Professional Documents
Culture Documents
_________________________________________
A Care Study
Presented to
Mandaue City
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In Partial Fulfillment
Of the Requirement in
501201
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By:
Janice B. Omolon
BSN III-A
August 2008
TABLE OF CONTENTS
I INTRODUCTION……………………………………………………………..
II GENERAL DATA…………………………………………………………….
A. Family history………………………………………………………………
C. Environmental history……………………………………………………..
D. Symptomatology……………………………………………………………
X MEDICAL MANAGEMENT………………………………………………….
C. Medications………………………………………………………………….
D. Diet………………………………………………………………………….
XI NURSING MANAGEMENT………………………………………………….
D. Evaluation…………………………………………………………………...
E. Patient Teaching…………………………………………………………….
A. Nursing Education…………………………………………………………..
B. Nursing Practice……………………………………………………………..
C. Nursing Research……………………………………………………………
APPENDICES…………………………………………………………………..
Appendix B: NCP
BBLIOGRAPHY
I INTRODUCTION
elevated BP during pregnancy without the signs proteinuria and edema. There is no
Gestational hypertension (GH) is high blood pressure that develops after the
twentieth week of pregnancy and returns to normal after delivery, in women with
develops but remains mild, the outcome of pregnancy is usually good for both the mother
and newborn. GH has been shown to occur more frequently in women who are obese1 or
Nationality: Filipino
Hospital number: 1P
Final Diagnosis: Pregnancy Uterine Full Term delivered a live baby girl by 1°
hypertension.
III HISTORY OF PRESENT ILLNESS
One week prior to admission noted irregular uterine contraction and mild sought
result with AP and was advised condition persisted. She has an OB score of G4P1 1021.
At the age of 13 years old the patient had her menarche, three to five days of
duration for twenty eight to thirty days of menstrual cycle. She claimed to use three pads
She had her first menstrual contact at the age of twenty five with her husband as
She had her first delivery through normal spontaneous delivery on 1999 baby girl
Cardiovascular: “Wala man koy gi pamati pero taas ang ako BP” as verbalized by the
patient.
patient.
the patient.
patient.
VI FAMILY, PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY
A. FAMILY HISTORY
She does not drink alcohol and does not smoke. She is a college level and now is
a housewife. Her religious affiliation is Baptist. She seldom travel to any places. She was
able to take over the counter drug like neozep, biogesic, and advil.
C. ENVIRONMENTAL HISTORY
The house is a bungalow type and made of concrete and no gate. It has three
rooms. She lived together with her parents and her eldest daughter. Her husband is a
seaman .The garbage is collected every Monday and the drainage is an open type.
VII PHYSICAL ASSESSMENT
standing as evidence by grimaced face and verbal expression of pain. She is cooperative
Integument: Patient has affair complexion . The skin is warm and in good turgor.
Eyes: Pupils are equal round and react to light and accommodation.
School age Industry versus -skill mastery She was not an honor
6-12 years Inferiority -work and play in student but is highly
groups appreciated by her parents.
-intellectual growth.
(Bellack, 1988)
Adolescence Identity versus .-sense of self and She had her first crush at
12-20 years Role Confusion identity apart from the age of 12.
parents. (Bellack, 1988)
Young adult Intimacy versus -learn to establish She was married to her
20-40 years Isolation relationships with husband at the age of 26.
partner, gratifying
social relationships.
(Bellack, 1988
IX ANATOMY, PHYSIOLOGY AND RELATED PATHOPHYSIOLOGY
If you develop high blood pressure after 20 weeks of pregnancy but don't have
blood pressure after midpregnancy and have protein in their urine have a complex
disorder called preeclampsia, and those who had high blood pressure before
pregnancy, or are diagnosed with it before 20 weeks, have what's called chronic
hypertension.
only one of the numbers is elevated. It doesn't usually cause any noticeable
Because high blood pressure can affect blood flow to the placenta, if the
to be sure that the baby has been growing well and to see if the mother have a
normal amount of amniotic fluid. The patient may also have a biophysical profile
(BPP) done at the same time to check on the baby's well-being. And in certain
cases, the patient have a Doppler ultrasound to check blood flow to her baby.
The caregiver may also order a set of blood tests and ask you to collect urine for
24 hours to check for protein (this is a more sensitive test than the urine dip done
at each prenatal visit). These lab tests will help her determine whether the patient
have preeclampsia and allow her to gauge any later changes in the mother’s
condition.
B. Theoritical and Conceptual Framework of Gestational Hypertension
Generalized
Vasopasm
Endothelial
Vasoconstriction
damage
Abnorml
clotting
occurs
Decrease Fkuid moves out on
bkood flow blood stream and in
interstitial spaces
It depends on how far along you are in pregnancy when you develop gestational
hypertension and how high your blood pressure gets. The more severe your hypertension
and the earlier in pregnancy it appears, the greater your risk for problems. The good news
is that most women who get gestational hypertension have only a mild form of the
condition and don't develop it until near term (37 weeks or later). If you're in this
category, you still have a somewhat higher risk of being induced or having a c-section,
but other than that, you and your baby are likely to do as well as you would if you had
preeclampsia during pregnancy or labor, or soon after giving birth. And the chances of
Having gestational hypertension also puts you at increased risk for a number of other
D. SYMPTOMATOLOGY
-Symptoms, which appear - Patient was advised for -A physical indication such
after the twentieth week of cesarean section. She as elevated blood pressure
pregnancy, include swelling claimed that the doctor should be documented
of the face and hands, scheduled her for cesarean before a cesarean procedure
visual disturbances, section because of elevated can be performed.
headache, high blood blood pressure
pressure, and a yellow
discoloration of the skin
and eyes.
X. MEDICAL MANAGEMENT
PROCEDURE
IDEAL ACTUAL
Appearance: clear
• Sonogram to determine fetal
Ph: 6.2
Presentation and maturity.
Specific gravity: 1.010
Protein: negative
(Pilliteri,2007)
Glucose: negative
Microscopic
IDEAL ACTUAL
(Pilliteri,2007)
MEDICATIONS
IDEAL ACTUAL
6 hours
(Pilliteri,2007)
• Mathergine 1 amp IM every 8
hours
prn
DIET
IDEAL ACTUAL
Standard Diet after cesarean section • NPO for 8 hours after surgery
windows
tolerated
Assessment of the patient’s incision site -- to know whether infection has occur
and to assess the wound healing.
Careful explanation was provided o the patient to establish rapport and gain
cooperation.
D. Evaluation
The patient was cooperative and was responsive to the care given.
E. Patient Teaching
A. Nursing Education
This study implies learning about what is gestational hypertension and its causes.
It will provide brief information about the anatomy and physiology of the systems
B. Nursing Practice.
enhance our skills in performing skills such as monitoring vital signs and measuring
intake and output. Enhance skills in assessing incision site. and implies a positive attitude
in caring patient .
C. Nursing Research
This study will provide data in doing future research related to gestational
hypertension.