UNIVERSITY OF THE CORDILLERAS

College of Nursing
Governor Pack Road, Baguio City, Philippines 2600
(+6374) 442-3316, 442-2564, 442-8219, 442-8256
E-mail: webmaster@[Link]
Website: [Link]

PREECLAMPSIA WITH SEVERE FEATURES, UNCONTROLLED

A Case Presented to the

College of Nursing

In Partial Fulfillment of the requirements in the Course

Nursing Care Management 107

Submitted By:

Submitted By:

Bumidang, Angelica P.

Damogo, Aivy Lyn A.

Galvan, Melinda B.

Francisco, Eloisa Mae V. 

Kalangeg, Rajini M.

Marcos III, Marino Andrei D.

Mendoza, Luilla Grace P.

Sansano, Lei Valerie Faith D.

Tade, Chuck Norris B.

Tomanan, Carmela Faye P.

Date: 11-DECEMBER-2022

Noted and Approved for Presentation:

Name of Case Presentation Adviser or Panel/s

________________________
Signature of Adviser / Date
 ABSTRACT

TITLE: Preeclampsia with severe features, uncontrolled

AUTHOR INFORMATION: University of the Cordilleras College of Nursing 2nd Year, Section M,
Group A- Angelica P. Bumidang, Aivy Lyn A. Damogo, Melinda B. Galvan, Eloisa Mae V. Francisco,
Rajini M. Kalangeg, Marino Andrei D. Marcos III, Luilla Grace P. Mendoza, Lei Valerie Faith D.
Sansano, Chuck Norris B. Tade and Carmela Faye P. Tomanan

BACKGROUND: Preeclampsia is a pregnancy-related systemic illness that has its source in the
placenta. Inadequate placental cytotrophoblast invasion is assumed to be the root of it, which is
followed by extensive endothelial dysfunction in the mother.  According to studies, the placenta
releases too much of the antiangiogenic substances soluble fms-like tyrosine kinase 1 (sFlt1) and
soluble endoglin (sEng) into the mother's blood, which results in widespread endothelial dysfunction
and causes hypertension, proteinuria, and other systemic signs of preeclampsia. Unknown
molecular mechanisms underlie the deregulation of these harmful molecules in the placenta.
Preeclampsia is a dangerous condition linked to pregnancy that is characterized by the onset of
edema, proteinuria, and hypertension. Despite extensive research, we still know very little about
pathogenesis. Preeclampsia symptoms in the mother are relieved by an emergency delivery, but the
baby may experience increased morbidity as a result of iatrogenic prematurity. Preeclampsia is
thought to be a contributing factor in 15% or so of preterm births. 

CASE DESCRIPTION: Patient X, a 32 years old pregnant female residing at Lower Purok 12, Irisan,
Baguio and was admitted at Baguio General Hospital Medical Center, Obstetric ward. The patient
stated that she enjoys eating high-salt foods like "watwat”. At first, she just came for a checkup but
was admitted instead due to her having a high blood pressure of 170/110 which was conducive to
preeclampsia. Right after admission, vital signs were taken, v/s as follows: BP: 170/110, RR:19,
PR:99, T: 36.3, s02: 97%, the doctor also ordered a laboratory test to make sure what is the
condition of the patient and some medications were given to avoid progression of the disease. She
was then advised to undergo an emergency cesarean section by her medical doctor. She gave birth
to a 3.3kg baby boy on December 2 8:37pm. She was transferred to the obstetric ward to recover.
nd

Her blood pressure fluctuates between 150/90mmhg-170/100mmhg and also gotten edema on both
feet. 

1
 TABLE OF CONTENTS

I. Introduction.............................................................................................................................................３
II. Statement of Objectives..........................................................................................................................３
A. General Objectives..................................................................................................................................３
B. Specific Objectives..................................................................................................................................３
III. Patient’s Profile.......................................................................................................................................３
IV. Chief Complaint......................................................................................................................................３
V. Present History of Illness.......................................................................................................................３
VI. Past History of Illness.............................................................................................................................４
VII. Family Health History............................................................................................................................４
VIII. Developmental History...........................................................................................................................４
IX. Social and Environmental History........................................................................................................４
X. Lifestyle and Health Practices...............................................................................................................５
XI. Health Assessment..................................................................................................................................５
A. General Survey........................................................................................................................................５
B. Head to Toe Assessment.........................................................................................................................６
C. 13 Areas of Assessment..........................................................................................................................７
XII. Diagnostics.................................................................................................................................................9
XIII. Comprehensive Pathophysiology..........................................................................................................12
XIV. Treatment/Management........................................................................................................................13
A. Drugs....................................................................................................................................................13
B. IV Fluids..............................................................................................................................................13
C. Surgery................................................................................................................................................13
XV. Nursing Care Plans.................................................................................................................................15
A. Prioritization of Problems....................................................................................................................15
a.1. List of Problems..............................................................................................................................15
a.2. Basis for Prioritization....................................................................................................................15
B. Nursing Care Plans...............................................................................................................................16
NCP 1...........................................................................................................................................................16
NCP 2...........................................................................................................................................................16
NCP 3...........................................................................................................................................................16
NCP 4...........................................................................................................................................................16
NCP 5...........................................................................................................................................................16
C. Discharged Plan......................................................................................................................................17
XVI. Learning Insights....................................................................................................................................17
XVII. List of References...................................................................................................................................18
XVIII. Appendices..............................................................................................................................................19
Appendix A: Approval/ Request Letter........................................................................................................20
Appendix B: Interview Guides......................................................................................................................21
Appendix C: Others........................................................................................................................................22

I. Introduction

Preeclampsia is a pregnancy-related systemic illness that has its source in the placenta. Inadequate
placental cytotrophoblast invasion is assumed to be the root of it, which is followed by extensive

2
 endothelial dysfunction in the mother. According to studies, the placenta releases too much of the
antiangiogenic substances soluble fms-like tyrosine kinase 1 (sFlt1) and soluble endoglin (sEng) into the
mother's blood, which results in widespread endothelial dysfunction and causes hypertension, proteinuria,
and other systemic signs of preeclampsia. Unknown molecular mechanisms underlie the deregulation of
these harmful molecules in the placenta. We are only beginning to understand how these antiangiogenic
proteins affect trophoblast invasion and early placental vascular development. Hypoxia is probably a
significant regulator. The etiology of preeclampsia may also be influenced by the renin-aldosterone-
angiotensin II axis, excessive oxidative stress, inflammation, immunological maladaptation, and hereditary
vulnerability (Young et al.,2010).

Preeclampsia is a dangerous condition linked to pregnancy that is characterized by the onset of edema,
proteinuria, and hypertension. Despite extensive research, we still know very little about pathogenesis.
Preeclampsia symptoms in the mother are relieved by an emergency delivery, but the baby may experience
increased morbidity as a result of iatrogenic prematurity. Preeclampsia is thought to be a contributing
factor in 15% or so of preterm births. Pregnancy-related hypertension is a helpful clinical feature in the
screening for this condition, although it is not a specific finding and is sometimes mistaken with
gestational hypertension. About 5 to 8% of pregnant women get preeclampsia. Unexpectedly,
preeclampsia has become more prevalent recently. and could be considerably higher in developing nations
(Kanasaki & Khaluri, 2009). Preeclampsia, which affects 5% to 7% of all pregnant women but has the
highest morbidity and mortality, results in more than 700,000 maternal deaths and 500,00 fetal deaths
annually around the world (Rana et al., 2019). Preeclampsia is a frequent pregnancy problem that raises
the risk of maternal illness and death as well as restricts the growth of the fetus inside the womb.  

II. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of student
nurses on how to care for patients with Preeclampsia with Severe Features, Uncontrolled
effectively and efficiently.

B. Specific Objectives

Specifically, this case analysis aims to :

1. define Preeclampsia with Severe Features, Uncontrolled and its effects to the body as
a whole;
2. illustrate the pathophysiology of Preeclampsia with Severe Features, Uncontrolled
and in relation to the signs and symptoms specifically observed in the patient;
3. describe and identify the common signs and symptoms of Preeclampsia with Severe
Features, Uncontrolled;
4. discuss the medical and surgical interventions for the management of Preeclampsia
with Severe Features, Uncontrolled;
5. formulate appropriate nursing care plans suited for the patient based on the
assessment findings;
6. identify care measures to be given to the patient and family to
promote continuity of care and independence after discharge.

III. Patient’s Profile

Name : Patient X
Ethnic Background : Tagalog
Civil Status : Married
Religion : Roman Catholic
Occupation : Store keeper

Admitting Diagnosis : G2P0 (0010) Pregnancy Uterine 38 3/7 weeks Age

of Gestation, Cephalic in Beginning Labor, Preeclampsia with Severe Features, Uncontrolled
Final/Principal Diagnosis : G2P1 (1101) Pregnancy Uterine Delivered Cephalic Term
(39-40 weeks, live baby boy) (BW:3.3kg) Appropriate for Gestational Age by Emergency Primary Low
Segment. Cesarean Section Under Subarachoid Block for Preeclampsia with Severe Features, Uncontrolled

3
 Date and Time Admitted : December 02, 2022 at 5:48pm

IV. Chief Complaint

Patient X complains of Elevated Blood Pressure

V. Present History of Illness

Patient X is a G2P1 32-year-old, female and a resident of Irisan, Baguio city Benguet born on sept. 2
1990. 1 week prior to consultation, the patient was noted to have elevated bp at 160/100. No consultation, no
medication taken. Few hours prior to consultation, the patient had her regular prenatal check up at PMD where
BP was noted to be 170/110 patient was given Methyldopa 250 mg 2 tabs and was referred to Baguio general
hospital medical center for admission.

VI. Past History of Illness

The patient has a diagnosis of rheumatic heart fever in her childhood and was prescribed erythromycin
500mg tab, 1 tab BID lost to ff-up. Patient also was diagnosed with mild Covid-19 last October 2021. Patient
received her first dose of Moderna vaccine on December 17, 2021 and her 2nd dose on January 14 2022, no
boosters noted. Patient also verbalized that she does not have known allergies for foods or medication

VII. Family Health History

The patient claims no known heredofamilial illness. Family Health History problems such as
Hypertension, Diabetes Mellitus, Rheumatic heart fever, Asthma, Heart disease, Goiter and positive in
COVID-19 in October 2021. No present illness is currently experienced by any member of the family.

VIII. Developmental History

According to Erik Erikson’s theory of psychosocial development, the patient is in the stage of
Intimacy vs. Isolation. This stage takes place at ages 21-39 years. During this stage, a young adult's major
conflict centers on forming intimate, loving relationships with other people. She displayed behavior of
intimacy as she has the ability to share her personal feelings and thoughts about having a baby. She stated that
she loves her baby so much and that she is lucky to have a supportive husband. She knows her responsibility as
a mother, therefore she provides safety to her baby and gives the daily nutritional needs of her baby through
breastfeeding.

IX. Social and Environmental History

The patient states that she feels more comfortable focusing on her inner thoughts and ideas, rather than
what's happening externally. She enjoys spending time with her family and several close friends, rather than
large groups or crowds . The patient is a non-smoker and non-alcoholic beverage drinker. No verbalized vices
were identified. She currently resides in Irisan, Baguio City with her husband, her husband's brother, and in-
laws. The house where they stay is made up of concrete wood. Privacy is maintained with the 2 separate rooms
present. Water used daily is being supplied by the city water district, while the source of drinking water is
delivered weekly. 

              Due to regular, painful contractions lasting a minute each and occurring at every five minutes more
than two hours, the patient was rushed to the Baguio General Hospital and Medical Center for the delivery of
the baby. Access to medical facilities and treatments is not a major issue for a family from an average
socioeconomic background.

X. Lifestyle and Health Practices

The patient eats three complete meals a day which mostly consist of rice, egg, chicken, pork, and
vegetables. Patient stated that she drinks 5-7 glasses of water every day. She does not usually exercise but does
physical activities such as walking especially when going to the market since the main road is a bit far from the
main road where transportation is available. She is aware of the appropriate foods to eat and also the foods to
avoid in her postpartum period.

4
XI. Health Assessment
A. General Survey

The patient appears weak and needs assistance when doing activities of daily living, including eating and
using the restroom, as well as when changing positions. She maintains good hygiene and is dressed in a clean
gown. The patient is knowledgeable, has clear speech, is self-conscious and aware of her surroundings, and
can tell the time and date.

The patient is an ectomorph person. She claimed to be 78 kg and 5'4" tall.

B. Head to Toe Assessment

1. Head No abnormal findings

2. Eyes No abnormal findings
3. Ears No abnormal findings
4. Nose and sinuses No abnormal findings
5. Mouth No abnormal findings
6. Neck No abnormal findings
7. Chest Respiratory rate ranges from 19-31 cpm.
8. Cardiac Cardiac rate ranges from 75-120 bpm, with increased blood   pressure
as   evidenced   by 160/100; palpitations noted.
9. Breast/Chest Skin color is similar with the rest of the body, nipple is dark colored,
no discharges.
10. Abdomen Incision area is with dry and intact dressing and sometimes pain is
felt.
11. Genitals No abnormal findings

12. Musculoskeletal Patient is able to move but needs minimal assistance due to pain.
13. Integumentary Nails are intact and are well trimmed. Pitting edema noted on both
feet graded as +1.

C. 13 Areas of Assessment

 1. Psychosocial and Psychological Status

The patient is a 32-year-old female, married residing at lower Purok 12, Irisan, Baguio. She was previously a
call center agent and is now a sari-sari store owner; her partner is a laborer; both of their income is enough to
sustain their family’s basic needs. She is a Roman catholic with no tradition, culture or beliefs practices which
might affect in providing health care. According to Erick Erikson Psychosocial theory, the patient falls under
Generativity vs. Stagnation. Wherein the patient is establishing her mark in the society through raising their
child-to-be well, being a loving wife and becoming involved in community/social activities. 

2. Mental and Emotional Status

The patient is conscious, alert, and well oriented to time, date and place. She responds in every verbal, touch
and pain stimuli. She acts and talks according to her age. She responds appropriately to questions being asked
with minimal eye contact. She displays facial grimace and guarding behavior due to back pain and when
positioning.

3. Environmental Status

The patient lives with her in-laws together with her husband and her husband’s brother. The family resides not
too far from the city making it easy for them to go to hospitals when they need medical assistance. The patient
is admitted at Baguio General Hospital Medical Center. During admission, the patient’s bed is located near the
window providing her proper ventilation and adequate lighting during the day. Bed rails also were raised to
ensure safety. Drinks, foods and other necessities are easily accessible on the patient's bedside table.

4. Sensor Status

a. Visual Status

No abnormal findings were observed.

5
 b. Auditory

No abnormal findings were observed.

c. Olfactory Status

No abnormal findings were observed.

d. Gustatory Status

No abnormal findings were observed. 

e. Tactile Status

No abnormal findings were observed.

5. Motor Status                                                

Due to pain on her incision area, the patient has limited movement and needs assistance and support when
positioning

6. Thermoregulatory Status

Date Time Temperature

  10pm 36.9 °C

December 04, 2022 2am 36.2 °C

  6am 36.9 °C

  10pm 36.7 °C

December 05, 2022 2am 36.8 °C

6am 36.7 °C

  10pm 36.3 °C

December 06, 2022 2am 36.6 °C

6am 36.2 °C

7. Respiratory Status

Date Time RR SPO2

  10pm 21 cpm 99 %

6
 December 04, 2022 2am 20 cpm 96 %

  6am 20 cpm 95 %

  10pm 20 cpm 96 %

December 05, 2022 2am 35 cpm 96 %

6am 31 cpm 97 %

  10pm 21 cpm 95 %

December 06, 2022 2am 21 cpm 96 %

6am 21 cpm 96 %

8. Circulatory Status

Date Time CR Capillary

  10pm 100 bpm 1-2 seconds

December 04, 2022 2am 107 bpm

  6am 112 bpm

  10pm 99 bpm 1-2 seconds

December 05, 2022 2am 96 bpm

6am 92 bpm

  10pm 75 bpm 1-2 seconds

December 06, 2022 2am 95 bpm

6am 97 bpm

9. Nutritional Status

Prior to hospitalization, the patient verbalized that she likes eating salty-fatty foods such as pork. She is not a
picky eater and eats three times a day. During hospitalization, she strictly follows a low-fat-low-sodium diet as
per order. The patient is able to swallow her food and medications as well. There is no culture or religious
dietary restriction reported by the patient.

10. Elimination Status

7
The patient is in I&O monitoring, she urinated 4-6 times a day during the shift with yellowish colored urine.
Patient verbalized that she does not have any difficulties in defecating.          

11. Sleep, Rest and Comfort Status

During the shift, the patient verbalized having minimal sleep. She was unable to sleep comfortably due to the
routine of checking vital signs, and once her baby began to cry and is disturbed by the noises of her
surroundings. The patient reports back pain due to complete bed rest and the insertion of the anesthesia
however, she was assisted in turning on her sideway to promote comfort.

12. Fluids and Electrolytes Status

Prior to admission, the patient's fluid consumption ranges between 500 to 1000 mL. During hospitalization, the
patient is in I&O monitoring and strictly follows fluid intake as per order.

13. Integumentary Status        

Skin color is brownish. Dressing is dry and intact on incision area and sometimes felt pain. Nails and hair are
well kept by the patient. Noticeable pitting edema on both feet, graded as +1

8
XII. Diagnostics

Diagnostic Date of
Description of the Procedure Significance/Purpose of the Procedure Findings & Implications
Procedure Procedure

CBC A CBC may be ordered when a 12/02/2022

person has any number of signs and To determine general health status,
symptoms that may be related to screen, diagnose, or monitor any one of a
variety of diseases and conditions that
disorders that affect blood cells.
affect blood cells, such as anemia,
When an individual has an infection, infection, inflammation, bleeding
inflammation, bruising, or bleeding, a disorders, or cancer.
doctor may order a CBC to help
diagnose the cause and/or determine
its severity

Creatinine A creatinine test is used to see if your 12/02/2022

kidneys are working normally. It is to make a diagnosis if you have signs or
often ordered along with another symptoms of kidney disease. Screen for
kidney disease if you have diabetes, high
kidney test called blood urea nitrogen
blood pressure, or other conditions that
(BUN) or as part of a comprehensive increase the risk of kidney disease.
metabolic panel (CMP).

An alanine transaminase (ALT) blood The purpose of an ALT blood test is to 12/02/2022
ALT  test measures the amount of ALT in help evaluate the health of your liver. If
your blood. ALT levels in your blood cells in your liver are damaged, it can
(alanine transaminase)
can increase when your liver is cause ALT to leak into your blood, so an
damaged, so healthcare providers ALT blood test can help find liver issues.
often use an ALT blood test to help Your healthcare provider may order a
assess the health of your liver blood panel test that includes an ALT

9
 test for you to help screen for, monitor,
or diagnose liver conditions.

The purpose of an AST blood test is to 12/02/2022

AST  An aspartate aminotransferase (AST) detect damage to cells. If cells in your
test measures the amount of this liver are damaged, it can cause AST to
( aspartate enzyme in the blood.
leak into your blood, so an AST blood
aminotransferase )
AST is normally found in red blood test can help find liver issues
cells, the liver, heart, muscle tissue,
pancreas, and kidneys.

An LDH (lactate dehydrogenase) test Lactate dehydrogenase (LDH) is an 12/02/2022

LDH  measures the level of LDH in your important enzyme that helps with
blood or other body fluids to check cellular respiration, the process through
(lactate dehydrogenase)
for tissue damage. Healthcare which your body transforms glucose
providers order LDH tests to help (sugar) from the food you eat into energy
diagnose and monitor several for your cells. Enzymes are proteins that
different conditions help speed up metabolism, or the
chemical reactions in your body.

Abo +Rh typing ABO/Rh testing entails putting a determines the blood type of the patient 12/02/2022
sample of the cell suspension in and can also be used to decide if a
various reagents, centrifuging at a pregnant woman with Rh negative blood
specific speed for a specific period of will need to receive Rh immune globulin
time, and then gently shaking the
tube. If there is any clumping of blood
cells, known as agglutination, the
result for that reagent is positive

Blood tests that detect signs of the To actually identify the “surface antigen” 12/02/2022
HbsAg  hepatitis B virus in your body and tell of the hepatitis B virus in your blood
your provider whether it's acute or
(Hepatitis B surface
chronic. A simple blood test can also
antigen)

10
 determine if you're immune to the
condition.

Urinalysis A urinalysis (also known as a urine A urinalysis is a test of your urine. It's 12/02/2022
test) is a test that examines the visual, used to detect and manage a wide range
chemical, and microscopic aspects of of disorders, such as urinary tract
your urine (pee). A single urine infections, kidney disease and diabetes
sample may be used for a number of
tests that identify and quantify
different substances that travel
through your urine.

Syphilis tests screen for and diagnose to identify those who have had syphilis 12/02/2022
STS  syphilis by looking for certain previously treated, those who haven't had
antibodies in your blood. If the result it treated at all or only partially, and
(serologic  test for
of your screening test shows you have people who had false-positive test results
syphilis )
antibodies linked to syphilis
infections, you'll need a second test to
confirm whether or not you have
syphilis.

A test used in pregnancy to monitor a way to evaluate the health of the fetus, 12/02/2022
CTG both the fetal heart pattern as well as especially in pregnancies with a higher
the uterine contraction risk of problems.
(Cardiotocography )

11
XIII. Comprehensive Pathophysiology

12
13
XIV. Treatment/Management
A. Drugs
DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION
GENERIC NAME:
Furosemide Inhibits sodium and chloride re- INDICATION  CNS: vertigo, headache, dizziness, BEFORE:
BRAND NAME: absorption at the proximal and paresthesia, weakness, restlessness,
distal tubules and the ascending EDEMA: Furosemide is indicated fever Dx:
Lasix
loop of Henle.  for the treatment of edema
THERAPEUTIC CLASS: associated with congestive heart EENT: blurred or yellowish vision, -Verify doctor’s order
Anti hypertensive Wolters Kluwer (2022). failure, cirrhosis of the liver, and transient deafness, tinnitus
PHARMACOLOGIC CLASS: Nursing 2022 Drug renal disease, including the -Assess allergy to sulfonamide or its
Loop diuretics Handbook.  nephrotic syndrome, in adults and GU: azotemia, frequent urination component
DOSAGE: pediatric patients. Oral furosemide is
20mg Furosemide exerts direct indicated alone for the management METABOLIC: volume of Tx:
vasodilatory effects, which results of mild to moderate hypertension or depletion and dehydration
ROUTE
in its therapeutic effectiveness in severe hypertension in combination -Prepare the medication at the right time
Oral the treatment of acute pulmonary with other hypertensive
edema. Vasodilation leads to medications.  SKIN: dermatitis EDx: 
reduced responsiveness to
vasoconstriction, such angiotensin CONTRAINDICATION: OTHER: gout -Educate the patient and SO about the
II and noradrenaline, and decreased purpose and importance of the drug 
production of endogenous Contraindicated in patients
natriuretic hormones with hypersensitive to drug and in those -Educate patient on the drug 
vasoconstricting properties with anuria. Use cautiously in
patients with hepatic cirrhosis and in DURING:
those allergic to sulfonamides. 
Dx:
DRUG TO DRUG
INTERACTION -Verify patient’s identity

Aminoglycoside antibiotics, -Obtain patient’s weight before and

cisplatin: May increase ototoxicity. periodically during furosemide therapy to
monitor fluid loss

14
Tx: 

-Administered medication as ordered 

-Assist when taking the medication

EDx

-Advise patient to change position slowly

to minimize effect of orthostatic
hypotension and to take furosemide with
food or milk to reduce GI tract distress

-Instruct patient to report palpitations,

signs of electrolyte imbalances or hearing
abnormalities

AFTER:

Dx: 

-Monitor vital signs especially blood

pressure

-Monitor for possible adverse effects of

medication

Tx:

-Promote safety and comfort measures 

-Assess the patient and determine unusual

signs 

EDx:

15
-Encourage patient to verbalize feelings
and concerns 

-Emphasize the importance of weight and

diet control, especially limiting sodium
intake.

16
 DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION
A selective beta blocker that INDICATED: CNS:fatigue, dizziness, depression,
GENERIC NAME: selectively blocks beta; receptors; Metoprolol is indicated for the headache, insomnia BEFORE:
decreases cardiac output, peripheral treatment of angina, heart failure, CV:hypotension, bradycardia
Metoprolol resistance, and cardiac oxygen myocardial infarction, atrial EENT:blurred vision, tinnitus, Dx
consumption; and depresses renin fibrillation, atrial flutter and rhinitis
BRAND NAME: secretion hypertension. All the indications of GU:decreased libido -Check doctor’s order
metoprolol are part of cardiovascular RESPIRATORY:dyspnea,
Troprol XL disease. These conditions correspond wheezing,bronchospasm -Review medication record
Wolters Kluwer (2022). Nursing to a number of diseases that involve SKIN:rash
THERAPEUTIC CLASS: 2022 Drug Handbook the function of the heart and blood -Asses allergy to metoprolol and its
vessels.  components
Anti hypertensive When metoprolol is administered
orally, it is almost completely Tx:
PHARMACOLOGIC CLASS: absorbed in the gastrointestinal tract. CONTRAINDICATION:
The absorption of metoprolol in the Contraindicated in patients -Prepare the medication
Selective beta adrenergic blockers  form of the tartrate derivative is hypersensitive to drug or other beta
increased by the concomitant blockers. Contraindicated in patients EDx:
DOSAGE: administration of food  with sinus bradycardia, greater than
first degree heart block. -Educated the patient and SO about
50 mg the purpose and importance of the
drug
ROUTE DRUG TO DRUG 
INTERACTION -Educated SO on the drug therapy to
Oral promote compliance

Amiodarone may increase DURING

bradycardic effects. Monitor therapy.
Barbiturates may reduce metoprolol Dx:
effect.
-Introduce self to the  patient

-Verify patient’s identity

-Assess patient’s condition

Tx:

-Administer medication as ordered

-Assist patient when taking the

medication

Edx
17
-Inform drug’s therapeutic effect

-Inform side effects.

DRUG NAME MECHANISM OF ACTION INDICATION / CONTRAINDICATION ADVERSE EFFECT NURSING
RESPONSIBILITIES

BEFORE: 
Generic Name: Inhibits the enzyme cyclooxygenase, blocking Indication CNS: Agitation, anxiety, fatigue, Dx:
prostaglandin production and interfering with fever, headache, insomnia a. Assess for an allergy to
Paracetamol pain impulse generation in the peripheral Treat mild to moderate pain and acetaminophen. 
nervous system. Acetaminophen also acts reduction of fever. CV: Hypotension, hypertension, b. Assess for pain by having
(Acetaminophen) directly on temperature-regulating center in peripheral edema the patient rate on a scale of 1-
the hypothalamus by inhibiting synthesis of Contraindication 10, and describe
Brand Name: prostaglandin E2 . EENT: Stridor (parenteral form) characteristics, duration, and
Hypersensitivity to acetaminophen or frequency.
Calpol its components, severe hepatic ENDO: Hypoglycemic coma Tx:
impairment, severe active liver c. Verify doctor’s order.
Pharmacologic disease. GI: Abdominal pain, constipation, d. Prepare the medication at
class: Nonsalicylate, diarrhea, hepatotoxicity, jaundice, the right time and dose.
para-aminophenol Interactions Drugs nausea, vomiting Edx:
derivative e. Educate in the purpose of
Anticholinergics: Decreased onset of GU: Oliguria (parenteral form) the drug. 
  acetaminophen action f. Explain the possible side and
HEME: Hemolytic anemia (with adverse effects of the drug. 
Therapeutic class:  Barbiturates, Carbamazepine, long-term use), leukopenia, g. Encourage to verbalize any
Hydantoins, Isoniazid, Rifampin, neutropenia, pancytopenia, queries or concerns about the
Antipyretic, nonopioid Sulfinpyrazone: Decreased thrombocytopenia medication.
analgesic  therapeutic effects and increased  
hepatotoxic effects of acetaminophen  MS: Muscle spasm (parenteral During
Dosage: 600mg form) Dx:
Dasatinib, Imatinib: Possibly h. . Verify patient’s identity. 
  increased risk of hepatotoxicity RESP: Parenteral form: atelectasis, i. Assess patient’s condition. 
dyspnea, plural effusion, pulmonary Tx: 
Route: IV  Lamotrigine: Possibly decreased edema, wheezing j. Administer medication as
therapeutic effects of these drugs  prescribed.
SKIN: Acute generalized EDx:
Oral contraceptives: Decreased exanthematous pustulosis, blisters, k. Emphasize the importance of

18
 drinking adequate fluids and to
effectiveness of acetaminophen pruritus, rash, reddening, Stevens– report signs and symptoms of
Johnson syndrome, toxic epidermal dehydration.
Probenecid: Possibly increased necrolysis, urticaria
therapeutic effects of Acetaminophen 
Other: Anaphylaxis, angioedema, After
Propranolol: Possibly increased hypersensitivity reactions; for Dx:
action of acetaminophen parenteral form: hypoalbuminemia, [Link] the patient's activity
hypokalemia, hypomagnesemia, and vital signs. m. Monitor for
Warfarin: Possibly increased hypophosphatemia, injection-site possible adverse effects of
international normalized ratio pain medication. 
Tx:
Zidovudine: Possibly decreased n. Assess the patient and
zidovudine effects determine unusual changes. 
EDx:
o. Instructed to immediately
report to the prescriber, if
unusual changes are noticed. 
p. Educate the patient about
the action, indication, common
side effects and adverse
reactions to note.

DRUG NAME MECHANISM OF ACTION INDICATION/CONTRAINDICATION ADVERSE EFFECT NURSING

RESPONSIBILITIES

Before
Generic Blocks cyclooxygenase, an enzyme needed to Indication CNS: Aseptic meningitis, cerebral Dx: 
Name: synthesize prostaglandins. Prostaglandins mediate hemorrhage, coma, CVA, a. Assess for other
inflammatory response and cause local Indicated for the short-term (up to 5 days in dizziness, drowsiness, headache, contraindications in drug
Ketorolac vasodilation, pain, and swelling. They also promote adults), management of moderately severe acute psychosis, seizures administration. Monitor bp.
tromethamine pain transmission from periphery to spinal cord. By pain that requires analgesia at the opioid level b. Check for allergies.
blocking cyclooxygenase and inhibiting and only as continuation treatment following IV or CV: Edema, hypertension Monitor for pain: type,
prostaglandins, this NSAID reduces inflammation IM dosing of ketorolac tromethamine, if location, intensity, ROM

19
 necessary. before treatment.
  and relieves pain. EENT: Laryngeal edema, c. Assess the patient's
stomatitis health history.
Brand Name:   Contraindications: Tx:
ENDO: Hyperglycemia d.  Keep emergency
Toradol   -Toradol is contraindicated in patients with equipment readily available
previously demonstrated hypersensitivity to GI: Abdominal pain; acute at time of initial dose in
    ketorolac tromethamine.  pancreatitis; bloating; case of severe
constipation; diarrhea; hypersensitivity reaction
Chemical   -Toradol is contraindicated in patients with active diverticulitis; elevated liver EDx:
Class: peptic ulcer disease, in patients with recent enzymes; flatulence; GI bleeding, e. Explain the possible side
SOURCE: gastrointestinal bleeding or perforation and in perforation, or ulceration; effects.
NSAIDs patients with a history of peptic ulcer disease or hepatitis; hepatic failure; f. Educate the purpose.
[Link] gastrointestinal bleeding. jaundice; indigestion; nausea;
drugsatfda_docs/label/2013/ [Link] vomiting; worsening of
-Toradol should not be given to patients who inflammatory bowel disease During
Therapeutic   have experienced asthma, urticaria, or allergic- Dx:
Class: type reactions after taking aspirin or other GU: Interstitial nephritis, renal g. Monitor blood pressure
SOURCE: NSAIDs. failure, urine retention closely to evaluate
Analgesic  effectiveness of therapy.
Jones & Bartlett Learning (2022). Nurse’s Drug -Toradol is contraindicated in patients with HEME: Agranulocytosis, anemia, h. Ensure to observe the
Dosage: Handbook. advanced renal impairment or in patients at risk aplastic or hemolytic anemia, following rights of the
30mg for renal failure due to volume depletion. eosinophilia, leukopenia, patient (right medication,
21st Edition. pancytopenia, thrombocytopenia right route, right patient,
Route: IV right time and right
RESP: Bronchospasm, dosage).
pneumonia, respiratory Tx: 
depression i. Provide safety measures
such as adequate lighting,
SKIN: Diaphoresis, erythema raised side rails etc. to
multiforme, exfoliative dermatitis, prevent injury.
photosensitivity, pruritus, rash, j. Administer medication as
Stevens–Johnson syndrome, ordered. 
toxic epidermal necrolysis, EDx:
urticaria k. Inform drug’s therapeutic

20
 effect. 
Other: Anaphylaxis, angioedema, l. Instruct to report change
hyperkalemia, hyponatremia, in urine pattern, black tarry
injection-site pain, stool, fever.
lymphadenopathy, sepsis,
unusual weight gain
After
Dx:
m. Assess patient
response to the drug.
n. Monitor for adverse
effects. 
o. Evaluate therapeutic
response.
Tx:
p. Promote safety and
comfort measures.
q. Watch for adverse
effects. 
EDx:
r. Encouraged patient to
verbalize feelings and
concerns.

DRUG NAME MECHANISM OF ACTION INDICATION/CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES

Generic Name: Binds with mu receptors and Indications  CNS: Agitation, anxiety, BEFORE:
Tramadol inhibits the re-uptake of depression, dizziness,
hydrochloride norepinephrine and To relieve pain severe enough to require opioid-like treatment emotional lability, fatigue, Dx:
serotonin, which may and for which alternative treatment options such as nonopioid fever, hallucinations,
Brand Name: account for tramadol’s analgesics or opioid combination products are inadequate or not headache, restlessness, [Link] doctor’s order.
Ultram analgesic effect. tolerated. Management of moderate to severe pain, chronic tremor, vertigo, weakness
 [Link] allergy to tramadol or its

21
Pharmacologic   pain. CV: Chest pain, orthostatic components. 
class: Opioid hypotension
agonist  SOURCE: Jones & Bartlett Contraindications Tx:
Learning (2015). Nurse’s EENT: Blurred vision
Therapeutic Drug Handbook. Fourteenth Alcohol intoxication; excessive use of central-acting analgesics, c. Prepare the medication at the
class: Opioid Edition. hypnotics, opioids, or other psychotropic drugs; hypersensitivity GI: Abdominal pain, right time and right dosage.
analgesic to tramadol or its components; use within 14 days of MAO constipation, diarrhea,
inhibitor therapy. indigestion, nausea, EDx:
Dosage: 50 mg vomiting
Drug to drug Interaction: Alpha blockers, CYP2D6 and d. Educate the patient and SO
Route: IV CYP3A4 inhibitors (amitriptyline, erythromycin, fluoxetine, GU: Urinary frequency, urine about the purpose and importance
paroxetine, quinidine), MAO inhibitors, and norepinephrine retention of the drug. e. Educate patients on
reuptake inhibitors, tricyclic antidepressants, triptans: drug therapy to promote
Increased risk of serotonin syndrome MS: Arthralgia; back, limb, compliance.
or neck pain 
CNS depressants such as barbiturates, phenothiazines,  
sedativehypnotics, tranquilizers: Additive CNS depression  RESP: Cough, dyspnea
DURING:
Warfarin: Possibly increased INR SKIN: rash
 Dx:

f. Verify the patient's identity. 

g. Assess the patient's condition. 

Tx: 

h. Administer medication as
prescribed.

EDx:

i. Instruct the patient to notify the

prescriber promptly if she

22
 experiences side effects such as
fever, dizziness, chest pain,
vomiting, nausea, and weakness.

AFTER:

Dx:

j. Monitor patients for side effects.

k. Monitor the effectiveness of the

drug

Tx:

l. Promote safety and comfort

measures.

EDx:

m. Instruct patients to inform all

prescribers of tramadol therapy
because of potential drug
interactions.

DRUG NAME MECHANISM OF ACTION INDICATION/CONTRAINDICATION ADVERSE EFFECT

Generic Name: Selectively inhibits the enzymatic activity of Indication CNS: Aseptic meningitis, cerebral
cyclooxygenase-2 (COX-2), the enzyme needed to hemorrhage, CVA, depression, dizziness,
convert arachidonic acid to prostaglandin. fever, headache, insomnia, suicidal

23
Celecoxib Prostaglandins are responsible for mediating the To relieve signs and symptoms of osteo-arthritis. ideation, syncope, transient ischemic
inflammatory response and causing local attacks, vertigo
Brand Name: vasodilation, swelling, and pain. Prostaglandins Contraindications
also play a role in peripheral pain transmission to CV: Aortic valve incompetence,
Celebrex the spinal cord. By inhibiting COX-2 activity and Allergic reaction (such as anaphylaxis or angioedema) to bradycardia, chest pain, congestive heart
prostaglandin production, this reduces aspirin, other NSAIDs, or sulfonamide derivatives or history of failure, deep vein thrombosis, fluid retention,
Pharmacologic inflammatory symptoms and relieves pain. aspirin-induced nasal polyps with bronchospasm; hypertension, MI, palpitations, peripheral
class: NSAID hypersensitivity to celecoxib or its components; treatment of edema, tachycardia, thrombosis, unstable
  pain after coronary artery bypass graft surgery. angina, vasculitis, ventricular fibrillation,
  ventricular hypertrophy
  Interactions Drugs
Therapeutic class: EENT: Conjunctival hemorrhage, deafness,
Analgesic, anti-   ACE inhibitors, angiotensin II receptor antagonists, beta labyrinthitis, nasopharyngitis, pharyngitis,
inflammatory, blockers: Decreased antihypertensive effect of these drugs, rhinitis, sinusitis, vitreous floaters
antirheumatic SOURCE: increased risk of renal failure in patients who are elderly, have
existing renal dysfunction. ENDO: Hyperglycemia, hypoglycemia
Dosage: 200 mg Jones & Bartlett Learning (2022). Nurse’s Drug
Handbook. GI: Abdominal pain, diarrhea, elevated liver
Route: Oral enzymes, esophageal perforation,
21st Edition. flatulence, GI bleeding or ulceration, hepatic
failure, ileus, indigestion, jaundice, nausea,
  pancreatitis, perforation of intestines or
stomach, vomiting

GU: Acute renal failure, interstitial nephritis,

ovarian cyst, proteinuria, urinary
incontinence

HEME: Agranulocytosis, aplastic anemia,

decreased hematocrit and hemoglobin,
leukopenia, pancytopenia, prolonged APTT,
thrombocytopenia

MS: Arthralgia, back pain, elevated serum

24
 creatine kinase level, epicondylitis, tendon
rupture

RESP: Bronchospasm, cough, dyspnea,

pneumonia, pulmonary embolism, upper
respiratory tract infection

SKIN: Erythema multiforme, exfoliative

dermatitis, phototoxicity, rash, Stevens–
Johnson syndrome, toxic epidermal
necrolysis, urticaria 

Other: Anaphylaxis, angioedema,

hyperkalemia, hypernatremia,
hyponatremia, sepsis

DRUG NAME MECHANISM OF ACTION INDICATION/CONTRAINDICATION ADVERSE EFFECT NURSING

RESPONSIBILITIES

Generic Name: Binds to dihydropyridine and non- Indication CNS: Anxiety, dizziness, fatigue, BEFORE:
dihydropyridine cell membrane receptor sites headache, lethargy,
Amlodipine on myocardial and vascular smooth muscle Indicated for the treatment of hypertension. lightheadedness,paresthesia, tremor Dx:
cells and inhibits influx of extracellular
Besylate calcium ions across slow calcium channels. Contraindications Hypersensitivity to CV: Arrhythmias, chest pain, a. Verify doctor’s order.
This decreases intracellular calcium level, amlodipine or its components. hypotension, palpitations
Brand Name: inhibiting smooth muscle cell contractions b. Assess allergy to
and relaxing coronary and vascular smooth Drug to drug Interaction: EENT: Dry mouth amlodipine or its
Norvasc muscles, decreasing peripheral vascular components.
resistance, and reducing systolic and Beta blockers: Possibly excessive GI: Abdominal cramps, abdominal
Chemical diastolic blood pressure. Decreased hypotension pain, anorexia, constipation, diarrhea, Tx:
Class: peripheral vascular resistance also dysphagia, flatulence, indigestion,

25
Dihydropyridine decreases myocardial workload, oxygen Cyclosporine: Possibly increased blood jaundice, nausea, vomiting c. Prepare the medication at
demand, and possibly angina. Also, by cyclosporine levels  the right time and right
Therapeutic inhibiting coronary artery muscle cell MS: Myalgia dosage.
Class: contractions and restoring blood flow, drug CYP3A4 inhibitors such as diltiazem,
may relieve Prinz metal’s angina. ketoconazole, itraconazole, and ritonavir: RESP: Dyspnea EDx:
Antianginal, Possible increased blood amlodipine level.
  SKIN: Dermatitis, flushing, rash d. Educate the patient and
Antihypertensive Fentanyl: Increased risk of severe SO about the purpose and
  hypotension and increased fluid volume Other: Weight loss
Dosage: 600 requirements during surgery importance of the drug.
mg  
Simvastatin: Increased exposure to e. Educate patients on drug
Route: Oral   simvastatin therapy to promote
compliance.
 
DURING:

SOURCE: Dx:

Jones & Bartlett Learning (2015). Nurse’s f. Verify client’s identity.

Drug Handbook. Fourteenth Edition.
g. Assess patient frequently
for chest pain when starting
or

increasing the dose of

amlodipine, because
worsening of angina or an
acute MI can occur.

Tx:

h. Administer medication
following the 10 rights of

26
medication.

i. Suggest taking amlodipine

with food to reduce GI upset.

j. Assist patients when taking

the medication.

EDx:

k. Instruct SO to report
persistent adverse effects
such as dizziness, difficulty
breathing, arm or leg
swelling, and rash.

AFTER:

Dx:

l. Monitor patient’s BP for

postural changes.

m. Monitor drug
effectiveness.

Tx:

n. Promote safety and

comfort.

EDx:

o. Encourage the patient to

27
 verbalize feelings and
concerns.

B. IV Fluids

Name Classification Component/s Use & Effects Nursing Responsibilities

Isotonic Intravenous The solution contains 9 grams of
PNSS (Plain Normal Saline Solution sodium chloride (NaCl) INDICATION BEFORE:
Solution) dissolved in 1L of water. At 22
Used because it has little to no effect on Dx:
degrees Celsius, 1 milliliter of
Form: IV Fluid  the tissues and makes the person
normal saline weight is 1.0046 hydrated, preventing hypovolemic -Obtain history of the patient’s fluid and electrolyte
Dosage/Frequency/Route grams. Because sodium chloride shock or hypotension status before therapy and reassess regularly.
has a molecular weight of
1L x 12 hours, IV @ 27-28 approximately 58 grams per ADVERSE REACTIONS -Identify the patient before administering IVF
gtts/min mode, 58 grams of sodium
chloride equals 1 mole. The -Fast heartbeat Tx:
concentration is 9 grams per
-Fever -Assess vital signs
liter divided by 58 grams per
mole, or 0.154 moles per liter, -Rash -Check and regulate the drop rate
because normal saline contains
9 grams of NaCl. Because NaCl -Joint pain, or  -Change the IVF solution if needed
dissociates into two ions,
-Shortness breath EDx:
sodium and chloride, 1 molar
NaCl is equivalent to 2 osmolar -Instruct the patient not to move her hands frequently
NaCl. As a result, NS contains where the IVF was attached
154 mEq/L of Na+ and Cl.
-Educate the patient about the IVF solution
28
-Instruct to report if dislodged occurs

DURING:

Dx:

-Monitor for signs of infiltration/sluggish flow

Tx: 

-Be alert of fluid overload

-Promote safety and comfort measures

EDx:

-Instructed the patient and watcher not to self-regulate

the IVF to avoid over infusion

AFTER

Dx: 

-Monitor for side effects

-Monitor fluid intake and output per shift 

Tx:

-Palpate and inspect site for puffiness,

redness,blanching, skin temperature (very warm or very
cool), wetness

EDx:

29
 -Instruct SO to report untoward signs and symptoms

C. Surgery

Procedure Description & Indication Nursing Care/Responsibilities

Low segment transverse
Cesarian Section Cesarean section is the ultimate method of successful Perform a complete maternal and fetal assessment
delivery of infants under various circumstances and is an
indispensable operation in obstetrics. However the degree of -Provide physical and emotional support
difficulty varies greatly depending on the gestational weeks,
number of fetuses, number of previous cesarean sections,
degree of placental adhesion, presence of uterine myomas,
maternal obesity and other factors.

    The most common indications for primary cesarean delivery

include, cephalo-pelvic disproportion, fetal malpresentations,
Previous cesarean section, fetal distress, cord prolapse, fetal
malformations likely to cause obstructed labor and high order
multifetal gestation

30
XV. Nursing Care Plans

A. Prioritization of Problems

a.1. List of Problems

1. Decreased cardiac output related to alterations in rate as evidenced by changes in BP(hypertension)

2. Acute pain related to Surgical incision as evidence by pain score of 8/10
3. Imbalanced Nutrition: Less than body requirements related to decreased glomerular filtration as
manifested by pedal edema
4. Ineffective Tissue Perfusion related to Hypovolemia as evidenced by Changes in vital signs and
restlessness
5. Knowledge Deficit related to lack of information regarding diet (high sodium and high fat)

a.2. Basis for Prioritization

NURSING DIAGNOSES JUSTIFICATION

Physiological needs are the highest priority in Maslow's
1. Decreased cardiac output Hierarchy of Needs. This indicates that in order to reach the
related to alterations in rate as four remaining levels, one must meet his or her physiological
evidenced by changes in BP
needs, which include keeping one's body in good condition.
(hypertension)
Elevated blood pressure is a diagnosis that affects a person's
physical health; thus, it is crucial to take the appropriate
measures and medications to maintain it at a healthy level.
2. Acute pain related to Surgical The desire for safety is considered a basic human need, which
incision as evidence by pain is provided on the second tier of the pyramid, the safety sector,
score of 8/10 according to Maslow's Hierarchy of Needs. Being in pain can
impair a patient's well-being, thus we make this our 2nd
priority.
3. Imbalanced Nutrition: Less Physiological requirements should be met as the 4th priority,
than body requirements according to Maslow's hierarchy of needs. As a result,
related to decreased measures to alleviate the condition must be carried out.
glomerular filtration as
manifested by pedal edema
4. Ineffective Tissue Perfusion Biological requirements for human survival, e.g. air, food,
related to Hypovolemia as drink, shelter, clothing, warmth, sex, sleep. If these needs are
evidenced by Changes in vital not satisfied the human body cannot function optimally.
signs and restlessness

5. Knowledge Deficit related to Cognitive needs are needs based on knowledge and
lack of information regarding understanding, curiosity, exploration, predictability, creativity,
diet (high sodium and high fat) discovery, and meaning. Per Maslow, people yearn to
understand the world around them. People yearn for
experiences that mold them as individuals.

31
 B. Nursing Care Plans

TNCP 1:   Decreased cardiac output related to alterations in rate as evidenced by changes in BP (hypertension)
Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation

Subjective: Preeclampsia is one high STO: Within 4 hours of Dx: Dx: GOAL MET
blood pressure (hypertension) effective nursing interventions,
“Nahihilo ako at Masakit disorder that can occur during the patient will be able: • Monitored blood pressure. • Severe hypertension is classified [in STO: After 4 hours of
batok ko” as verbalized. pregnancy. adults as a diastolic pressure elevation of effective nursing
a. To experience lower blood Tx: 110 mmHg; progressive diastolic interventions, the (Patient
Objective: SOURCE: pressure readings above 120 mmHg are experienced lower blood
• Provided comfort measures such as considered first accelerated, then pressure.) 
Bp: 160/100 Https://[Link]/ LTO: Within 12 hours of back and neck massage, and elevation malignant (very severe).
diseases-conditions/ effective nursing intervention, of head. GOAL MET LTO: Within
Nursing diagnosis: preeclAmpsia/symptoms- patient will be able: Tx: 12 hours of effective
causes/syc-20355745 •Administer anti-anginal medication as nursing intervention, patient
Decreased cardiac output a. To report an improvement in indicated. • Decreases discomfort and may reduce was able to report an
related to alterations in his blood pressure as evidenced sympathetic stimulation. improvement in his blood
rate as evidenced by by no shortness of breath with Edx: pressure as evidenced by no
changes in BP minimal exertion and heart rate •Diuretics are considered first-[line shortness of breath with
(hypertension) within safe limits. • Instructed to reduce salt [(sodium), medications for uncomplicated stage l or minimal exertion and heart
fat and cholesterol [intake. lI hypertension and may be used alone or rate within safe limits.
in association with other drugs (such as
• Advised to take plenty of fiber in the beta-blockers) to reduce BP in patients
form of vegetables and fruits. with relatively normal renal function.

Edx:

•These restrictions can help manage fluid

retention and, with the associated
hypertensive response, decrease
myocardial workload.

•Bulking up on fiber may help people

32
 keep their blood pressure under control.

NCP 2:  Acute pain related to Surgical incision as evidence by pain score of 8/10

Assessment Explanation of the Problem Objective Nursing Rationale Evaluation

Intervention

Subjective: Acute pain is caused by injury, surgery, illness, trauma or painful STO: After 4 hours of nursing Dx: Dx: GOAL MET STO: After 4
medical procedures. It serves as a warning of disease or a threat to interventions, patients would be hours of effective nursing
“Masakit ang the body. It generally lasts for a short period of time, and usually able to verbalize the Instructions •Monitored vital • For baseline data interventions,The patient was
sugat ko" as disappears when the underlying cause has been treated or has given. signs and recorded and to note progress. able to  verbalize the
verbalized by the healed. instructions given.
patient.   •Assessed wound • Wound dehiscence
for intactness. occurs with excessive GOAL MET LTO: Within 12
Objective:   stress on a new hours of effective nursing
SOURCE: •Assessed for signs incision. intervention,  patient was able
(+) surgical of infection to verbalize relief of pain and
incision [Link] • Purulent drainage is rated pain 4/10.
 Tx: an indication of
> Warm infection.
LTO: •Positioned the
Nursing patient comfortably Tx:
Diagnosis: Within 12 hours of effective
nursing intervention, patient will •Encouraged • To promote comfort.
Acute pain related be able: verbalization of
to Surgical feelings • To know what
incision as a. To verbalize relief pain on the nursing interventions
evidence by pain incision part. •Applied will be Performed.

33
score of 8/10 appropriate • To help in wound
dressing. healing
 
• Kept the area • To prevent infection.
clean/dry
Edx:
Edx:
• To control the
• Instructed the spread of
importance of hand microorganisms.
washing
• To aid in tissue
• Instructed the repair.
patient on the
importance of • These can cause
foods rich in further injury and
protein. delay healing.

•Educated not to •To prevent infection.

rub or scratch the
area.

•Instructed the  
patient in proper
care of area.

NCP 3:  Imbalanced Nutrition: Less than body requirements related to decreased glomerular filtration as manifested by pedal edema

Assessment Explanation of the problem. Objective Nursing interventions. Rationale Evaluation

34
Subjective: Fluid Volume Excess (FVE), or hypervolemia refers to an STO: Within 4 hours Dx: Dx: GOAL MET STO: Within 4
isotonic expansion of the ECF due to an increase in total of effective nursing hours of effective nursing
“Agmanas toy sakak” body sodium content and an increase in total body water. interventions: ●  Monitored vital signs. ●Increased heart rate and interventions:
as verbalized. This fluid overload usually occurs from compromised respiratory rate and
regulatory mechanisms for sodium. a. The client will ●  Monitored Intake and bounding peripheral pulse a. The client was able to
Objective: display normal fluid Output. can indicate an increase in display normal fluid volume
SOURCE: volume and fluid volume. and electrolytes.
·BP: 160/100 mmhg electrolytes. Tx:
●Monitoring sources of
Wayne, G. (2022). Nurseslabs. Fluid Volume Excess b.   The client will be ●  Noted for presence of intake via oral and b. The client was able to
·Noticeable pitting Nursing Care Plan. [Link] fluid- able to verbalize edema by palpating over Intravenous and verbalize understanding on
edema on both feet, volume/ understanding on fluid the tibia, ankles, and comparing to the patient’s fluid restrictions.
graded as +1 restrictions.  feet. output will prevent fluid
overload. GOAL MET LTO: Within
Nursing Diagnosis: LTO: Within 12 hours ●  Administer diuretics 12 hours of effective nursing
of effective nursing (furosemide) as ordered. Tx: interventions, the client
Fluid volume excess r/t interventions: edema particularly in lower
compromised ●  Elevated edematous ●  Pitting edema is extremities was slowly
regulatory mechanism a. The client edema extremities. manifested by a decreasing.
as manifested by particularly in lower depression that remains
edema  extremities will slowly ●  Provide a low-sodium after one’s finger is  
decrease. diet/beverage. pressed over an edematous
area and then removed. 
Edx:
●  May be necessary to
Enforced fluid correct fluid overload.
restrictions and educated Drug choice is usually
on the importance. dependent on the acute or
chronic nature of
symptoms.

35
 ●  Elevation increases
venous return to the heart
and, in turn, decreases
edema.

●  Sodium enhances fluid

retention and should
therefore be restricted
during active MI phase
and/or if heart failure is
present.

Edx:

For better adherence.

Fluid restrictions prevent
the patient from taking in
too much extra fluid.

NCP 4:  Ineffective Tissue Perfusion related to Hypovolemia as evidenced by Changes in vital signs and restlessness

Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation

Subjective: Fluid Volume Excess (FVE), or hypervolemia STO: Within 4 Dx: STO: Within 4

36
“Hanak nakaturturog refers to an isotonic expansion of the ECF due to hours of effective  Monitor vital signs  Sludging and sickling in peripheral hours of effective
manipud idi rabii” an increase in total body sodium content and an nursing carefully. Assess pulses vessels may lead to complete or nursing
increase in total body water. This fluid overload interventions: for rate, rhythm, and partial obliteration of a vessel with interventions:
Objective: usually occurs from compromised regulatory volume. diminished perfusion to surrounding
mechanisms for sodium. a. Will be able to tissues. Sudden massive splenic a. Demonstrated
·BP: 160/100 mmhg demonstrate sequestration of cells can lead to behaviors to
SOURCE: behaviors to shock. improve or maintain
Nursing Diagnosis: improve or  Note changes in LOC;  Changes may reflect diminished circulation.
Wayne, G. (2022). Nurseslabs. Fluid Volume maintain reports of headaches, perfusion to the CNS due to ischemia
Ineffective Tissue Excess Nursing Care Plan. circulation. dizziness; development or infarction LTO: Within 12
Perfusion related to [Link] fluid-volume/ of sensory or motor hours of effective
Hypovolemia as LTO: Within 12 deficits, such as nursing
evidenced by hours of effective hemiparesis or paralysis; interventions:
Changes in vital nursing and seizure activity.
signs and restlessness interventions: a. Improved tissue
Tx: perfusion as
a. Improve tissue evidenced by
perfusion as  Monitor urine output. stabilized vital signs
evidenced by
stabilized vital  Decreased renal perfusion and b. Was able to sleep
signs failure may occur because of comfortably
 Maintain environmental vascular occlusion.
b. Able to sleep temperature and body  Prevents vasoconstriction,
comfortably warmth without aids in maintaining
overheating. Avoid circulation and perfusion.
hypothermia Excessive body heat may
cause diaphoresis, adding to
insensible fluid losses and
risk of dehydration.
Hypothermia may
exacerbate cardiovascular
compromise with severe
anemia.

37
 Edx:  Dehydration not only causes
hypovolemia but increases
 Maintain adequate fluid sickling and occlusion of
intake. capillaries.

NCP 5:  Knowledge Deficit related to lack of information regarding diet (high sodium and high fat)

Assessment Explanation of the Problem Objective Nursing Intervention Rationale Evaluation

Subjective: A knowledge deficit in relation to healthcare is a lack of information STO: After 4 hours of the Dx: Dx: GOAL MET
needed for a thorough understanding of a disease process and nursing interventions, the
“Kapag kumakain recommended treatments and the ability to make informed choices or patient will be able to Assess ability to learn or • Cognitive impairments STO: After 4 hours of the
kasi kami sa bahay carry out tasks in alignment with health maintenance. verbalize understanding of perform desired health- must be recognized so nursing interventions, the
ngay ket may karne diet. related care. an appropriate teaching patient verbalized
ng baboy”. Source: plan can be outlined. understanding of
LTO: Within 12 hours of understanding of diet
Objective: [Link] effective nursing  Tx:
care-plan/ intervention, patient will GOAL MET
Tx:
BP: 160/100 mmhg be able to adhere to the • Conveying respect is
info given and differentiate especially important LTO: After 12 hours of
Nursing Diagnosis: what to eat and what not to  Provide an when providing the nursing interventions,
eat. atmosphere of education to patients the patient was be able to
Knowledge Deficit respect, openness, with different values adhere to the info given
related to lack of trust, and and beliefs about health and differentiate what to
information collaboration. and illness. eat and what not to eat.
regarding diet (high

38
sodium and high fat)

• To know what to
demonstrate to the
patient.
 Encouraged
verbalization of
questions on infant
care.

• In patients with low

 When teaching, literacy skills, materials
build on patient’s should be short and
literacy skills. have culturally sensitive
illustrations.

• Immediate feedback
allows the learner to
 Provide immediate make corrections rather
feedback on than practicing the skill
wrongly.
performance.

 Allow repetition of
the information or • Repeated practice
skill. allows patients to gain
confidence in self-care
ability.

39
Edx:

 Instructed on the Edx:

importance if right
• This will create an
infant care.
important foundation
for the child’s growth.

40
 C. Discharged Plan
Health Teaching
Diet/Nutrition
1. Encouraged to avoid excessive intake of
carbohydrates, especially refined carbohydrates

2. Advised to stay away from high-fat, sugar and salt-rich

diets

3. Instructed to avoid beverages containing caffeine

Activity
[Link] to be placed on activity restrictions or bed
rest.

2. Avoid heavy lifting. Get some help with chores if you

can.

3. Instructed to monitor and record blood pressure daily.

4. Instructed to elevate legs when sitting or lying down.

Medication
1. Instructed to take medicines exactly as directed and
not skip doses.  

2. Instructed to check with healthcare provider in case of

missed dose/doses.  

3. Educated regarding the importance of taking

medication at a proper dose and time.  

4. Informed on the side effects of the drugs being taken. 

I
Instructed to contact physician if there are any adverse
effects to the medication prescribed.

5. Instructed to take low-dose aspirin as indicated

XVI. Learning Insights

(Individual and arranged alphabetical order. Includes what you have learned from the case of your
patient, from assessment, diagnosis, planning, implementation or nursing care and evaluation.
PARAGRAPH FORM, express your writing skills.)
A. ABALAOS, Mary Anne Monica
In our three days duty, handling patient X is…
B. CANERO, Elaine Ruth
The case of patient X is…
C. CAROLINO, Ritz
I believe that…
D. DD
Honestly, I am not part of the directly monitoring the patient but I was able to learn a
lot from our case by sharing my insights regarding…
E. EE
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
F. FF

41
 I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
G. GG
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
H. HH
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
I. II
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
J. JJ
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…

42
XVII. List of References

.Young, B. C., Levine, R. J., & Karumanchi, S. A. (2010). Pathogenesis of preeclampsia.

Annual review of pathology, 5, 173–192. [Link]
102149. 

Kanasaki, K., & Khaluri, R. (2009, October 2). The biology of Preeclampsia . Kidney
International. Retrieved December 7, 2022, from
[Link]

Rana, S., Sarosh Rana  From the Division of Maternal Fetal Medicine, Lemoine, E., Elizabeth
Lemoine  Harvard Medical School, Granger, J. P., Joey P. Granger  Department of
Physiology, Karumanchi, S. A., S. Ananth Karumanchi Correspondence to S. Ananth
Karumanchi, Karumanchi, C. to S. A., & Al, E. (2019, March 28). Preeclampsia.
Circulation Research. Retrieved December 8, 2022, from
[Link]

Drug Bank Online (n.d.) Furosemide. Retrieved from [Link]

Drug Bank Online (n.d.) Metoprolol . Retrieved from [Link]

43
Hiramatsu, Y. (n.d.). Lower-Segment Transverse Cesarean Section. Retrieved from
[Link]

RNpedia (n.d.). Cesarean Delivery Nursing Care Plan and Management. Retrieved from
[Link]
cesarean-delivery/

44