyon ko” as stepsiblings but close. Relationships
sakanya pra sa verbalized by the deprives her from can be supportive
everyday needs client. helping them and growth
nila” as verbalized because of her producing, or at the
by the client situation. opposite extreme.
(Fundamentals of
“Nung nalaman ni Nursing Kozier and
Mama na buntis ERB'S pg. 1009)
ako, masaya sya at
excited na din sa
bata” as the client
verbalized.
9. SEXUALITY- “12 years old ako The client’s sexual Providing education
REPRODUCTIVE nung una akong activity was put on for sexual health is
PATTERN dinatnan” as hold due to her an important
verbalized by the pregnancy and the component of
client. client and client’s nursing
partner focuses on implementation.
“Before ako “Simula nung the health of the Many sexual
mabuntis, active nabuntis ako, hindi patient. problems exist
naman kami ng na muna” as because of sexual
partner ko, wala verbalized by the ignorance; many
akong patient. others can be
nararamdaman na prevented with
kahit na anong sakit effective sexual
sa ari ko. Pag dating health teaching.
naman sa family (Fundamentals of
planning, hindi Nursing Kozier and
namin napapag ERB'S pg. 1033)
usapan specifically
pero yung tungkol
sa ilan ang gusto
namin na magiging
anak, yun napapag
usapan naming” as
verbalized by the
 client.
10. COPING AND “Wala naman akong “Worried lang ako Client was Although stress is
STRESS masyadong iniisip ng konti about sa saddened about her part of daily life, it
TOLERANCE or inaalala, pag mga gagawing hospitalization and is also highly
meron man, usually procedure pero kaya the removal of the individual; a
yung partner ko ang naman” as fetus but accepted situation that to one
kinakausap ko, verbalized by the the situation and person is a major
hinihingan ko ng client willing to move on stressor may not
advice kung with the help of her affect another. Some
papaano or ano mother and partner. methods to help
gagawin, ganun” as reduce stress will be
the client effective for one
verbalized. person; other
methods will be
appropriate for a
different person.
(Fundamentals of
Nursing Kozier and
ERB'S pg. 1071)
11. VALUE- “Most of the time, “Siguro pagkalabas The client is an Spiritual health is
BELIEF natutupad naman ko dito, pahinga outgoing and the ability to
PATTERN pag nagpa-plan ako. muna ako since religious person develop one's
Sa amin kasi naka leave naman even before she was potential, including
magkakaibigan ako ako sa work” as hospitalized. During the ability to
yung laging verbalized hospitalization, her discover and
humahatak sa kanila faith became articulate one's
umalis at gumala stronger that God basic purpose in
eh” as the client has better plans for life, to learn how to
verbalized. her. experience
love,joy,peace, and
“Every Sunday nag fulfillment, and how
aattend ako ng to help ourselves
service” as and others achieve
verbalized by the their fullest
client. potential (Pender et
al., pg. 108)

We asked the client

if she considered
being hospitalized a
barrier to her faith:

“Hindi naman, kasi

alam ko may plan si
Lord at hindi ko pa
talaga siguro time
 para magka anak”
as verbalized by the
client.

2. Objective Data

• MINI-MENTAL STATUS EXAMINATION

I. General Appearance

II. Level of Consciousness

Physical Examination (Head to Toe Assessment)

Vital Signs:

BP: 150/100 mmHg

PR: 53 bpm

RR: 18 bpm

T: 36.7 C

Height: 5'2

Weight:61.4 kg

Body Mass Index (BMI): 23.83 kg/m^2 NORMAL

BODY PARTS TECHNIQUE NORMAL ACTUAL INTERPRET ANALYSIS

S FINDINGS FINDINGS ATION
Appearance
and Mental
status

Body build Inspection Proportionate, Proportionate, Normal

varies with varies with
lifestyle lifestyle
Hygiene Inspection Clean, neat Clean, neat Normal

Gait Inspection Relaxed, erect Relaxed, erect Normal

posture, posture,
coordinated coordinated
movement movements

Level of
consciousness

Signs of Asking Alert and Alert and respond Normal

distress Client's respond appropriately
attitude appropriately

Quantity of Inspection/Ask Healthy Healthy Normal

speech ing appearance appearance

Asking cooperative cooperative Normal

Listening Understandable, Understandable, Normal

moderate pace; moderate pace;
exhibits thought exhibits thought
association association

Skin

Skin Color Observation Varies from pallor Abnormal Result of

light to deep inadequate
brown circulating blood
or hemoglobin
and subsequent
reduction in
tissue oxygen
(Fundamentals
of Nursing
Kozier & Erb's
8th ed.
Pg. 576)
Skin lesions Palpation/ No abrasions or No abrasions or Normal
Observation other lesions other lesion

Skin moisture Palpation Moisture in skin Slightly dry Normal

folds

Skin Palpation Uniform, within Uniform, within Normal

temperature normal range normal range

Skin turgor Pinching skin When pinched, When pinched, Normal

on an skin springs skin springs back
extremity back to previous to previous state
state

Edema Measuring No edema No edema Normal

circumference
with mm tape
Hair

Evenness of Inspection Evenly Evenly distributed Normal

growth over the distributed hair hair
scalp

Hair thickness Inspection Thick Hair Thick Hair Normal

or thinness

Hair texture Inspection Silky, resilient Silky, resilient hair Normal

and oiliness hair

Presence of Inspection No infection or No infection or Normal

infestations infestation infestation, mild
dandruff
Amount of Inspection Normal
body hair Variable Variable

Nail

Plate shape Inspection Convex Convex curvature; Normal

curvature and curvature; angle angle of nail plate
angle of nail plate about 160 degree
about 160
degree
Fingernail and Inspection Smooth texture Smooth texture Normal
toenail texture

Fingernail and Inspection Highly vascular Highly vascular Normal

toenail bed and pink in and pink in light-
color light-skinned skinned client
client

Blanch tests Pressing nail Prompt return of Prompt return of Normal

 pink or usual pink or usual color
color
Skull and Face

Skull size, Inspection Rounded Rounded Normal

shape and (normocephalic (normocephalic
symmetry and symmetric, and symmetric,
with frontal, with frontal,
parietal, and parietal, and
occipital occipital
prominences); prominences);
smooth skull smooth skull
contour contour

Nodules or Palpation Smooth, Smooth, uniform Normal

masses uniform consistency;
consistency; absence of nodules
absence of and masses
nodules and
masses

Facial Features Inspection Symmetric or Symmetric or Normal

slightly slightly
asymmetric asymmetric facial
facial features; features; palpebral
palpebral fissures equal in
fissures equal in sizes; symmetric
sizes; symmetric nasolabial folds
nasolabial folds

Symmetry of By asking the Symmetric Symmetric facial Normal

facial client to facial movements
movements elevate movements
eyebrows,
frown, close
eyes tight, puff
cheeks, smile
and show the
teeth
Eye

Structures and Inspection Hair evenly Hair evenly Normal

Visual Acuity distributed; skin distributed; skin
Eyebrow intact intact
Bulbar Inspection Skin intact; no Skin intact; no Normal
conjunctiva discharge; no discharge; no
discoloration discoloration

Palpebral Inspection Transparent; Transparent; Normal

conjunctiva capillaries capillaries
sometimes sometimes
evident; sclera evident; sclera
appears white appears white

Lacrimal gland
Shiny, smooth, Shiny, smooth, and Normal
Lacrimal sace and pink or red pink or red
and
nasolacrimal
duct Inspection

Cornea

Corneal
sensitivity
(trigeminal)

Pupils

Pupil's direct Inspection and Transparent; Transparent; shiny Normal

and consensual Palpation shiny and and smooth;
reaction to light smooth; details details of the iris
(oculomotor of the iris are are visible
and Trochlear) visible

Inspection Client blinks Client blinks when Normal

when the cornea the cornea is
is touched, touched, indicating
indicating that that the trigeminal
the trigeminal nerve is intact
nerve is intact

Visual Acuity

Distance vision By touching Black in color; Black in color; Normal

lightly the equal in size; equal in size; 4
cornea with a normally 3 to mm in diameter;
corner of the 7mm in round, smooth
 gauze diameter; round, border, iris flat and
smooth border, round
iris flat and
round

Inspection When looking When looking Normal

straight ahead, straight ahead,
client can see client can see
objects in the objects in the
periphery periphery

By looking at Both eyes Both eyes Normal

near objects coordinated; coordinated; move
and far objects move in unison in unison with
with parallel parallel alignment
alignment

Ask client to Able to read Able to read article Normal

read book article

Ears and
Hearing
Auricle

External Ear Inspection Color same as Color same as Normal

Canal and facial skin, facial skin,
tympanic symmetrical symmetrical
membrane

Gross Hearing Assessing Normal voice Normal voice Normal

Acuity client's tones audible tones audible
response to
normal voice
tones

Whisper test Able to hear Able to hear Normal

whispered word whispered word in
in both ears both ears

Nose and
Sinuses
External Nose Inspection Symmetric and Symmetric and Normal
straight; no straight; no
discharge; discharge; uniform
uniform in color in color

Palpation Not tender; no Not tender; no Normal

lesions lesions
Mouth and
Orapharynx

Lips and buccal Inspection Uniform pink Pallor Abnormal Due to low
mucosa color Hematocrit level
(below normal)
Normal Value
Female: .38-.48
and she got .37
( Fundamentals
of Nursing by
Kozier & ERB'S
pg. 576)

soft, moist, Dry texture Abnormal Nutritional

smooth texture deficiency, or
fluid deficit.
(Fundamentals of
Nursing by
Kozier & ERB'S
Pg. 602

Teeth and Inspection symmetry of symmetry of Normal

Gums contour contour

Ability to purse Ability to purse Normal

lips lips

Inspection

smooth, white, smooth, white, Normal

shiny tooth shiny tooth enamel
enamel Pink Pink gums, moist,
gums, moist, firm gums
Inspection of firm gums
Tongue/floor of tongue
the mouth movement Central position Central position Normal
 pink color pink color smooth,
smooth, lateral lateral margins; no
Tongue Inspection margins; no lesions
lesions

Moves freely; Moves freely; no Normal

no tenderness tenderness

Orapharynx Inspection of smooth tongue smooth tongue Normal

and tonsils oropharynx base with base with
prominent veins prominent veins

Same as color of Same as color of Normal

buccal mucosa buccal mucosa and
and floor of the floor of the mouth
mouth

Pink and smooth Pink and smooth Normal

posterior wall posterior wall

Pink and smooth Pink and smooth Normal

No discharge No discharge Normal

Neck

Neck muscles Inspection Muscles equal Muscles equal in Normal

(sternocleidoma in size; head size; head centered
stoid and centered
trapezius)

Lymph nodes Observation of Coordinated, Coordinated, Normal

head smooth smooth
movement movements with movements with
no discomfort. no discomfort.

Trachea Palpation No palpable No palpable lymph Normal

lymph nodes nodes

Thyroid gland Palpation Central Central placement Normal

placement in in midline of neck
midline of neck

Inspection Not visible Not visible Normal

Extremities Inspection No edema No edema Normal

No hematoma No hematoma Normal

Thorax and Observation Spine vertically Spine vertically Normal
Lungs aligned aligned

Skin intact, no Skin intact, no Normal

tenderness no tenderness no
masses, full and masses, full and
symmetric chest symmetric chest
expansion expansion

Auscultation Vesicular and Vesicular and Normal

bronchovesicula bronchovesicular
r breath sound breath sound

Breast Inspection Skin uniform in Skin uniform in Normal

color (same in color (same in
appearance as appearance as skin
skin of abdomen of abdomen or
or back) back)

Palpation No tenderness, No tenderness, Normal

masses, nodules masses, nodules

Areola Inspection Round or oval Round or oval and Normal

and bilaterally bilaterally the
the same same

Color varies Color varies Normal

widely, from widely, from light
light pink to pink to dark brown
dark brown

Nipples Inspection Round, everted , Round, everted , Normal

and equal in and equal in size;
size; similar in similar in color;
color; soft and soft and smooth;
smooth; both both nipples point
nipples point in in same direction
same direction

Palpation No discharges, No discharges, Normal

 except from except from
pregnant or pregnant or
breastfeeding breastfeeding
females females
Abdomen Inspection Uniform color Uniform color Normal

Silver white Silver white striae Normal

striae or surgical
scars

Flat, rounded, or Rounded; globular Normal

scaphoid
(concave)

Palpation No tenderness; Tenderness Normal

palpable

Musculoskeleta
l System

Muscles Inspection relaxed relaxed abdomen Normal

abdomen with with smooth,
smooth, consistent tension
consistent
tension

Muscle are Muscle are intact Normal

intact and no and no associated
associated tenderness
tenderness

Bones Inspection Bones are Bones are aligned Normal

aligned

Joints Observation Moves freely Moves freely Normal

Neurologic
Sytem

Language Asking She can She can response Normal

 (Neurologic response to to simple
examination) simple commands
commands

Memory Asking She could recall She could recall Normal

(Neurologic information information given
examination) given early in early in the
the interview interview

Reflex Patellar reflex +2 Normal +2 Normal Normal

examination response response

Motor Function Alternating She can She can alternately Normal

supination and alternately supine and pronate
pronation of supine and hands at rapid pace
hands on knees pronate hands at
rapid pace

Pain sensation She could be She could be able Normal

able to to discriminate
discriminate sharp and dull
sharp and dull sensation
sensation
Urethral orifice Observation of Able to void Able to void Normal
urine
color and clarity color and clarity is Normal
is straw, amber straw, amber
transparent transparent

Odor is faint Odor is faint Normal

aromatic aromatic
Diagnostic Procedure

Test Result Unit Normal Ranges

FT3 ELISA 3.6 pg/Ml 1.4 – 4.2
FT4 ELISA 1.9 ng/dl 0.8 – 2.0
TSH ELISA 1.5 Uiu/ml 0.6 – 5.0

HIV/AIDS screening

HIV testing shows whether a person is infected with HIV. HIV stands for human

immunodeficiency virus. HIV is the virus that causes AIDS (acquired immunodeficiency

syndrome). AIDS is the most advanced stage of HIV infection. Maternal and Child Health

Nursing (Page 1228 - 1229)

Date obtained Test Result Normal range Clinical analysis

interpretation
FT3 ELISA 3.6 1.4 – 4.2 Within normal Normal
range

December FT4 ELISA 1.9 0.8 – 2.0 Within normal Normal

11,2017 range

TSH ELISA 1.5 0.6 – 5.0 Within normal Normal

ranges

LDH Test

LDH is most often measured to check for tissue damage. LDH is in many body tissues,

especially the heart, liver, kidney, muscles, brain, blood cells, and lungs. Other conditions for

which the test may be done include: Low red blood cell count (anemia)

SYSTEM INTERNATIONAL CONVENTIONAL

TEST
RESULT UNIT REFERENCE RESULT UNIT REFERENCE
LDH 355.00 U/L 103 – 227 355.00 U/L 103 – 227
Date obtained Test Result Normal range Clinical analysis
interpretation
December LDH 355.00 103 – 227 More than the The patient
11,2017 normal range might have a
injured cell
that contain
LDH spill to
her
bloodstream

Examination Result Normal Range

Ionized Calcium 1.14 1.13 – 1.32 mmol/L

Chemistry

Sodium (Na+) 131.4 135 - 148mmo/L

Potassium (K+) 3.43 3.6 – 5.5mmo/L

Chloride (Cl) 91 – 101mmo/L

Calcium (Ca++) 0.97 – 1.27mmo/L

Date obtained Test Result Normal range Clinical analysis

interpretation
December 11, Ionized 1.14 1.13 – 1.32 Within Normal Normal
2017 Calcium mmol/L Findings
Urinalysis exam

A routine urinalysis tests for urinary and system disorders. This test evaluates physical

characteristics (color, odor, turbidity, and opacity) of urine; determines specific gravity and pH;

detects and measures protein, glucose, and ketone bodies; and examines sediment for blood cells,

casts, and crystals.

Date Test Result Normal Clinical Analysis

obtained range interpretati
on
December Glucose Negative (-) Negative Within
11,2017 normal
findings. Normal

Protein Positive (+2) Negative More than Protein in urine is always

the normal present in a eclampsia
range patient. And it may be a
sign in kidney problems

Leukocytes Trace (+/-) Negative May or may Trace may indicate

not in a that the mother is
normal susceptible for having
range urine infection

Blood Positive (+1) Negative More than The pressure of the

normal uterus on the bladder can
range sometimes cause blood in
urine due to some minor
hemorrhage.
Chemistry result

Kidney Function Test

During pregnancy, a woman’s kidneys must excrete not only the waste products from her body

but also those of the fetus. Also, her kidneys must be able to excrete additional fluid and manage

the demands of an increase renal blood flow. Maternal and Child health nursing ( Page 237-

238)

Date obtained Test Result Normal range Clinical Analysis

interpretation
December 11, Urea nitrogen 3.32 2.6 – Within normal Normal
2017 7.2mmo/L range

Creatinine 54 53 – Within normal Normal

115mmo/L range

Uric acid 688 137 – More than High in uric

353mmo/L normal range acid may put
the mother at
risk for both
GDM and
preeclampsia

SGOT 43.5 <31 U/L More than Increase in

normal range SGOT can
cause liver
problems.
Liver problems
may result to
pre eclampsia

SGPT 30.2 <31 U/L Within normal Normal

range
Hematology Result

Blood is drawn for hemoglobin and hematocrit, a serologic test for syphilis, hepatitis B

antibodies, and blood typing to determine whether a blood incompatibility is likely to exist in the

newborn and what type of blood will need to be supplied if the woman should have and acute

blood loss. Maternal and Child health nursing (Page 376)

Date obtained Test Result Normal range Clinical Analysis

interpretation
December 11, Hemoglobin 133 120 – 150gm/L Within normal Normal
2017 range

Hematocrit 37 38 – 48 Within normal Normal

range

Erythrocyte 4.29 4 to 10 Within normal Normal

Count range

Leukocyte 28.5 5 to 10 More than Increased in

Count normal range WBC may be
caused of
Leucocytosis

Segmenters .93 0.45 – 0.65 More than High levels of

normal range segmenters/n
eutrophils
usually
represent and
ongoing
infection, an
inflammation,
malignancy,
cause by some
drugs

Lymphocytes .07 0.25 – 0.35 Less than Decreased by

normal range lymphocyte
will indicate of
having
immunodefici
ency
 Thrombocytes 241 150 - 350 Within normal Normal
count range

Reference:

Handbook of diagnostic tests (third edition) Page 328

Maternal and Child Health Nursing Page 580, 1324, 1538

Maternal and Child Health Nursing page (in labor) 376 - 377, 628
C. Comprehensive Definition & Description

1. Anatomy and Physiology

Functions of the Heart

1. Generating blood pressure. Contractions of the heart generate blood pressure, which is

required for blood flow thorough the blood vessels.

2. Routing blood. The heart separates the pulmonary and systemic circulations, which ensures

the flow of oxygenated blood to tissues.

3. Ensuring one-way blood flow. The valves of the heart ensure one-way flow of blood thorough

the heart and blood vessels.

4. Regulating blood supply. Changes in the rate and force of heart contraction match blood flow

to the changing metabolic needs of the tissues during rest, exercise, and changes in body

position.

Size, Form, and Location of the Heart

The adult heart is shaped like a blunt cone and is approximately the size of a

closed fist. It is larger in physically active adults than in less active but otherwise healthy adults,

and it generally decreases in size after approximately age 65, especially in those who are not

physically active. The blunt, rounded point of the cone is the apex; and the larger, flat part at the

opposite end of the cone is the base.

The heart is located in the thoracic cavity between the two pleural cavities,

which surround the lungs. The heart, trachea, esophagus, and associated structures form a

midline partition, the mediastinum. The heart is surrounded by its own cavity, the pericardial

cavity...

Anatomy of the heart

The heart is surrounded by the pericardial cavity. The pericardial cavity is formed

by the pericardium or pericardial sac, which is surrounds the heart and anchors it within the
mediastinum. The pericardium consists of two layers. The tough, fibrous connective tissue outer

layer is called fibrous pericardium and the inner layer of flat epithelial cells, with a thin layer of

connective tissue, is called the serous pericardium.

External anatomy

The right and left atria are located at the base of the heart, and the right and left ventricles extend

from the base of the heart toward the apex. A coronary sulcus extends around the heart,

separating the atria from the ventricles.

Heart chambers and Internal Anatomy

The heart is a muscular pump consisting of four chambers: two atria and two ventricles.

Right and left atria

The atria of the heart receive blood from veins. The atria function primarily as reservoirs, where

blood returning from veins collects before it enters the ventricles. Contraction of the atria forces

blood into the ventricles to complete ventricular filling. The right atrium receives bloods through

three major openings. The superior vena cava and the inferior vena cava drain blood from most

of the body, and the smaller coronary sinus drains bloods from most of the heart muscle. The left

atrium receives bloods thorough the four pulmonary veins, which drain blood from the lungs.

The two atria are separated from each other by a partition called the interatrial septum.

Right and left ventricles

The ventricles of the heart are its major pumping chambers. They eject blood into the arteries

and force it to flow thorough the circulatory system. The atria open into the ventricles, and each

ventricle has one large outflow route located superiorly near the midline of the heart. The right
ventricle pumps blood into the pulmonary trunk, and the left ventricle pumps blood into the

aorta. The two ventricles are separated from each other by the muscular interventricular (between

the ventricles) septum.

Heart valves

The atrioventricular (AV) valves are located between the right atrium and the right ventricle

and between the left atrium and left ventricle. The AV valve between the right atrium and the

right ventricle has three cusps and is called the tricuspid valve. The AV valve between the left

atrium and left ventricle has two cusps and is called the bicuspid, or mitral valve. These valves

allow blood to flow from the atria into the ventricles but prevent it from flowing back into the

atria. When the ventricles relax, the higher pressure in the atria forces the AV valves to open and

blood flows from the atria into the ventricles. In contrast, when the ventricles contract, blood

flows toward the atria and causes the AV valves to close.

Route of blood flow through the Heart

Even though blood flow through the heart is described for the right and then the left side of the

heart, it is important to understand that both atria contract at the same time, and both ventricles

contract at the same time.

Blood enters the right atrium from the systemic circulation through the superior and inferior vena

cava, and from heart muscle through the coronary sinus. Most of the blood flowing into the right

atrium flows into the right ventricle while the right ventricle relaxes following the previous

contractions. Before the end of ventricular relaxation, the right atrium contracts, and enough

blood is pushed from the right atrium into the right ventricle to complete right ventricular filling.
Blood supply to the Heart

Coronary arteries

Cardiac muscle in the wall of the heart is thick and metabolically very active. Two coronary

arteries supply blood to the wall of the heart. The coronary arteries originate from the base of

the aorta, just above the aortic semilunar valves. The left coronary artery originates on the left

side of the aorta. It has three major branches: The anterior interventricular artery in the

anterior interventicular sulcus on the circumflex artery extends around the coronary sulcus on

the left to the posterior surface of the heart, and the left marginal artery extends inferiorly along

the lateral wall of the left ventricle from the circumflex artery. The branches of the left coronary

artery supply much of the anterior wall of the heart and most of the left ventricle. The right

coronary artery originates on the right side of the aorta. It extends arounds the coronary sulcus on

the right to the posterior surface of the heart and gives rise to posterior interventicular artery,

which lies in the posterior interventicular sulcus. The right marginal artery extends inferiorly

along the lateral wall of the right ventricle. The right coronary artery and its branches supply

most of the wall of the right ventricle.

2. Pathophysiology
 Etiology

Predisposing Factor Presence Justification

Primigravida Present The risk of developing

preeclampsia is highest
during your first pregnancy.
Although the cause of the
disease is unknown, it was
found out by the WHO that
first time mothers contributes
to having preeclampsia -
eclampsia.
A lack of exercise during
Sedentary lifestyle Present pregnancy puts you at risk for
complications, such as
increased pulse rate and blood
pressure, and puts you at an
additional risk for developing
preeclampsia. These all can
affect not only your health,
but also the health of your
unborn child.
Too much intake of fats
High intake meat; diet rich in Present directly raises your
fats cholesterol levels and can
cause weight gain. Too much
cholesterol in your blood
causes narrowing or furring in
your arteries which causes
vasoconstriction and
reduction of blood flow to
certain body parts and
increase blood pressure.

Female 25y/o Present Studies present more risk for

developing eclampsia are
mothers with advanced
maternal age however some

Family history of Present
Hypertension
 Symptomatology
Clinical Manifestation Present in Patient
Headache
Blurry of vision
Increased blood pressure
researchers also include
mothers <35 years old
contributes to having
preeclampsia.
Genetic factors likely play
some role in high blood
pressure, heart disease, and
other related conditions.
However, it is also likely that
people with a family history
of high blood pressure share
common environments and
other potential factors that
increase their risk.
The risk for high blood
pressure can increase even
more when heredity combines
with unhealthy lifestyle
choices, such as smoking
cigarettes and eating an
unhealthy diet.
Rationale
/ The hypertensive changes seen
in preeclampsia are attributed
to intense vasospasm thought
to be caused by increased
vascular reactivity. The
/ underlying mechanism
responsible for the increased
vascular reactivity is presumed
to be alterations in the normal
interactions of vasodilatory
/ and vasoconstrictive
substances.
Due to narrowing of the blood
vessels, there is a less
 production of blood reaching
to certain body parts. There
will be vasoconstriction that
causes the patient to manifest
headache, blurry of vision and
increased blood pressure.
Elevated pressure within blood
Edema / vessels, less proteins in the
blood and damaged
endothelial tissue causes the
fluid in the blood vessels to
flow into surrounding tissue.
This can cause edema
(swelling) in the brain, retinas,
lungs, liver, and subcutaneous
tissues. Edema is one of the
central features of
preeclampsia.
Hypertension and endothelial
Proteinuria / damage to capillaries (small
blood vessels) in the kidneys
cause a breakdown in the
kidney's functions. This results
in proteins-which are
generally retained by the
body-being excreted in the
urine (proteinuria), a classic
symptom of preeclampsia.
It’s a rare but serious
Seizure / condition where high blood
pressure results in seizures
during pregnancy. Seizures are
periods of disturbed brain
activity that can cause
episodes of staring, decreased
alertness, and convulsions
(violent shaking). Seizures are
changes in the brain’s
electrical activity. This change
can cause dramatic, noticeable
symptoms or it may not cause
any symptoms. The symptoms
of a severe seizure include
violent shaking and a loss of
control.
 Diagram

Pathophysiology of Eclampsia
Patient based

Modifiable Non-Modifiable
-Primigravida -Female 25y/o
-Sedentary lifestyle -Family history of
hypertension
-High intake meat; diet
rich in fats

Unknown Etiology

Abnormal development of the placenta

Uteroplacental arteries becomes

Can lead to: fibrous causing them to narrow which
means less blood gets to placenta
Intrauterine growth
restriction
Poorly hypo perfused placenta
Fetal Death

Releases pro inflammatory proteins that

> Vasoconstriction or came into the mother circulation
narrowing of the blood
vessels.
>Affects the kidneys in Endothelial cells that line her blood
a way that makes them vessels becomes dysfunctional
Reduced blood flow
retain more salt. to the liver can cause
severe injury and
Local areas of vasospasms which means swelling that causes
less blood will reach certain parts of the epigastric pain which
Hypertension body. is one of the cardinal
symptoms of severe
preeclampsia
 Reduced blood flow
to the retina can cause
blurry of vision

Reduced blood flow

Endothelial injury increases vascular to the kidneys which
permeability which allow water to slip are particularly
out of blood vessels between neighboring susceptible, can cause
endothelial cells then get into the tissues glomerular damage
leading to oliguria as
well as proteinuria – a
classical symptom of
preeclampsia
Generalized edema-legs, face, hands
Pulmonary edema- cough, shortness of breath
Due to proteinuria there is a less proteins
Cerebral edema-headaches, confusion, in the blood which makes even more
SEIZURES fluid moves from the blood vessels into
the tissues.

If seizure occurs the patient has ECLAMPSIA

 CHAPTER III

PLANNING

A. List of identified Nursing Diagnosis according to priority

1. Decrease Cardiac Output r/t altered heart rhythm

2. Ineffective tissue perfusion r/t presence of fluid retention in subcutaneous tissue

3. Risk for maternal injury r/t tonic-clonic convulsions

4. Risk for imbalance nutrition less than the body requirements related to inability to procure

proper nutritional needs

5.Grieving related to loss of significant object

B. List of priority nursing diagnosis (3 NCP) with rationale

1. Decrease Cardiac Output r/t altered heart rhythm

- Inadequate blood pumped by the heart to meet the metabolic demands of the body. Cardiac

output and tissue perfusion are interrelated , although there are differences. When cardiac output

is decreased, Tissue perfusion problems will develop. However tissue perfusion problems can

exist decreased cardiac output.

2. Ineffective tissue perfusion r/t presence of fluid retention in subcutaneous tissue

-Decrease in oxygen result in the failure to nourish the tissues at the capillary level.

3. Risk for maternal injury r/t tonic-clonic convulsions

- Vulnerable for injury as a result of environmental conditions interacting with the individual’s

adaptive and defensive resources, which may compromise health.

 C. Nursing Care Plan

1. Decrease Cardiac Output r/t altered heart rhythm

CUES NURSING INFERENC OBJECTIVE INTERVEN RATIONAL EVALUTIO

DIAGNOSIS E OF CARE TION E N
objective: Decreased After 4 hours Determine -Provides Goal met:
PR : 53-73 cardiac of nursing vital signs baseline for After 4
BP: 110/80 – output r/t intervention hemodynami comparison hours of
170/110 altered heart the client c parameters to follow nursing
Edema- hands and rhytm display including trends and intervention
feet hemodynami cognitive evaluate the client
c stability status, note response to display
(e.g blood vital signs interventions. hemodynami
pressure, response to c stability
cardiac activity/ ( e.g blood
output, renal procedures pressure,
perfusion and time cardiac
urinary required to output, renal
output, return to perfusion,
peripheral baseline. urinary
pulses -monitor -To note output,
vital signs response to peripheral
frequently activities/inte pulses.
rventions
-Monitor -to note
cardiac effectiveness
rhytm of
continousy medications
and /
assistive
devices, such
as implanted
pacemaker,
defibrilator

2. Ineffective tissue perfusion r/t presence of fluid retention in subcutaneous tissue

Assessment Diagnosis Planning Interventio Rationale Evaluation

Short term:
Objective cues: Ineffective Short term: Independen After 1-2 days
After 1-2 t: >Patient’s vital signs of nursing
BP: 150/100 Tissue days of .>Monitor serve as the baseline intervention,
PR: 134 nursing vital signs data. Monitoring the patient had
RR: 22 Perfusion intervention, vital signs will help demonstrated
Temp: 36.5 the patient identify underlying adequate perfu
related to willdemonstr complications. sion, as
Skin color: pale ate >Assist with >Gently evidenced by
presence of adequate perf position repositioning patient stable vital
Presence of usion, as changes. from a supine to signs,
edema in hands fluid evidenced by sitting/standing palpable pulses
and legs stable vital position can reduce , balanced
retention in signs, the risk for intake and
Proteinuria +2 palpable puls >Promote orthostatic BP output and
subcutaneou es, balanced active/passi changes. decrease
intake and ve ROM >Exercise prevents in presence of
s tissue. output and exercises. venous stasis and edema.
decrease >Monitor further circulatory
in presence peripheral compromise. Long term:
of edema. pulses. >These are after 2-3 days
Check symptoms of arterial of
Long term: for loss of obstruction that can nursing
After 2-3 pulses with result in loss of a intervention,
days of bluish, limb if not the patient had
nursing purple, or immediately
intervention, black areas reversed. demonstrated
the patient and
extreme pai normal vital
will n. >Patients with
>Keep arterial insufficiency signs
demonstrate patient complain of being
warm, and constantly cold; specifically the
normal vital have patient therefore keep
wear socks extremities warm to blood pressure
signs and shoes or maintain
sheepskin- vasodilation and and heart rate,
specifically lined blood supply. Heat
slippers application can urine output
the blood when easily damage
mobile. Do ischemic tissues. and no signs of
pressure and not apply >Elevation improves
heat. venous return and edema in
heart rate, helps minimize
edema. Pressure extremities.
urine output >Elevate under the knee limits
edematous venous circulation.
and no signs legs and > This saturates
ensure that circulating hemoglo
of edema in there is no bin and augments
pressure the efficiency of
extremities. under the blood that is
knee. reaching the
> Provide ischemic tissues.
oxygen
therapy. >Urine output
should be in
congruence with
fluid intake.
Dependent:
>Insert
Foley > These medications
catheter as facilitate perfusion
indicated by for most causes of
the impairment.
physician
and monitor
urine - These reduce blood
output. viscosity and
> coagulation.
Administer - These enhance
medications arterial dilation and
as improve peripheral
prescribed blood flow.
to treat - These reduce
underlying
problem. systemic vascular
Note the
response. resistance and
-
antiplatelets optimize cardiac
/
anticoagula output and
nts
-peripheral perfusion.
vosodilators

antihyperten

sives
 3. Risk for maternal injury r/t tonic-clonic convulsions

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the
individual’s adaptive and defensive resources, which may compromise health.

Assessment Diagnosis Planning Nursing Rationale Evaluation

Intervention
Subjects: Risk for maternal After 48hours of - Chek CNS for - Cerebral edema After 48hrs of
“Bigla akong injury rt tonic- nursing involvement (on and nursing
nahilo pagkatapos clonic intervention, the going headache, vasoconstriction intervention, the
umihi, tapos convulsions client will irritability, visual can be evaluated client participates
natumba, ayun participates in disturbances) in terms of in treatment and
hindi ko na alam treatment or symptoms, environmental
mga sususnod na environmental behaviors, or modifications to
ngyari” as modifications to retinal changes protect self and
verbalized by the protect self and - Emphasize enhance safety.
client enhance safety. importance of - Delayed
client promptly treatment or
Objectives: reporting progressive onset
- Skin pale; warm signs/symptoms of symptoms may
to touch of CNS result in tonic-
- VS: involvement clonic
BP - 150/100 convulsions or
pr - 53 eclampsia
rr – 18
t – 36.7 - Check for - In progressive
alterations in eclampsia,
level of vasoconstriction
consciousness and vasospasms
of cerebral blood
vessel reduce
oxygen
consumption by
20% and result in
cerebral ischemia.

-Lessens
- Establish environmental
measures to factors that may
lessen likelihood stimulate irritable
of seizures (i.e cerebrum and
keep room quite cause a
and dimly lit, convulsive state.
limit visitors, plan
and coordinate
care and promote
rest)

- Enforce seizure - If seizure does

precautions per occur, reduces
protocol risk of injury
 CHAPTER IV
Medical Management

1. Drug Study
Trade Patient’s Classification Action Indication Contra- Adverse Nursing
name Dosage indication reaction Responsibility
Omepra 40mg Antiemetic It To prevent Hyper CNS:Agit -give
zole TIV OD interferes chemother sensitivity ation, omeprazole
with aphy- to asthenia,di before meals,
gastric induced omeprazole, zziness, preferably in
Packet acid nausea other proton drowsines the morning
2.5mg secretion and pump s,fatigue, for once-daily
by vomiting inhibitors, headache, dosing. If
Suspensi inhibiting substituted psychic needed, give
on the benzimi- disturbanc also antacid, ,
hydrogen dasole e, as prescribed.
2mg/mL potassium somnolenc
Generic - e -Be aware that
name: Tablet adenosine long term use
Prilosec, 20mg triphospha CV:chest of omeprazole
se enzyme pain, may increase
system or hypertensi the risk of
proton on , gastric
pump, in peripheral carcinoma
gastric edema
parietal -Monitor the
cells. EENT: patient,
Anterior especially the
ischemic patient on
optic long-term
neuropath therapy, for
y, optic hypomagnesim
atrophy, ia. If patient is
or neuritis, to remain on
stomatitis omeprazole
long-term,
ENDO: expect to
Hypoglyc monitor the
emia patient’s serum
magnesium
GI: level, as
Abdomina ordered, and if
l pain, level becomes
constipati low, anticipate
on, magnesium
diarrhea, replacement
clostridiu therapy and
m difficle- omeprazole to
associated be
diarrhea, discontinued.
dyspepsia,
elavated
liver
function
tests,
flatulence,
hepatic
dysfunctio
n or
failure,
indigestio
n, nausea,
pancreatiti
s,
vomiting

GU:
Interstitial
Nephritis

HEME:
agranuloc
ytosis ,
anemia,
hemolytic
anemia,
leukopeni
a,
leukocytos
is,
neutropeni
a,
pancytope
nia,
thrombocy
topenia

MS: Back
pain, Bone
fracture

RESP:
 Cough

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Magnesiu MgSO4 Antacid, Assists all To correct Hypersensiti CNS: -Be aware that
m sulfate drip to Antiaarhytmic enzymes magnesiu vity to confusion magnesium
PNSS: ,anticonvulsan involeved m magnesium decreased sulfate is the
500c + t,electrolyte in deficiency salts or any reflexes, elemental form
units of replacement, phoshate caused by component dizziness, of magnesium.
MgSO4 laxative transfer alcoholis of syncope Oral
to run reactions m, magnesium- CV: preparations
for 4hrs. that use magnesiu containing arrhythmi aren’t all
adenosine m- preparations as, equivalent.
320 mg triphospha depleting . hypotensi
daily te (ATP). drugs, MgSO4: on -Be aware that
Magnesiu malnutriti heart block, Gi: drug isnt’t
m is on, pr MI, Flatulence metabolized.
Generic required restricted preeclampsi , Vomiting Drug
name: for normal diet; to a 2 hours or MS: remaining in
Epsom function prevent less before Muscle the GI tract
salt of the magnesiu delivery cramps produces
ATP- m (I.V. form) RESP: watery stool
dependent deficiency For use of Dyspnea, within 30
sodium- based on lacatives: respiratory minutes to 3hrs
potassium U.S. and acute depression -avoid giving
pump in canadian abdominal or other oral
muscle recommen problem ( as paralysis drugs within 2
membrane ded daily indicated by SKIN: hrs of
s. allowance abdominal Diaphores magnesium
s pain, nausea is containing
or Other: antacid
vomiting), Allergic
diverticulitis reaction, -Before giving
, fecal hypermag drug as
impaction,in nesemia,in laxative, shake
testinal jection- oral solution,
obstruction site pain liquid, or
or or liquid
perforation, irritation concentrate
colosomy or (I.M. well and give
ileostomy , form). with large
severe renal laxative amount of
impairment, dependenc water
ulcelirative e,
culcilitis. magnesiu
m toxicity
Trade Patient’s Classification Action Indication Contra- Adverse Nursing
name Dosage indication reaction Responsibility
Hydralazi 5mg IV Antihypertens May act in To Coronary CNS: Monitor CBC,
ne ive a manner manage artery chills, lupus
that essentian disease, fever,head erythematosus
Generic 20mg/m resembles hypertensi hypersensiti ache, cell
name: L organic on, alone vity to peripheral preparation,
Apresolin nitrates or with hydralazine neuritis and ANA titer
e(CAN) Tablets and other or its before therapy
Novo- 10mg sodium antihypert components, CV: and
Hylazin 25mg nitroprussi ensive mitral valve Angina, periodically as
50mg de, except disease edema, appropriate
10mg that orthostatic during long-
hydralazin hypotensi term treatment.
e is on,
selective palpitation -monitor blood
for s, pressure and
arteries. It tachycardi pulse rate
exerts a a regularly and
direct weigh patient
vasodilati FENT: daily during
ng effect lacrimatio therapy
on n, nasal
muscular congestion -check blood
smooth pressure with
muscle GI: patient in
anorexia, lying, sitting,
constipati and standing
on, positions and
diarrhea, watch for signs
nausea of orthostatic
vomiting hypotension.
Expect
RESP: orthostatic
Dyspnea hypotension to
be most
SKIN: common in the
Blisters, morning,
flushing, during hot
pruritis, weather and
rash, with exercise
urticaria

OTHER:
 lupus like
symptoms
, espcially
with high
doses;
lymphade
nopathy

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Ampicillin 1.5 grm antibiotic Inhibits To treat Hypersensiti CNS: -avoid giving
bacterial GI vity to any chills,fatig ampicillin to
cell wall infections penicillin, ue,fever,h patient with
Capsule synthesis. and infection eadache, mononucleosis
Generic 250 mg The rigid, genitourin cause d by malaise beacuse of
name: 500mg cross- ary penicillinase increased risk
Apo-ampi linked cell infections -producing CV: chest of rash
(CAN), Oral wall is (other organism pain,
Novo- suspensi assembled than edema, -Expect to give
ampicillin on in several gonorrhea thrombop ampiciilin for
(CAN), steps. ) caused hlebitis 48 to 72 hours
Nu-ampi 125mg/5 Ampicillin by after [atoemt
(CAN), ml exerts its susceptibl EENT: necp,es
Omnipen 250mg/ effects on e strains epistaxis, asymptomatic.
ml susceptibl of glossitis, For
e bacteria shigella, laryngeal streptococca;
in the final salmonella stridor, infection,
stage of typhi and mucocuta expect to give
the cross- other neous ampicillin for
linking species, andidiasis, at least 10 days
process by escherichi stomatitis, after cultures
binding a coli, throat show
with and proteus tightness streptococcal
inactivatin mirabilis, erradication to
g and GI: reduce risk of
penicillin- enterocci Abdomina rheumatic
binding l feveror
proteins distention, glomeruloneph
(enzymes diarrhea, ritis
responsibl diarrhea
e for related to
linking the clostridiu
cell wall m
strands.) difficile,
this action enterocolit
causes is,flatulen
bacterial ce,gastritis
cell lysis nausea,pse
and death. udomembr
anous
colitis,
vomiting

GU:
dysuria,
urine
retention,
vaginal
candidiasi
s

HEME:
Agranuloc
ytosis,
anemia,
eosinophil
ia,
leukopeni
a,
thrombocy
topenia,thr
ombocyto
penic
purpura

SKIN:
Erythema
multiform
e;
erythemat
ous,
mildly
pruritic
maculopa
pular rash
or other
types of
rash;
exfoliative
dermatitis;
pruritus;
 urticaria

Other:
anaphylax
is, facial
edema,
injection
pain-site

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Nifedipine 10 mg Antianginal,a May slow To Hypersensiti CNS: -Be aware that
BID ntihypertensiv movement manage vity to a anxiety, patient with
e of calcium angina calcium ataxia, galactose
Generic 10 to 20 into channel confusion intolerance
name: mg myocardia blocker, , should not take
Adalat, twice l and second- or dizziness, nifedipine
daily, vascular third-degree drowsines because the
increase smooth- AV block s, drug contains
d every muscle without headache, lactose. The
3 weeks cells by artificial nervousne capsule form
based on deforming pacemaker, ss of nifedipine
patient calcium sick sinus (possibly should not be
response channgels syndrome extremle), used to treat
. in cell nightmare hypertension
membrane s, because its
Mainten s, paresthesi effects on
ance: 20 inhibiting a, blood pressure
mg ion- psychiatri are not known.
twice controlled c -monitor fluid
daily gating disturbanc intake/output
Maximu mechanis e,syncope, and daily
m: 80 ms, and tremor,we weight; Fluid
mg daily disrupting akness retention may
calcium lead to heart
release CV: failure. Also
from arrhythmi assess for signs
sarcoplas as of heart failure,
mic, and (bradycard such as
disrupting ia,tahcycar crackles,dyspn
calcium dia), chest ea,jugular vein
release pain, heart distention,
from failure. peripheral
sarcoplas Hypotensi edema, and
mic on, weight gain.
reticulum. Palpitation
Decreasin s,
g peripheral
intracellul edema
ar calcium
level EENT:
inhibits, altered
smooth- taste,
muscle blurred
cell vision, dry
contractio mouth,
n and epistaxis,
dilates gingival
arteris, hyperplasi
which a, nasal
decreases congestion
myocardia ,
l oxygen pharyngiti
demand , s,sinusitis,
peripheral tinnitus
resistance
, blood ENDO:
pressure, Gynecoma
and stia,
afterload. hyperglyc
emia

GI:
anorexia;
constipati
on;
diarrhea;
dyspepsia;
elevated
liver
function
test
results;
gastrointes
tinal
bleeding,
irritation,
or
obstructio
n;
hepatitis;
nausea ;
vomiting

GU:
dysuria ,
nocturia,
polyuria,
sexual
dysfunctio
n,urinary
frequency

HEME:
anemia,
leukopeni
a, positive
coomb’s
test,
thrombocy
topenia

MS: joint
stiffness,
muscle
cramps

RESP:
chest
congestion
, cough,
dyspnea,
respiratory
tract
infection,
wheezing

SKIN:
acute
generalize
d
exanthema
tous
pustulosis,
diaphoresi
s,
erythema
 multiform
e, pruritis,
rash,
stevens-
johnson
syndrome,
toxic
epidermal
necrolysis,
urticaria.

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Ferrous TAB Vitamins Replace Prophylax Hypersensiti GI- -nutrition:
sulfate OD iron stores is for iron vity nausea, amount of iron
needed for deficiency ulcerative constipati in diet (meat,
Generic PO 300- red blood in colitis,regio on, dark green
name: 600 cell pregnancy, nal enteritis, epigastric leafy
Apo- mg/day developm nutrional hemosideros pain, vegetables,
ferrous in ent, supplemen is, black and dried beans,
sulfate divided energy tation hemochrom red tarry dried fruits,
doses and atosis, tools, eggs)
oxygen peptic ulcer vomiting -cause of iron
transport, disease, diarrhea loss or anemia,
utilization; hemolytic including
fumarate anemia, INTEG- salicylates,sulf
contains cirrhosis. temporaril onamides,
33% y antimalarials
elemental discolored -swallor tab
iron; tooth whole; not to
gluconate enamel break,crush or
12%;sulfat and eyes chew unless
e, 20% labeled as
iron , 30% SYST: chewable
ferrous hypersensi -between
sulfate tivity meals for best
exisccated reactions absorption;
(ferrlecit) may give with
juice; do not
give with
antacids or
milk, delay at
least 1 hr; if GI
symptoms
occur, give
 after meals
even if
absorption is
decreased;
eggs,milk
products,choco
late,caffeine,in
terfere with
absorption

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Ceftin 500 mg Antiinefective Inhibits Anticoagu Hypersensiti CNS: -I&O ratio
BID / bacterial lants,thro vity to dizziness, -bowel pattern
Generic 7x day antibacterial cell wall mbolytics, cephalospor headache,f daily; if severe
name synthesis,r NSAIDs, ins or atigue,par diarrhea
Cefuroxi -IM/IV endering antiplatele related esthesia,fe occurs, product
me 750 mg- wall ts, antibiotics, ver,chills, should be
1.5 q osmoticall plicamyci seizures. confusion discontinued;
q8hr fpr y n, valproic may indicate
5-10 unstable,le acid GI: pseudomembra
days ading to Diarrhea, nous colitis
cell death nausea, -
by binding vomiting, bleeding:ecchy
to cell anorexia, mosis,
wall dygeusia, bleeding gums,
membrane glossits, hematuria,
. bleeding; stool guiac
increased daily
AST,
ALT,
Bilirubin,
LDH, alk
phos;
abdominal
pain, loose
stools,
flatulence,
heartburn,
stomach
cramps,
colitis,
jaundice,p
seudomem
branous
colitis
GU:
vaginitis,p
ruritis,can
didiasis,
increased
BUN,
nephrotoxi
city, renal
failure,
pyuria,
dysuria,
reversible,
interstital
nephritis

HEMA:
leukopeni
a
thrombocy
topenia,ag
ranulocyto
sis,
anemia,
neutropeni
a,
lymphocyt
osis,
eosinophil
ia,
pancytope
nia,
hemolytic
anemia,le
ukocytosis
,
granulocyt
openia

INTEG:
rash,
urticaria,
dermatitis,
steven-
johnson
syndrome
 RESP:
Dyspnea
SYST:
anaphylax
is,serum
sickness,s
uperinfecti
on

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Oxytocin 1 amp Hormone/ Acts Stimulatio Hypersensiti CNS: -I&O ratio
(IM) uterine active directly on n, vity , serum seizures, -BP pulse;
Generic agent myofibrils induction toxemia, tetanic watch for
name: 10 unit / producing of labor; cephalopelv contractio changes that
Pitocin mL uterine missed or ic ns may indicate
contractio incomplet disproportio CV: hemorrhage
ns; e abortion; n, fetal hypo/hype -respiratory
stimulates postpartu distress, rtension, rate, rhythm,
milk m hypertonic dysrhythm depth; notify
ejection bleeding uterus, ias prescriber of
by the prolapsed increased abnormalities
breast; umbilical pulse,
vasoactive cord, active bradycardi
anti- genital a,
diuretic herpes. tachycardi
effect a,PVC
FETUS:
dysrhytmi
aas,
jaundice,
hypoxia,
intracrania
l
hemorrhag
e

GI:
anorexia,n
ausea,vom
iting,const
ipation

GU:
abruptio
 placentae,
decreased
uterine
blood
flow
HEMA:
Increased
hyperbilir
ubinemia
INTEG:
rash
RESP:
asphyxia
SYST:
water
intoxicatio
n of
mother

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Prometha 25 mg + Anti- Acts on Motion Hypersensiti CNS: -I&O ratio: be
zine Nubain histamine blood sickness,r vity,breastfe dizziness, alert for
5mg vessels, hinitis,alle eding,agran drowsines urinary
(IV) GI, rgy ulocytosis,b s, poor retention,
Generic respiratory symptoms one marrow coordinati frequency,
name: PO/IM/I system by , sedation , supression,c on, dysuria,
Phenerga V 25- competing nausea, oma,jaundic fatigue, product should
n 50mg with preoperati e,reye’’s anxiety, be
histamine ve and syndrome euphoria, discontinued
for H1- postoperat confusion,
receptor ive paresthesi -Cardiac
site; sedation a, neuritis, status:
decreases EPS, palpitations,
allergic neurolepti increased
response c pulse, hypo-
by malignant hypertension,
blocking syndrome B/P, in those
histamine receiving IV
CV: doses
hypo/hype
rtension, -
palpitation Antiemetic/mo
s, tion sickness:
tachycardi nausea and
a vomiting
before and
EENT: after dose
blurred
vision,
dilated
pupils,
tinnitus,
nasal
stuffiness:
dry
nose,throa
t,mouth;p
hotosensiti
vity

GI:constip
ation, dry
mouth,nau
sea,vomiti
ng,anorexi
a and
diarrhea

GU:
urinary
retention,d
ysuria,freq
uency

HEMA:
thrombocy
topenia,
agranuloc
ytosis,
hemolytic
anemia

INTEG:
rash,
urticaria,
photosensi
tivity
RESP:
 increased
thick
secretions,
wheezing,
chest
tightness.

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Potassium 600mg Electrolyte Acts as To prevent Acute CNS: Administer
chloride OD replacement the major or treat dehydration, confusion, oral potassium
cation in hypokale addison’s paralysis, with or
Tablet intracellul mia in disease paresthesi immediately
ar fluid, patients (untreated),c a, after meals
20mEq activating who can’t oncurrent weakness
many ingest use of -Be aware that
Tablet, enzymatic sufficient potassium CV: liquid form of
extende reactions dietary sparing arrhythmi oral potassium
d release essential pottasium diuretics, as, ECG is prescribed
fpr or who are crush changes for patients
Generic 8mEq physiologi losing syndrome. with delayed
name: 10mEq c potassium Disorders EENT: gastric
KDur, KCI 15mEq processes, because of that may Throat emptying,
20mEq including a delay drug pain when esophageal
nerve condition passing swallowin compression,
impulse (such as through GI g or intestinal
transmissi hepatic tract obstruction or
on and cirrhosis (potassium GI: structure to
cardiac or citrate), heat abdominal decrease the
and prolonged cramps, pain; risk of tissue
skeletal vomiting) hyperkalemi bloody damage.
muscle or drug a,hypersensi stools;
contractio (such as tivity to diarhea;
n. potassium potassium flatulence;
Potassium wasting salts or their GI
also helps diuretics components, bleeding,
maintain or certain peptic ulcer Perforatio
electroneu antibiotics disease n, or
trality in ) (potassium ulceration;
cells by citrate), intestinal
controllin renal obstructio
g impairment n; nausea;
exchange with vomiting
of azotemia or
intracellul oliguria, RESP:
 ar and severe Dyspnea
extracellul hemolytic
ar ions. It anemia, UTI SKIN:
also helps (potassium Rash
maintain citrate)
normal Other:
renal Hyperkale
function mia
and acid-
base
balance

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
Mefenami 500 mg NSAIDs Inhibits Initial 500 Hypersensi GIT: Assess patient
c Acid TID = synthesis mg PO tivity to abdominal with
FRR for of once, aspirin pain,anore developing
pain prostaglan THEN (acetylsalicy xia,diarrhe severe diarrhea
dins in lic acid) or a,nausea,p ad vomiting
Initial body 250 mg other non- yrosis,gast for dehydration
500mg tissues by PO q6hr steroidal ritis,flatul and electrolye
PO inhibiting PRN anti- ence,const imbalance.
Generic once, at least 2 usually inflammator ipation,ste
name: THEN cyclooxyg not to y agents. atorrhea Lab test : with
enase exceed 3 long term
250 mg isoenzyme days HEMA: therapy (not
PO q6hr s, Leukopeni recommended)
PRN cyclooxyg a, obtain
usually enase-1 eosinophil perioduc
not to (COX-1) ia, complete blood
exceed 7 and - Agranuloc counts, Hct
days 2(COX-2) ytosis,pan and Hgb and
May cytopenia, kidney
inhibit bone function tests
chemotaxi tomorrow
s, may hypoplasia
alter , renal
lymphocyt failure
e activity, (including
and may papillary
inhibit necrosis &
neutrophil acute
aggregatio interstitial
n. These nephritis)
effects
 may
contribute
to its anti-
inflammat
ory
activity

Trade Patient’s Classification Action Indication Contra- Adverse Nursing

name Dosage indication reaction Responsibility
nalbuphin 5mg Opiod Depresses Moderate Hypersensiti CNS: I&O ratop:
e analgesics pain to severe vity, drowsines check for
Analgesi impulse pain addiction s, decreasing
c: transmissi (opiate) dizziness, output may;
SUBCU on at the confusion, may indicate
T/IM/IV spina cord headache, urinary
Generic 10 mg level by sedation,e retention
name:Nub q3-6hr interacting uphoria,dy
ain prn, not with opiod sphoria -bowel
to receptors (high constipation is
exceed doses), common
160mg/d hallucinati
ay ons, -CNS changes;
dreaming, dizziness,
tolerance, drowsiness,
physical,p hallucinations,
sychologic euphoria,
dependenc LOC, pupil
y reaction

GV: -need for pain

palpitation medication by
s, pain sedation
bradycardi scoring,
a, change physical
in B/P, dependency
orthostatic
hypotensi -allergic
on, reactions: rash,
cardiac urticaria
arrest

EENT:
tinnitis,
blurred
vision,
miosis,
diplopia

GI:
nausea,
vomiting,
anorexia,
constipati
on,
cramps,
abdominal
pain,
dyspepsia,
xerostomi
a, bitter
taste.

GU:
increased
urinary
output,
dysuria,
urinary
retention,
urgency

INTEG:
rash,
urticaria,
bruising,
flushing,
diaphoresi
s, pruritus

RESP:
respiratory
depression
,
pulmonary
edema
2. TREATMENT

 Vital Signs

INDICATION

-To identify physical responses associated with medical conditions

CONTRAINDICATIONS

-Fatigue

3. .DIET/ ACTIVITY / EXERCISE

DIET ACTIVITY EXERCISE

-Eat more green leafy -Suggest to do physical -Ms.J was instructed to do

vegetables activity anything that get stretching as a warm up

-continue drinking water her moving, such as and walking for 30

-avoid fried foods walking, dancing, running. minutes.

Staying active improves

her overall wellness.

B. Patient's Daily Progress Note

Day Procedure Diet Activity Drug Treatment Surgery Nursing

problem
12-13-17 Low 8am 8am Vital Signs NONE The client's
Dilation Sodium V/S omeprazole blood
and and Low BP: Sodium pressure
Curettage Salt Diet 110/80mmHg 40g via IV has risen
PR: 74bpm over the
RR:14bpm pass hours
T: 36.6 C that made
her still a
12pm eclamptic
V/S patient.
BP:150/100
mmHg
PR: 53bpm
RR:18bmp
T:36.7 C
12-14-17 NONE NPO 8am Ampicillin Vital Signs NONE The client's
V/S via IV blood
BP: pressure
170/110mmH has risen
g because of
PR: 81 bpm aggravating
RR:18 bpm pain due to
T: 37.2 C labor
process.
12pm
at DR for
Delivery
12-15-17 NONE NONE 8am -Klyte Vital Signs NONE Patient is
V/S - still on
BP: 130/90 Mefenamic recovery
mmHg acid stage after
PR: 70bmp -Ferrous the
RR: 14 bpm Sulfate+ delivery of
T:36.8 C Folic acid the baby
that may
alter the
result of
the vital
signs.
 CHAPTER V

DISCHARGE PLANNING INSTRUCTION

-Medications

Ms.J should take the prescribed take home medications on the right time with right dose.

 Ms.J was advised to take ferrous sulfate one tab OD between meals for best absorption may

give with juice : do not give with antacids or milk delay at least 1 hr; if GI symptoms occur.

 Ms.J was advised to take mefenamic acid 500 mg TID = FRR to ease pain take it with food

every 6 hours as needed for up to 1 week.

 Take Potassium chloride take each dose of potassium chloride with a full glass of water or

fruit juice. Do not lie down for 10 minutes after taking this medication. You should take

potassium chloride exactly as directed. You should swallow the extended-release capsules or

tablets whole.

EXERCISE

 Encouraged Ms. J to do stretching as a warm up and walking for 30 minutes.

 Suggest that do physical activity anything that get her moving, such as walking, dancing,

running. Staying active improves her overall health

 Adequate rest is important

TREATMENT: Monitoring Vital signs

INDICATION: To identify physical responses associated with medical conditions

CONTRAINDICATIONS

-fatigue
HEALTH TEACHING

It is important to teach the patient proper diet by eating green leafy vegetables and encourage the

patient to perform exercise every morning as long she is moving to promote overall health

wellness such as walking,biking or activity she likes to perform. Encouraged the client to visit

nearest health center for monitoring her vital signs, specifically the blood pressure.

Ms. J was advised the following:

-Exercise daily

-add more green leafy vegetables in her daily food intake

Ms. J should have adequate Multivitamins, it is used to provide vitamins that are not taken in

through the diet. Multivitamins are also used to treat vitamin deficiencies (lack of vitamins)

caused by illness, pregnancy, poor nutrition, digestive disorders, and many other conditions.

OUTPATIENT DEPARTMENT

-To be back after one week (DECEMBER 26, 2017), for follow up check up

DIET

-Eat more green leafy vegetables

-continue drinking water

-avoid fried foods