Abruptio Placenta

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I. Introduction
A. Description of Health Condition
Overview of the Case
Pre-eclampsia
Pre-eclampsia is the presence of hypertension and proteinuria occurring after the
20th week of gestation except in cases of extensive trophoblastic proliferation. Pre-eclampsia
has been further classified as severe in the presence of one or more of
the following signs and symptoms.
Signs and Symptoms Mild Preeclampsia Severe preeclampsia
Blood pressure 140/90 or higher, or an
increase of 30 mmHg in
systolic pressure and 15
mmHg increase in
diastolic pressure
160/110, or an increase of
greater than 30 mmHg in
systolic pressure and
greater than 15 mmHg
Edema Mild to moderate edema of
hands and face (+1 to +2)
Severe edema of hands
and face (+3 to
+4),including cerebral
edema
Proteinuria Greater than 0.3 g-1g/L/
24-hour urine (+1 to +2)
5 g/L/24-hour urine or
more (+3 to +4)
Weight gain Greater than 1lb/week Equal to or greater than 5
lb/week
Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero,
Diamenteband Gamilla at Chapter 39 page 587)

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Abruptio Placenta
Abruptio Placenta is the premature separation of a normally implanted placenta
occurring after the 20nd week of gestation when the clinical and pathologic criteria are
met. Though it is one of the causes of third trimester bleeding, it may also complicate
labor. Hypertonic uterine contractions in labor or sudden uterine decompression may
precipitate abruption placenta. Other terms of abruption placenta are accidental
hemorrhage, premature separation of the placenta and placental apoplexy.
Etiology / Predisposing Factors
Numerous factors have been suggested to play a role in abruption placenta but a
unifying etiologic concept is still lacking.
These predisposing factors are:
1. Maternal Hypertension.
2. Cigarette Smoking.
3. Premature rupture of membrane.
4. Chorioamnionitis.
5. Severe fetal growth restriction.
6. Advanced maternal age and parity.
7. Thrombophilias.
8. Race or ethnicity.
9. Women with previous abruption.
10. Trauma.
11. Short umbilical cord late in labor as the fetus descends.
12. External or internal version.
13. Sudden decompression of the uterus in cases of over distention, loss of amniotic
fluid or after delivery of the first twin.
14. Uterine anomalies or tumors like in retroplacental myomas.
15. Cocaine abuse during pregnancy increases the risk of abruption.

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Classification
As to extent:
1. Partial – a part has separated
2. Total – the whole placenta has separated
As to onset:
1. Acute abruption- sudden onset of signs and symptoms
2. Chronic abruption- shows hemorrhage with retroplacental hematoma formation
being arrested completely without delivery.
As to type of bleeding:
1. External- the bleeding passes between the membranes and the blood escapes
through the cervix.
2. Concealed- the bleeding is not seen externally but is retained between the
detached placenta and the uterus or may extravasate into the amniotic cavity.
The fetal head is closely applied to the lower uterine segment that blood cannot
pass through. The extent of bleeding may not be apparent and may present as
maternal shock that is disproportionate to the amount of blood loss. The uterus
may be larger than age of gestation due to the accumulation of retroplacental
blood.
3. Marginal sinus rupture- the placental separation is limited to the margin with
minimal bleeding but without uterine tenderness and pain.
Signs and Symptoms
1. Vaginal Bleeding- hallmark of abruption placenta. Only 10% of affected women
present with concealed hemorrhage.
2. Abdominal pain- may indicate extravasation of blood into the myometrium or
painful hypertonic contractions induced by the abruption.

3. Uterine Tenderness- may be generalized or localized to the site of placental
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detachment.
4. Uterine hypertonus- uterine tonus is elevated, feeling rigid or board like.
5. Fetal distress.
6. Dead fetus.
Complications
Complications of abruption are hemorrhage, coagulation failure, acute renal
failure, acute corpulmonale, Sheehan’s syndrome and post transfusion hepatitis.
Maternal oliguria and shock may occur. Fetal distress may end in fetal death.
(Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito,
Carnero, Diamenteband Gamilla at Chapter 562 page 562-568)
B. Statistical Data
The reported incidence of abruption placenta varies widely in published series
according to the population studied and the diagnostic criteria applied.
Incidence in the Philippines varies, from 1 in 200-300 pregnancies. Worldwide
incidence is the same.
(Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito,
Carnero, Diamenteband Gamilla at Chapter 562 page 562-568)
C. Scope and Limitation
We handled our patient on August 3, 7 and 10 2014 at 6-2 shift and 2-10 shift in
Bed 10 OB Ward of Laguna Medical Center- Santa Cruz under Ms. Elizabeth Vivian
Mozo, R.N, M.A.N. and Mr. Jayson Celerio, R.N, M.A.N. We received our patient lying
on bed with an intravenous fluid of D5NR and Oxygen therapy at 3liters via nasal
cannula. The coverage of our duty was Nurse – Patient – Interaction/ Interview, Head –
to - Toe Physical Assessment, IV regulation, monitoring and recording of vital signs, and
drug administration by oral route. After the patient confinement our group decided to do

a home visit for further assessment and to observe the patient’s progress at September
12, 2014.
During our duty we never encounter any problems in gathering data and
information about our patient and her condition.
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D. Background of Study
The researchers chose the case to attain additional knowledge and skills about
the stated problem as presented, to gather health information regarding our client, to
know the different laboratory done and result, to attain with the correct nursing care plan
for our client and for us to fully understand and be reminded on one of the complications
associated with pregnancy.

II. Patient’s Profile
Hospital no. : 000000000155915
Hospital Code: 0000194
Patient’ Name: Patient X
Address: 065 Gatid,Santa Cruz (Capital) (26) Laguna
Gender: Female
Birthday: June 3, 1984
Age: 30 y/o
Birthplace: Manila
Nationality: Filipino
Civil Status: Single
Religion: Roman Catholic
Educational Attainment: High School Graduate
Occupation: Waitress when she was 18 years old
Allergies: Seafood
LMP:11/06/13
EDC: 08/13/14
AOG: 37 weeks and 5 days
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ADMISSION
Admitting Time: 4:05 am
Admitting Date: 08/02/14
Admitting Clerk: Jane Mae H. Nolasco
Admitting Diagnosis: G3 P2 37 5/7 Weeks
Other Diagnosis: Still Birth
Abruptio Placenta
Pre-clampsia Severe
Procedure: Caesarean
Admitting Physician: Dra. Marila T. Villalon
Chief Complaint: Her reason why she was admitted on the hospital was because she
suddenly saw a moderate bleeding from her vagina and felt a severe pain on her low
back and abdomen with rapid contractions on her uterus.

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A. Present Health History
Last August 2, 2014, at nine o’clock in the evening, while our patient was watching
television she suddenly saw a moderate bleeding from her vagina and felt a severe pain
on her low back and abdomen with rapid contractions on her uterus. Her husband
decided to rush her to Laguna Medical Center – Santa Cruz. There and then, her blood
pressure was checked and as the doctor found it to be high of 190/120mmHg , she was
advised to be confined especially when they found out that the baby was already
suffering fetal distress with fetal heart rate of 31 b/m. Later that same night, due to her
high blood pressure, the doctor then decided that the patient needed to undergo surgery
and was scheduled at four o’clock of the following morning. While she was at the C -
Section, her blood pressure was 170/100 mmHg. By 4:23 am, the baby was delivered
and unfortunately, the baby was already dead by then. Our patient was confined for
fourteen days more.
B. Past Health History
Since 18 years old, she used to drink alcoholic beverages, caffeine-rich drinks and
enjoyed eating salty foods. Since she was 20 years old, she thinks she is having a high
blood pressure. She did not seek any medical consultation because she felt she could
tolerate the head ache. Instead, she is taking herbal medicines like garlic that improved
her condition. But, despite continued consumption of herbal intakes, she noticed nape
pain and headache. That was when she decided to have a check-up in their Barangay
where she was given proper medication to lower her blood pressure.
When she got pregnant, her blood pressure would gradually increase from time to
time. But she was able to undergo normal delivery. During pregnancy she noticed again
that within the three months, she felt a nape pain and headache. And on the third month

of pregnancy she decided to have an ultrasound and they found out a low transverse
position of the baby. Lastly, on the seven month of pregnancy, they decided again to
have an ultrasound and found out that the baby’s position is back to normal which is
cephalic.
11

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C. Family History
Legend:
Man Woman A.W - Alive & Well
Mother
Cardiomegaly
Diabetes
Hypertension
R.I.P
51 y/o
Father
Hypertension
R.I.P
63 y/o
PATIENT X
Hypertensive SISTER
A.W
SISTER
A.W
LOLO (RIP)
Hypertensive
LOLA
(RIP)
(A.W) (RIP)
(A.W) A.W
(A.W
(R.I.P
)
(RIP)
(A.W)
(A.W)
(A.W)

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D. Developmental History
Experience Indicators of
Positive Resolution
Analysis
Erick Erikson’s
Psychosocial
( Adulthood 30-65 old )
Generativity vs Stagnation
“Masaya naman ako sa
buhay naming, nakakakain
naman kami ng tatlong beses
sa isang araw minsan nga
pag may pera apat hanggag
limang beses pa kahit na
janitor ang sawa ko at
nagpag-aaral ko naman ang
anak ko”
Indication of positive
resolution productivity
and concern with others.
The patient is aware
in her environmental
and emphasizes that
she is able to cope
up with it she is
satisfied in what she
had now and also
she understand the
importance of caring
for other people
E. Socioeconomic
Starting at the age of 18, the patient became a part time waitress during nighttime,
AVON retailer at daytime, and sometimes a laundry washer with an estimated monthly
salary of 2500-3000 pesos per month. But since when she had her new partner in life
last 2013, she stopped working and became a fulltime housewife as advised by his
partner.
F. Psychological
The patient was able to answer every question that was asked to her and can
appropriately give a feedback about it.

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G. Spiritual
The patient is a Roman Catholic. She views God as the father of heaven and a
supreme creator although she’s not an active member of a church. She rarely go to
church. But still, she has her faith and was able to express her feelings to God through
prayer.
Sociocultural
The patient consults to a “hilot” and herbularyo as the primary health care provider.
When one of the family member experiences a cough, colds or fever, they are treating it
first at their home with self-medication like taking “Mag asawang gamot” , the Antibiotic
and Paracetamol. But when the time comes that a more serious health condi tion
happens, she is immediately consulting it to the hospital.
H. Elimination
Before Hospitalization During Hospitalization After Hospitalization
Patient’s bowel routine is
1 – 2 times daily. The
stool is color brown and
solid in appearance. She
voids 2 -3 times a day
with a yellow color urine
output.
The patient has inserted
indwelling Foley catheter.
She had her bowel
movement on her second
day of hospitalization.
Patient’s bowel routine is
once or twice a day. The
stool color is brown or
sometimes yellow in a
usual amount. She voids 5
times a day with a urine
color of yellow.
I. Exercise
Patient doesn’t have regular exercise. But she always do the household chores like
sweeping the floor, washing clothes and dishes and views these as her primary form of
exercise.

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J. Hygiene
The patient takes a bath
once a day. But
sometimes when she
feels uncomfortable she’s
doing it twice. In the
morning before going to
work and evening before
going to sleep.
The patient takes a
shower when she can
walk through and go to
the comfort room but ask
her father to apply
sponge bath when she
cannot.
The patient takes a bath
once every day.
K. Sleep and Rest
According to the patient,
she enjoys watching
Korean Telenovela in the
middle of the night.
Habitually, she sleeps at
2 am or 3 am and
waking up in the morning
at 9 am or 10 am.
The patient experienced
disturbance in her sleeping
pattern when she was in the
hospital. Every time she
heard a crying baby while
she’s sleeping during the
night, she suddenly wakes
up and imagined that this
sound was from her own
baby and feels like she was
longing for the presence of it.
She continues her sleep
after 4-5 hours and mostly
has time to sleep in the
The patient still enjoys
watching movies at
night especially Korean
Telenovelas during
midnight. She now
sleeps at 11 pm to 5:30
am and wake up at 9
am – 10 am.
Sometimes, depression
sets it during the night
and still disturbs her
sleeping pattern.

morning after the rounds of
the Doctor at 8 am.
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L. Nutritional Status
The patient loves to eat noodles and salty foods like junk foods. She also eats
vegetables like bitter gourd, lady finger and green beans. She drinks 3-4 glasses of
water and consumes 3-4 cups of coffee a day. For her meal she consumes about 2-3
cups of rice and she enjoys eating with condiments such as 1 ½ tablespoon of soy
sauce and fish sauce. Sometimes, she consumes 3 matchbox size of meat a day.
During her hospitalization, the patient always eat 6-7 pandesals or sometimes 1-2 cups
of rice per meal with vegetables soup, fried chicken and a cup of coffee in the morning.
And at home after her hospitalization, she still loves to eat noodles and salty foods like
junk foods. She drinks 4 glasses of water and consumes almost 4 cups of coffee a day.
For her meal, she consumes about 1 ½ - 2 cups of rice and still enjoys eating with
condiments such as 1 ½ tablespoon of soy sauce and fish sauce.
M. Alcohol Use
According to her, she started drinking alcoholic beverages at a young age of 18. She
feels like it is a stress reliever when she’s in pain or depressed. She likes drinking with
her friends. They drink beer and sometimes Lambanog. In a group of 3-4 people, each
can consume 6 bottles of beer and they sometimes consume 4 bottles of Lambanog
every session, thrice a month. But as the time goes by, reaching the age of 30’s, she
drinks alcohol occasionally. Until now, the patient is drinking alcohol whenever her
friends invite her or when she and her partner want.
N. Tobacco Use
According to our patient, she started using tobacco at the age of 18, she
consumes 6-7 sticks a day but when she got her first pregnancy she stopped smoking

and after she delivered the baby she started consuming tobacco again. The same when
she was pregnant in her 2nd baby and the last baby whose stillbirth. At the present, she
stated that she have already stopped smoking.
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O. Obstetric
The patient is G3 T2 P0 A0 L2. She first became pregnant when she was 22 years
old. She delivered her first baby normally. It was a full term baby boy. At the age of 24,
she became pregnant again and delivered a full term baby girl. And she got pregnant
again at 30 years old.

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PHYSICAL ASSESSMENT
Area Methods Findings Interpretation &
Reference
Integumentary
System
 Skin
 Inspection/
Palpation
- Pallor
- poor skin turgor
 This is due to
the blood loss
during the post-surgical
procedure/ post
caesarean
delivery, and
due to low level
of RBC as
evidence by
Hgb result of
5.4 mg/dl.
 In the presence
of excess
interstitial fluids
on area of
edema , the
skin becomes
dry and shiny
Ref: Fundamentals of
Nursing by Kozier,
Erbs Vol 2 pg 1436
 Hair  Inspection - well distributed &
black in color hair
NORMAL
 Nails  Inspection
- Pale Nail Beds
 This is due to
the blood loss
during the post-surgical

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 Blanching of
capillaries
- 3-4 seconds
capillary refill upon
blanching
procedure/ post
caesarean
delivery, and
due to low level
of Hgb result of
5.4 mg/dl.
 This is the
manifestation of
decrease level
of Hgb`s due to
blood loss.
Head
 Skull & Face
 Inspection
 Palpation
- Facial& periorbital
Edema
- Smooth Skull
contour; no Nodules
or masses
 Increased
interstitial fluid
due decreased
oncotic
pressure fluid
retains in the
interstitial
tissues.
Ref.: Fundamentals of
Nursing by Kozier, Vol
2 pg 1436
 NORMAL
 Eyes & Vision
 Inspection
- both sclera are
white
 NORMAL

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 Ears & Hearing
Inspection
- with blurring of
vision
-Pupils(4mm)
equally round,
reactive to light and
accommodation
- Pale
Conjunctiva
- symmetrical ears
and equal size
- no build up of
cerumen/ear wax
No pain noted upon
palpation and no
presence of swelling
- both ear auricles
non tender
 This is due to
high blood
pressure of
160/100, there
is decreased
blood flow to
the retina.
 NORMAL
 This is due to
the blood loss
during the post
surgical
procedure/ post
caesarean
delivery.
 NORMAL
Nose & Sinuses Inspection
- nose is
symmetrical in
shape and same in
color with face
- patient can
 NORMAL

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Palpation
breathe with one
nostril when other is
closed
- no presence of
discharge
-No presence of
bumps and
tenderness
-No pain noted
- Non tender
Sinuses
 NORMAL
Mouth &
Oropharynx
Inspection - Pale Oral Mucosa  This is due to
low level of Hgb
result of 5.4
mg/dl
Neck
 Neck Muscles
 Lymph nodes of
the neck
 Trachea
 Thyroid gland
Inspection
Palpation
Palpation
Auscultation
-symmetrical in
strength
-symmetrical
movement of neck
muscles
-lymph nodes are
non-palpable
-trachea is in
midline position
- tracheal sound is
heard
-butterfly in shape in
 NORMAL
 NORMAL
 NORMAL
 NORMAL
 NORMAL

Palpation midline position,
non-palpable lobes,
not enlarged, and
rises as patient
swallows
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Thorax & Lungs
 Chest shape &
size
RR = 15cpm
 Breath sounds
Inspection
Palpation
Percussion
Auscultation
-symmetrical chest
shape & size
-No barrel chest
-no use of accesory
muscles,(scalene
and
sternocleidomastoid
) muscles while
breathing
-there are no
retractions of
intercostals spaces
-upon deep
breathing anterior
thoracic expansion:
approximately 2 cm.
-symmetrical chest
expansion
-symmetrical
fremitus
-resonant tone in
intercostal spaces
- coarse crackles
sound heard on
 NORMAL
 Normal
 Normal

both lungs with
intermittent, non
musical, loud, low
pitch, bubbling and
gurgling sounds,
heard during early
inspiration and
possibly during
expiration.
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 NORMAL
Cardiovascular &
Peripheral
Vascular system
 Heart (sound)
 Central
Vessels(caroti
d arteries &
jugular vein)
Auscultation
Palpation
Palpation
Auscultation
Inspection
- S1 corresponds
with each carotid
pulsation. S2
immediately follows
after S1
- no extra heart
sounds and
murmurs
-apical pulse
>3cm:displaced
away from MCL 5th
ICS
-equal in pulse rate,
rhythm of carotid
arteries, and
amplitude of 2+
-no bruits upon
auscultation of the
carotid arteries
-jugular vein not
 NORMAL
 NORMAL
 NORMAL

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 Perpheral
Vascular
System(Periph
eral
pulses,veins
and perfusion)
distended
-Capillary refill of
nail beds is 3-4
second.
-peripheral
pulses(radial,
Brachial) are equal
in pulse rate and
rhythm grade +2
-No bulging veins
 This is due to
low level of Hgb
result of 5.4
mg/dl
 NORMAL
Neurologic:
 Mental status
 Level of
consciousnes
s
Inspection
Inspection
- speech is of
appropriate age and
flows easily
-maintains eye
contact, can smile
and frown
appropriately
-awake, alert and
oriented to
date,time and place,
person and
responds to stimuli -
Glascow coma
Scale: Score 15
 NORMAL
 NORMAL

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Cranial Nerves
 CN I (olfactory)
 CN II
 CN III,CN IV,
CN VI
 CN V
 CN VII
 CN VIII
Inspection/
Observation
- identifies odors
correctly
-can read a printed
writing at 16 inches
without difficulty
-eyes move
smoothly and
coordinated
coordinated motion
in all six cardinal
directions
-temporal and
masseter muscles
contarct bilaterraly
-correctly identified
sharp and dull
stimuli of an object
-there symmetry of
the left side of the
face upon puffing of
cheeks,
smiling,rising of
eyebrow
-can hear
whisphered words
at a distance of 1/2
ft. In both ears
-uvula and sift
palate rises
bilaterally and
symmetrical upon
saying “ ah”
 NORMAL

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 CN IX & X
 CN XI
 CN XII
-gag reflex is
present
-there is symmetric
contraction of the
trapezius muscles
upon shrugging of
shoulders against
resistance
-tongue movement
is symmetrical and
smooth and
strength is bilateral.
- no tremors seen
- having no
difficulties of rapid
alternating
movements
-intact light touch
sensation
-correctly identifies
direction of
movement of finger
& toes withe yes is
closed
Breast and Axillae Inspection
- Breast is smooth,
undimpled and the
same color of the
skin
- no edema noted
- with breast
assymmetry on left
side
- no lesion seen
 Normal

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Palpation
- no palpable Mass
- with both breast
tenderness
 Normal
Uterus Inspection
Palpation
Uterus is in midline
- uterus is firm,
globular and
contracted
- with periumbilical
incision
 Normal
 Normal
Bladder Palpation - bladder is not
distended
 The Patient has
inserted a foley
catheter.
 Undocumented
urine output
Bowel Movement Observation - with positive bowel
movement
- with positive flatus
 Normal
Lochia discharge Inspection - pinkish in color  Normal
Inscision Inspection - dry and intact  Normal
Extremities Inspection - there is a pitting
edema seen on
both extremities
with 2cm
indentation
 Due to
decrease
oncotic
pressure fluid is
retained in the
interstitial
spaces.
Musculoskeletal
system:
 Muscle
Inspection
- symmetrical and
equal muscle mass,
tone and strength
-rate of muscle
strength is 4 in all
four extremities
 Normal
 indicates that the
muscle yields to
maximum resistance.
The muscle is able to
contract and provide
some resistance, but
when your physical
therapist presses on
the body part, the
muscle is unable to
maintain the
contraction.
Breast and Axillae Palpation/Inspection - No breast
engorgement
 Normal

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Reproductive System
Functions:
 Production of female sex cells.
The reproductive system produces female sex cells, or oocytes, in the ovaries.
 Reception of sperm cells from the male.
The female reproductive system includes structures that receive sperm cells from
the male and transports the sperm cells to the site of fertilization
 Nurturing the development of and providing nourishment for the new individual.
The female reproductive system nurtures the development of a new individual in
the uterus until birth and provide nourishment in the form of milk after birth.
 Production of female sex hormones produced by the female reproductive system
control the development of the reproductive system itself and of the female body
form. These hormones are also essential for the normal function of the reproductive
system and reproductive behavior.
Uterus:
 Uterus is a big as a medium-sized pear.
 Oriented in the pelvic cavity with the larger, rounded part directed superiorly.
 The part of the uterus superior to the entrance of the uterine tube is called the
fundus.
 Main part of the uterus is called body, and the narrower part, the cervix.
The Placenta
 The placenta (Latin for “pancake” which is descriptive of its size and appearance
at term ) arises out of the continuing growth of trophoblast tissue. Its growth
parallels that of the fetus growing from a few identifiable cells at the beginning of
pregnancy to an organ 15 to 20 cm in diameter 3 cm in depth covering about half
the surface area of internal uterus at term.
 Functions of the Placenta
 Nutrition- transport nutrients and water soluble vitamins.
 Exchanges- Fluid and gas transport (diffusion- oxygen, carbon dioxide,
electrolytes)
 Facilitated transport (glucose)
 Active transport- Amino acid, Calcium, iron

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Circulation
 As early as the 12th day of pregnancy, maternal blood begins to collect in the
intervillous spaces of the uterine endometrium surrounding the chorionic villi.
 By the 3rd week, oxygen and other nutrients such as glucose, amino acids, fatty
acids, minerals, vitamins, and water, osmose from maternal blood through the
cell layers of the chorionic villi into the villi capillaries. From there, nutrients are
transported to the developing embryo.
Blood Vessels
Arteries
Are blood vessels that carry blood away from the heart.
Veins
Blood vessels that carries blood toward the heart.

Maternal & Child Health Nursing 6 edition Vol.1
Chapter 9 the growing fetus Page 193, 195
33

Predisposing Factors:
Family History of Hypertension( on mother side)
Pregnancy
Lifestyle(vices of cigarette smoking)
Abnormal Placental development and reduce perfusion Oxidative stress
35
Immune maladaptation
Endothelial Activation/Dysfunction
Inflammatory
response
Reduce organ perfusion Edema
(grade III, pitting
edema)
Maternal hypertension
(BP 160/100)
Organ
dysfunction/hemorrhage
Kidney(protenuria)
Liver(Altered enzymes level)
Brain(eclampsia)
Heart(vascular stenosis)
Development of
preeclampsia

Decrease resiliency of blood vessel at placental bed
Torn or ruptured blood vessels
Decrease resiliency of blood vessel at placental bed
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Partial Separation
Peripheral portion detached
Mi ld to moderate vaginal
bleeding
Increase uterine wall irritabil i ty
FHT may be reas suring
Progres s ive separation
Uterine tetany fetal distress (decrease variability) (late acceleration)
50% separation Severe feta l di s tres s
Emergency Delivery
Central Portion Detached
(mi ld to moderate concealed bleeding)
Blood trapped to intact peripheral portion
Fluids enter mus cle fibers
Uterus turns
blue or purple
uteroplacental
apoplexy
Tota l separation
Mas sive Vaginal or Concealed Hemorrhage
Decrease
Platelet
Decrease Fibrin
Degeneration
Maternal Shock
(100%)
Decrease BP
Increase PR
DIC
Renal Failure
Heart
Fai lure
Maternal
death
Fetal
death
(100%))
Uterine
tetany
Board like
rigidity
Abdominal/
Back pain
Increase
abdominal
girth
Predisposing Factor:
Maternal Hypertension( BP 160/100)
Complication: Abruptio Placenta Cigarette smoking

Date Doctors Order Remarks
38
08-02-14
 Please admit
 Secure consent
 Nil Per Os
 Hospital policy designates the
exact procedure that should be
followed when admitting the
patient to the holding area or
operating room suite. Admission
will help to monitor the client’s
condition. The admitting
procedure is continued with
reassessment of the patient and
allowance of time for last minute
question. (references: medical-surgical
nursing 5th edition by Lewis, Heitkemper &
Dirksen Chapter 17 Patient During Surgery,
page 380)
 Before signing the consent, The
risks and benefits of the
procedure must be explained in
terms the client could easily
understand.(References Maternal and
Child Health Nursing 6th Edition by
AdellePilliteri Chapter 24 page 658)
 Patient must be instructed about
preoperative food and fluid
restrictions. The patient is
usually instructed to have
nothing by mouth (NPO),
including food and fluids.)For
decades, obstetricians,
midwives, and anesthesiologists
have debated the need for
women in labor to be restricted
to nil per os (NPO). Competing
concerns include risk of gastric
aspiration if women required
general anesthesia.(References:
Medical Surgical Nursing Fifth Edition by
Lewis Heitkemper Dirksen at page 366,
Singata, M., Tranmer, J. & Gyte, G.M.L.
(2010). Restricting oral fluid and food
intake during labour)

 Intravenous Fluid Normal
Saline Solution 1L x 8
hours
39
Laboratory:
 Complete Blood Count with
 Platelet count
 Blood Urea Nitrogen
and Creatinine
 It is indicated as a source of
water and electrolytes. This is
used for fluid replenishment or
administration of medication
 CBC is done to the patient to test
if there is blood loss,
abnormalities and destruction of
blood cells. And to determine
what kind of blood is decreased
or increased to determine what
intervention must be done to
correct it.(references: cell medicine, 24th
edition by Golman and Schater page 345)
 Provide basis for coagulation to
occur; maintains homeostasis. Pre-eclampsia
has been further
classified as severe in the presence
of one or more of the signs and
symptoms such as Low platelet
count (thrombocytopenia),
100,000/mm is probably due to
micro angiopathic hemolysis
induced by spasm. The triad of
Hemolysis, Elevated Liver Enzymes
and Low Platelet Count is given the
pnemonic HELLP syndrome.
(References: (Textbook of Obstetrics
(Physiologic & Phatologic Obstetrics) 3rd Edition
by Sumpaico, Andres, Capito, Carnero,
Diamenteband Gamilla at pages 586- 587)
 Blood Urea Nitrogen measure
the by product or protein
metabolism in the liver, filtered
by the kidney and excreted in
urine. And Creatinine is end
product of muscle and protein
metabolism; filtered by the
kidney and excreted in urine.

40
 Urinalysis
 Serum Glutamic
Pyretic
Transaminase
(SGPT)
This is done to determine how
well the kidneys and liver are
working. Pre-eclampsia has
been further classified as severe
in the presence of one or more of
the signs and symptoms such as
Proteinuria of at least 4
grams/day or a persistent
qualitative 2+ or more on
dipstick. With severe renal
involvement, the serum
creatinine will be expected to
rise. (References: Nursing Care Plan
Edition 8 of 2010 by Marlynn E. Doenges,
Mary Frances Moorhouse, Alice C.
MurrChapter 10 Renal and Urinary Tract
page. 540 , Textbook of Obstetrics
(Physiologic & Phatologic Obstetrics) 3rd
Edition by Sumpaico, Andres, Capito,
Carnero, Diamenteband Gamilla at pages
586-587)
 Study of a general examination
of urine to establish baseline
information or provide data to
establish a tentative diagnosis
and determine whether further
studies are to be ordered.For
establishment of Abruption
Placenta. (References: Medical-Surgical
Nursing 5th Edition by Lewis, Heitkemper &
Dirksen, Chapter 42 Urinary System, page
1250-1251)
 Marker of hepatic injury; more
specific of liver damage than
Aspartate Amino Transferase.
Baseline laboratory examinations
should be obtained for organs
likely to be affected by
hypertensive changes or to
deteriorate during pregnancy.
(References: Kozier & Erb ’s Fundamentals
of Nursing 8th Edition Volume 2 by Berman,
Snyder, Kozier, Erb, page 803, Physiologic
& Phatologic Obstetrics) 3rd Edition by

 Serum Glutamic-
41
Oxaloacetic
Transaminase
(SGOT)
 Medicine
 Hydralazine 5mg TID
for BP of >160/100
 Magnesium Sulfate 4g
now then 5g TID on
each buttocks then 5mg
TID on alternating
buttocks every 4 hours
until 24 hours
postpartum
Sumpaico, Andres, Capito, Carnero,
Diamenteband Gamilla at page 597)
 Found in the heart, liver and
skeletal muscles. Can also be
used to indicate liver injury.
Baseline laboratory examinations
should be obtained for organs
likely to be affected by
hypertensive changes or to
deteriorate during pregnancy.
(References: Koz ier & Erb ’s Fundamentals
Snyder, Kozier, Erb, page 803,Textbook of
Obstetrics (Physiologic & Phatologic
Obstetrics) 3rd Edition by Sumpaico, Andres,
Capito, Carnero, Diamenteband Gamilla at
page 597)
 A direct vasodilator that relaxes
arteriolar smooth muscle. It is
given to the patient to control
hypertension because she was
manifesting an increase in BP of
190/120 at time of 12:40am.
(References: nursing 2006 Drug Handbook
26th edition by Lippincott Williams & Wilkins,
page 293)
 May decrease acetylcholine
released by nerve impulses, but
its anticonvulsant mechanism is
unknown. It is given to the
patient in preparation to the
upcoming operation of having a
high blood pressure to prevent
convulsion that will lead to
eclampsia.(References: nursing 2006
Drug Handbook 26th edition by Lippincott
Williams & Wilkins, page 425, Physiologic &
Phatologic Obstetrics) 3rd Edition by
Diamenteband Gamilla at page 587 and
599)

 Insert Indwelling Foley
42
Catheter
 Watch out for Magnesium
toxicity
 Monitor every 1 hour Fetal
Heart Tone
 Refer
 To drain the bladder prior to
surgery that prevents the
involuntary elimination under
anesthesia, lessens the chance
of accidental nicking of the
bladder during surgery, and
reduces the possibility of urinary
retention during early
postoperative recovery. This is
inserted to accurately measure
the patient’s urine output
(References: Medical Surgical Nursing Fifth
Edition by Lewis Heitkemper Dirksen at
page 370)
 Magnesium Sulfate is a central
nervous system depressant.
Magnesium excess could
develop in the pregnant woman
who receives magnesium sulfate
for the management of
eclampsia and prophylaxis of
eclampsia in patients with severe
pre-eclampsia.(References: Medical
Surgical Nursing by Lweis Heitkemper
Dirksen, Fifth Edition at pages 341-342)
 To detect the fetal distress so
immediate delivery is
accomplished for fetuses to have
a chance of surviving. References:
Physiologic & Phatologic Obstetrics) 3rd
Edition by Sumpaico, Andres, Capito,
Carnero, Diamenteband Gamilla at page
586)
08-02-14
3:40 am
 Direct to Operating Room
for ‘E’ Cesarean Section
 The patient is directed for
emergency cesarean section
because of the fetal distress as

43
Medicine:
 Hydralazine
Hydroclhoride10 mL
 Terbutaline sulfate one
half ampule SL now
 Inform OR Nurse/ Chief
of clinic /Pedia/
Anes/JDO/ OB gyne
manifested by the fetal heart rate of
31 beats per minute due to pre-eclampsia
severe. Fetal distress is
the third common reason for the
rise in cesarean birth over the last
decade. References: Physiologic &
Phatologic Obstetrics) 3rd Edition by Sumpaico,
Andres, Capito, Carnero, Diamenteband
Gamilla at page 7953)
 A direct vasodilator that relaxes
arteriolar smooth muscle. It is
given to the patient to control
hypertension because she was
manifesting an increase in BP of
190/140 at time of 3:40am
page 293)
 Relaxes bronchial smooth
muscle by stimulating beta2
receptors. Because the client is
experiencing difficulty o
page631)
 For preparing their department
that there is an upcoming
procedure and they will need at a
time.
08-02-14
3:50 am
 Pre Op Care  Begins when the decision to
proceed with surgical
intervention is made and ends
with the transfer of the patient
onto the operating room. Table.
The psychosocial outcomes of
unplanned or emergency
cesarean birth are usually more
pronounced and negative in
nature when compared with the
outcomes associated with a
scheduled or planned cesarean

44
birth. The patient experience
abrupt changes in their
expectations for birth, post birth
care, and the care of the new
baby at home.This may be an
extremely traumatic experience.
Maternal vital signs and blood
pressure and fetal heart rate and
pattern continue to be assessed.
(References: Brunner &Suddarth’s Textb ook
of Medical-Surgical Nursing 12th edition
Volume 1 by Smeltzer, Bare, Hinkle and
Cheever,Chapter 18 preoperative nursing
management, page 425, References
Maternal and Child Health Nursing at page
574-575)
08-02-14 Post – Op Order
 To ward with close
monitoring
 Postoperative patients must be
monitored and assessed closely
for any deterioration in condition
and the relevant postoperative
care plan or pathway must be
implemented. The National Early
Warning Score (NEWS) was
developed by a working party to
provide a national standard for
assessing, monitoring and
tracking acutely and critically ill
patients (not for use with children
under 16 years or in pregnancy);
the intention was that trusts
would use it to replace their
locally adapted early warning
systems (Royal College of
Physicians, 2012). Like other
early warning systems, NEWS
has six physiological parameters:
 Respiratory rate;
 Oxygen saturation;
 Temperature;
 Blood pressure;
 Pulse rate;
 Level of consciousness;
 Fluid Balance
 Intravenous Infusion
 (References: Liddle C (2013) Postoperative care 1:
Principles of Monitoring Postoperative

 Oxygen inhalation at 3
45
LPM via nasal cannula
 Monitor Vital Signs every
15 minutes until stable and
record please
 Nothing Per Orem
 Intravenous Fluid Normal
Saline Solution 800 mL +
Oxytocin 20 ‘u’ x 30 gtts
patients. Nursing Times; Chapter 109 at pages 22,
24-26)

 Administration of oxygen helps
increase the percentage of
oxygen in inspired air. The goal
of oxygen administration is to
supply the patient with adequate
oxygen to maximize oxygen
carrying ability of the
blood.(References: Medical Surgical
Nursing by Lweis Heitkemper Dirksen, Fifth
Edition at pages 689)
 Monitoring in uncomplicated
pregnancy; intermittent
auscultation should be done after
a contraction at least every 15
minutes (References: Physiologic &
Phatologic Obstetrics) 3rd Edition by
Diamenteband Gamilla at page 424)
 Spinal and epidural anesthesia
may result sensory block and
motor block. The patient is
advised to nothing per mouth to
prevent aspiration by nausea and
vomiting especially when was
under anesthetic
agents.(References: Medical Surgical
Nursing Fifth Edition by Lewis Heitkemper
Dirksen at page 386-387 & 399)
 Intravenously, it is used for
hydration, and as a carrier to get
other things (drugs, banked
blood) into a person. It has the
same amount of salt as most of
our body fluids do (0.9%).

46
To follow:
o Intravenous Fluid D5NR 1L
uncorporate Oxytocin 10
‘u’ x 8 hours
 Medicine:
 Ampicillin 2g IV; ANST
then 1g IV every 6
hours
 Tramadol 50mg slow IV
every 6 hours x 4
doses, ANSTU
Traditionally, 10 units of oxytocin
are incorporated in 1 liter
dextrose. It is a potent drug for
adequate uterine contraction
after cesarean section to control
bleeding after childbirth.
 D5NR is an hypertonic solution
to prevent dehydration and to
replace the blood loss after
delivery. The oxytocin was
uncorporate as manifested of
uterine firmed and contracted.
 A broad-spectrum semi-synthetic
aminopenicillin, is highly
bactericidal even at low
concentrations, but is inactivated
by penicillinase. It will minimize
the risk of developing puerperal
sepsis and pelvic
abscess.(References: Nurses Drug
Guide of 2004 Volume 1 by Billie Ann
Wilson, Margaret Shannon, Carolyn Stang,
page86, Physiologic & Phatologic Obstetrics
3rd Edition by Sumpaico, Andres, Capito,
Carnero, Diamenteband Gamilla at page
902-904)
 Inhibits reuptake of serotonin and
norepinephrine in CNS.The
patient was administered of
Tramadol because the client has
moderate pain (4-6 on a 0-10
scale) on her incised wound from
C section.(References: Nurses Drug
Guide of 2004 Volume 2 by Billie Ann
Wilson, Margaret Shannon, Carolyn Stang,
page1561: Koz ier&Erb ’sFunadamental of
Nursing 8th Edition Volume 2 by Berman,
Snyder, Kozier, Erb Chapter 45 at

 Ranitidine 50mg IV
every 8 hours x 4
doses, ANSTU
47
 Flat on Bed x 6 hours
 Monitor Intake and Output
every 2 hours and record
please
 Refer
page1208-1209)
 Due to NPO of the patient it may
cause gastric acidity. An
Antihistamines reduce gastric
fluid volume and gastric acidity.
(References: Koz ier&Erb ’sFunadamental of
Snyder, Kozier, Erb Chapter 37 at page
950)
 Position the client as ordered.
Clients who have had spinal
anesthetics usually lie flat for 8 to
12 hours. An unconscious or
semi conscious client is placed
on one side with the head slightly
elevated, if possible, or in a
position that allows fluids to drain
from the mouth. It will prevent
maternal hypotension. (References:
Koz ier&Erb ’sFunadamental of Nursing 8 th
Edition Volume 2 by Berman, Snyder,
Kozier, Erb Chapter 37 at page 962)
 Accurate intake and output is
necessary for determining fluid
replacement needs and reducing
risk of fluid overload and reflects
circulating fluid shifts, and
response to therapy. (Reference :
Nursing Care Plan Edition 8 of 2010 by
Marlynn E. Doenges, Mary Frances
Moorhouse, Alice C. MurrChapter 10 Renal
and Urinary Tract page. 542 )
08-02-14 Medicine:

5:45 am  Voluven 500mL stat.  Therapy & prophylaxis
48
of hypovolaemia. (References:
http://www.scribd.com/doc/131436121/
Drug-Study-Po)
08-02-14  Nil Per Os
 Serve and transfuse 3 ‘u’
PRBC properly typed and
cross matched
 Medicine:
 Ampicillin 1g every 6
hours x 24 hours
 Metronidazole 50g TID
for every 8 hours ANST
x 24 hours
 Spinal and epidural anesthesia
may result sensory block and
motor block. The patient is
advised to nothing per mouth
to prevent aspiration by
nausea and vomiting
especially when was under
anesthetic agents.(References:
Medical Surgical Nursing Fifth Edition by
Lewis Heitkemper Dirksen at page 386-
387 & 399)
 Blood transfusion is the
introduction of whole blood or
blood components in venous
circulation. Packed Red blood
cells is used to increase the
oxygen-carrying capacity of
blood. This is ordered to replace
the blood that has been loss
while the client is undergoing the
operation.The patient might have
>1500 ml of total amount of
blood loss because of Abruptio
Placenta.(Reference: Fundamentals of
Nursing 8th Edition, Volume 2 by Snyder,
Berman, Kozier and ErbChapter 52 Fluid,
Electrolyte and Acid – Base Balance page
1473,Maternal Child Nursing Care Volume 1
3rd Edition by Wong, Hockenberry,Wilson,
Perry,Lowdermilk at page 401)
 Inhibits cell wall synthesis during
bacterial multiplication. (References:
nursing 2006 Drug Handbook 26th edition by
Lippincott Williams & Wilkins, page 81)
 Direct-acting trichomonacide and
amebicide that works inside and
outside the intestines. It’s
thought to enter the cells of

49
 Please do repeat:
o HIH for:
o Serum Pyretic
Transaminase
(SGPT)
o Serum Glutamic-
Oxaloacetic
Transaminase
(SGOT)
o Blood Urea Nitrogen
and Creatinine
o Sodium
microorganisms that contain
nitroreductase, forming unstable
compounds that bind DNA and
inhibit synthesis, causing cell
death. (References: nursing 2006 Drug
Handbook 26th edition by Lippincott Williams
& Wilkins, page 22)
(References: Koz ier&Erb ’s Fundamentals
Snyder, Kozier, Erb, page 803)
 BUN measure the by product or
protein metabolism in the liver,
filtered by the kidney and
excreted in urine. And Creatinine
is end product of muscle and
protein metabolism; filtered by
the kidney and excreted in urine.
(Reference : Nursing Care Plan Edition 8 of
2010 by Marlynn E. Doenges, Mary Frances
 Regulating ECF volume and
distribution, maintaining blood
volume, transmitting nerve
impulses and contracting
muscles. (References: Koz ier&Erb ’s

50
o Chloride
 Maintain Indwelling Foley
Catheter
 Please continue
Magnesium Sulfate 5g TIM
on alternating buttocks
every 4 hours x 24 hours
 Blood Transfusion to run
for 1 hour
Fundamentals of Nursing 8th Edition Volume
2 by Berman, Snyder, Kozier, Erb, page
1431)
 HCl production. Regulating ECF
balance and vascular volume.
Regulating acid-base balance.
Buffer in oxygen-carbon dioxide
exchange in RBCs. (References:
Koz ier&Erb ’s Fundamentals of Nursing 8th
Kozier, Erb, page 1431)
 Trauma to the bladder may
occur during the birth process, so
the bladder wall may be
hyperemic and edematous, often
with small areas of hemorrhage.
Clean-catch or catheterized urine
specimens after delivery often
reveal hematuria from bladder
trauma.(References :Maternal and Child
Health Nursing volume 1 3rd edition Chapter
19 at page 594)
 May decrease acetylcholine
released by nerve impulses, but
its anticonvulsant mechanism is
unknown.Intramuscular (IM)
magnesium ssulfate is used
rarely because the absorption
rate cannot be
controlled(References: nursing 2006
Williams & Wilkins, page 425)

51
 Refer
blood. In these case (Reference:
Fundamentals of Nursing 8th Edition,
Volume 2 by Snyder, Berman, Kozier and
ErbChapter 52 Fluid, Electrolyte and Acid –
Base Balance page 1473)
08-03-14  Diet as Tolerated
 Monitor Vital sign every 4
hours and record please
 Continue medications
 Ordered when the client’s
appetite, ability to eat, and
tolerance for certain foods may
change. And a flatus and bowel
movement is now present in the
patient. ( (References: Koz ier&Erb ’s
1262)
 Vital signs should be performed
in accordance with local policies
or guidelines and compared with
the baseline observations taken
before surgery, during surgery
and in the recovery area.
(references:http://www.nursingtimes.net/nur
sing-practice/specialisms/critical-care/
principles-of-monitoring-postoperative-patients/
5059272.article)
 For supportive Drug; supports
body function until other
treatments or the body’s
treatments or body’s response
can take over; because
medication is a substance
administered for the diagnosis,
cure treatment or relief of
symptoms of for prevention of

 Monitor Vital sign every 4
hours and record please
 For Actual ProThrombin
52
Time
 Still for
o Serum Glutamic
Pyretic
Transaminase
(SGPT)
o Serum Glutamic-
Oxaloacetic
Transaminase
(SGOT)
disease..(Reference:Fundamentals of
Nursing 8th Edition of 2008 by Berman,
Synder, Kozier and Erb Chapter
 Vital signs should be performed
in accordance with local policies
or guidelines and compared with
the baseline observations taken
before surgery, during surgery
and in the recovery area.
(references:http://www.nursingtimes.net/nur
sing-practice/specialisms/critical-care/
principles-of-monitoring-postoperative-patients/
5059272.article)
 It is a measure of how long it
take for the blood to start clotting.
(References: 5th Edition Essentials of
Anatomy and Physiology by Seeley,
Stephens,Tate at page 318)

o Blood Urea Nitrogen
53
and Creatinine
o Sodium
o Potassium
o Chloride
 Remove Indwelling Foley
Catheter at 12 noon
 BUN measure the by product or
protein metabolism in the liver,
filtered by the kidney and
excreted in urine. And Creatinine
is end product of muscle and
protein metabolism; filtered by
the kidney and excreted in urine.
(Reference : Nursing Care Plan Edition 8 of
2010 by Marlynn E. Doenges, Mary Frances
 Regulating ECF volume and
distribution, maintaining blood
volume, transmitting nerve
impulses and contracting
muscles. (References: Koz ier&Erb ’s
1431)
 Maintaining ICF osmolarity,
transmitting nerve and other
electrical impulses, regulating
cardiac impulse transmission and
muscle contraction. Skeletal and
smooth muscle function.
Regulating Acid-base balance. .
 HCl production. Regulating ECF
balance and vascular volume.
Regulating acid-base balance.
Buffer in oxygen-carbon dioxide
exchange in RBCs. (References:
Kozier, Erb, page 1431)

 Still for blood transfusion
54
 Apply abdominal binder
 Refer
 The spout of any drainage bag
can become contaminated when
opened to drain the bag. Bacteria
enter the urinary drainage bag,
multiply rapidly, and then migrate
to the drainage tubing, catheter
and bladder and not allowing
urine to flow back into the
bladder, this risk is reduced.
(References: Brunner&Suddarth’s Textb ook
Volume two by Smeltzer, Bare, Hinkle and
Cheever, Chapter 45 Management of
Patients with Urinary Disorders, page 1372)
blood. This is ordered to restore
the blood’s oxygen carrying
capacity since the patient has
hemoglobin result of 5.4 g/dL as
of August 2, 2014 .Blood typing
and cross matching is done to
determine the blood type of the
patient for blood transfusion
purposes not because all blood
is compatible with each other
and if unmatched blood has been
transfused to the client it may
cause harmful effect to the client.
(Reference: Fundamentals of Nursing 8th
Edition, Volume 2 by Snyder, Berman,
Kozier and ErbChapter 52 Fluid, Electrolyte
and Acid – Base Balance page 1473)
 This wraps help women
recovering from a C-section with
their posture and abdominal
support.

55
08-04-14  Low salt, Low fat diet
Medicine:
 Amoxicillin 500mg 1
cap x 7 days
 Metronidazole 500 mg
1 cap BID x 7 days
 Ferrous Sulfate 1 tab
BID x 30 days
 A healthy diet with adequate
calories, protein and other
nutrients is important to maintain
good immune function and
increase resistance to disease.
Along with certain vitamins and
minerals, dietary protein is
important to prevent anemia.
High salt intake can affect blood
pressure and contribute to the
development of hypertension. It
may increase the release of a
hormone called natriuretic
hormone which indirectly
contributes to hypertension. The
patient manifested a blood
pressure of 160/90 (References:
edition Volume 2 by Berman, Sunder,
Kozier&Erb, Chapter 51 Circulation, page
1411)
 Prevents bacterial cell-wall
synthesis during replication.
Increases amoxicillin
effectiveness by inactivating
betalactamases, which destroy
amoxicillin. (References: nursing 2006
 Direct-acting trichomonacide and
amebicide that works inside and
outside the intestines. It’s
thought to enter the cells of
microorganisms that contain
nitroreductase, forming unstable
compounds that bind DNA and
inhibit synthesis, causing cell
death. (References: nursing 2006 Drug
Handbook 26th edition by Lippincott Williams
& Wilkins, page 22)
 Provides elemental iron, an
essential component in the
formation of hemoglobin.

 Mefenamic Acid 500
mg 1 cap every 6 hours
 Amlodipine 10 mg 1
56
cap BID x 30 days
 Spironolactone 50 mg 1
cap TID x 7 days
page 879)
 Elevates the serum iron
concentration which then helps
to form High or trapped in the
reticuloendothelial cells for
storage and eventual conversion
to a usable form of
iron.(References:2011 McGraw-Hill
Nurse’s Drug HandBook b y Patricia Dweyer
Schull at pages 623-625)
 Inhibits calcium ion influx across
cardiac and smooth-muscle cells,
thus decreasing myocardial
contractility and oxygen demand;
also dilates coronary arteries and
arterioles. (References: nursing 2006
 Potassium –Sparing diuretic;
steroidal compound and specific
pharmacologic antaonist of
aldosterone. Presumably acts by
competing with aldosterone for
cellular receptor sites in distal
renal tubule. Promotes sodium
and chloride excretion without
concomitant loss of potassium.
Diuretic effect reportedly not
associated with hyperuricemia or
hypoglycemia. Activity depends
on presence of endogenous or
exogenous
aldosterone.(References: 2011
McGraw-Hill Nurse’s Drug HandBook b y
Patricia DweyerSchull at pages1097-1099,
nurse’s drug handb ook of 2004 Volume 2 b y
Wilson, Shannon &Strang,page 1444)

57
 Continue meds.
 Refer laboratory result
 Still for correction of
anemia
 For change of dressing
today
disease. To prevent occurrence
of further complications
(Reference:Fundamentals of Nursing 8th
Edition of 2008 by Berman, Synder,
Kozierand Erb Chapter 35 Medications page
830)
 So that the health worker would
be able to analyze the result and
to determine the problem and the
needed intervention to correct
the abnormalities.
 A condition in which the
hemoglobin concentration is
lower than normal; reflects a
presence of fewer erythrocytes
within the circulation; amount of
oxygen delivered to body is also
diminished; not a specific
disease but a sign of an
underlying disorder.Due to the
latest laboratory result of
Hemoglobin 5.4 g/dL and
Hematocrit 16%. (References: Brunner
&Suddarth’s Textb ook of Medical-Surgical
Nursing 12th edition Volume 1 by Smeltzer,
Bare, Hinkle and Cheever, page 910)
 To prevent infection in incision
site and provide comfort of the
patient.

58
 Refer
08-05-14  Still for correction of
anemia
underlying disorder. The patient
still not undergo laboratory exam.
(References: Brunner &Suddarth’s Textb ook
Volume 1 by Smeltzer, Bare, Hinkle and
Cheever, page 910)
08-06-14  Low salt, Low fat diet
Medicine:
 Decrease amlodipine
10 tab OD (5pm)
 A healthy diet with adequate
calories, protein and other
nutrients is important to maintain
good immune function and
increase resistance to disease.
Along with certain vitamins and
minerals, dietary protein is
important to prevent anemia.
High salt intake can affect blood
contributes to hypertension.
(References: Koz ier&Erb ’s Fundamentals of
Nursing 8th edition Volume 2 by Berman,
Sunder, Kozier&Erb, Chapter 51 Circulation,
page 1411)
 Inhibits calcium ion influx across
cardiac and smooth-muscle cells,
thus decreasing myocardial
contractility and oxygen demand;
also dilates coronary arteries and
arterioles. (References: nursing 2006

 Start Losartan 50 mg
59
tab OD (6am)
 Continue meds
 Still for blood transfusion to
run for 4 hours
 Blocks vasoconstricting and
aldosterone- secreting effects of
angiotensin II at various receptor
sites, including vascular smooth
muscle and adrenal glands. Also
increases urinary flow and
enhances excretion of chloride,
magnesium, calcium, and
phosphate.(References: 2011 McGraw-
Hill Nurse’s DrugHandBook b y Patricia
DweyerSchull at pages 685)
medication is a substance For
supportive Drug; supports body
function until other treatments or
the body’s treatments or body’s
response can take over; because
blood. This is ordered to restore

60
 Refer
the blood’s oxyen carrying
capacity since the patient has
hemoglobin result of 5.4 g/dL as
of August 2, 2014 .Blood typing
and cross matching is done to
determine the blood type of the
patient for blood transfusion
purposes not because all blood
is compatible with each other
and if unmatched blood has been
transfused to the client it may
cause harmful effect to the client.
anemia
 Continue oral meds and
blood pressure monitoring
Hematocrit 16% as of August 7,
2014.(References: Brunner &Suddarth’s
Textbook of Medical-Surgical Nursing 12th
edition Volume 1 by Smeltzer, Bare, Hinkle
and Cheever, page 910)

61
 Refer
disease. And to be able to know
if the blood pressure is now
normal range and to be able to
perform proper intervention
(Reference:Fundamentals of Nursing 8th
Edition of 2008 by Berman, Synder,
KozierandErb Chapter 35 Medications page
830)
08-07-14  Medicine:
 Paracetamol 1 amp FV
stat PRN for
Temperature ≥ 38.6˚C
every 6 hours
 Paracetamol 8 mg 1 tab
every 4 hours ≥ 37.8˚C
for CBC
 A nonopoid analgesic with
indication for fever was given
to the patient because of the
temperature of 39 degree
celcius at 3:30 pm.(26th Edition
Nursing 2006 Drug Hand Book by
Lippincott Williams and Wilkins at
pages 351-352)
 Cardiovascular agent;
central-acting;
antihypertensive; analgesics.
It will be given to if the patient
manifested decrease at
temperature of at least ≥
37.8˚C (2011 McGraw-Hill Nurse’s
Drug HandBook by Patricia
DweyerSchull at pages 264)
 Catapres 75 mg
1 tab SL stat PRN ≥ 160/90
 Stimulates aplha2 adrenergic
receptors in CNS to inhibit
sympathetic vasomotor centers.
Central actions reduce plasma
concentrations of
norepinephrine. It decreases
systolic and diastolic BP and
HR. orthostatic effects tends to

62
mild and occur in frequently. Also
inhibits renin release from
kidneys. The patient manifested
a blood pressure of 150/90
mmHg. (References:2011
McGraw-Hill Nurse’s Drug
HandBook by Patricia Dweyer
Schull at pages 264-266)
08-08-14  For change of dressing
 For Blood transfusion 3 ‘u’
cross matched
 Still for correction of
anemia
 Facilitate availabilities of
 To prevent infections in incision
site and provide comfort to the
patient.
Hematocrit 16% and RBC of
1.84 X 1023/L as of August 7,
2014(References: Brunner &Suddarth’s
 For preventing diversion and

meds abuse of medications.
63
anemia
underlying disorder. Due to the
latest laboratory result of RBC
1.84 X 1023/L, Hemoglobin
6.3g/dL and Hematocrit 16% as
of August 7, 2014.(References:
Brunner &Suddarth’s Textb ook of Medical-
Surgical Nursing 12th edition Volume 1 by
Smeltzer, Bare, Hinkle and Cheever, page
910)
anemia
 Continue meds.
underlying disorder. Due to the
latest laboratory result of RBC
1.84 X 1023/L, Hemoglobin
6.3g/dL and Hematocrit 16% as
of August 7, 2014. (References:
Brunner &Suddarth’s Textb ook of Medical-
Surgical Nursing 12th edition Volume 1 by
Smeltzer, Bare, Hinkle and Cheever, page
910)

 Monitor vital signs every 4
hours then record please
64
 Refer
 Take Vital signs and compare
initial findings with clients data.
(References: Koz ier&Erb ’sFunadamental of
Snyder, Kozier, Erb Chapter 37, page 958)
anemia
 For change of dressing
today
 Continue meds
underlying disorder. The patient
still not undergo on laboratory
exam. (References: Brunner &Suddarth’s
 To prevent infections from
incision site and provide comfort
to the patient.

65
 Refer
disease To prevent occurrence
of further
complications.(Reference:Fundamental
s of Nursing 8th Edition of 2008 by Berman,
08-12--14  Still for Low Fat diet
 Continue medication
 Refer
 High salt intake can affect blood
contributes to hypertension. For
sodium retention. (References:
edition Volume 2 by Berman, Sunder,
Kozier&Erb, Chapter 51 Circulation, page
1411)The patient manifested a
high blood pressure of 150/90
mmHg.
 To prevent occurrence of further
complications.
08-13-14  Serve and transfuse 2 ‘u’
cross-matched
blood. This is ordered to
restore the blood’s oxygen
carrying capacity since the
patient has hemoglobin result
of 7.2 g/dL as of August 13,
2014. Blood typing and cross
matching is done to
determine the blood type of
the patient for blood
transfusion purposes not
because all blood is
compatible with each other
and if unmatched blood has
been transfused to the client
it may cause harmful effect to

66
 Continue meds
 For daily change of
dressing
 For blood transfusion to
run for 4 hours
 Refer
the client. (Reference:
Volume 2 by Snyder, Berman, Kozier
and ErbChapter 52 Fluid, Electrolyte
and Acid – Base Balance page 1473)
disease To prevent occurrence
of further
complications.(Reference:Fundamental
s of Nursing 8th Edition of 2008 by Berman,
 To prevent infections from
incision site and provide comfort
to the patient.
08-14-14  May go home
 The patient does not need an
overnight stay on the hospital
because she was feeling better
and able to tolerate the pain.

67
 Continue meds
 Blood pressure monitoring
at home
disease.(Reference:Fundamentals of
 To monitor the wellness of the
patient and immediately asses
for further complication.

Hematology Results Date: August 3, 2014
Test Result Normal Range Interpretation Implication
Sodium
145.6
135 - 145
NORMAL
69
The patient has a normal serum
sodium concentration.It indicates that
there are is a normal fluid balance or
acid –base balance.
Potassium
3.85
3.5 - 5.0
NORMAL
There is maintenance of fluid and
electrolyte by means of cellular
exchange.
Chloride
107.5
97 – 107
NORMAL
It indicates that there is a
normal electrolyte balance , fluid and
acid-base balance. In relation to
sodium reabsorption which it is
fractional in its movement into the cell.
It all functions well . It maintain osmotic
pressure in blood and has important
buffering action of oxygen and carbon
dioxide in RBC.

70
Nursing Responsibilities:
 Monitor intake and output
 Monitor serum electrolytes
 Explain serum electrolytes
 Instruct the patient to avoid caffeine and alcohol to prevent any electrolytes
 Advise proper dietary intake
(Reference: Fundamentals of Nursing , 5th edition ,Carol Taylor, Carol Lillis, Priscilla Lemone, pp.1453 -1454.)

Hematology Results Date: August 7, 2014
Test Result Normal
Range
71
Interpretation Implication Nursing
Responsibility
Hemoglobin
Hematocrit
(%)
08-02-14
5.4 g/dl
16 %
08-07-14
6.3 g/dl
16 %
08-12-14
7.2 g/dl
21%
08-13-
14
9.2 g/dl
27%
F: 12-16
g/dl
F: 37-43%
LOW
LOW
The
hemoglobin is
below the
normal range
due to
Abruptio
placenta and
caesarean
operation.
 Monitor for
signs of
fatigue
 Monitor for
shock.
 Reinforce for
comply of
blood
transfusion.
RBC
1.84 X 1023/L
F: 4.0-5.4
X 1023/L
LOW
WBC -----
4.5 – 10.5
x 10 9/L
---
Platelet 410 x 10 9/dL
150-500 x
10 9/dL
Normal
Reference: Essentials of Anatomy & Physiology, 6th Edition by Rod Seeley, Trent Stephens and Philip Tate, pp. 301-318

Drug Name Dosage Classification Action Indication /
73
Contraindication
Side effects Nursing
Responsibilities
Date
Ordered:
08-02-14
Generic:
Ampicillin
Brand:
Ampicillin-N
1gm
q 6 hrs
TIV
Antibiotic,
penicillin
Inhibits cell-wall
synthesis
during
bacteria
multiplication.
Indication:
 As prophylaxis to
post surgical
infection.
Contraindication:
 Contraindicated
in patients
hypertensive to
drug or other
penicillins.
 Use cautiously in
patients with
other drug
allergies because
of possible cross-sensitivity,
and in
those with
mononucleosis
because of high
risk of
maculopapular
rash.
CNS
 Lethargy
 Hallucinatio
ns
 Seizures
GI
 Nausea
 Vomiting
 Diarrhea
 Glostitis
 Monitor
sodium level
because each
gram of ampicillin
contains 2.9 mEq
of sodium.
 Watch for
signs and
symptoms of
hypersensitivity ,
such as
maculopapular
rash, urticuria,
and anaphylaxis.
 After
negative
sensitivity must be
done.
(26th Edition Nursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages at 80-81)

74
Contraindication
Side Effects Nursing
Responsibilities
Date
ordered:
08-02-14
Generic:
Tramadol
Brand:
Ultram
50 mg
TIV
Every 6
hrs.
Opioid Agonist
Analgesics
Inhibits
reuptake of
serotonin and
norepinephrine
in CNS.
Indication:
 Moderate to
moderately
severe pain
Contraindication:
 Contraindica
ted in patients
hypersensitive to
drugs or other
opioids, those with
acute intoxication
from alcohol.
CNS
 Dizziness
 Confusion
 Fatigue
 Drowsiness
GU
 Renal failure
GI
 Nausea
 Anorexia
 Constipation
 Assess patient’s
level of pain atleast
30 mins before
administration.
 Monitor the bowel
and bladder
function.
 Monitor for
physical and
psychological drug
dependence.
 Monitor patient for
signs and
symptoms of
potentially life-threatening
serotonin
syndrome, which
may range from
shivering and
diarrhea to muscle
rigidity, fever,
mental-status
changes, and
seizures.
(2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 1183 -1185)

75
Drug Name Dosag
e
Classification Action Indication /
Contraindication
Responsibilities
Date
Ordered:
08-02-14
Generic:
Ranitidine
Hydrochlori-de
Brand:
Zantac
50 mg
IV q
8°X 4
doses
Histamine 2
blocker
Reduces
gastric acid
secretion
and
bicarbonate
production,
creating a
protective
coating on
gastric
mucosa
Indication:
 To prevent
Mendelson’s
disease (The
aspiration of
stomach
contents into the
lungs during
obstetric
anaesthesia)
Contraindication:
 Hypersensitivity
to drug or its
components
 Alcohol
intolerance (with
some oral
product)
 History of acute
porphyria
CNS
 Headache
 Agitation
 Anxiety
GI
 Nausea
 Vomiting
 Diarrhea
 Constipation
 Abdominal
discomfort or
pain
Hematologic
 Reversible
granulocytope
nia
 Thrombovytop
enia
Hepatic
 Hepatitis
Skin
 Rash
Other
 Pain at IM
injection site
 Burning
 Assess vital
signs
 Monitor CBC
and liver
function test
(26th Edition Nursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages 866-867)

76
Drug Name Dosage
Frequency
Route
Classification Indication
and
Contraindication
Side Effects
/Adverse Reaction
Mechanism
of Action
Nursing
Responsibilities
Date
Ordered:
08-02-14
Generic:
Metronidazole
Brand:
Flagyl
500 mg tab
BID
X 7 days
Anti- protozoal Indication:
Prevention for
anaerobic
infection
Contraindication:
to drug, other
nitroimidazole
derivatives, or
parabens (topical
form only)
CNS
 Dizziness
 Headache
 Ataxia
 Vertigo
 Insomia
GI
 Nausea
 Vomiting
 Diarrhea
 Abdominal
pain
 Anorexia
Disturbs
DNA
synthesis in
susceptible
bacterial
organism.
(But the
mechanism of
this action is not
well
understood)
 Inform patient to
report fever,
sorethroat,
bleeding or
bruising.
 Inform patient that
drug may cause
metallic taste and
may discolor urine
deep brownish-red.
(Reference: 2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages751-753)

77
Contraindication
Responsibilities
Date ordered:
08-04-14
Generic:
Spironolactone
Brand:
Aldactone
50mg
Cap
TID
PO
Potassium –
Sparing
diuretic
Inhibits
aldosterone
effects in
distal renal
tubule,
promoting
sodium and
water
excretion and
potassium
retention.
Indication:
 Essential
hypertension
Contraindication:
to drug
 Anuria
 Acute or renal
insufficiency
 Hyperkalemia
CNS
 Headache
 Drowsiness
 Lethargy
 Ataxia
 Confusion
GI
 Vomiting
 Diarrhea
 Cramping
 GI ulcers
Skin
 Rash
 Pruritus
 Hirsutism
 Monitor electrolyte
levels (especially
potassium).
Watch for signs
and symptoms of
imbalances and
metabolic
acidocis.
 Monitor weight and
fluid intake and
output. Stay alert
for indications of
fluid imbalance.
 Monitor CBC with
white cell
differential.
 Advise patient to
restrict intake of
high potassium
foods .
(2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages1097 -1099)

(Reference: 2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 66 -68)
78
Drug Name Dosage
Frequency
Route
and
Contraindication
Side Effects
/Adverse
Reaction
Mechanism of
Action
Nursing
Responsibilities
Date
Ordered:
08-04-14
Generic:
Amoxicillin
Brand:
Amoxil
500 mg
1 capsule
q 8
Antibiotic,
penicillin
Indication:
Infection
Contraindication
 Hypersensi-tivity
to
penicillin
,infectious
monucleosis
G.I
 Diarrhea
 Nausea
 Vomiting
 Abdominal
pain
Skin
 Rash
Respiratory
 Wheezing
 Other:
 superinfections
(oral and rectal
candidiasis)
 Fever
 Anaphylaxis
Inhibits cell-wall
synthesis
during
bacterial
multiplication,
leading to cell
death. Shows
enhanced
activity toward
gram-negative
bacteria
compared to
natural and
penicillinase-resistant
penicillins.
 Advise the patient
to take with food to
prevent
gastrointestinal
upset.
 Determine previous
hypersensitivity
reactions to
penicillin.
 Check patient’s
temperature.
 Monitor sign and
symptom of
urticarial rash.

79
Drug Name Dosage Classification Mechanism of
Action
Indication /
Contraindication
Responsibilities
Date
Ordered:
08-04-14
Generic:
Ferrous
Sulfate
Brand:
Brisofer
1 tab
BID
PO
X 30day
Iron
Preparation
Elevates the serum
iron concentration
which then helps to
form High or
trapped in the
reticuloendothelial
cells for storage
and eventual
conversion to a
usable form of iron.
Indication:
 To increase
hemoglobin
formation and
concentration in
the blood.
 Dietary
Supplement for
Iron.
Contraindication:
 Severe
Hypotension
 Dizziness
 Nasal
Congestion
 Dyspnea
 Hypotensi
on
 Muscle
Cramps
 Flushing
• Advise patient to take
medicine as prescribed.
• Advise to take meal
before taking the drug.
 Ask the patient that
she can drink orange
juice after she took
the drug for fast
absorption of the
drug.
• Encourage patient to
comply with additional
intervention for
hypertension like proper
diet, regular exercise,
lifestyle and changes
and stress
management.

(2004 Nurse’s Drug Guide Volume 2 at page 965-966)
80
Drug
Name
Dosage
Frequency
Route
Classification Mechanism
of Action
Indication /
Contraindication
Responsibilities
Date
ordered:
08-04-14
Generic:
Mefenamic
Brand:
Ponstan
500 mg
1 cap
Every 6
hrs.
P.O
Analgesic
NSAID
Inhibits
prostaglandin
synthesis
and affects
platelet
function.
Indication:
 Short term relief of
mild to moderate
pain.
Contraindication:
 Hypersensitivity to
drug
 Ulceration
 Nausea
 Vomiting
 Constipation
 Blurred vision
 Discontinue
drug
promptly if
diarrhea ,
dark stools,
hematemesis
, or rash
occur and do
no use again.

81
Drug
Name
Dosage
Frequency
Route
Classification Mechanism of
Action
Indication /
Contraindication
Responsibilities
Date
Ordered:
08-06-14
Generic:
Losartan
Brand:
Cozaar
100 mg
1tab OD
Route: P.O
Angiotensin II
receptor
antagonist
Blocks
vasoconstricting
and
aldosterone-secreting
effects of
angiotensin II at
various receptor
sites, including
vascular
smooth muscle
and adrenal
glands. Also
increases
urinary flow and
enhances
excretion of
chloride,
magnesium,
calcium, and
phosphate
Indication:
 Treatment of
hypertension
Contraindication:
to losartan
Pregnancy
(2nd trimester
and 3rd
trimester
 CNS
 Headache
 Dizziness
 Syncope GI
 Dry mouth
CV
 Hypotensio
n
 Monitor blood
pressure and
drug
 Notify
physician of
symptoms of
hypotension.
 Always count
the dose
given.
 Assist patient
when moving.
References : 2011 LIPPINCOTT’S Nursing Guide by Amy M. Karch at pages 728 -729
2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 685 -687)

82
Drug Name Dosage
Frequency
Route
and
Contraindication
Side Effects
/Adverse
Reaction
Mechanism of
Action
Nursing
Responsibilities
Date
Ordered:
08-06-14
Generic:
Amlodipine
Brand:
Norvasc
10 mg OD
Route:
P.O
Calcium channel
blocker
Indication:
 Essential
hypertension
Contraindication:
to drug
CNS
 Headache
 Dizziness
 Drowsiness
 Fatigue
 Weakness
CV
 Bradycardia
 Hypotension
 Palpitations
Respiratory
 Shortness
of breath
 Dyspnea
 Wheezing
Inhibits influx
of extracellular
calcium ions,
thereby
decreasing
myocardial
contractility,
relaxing
coronary and
vascular
muscles, and
decreasing
peripheral
resistance.
 Monitor heart
rate and rhythm
and blood
pressure,
especially at
start of therapy.
(Reference: 2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 65-66)

83
Drug
Name
Dosage Classificati
on
Mechanism of
Action
Indication /
Contraindication
Responsibilities
Date
ordered:
08-07-14
Generic:
Clonidine
hydrochloride
Brand:
Catapres
75 mcg 1
tab PRN
> 160/90
Cardiovascul
ar agent;
central-acting;
antihyperten
sive;
analgesics
Stimulates alpha-adregenic
receptors in CNS,
decreasing
sympathetic
outflow, inhibiting
vasoconstriction,
and ultimately
reducing blood
pressure.
Indication:
 Mild to
Moderate
hypertension
Contraindication:
to drug.
CNS:
 drowsiness
 dizziness
 fatigue
 sedation
 weakness
 malaise
 depression
CV:
 orthostatic
 hypotension
 bradycardia
 severe
rebound
hypertensio
n
GI:
 constipation
 dry mouth
 nausea
 vomiting
 anorexia
 Monitor blood
pressure and pulse
rate frequently
 Observe patient for
tolerance to drug’s
therapeutic effects,
which may require to
increase dosage
 Monitor patient for
signs and symptoms
of adverse
cardiovascular
reactions
 Inform patient that
dizziness upon
standing can be
minimized by rising
slowly from a sitting
or lying position and
avoid sudden position
changes.

84
Contraindication
Responsibilities
Date Ordered:
08-07-14
Generic:
Paracetamol
Brand:
Aeknil
1 amp IV
STAT
PRN
For > 38.6
degree
Nonopioid
Analgesic
Through the
produce
analgesia by
blocking pain
impulse by
inhibiting
synthesis of
prostaglandin
in CNS that
synthesize
pain receptor
to stimulation
Indication:
 Fever
Contraindication:
 Contraindicated in
patients
hypersensitive to
drug.
 Use cautiously in
patients with long
term alcohol use
because
therapeutic doses
causes
hepatotoxicity in
these patients.
 Hypoglycemia
 Rash
 Uticaria
 Instruct patient to
take with meals
have a plenty of
water when
taking this
drug.
 After negative
sensitivity
must be done.
(26th Edition Nursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages 351-352)

X. Problem
Identification &
Prioritization
85

Problem Identification and Prioritization
Problem
1. Increase blood pressure
2. Decreased blood flow
3. Increase body temperature
4. Headache
5. Difficulty of Sleeping
86

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EXPECTED
88
OUTCOME
S: “Nahihilo ako as
verbalized by the patient.
O:
 Temp: 39˚c
 PR: 95 b/m
 RR : 27
 BP: 160/120
 Generalized pale
 Body malaise
 Dizziness
 headache
Decrease cardiac
output related to
increase systemic
vascular
resistance as
manifested by
bp: 160/120
mmHg, dizziness,
headache.
Short Term
Goal:
Within 1-2
hours of shift
the patient’s
blood pressure
will decrease by
10-20 mmHg
systolic and
diastolic.
Long Term
Goal:
The client will
show signs
improved of
cardiac output
within 2-3 days.
Independent:
 Monitor vital
signs.
 Observe skin
color, moisture,
temperature,
and capillary
refill time.
 Provide calm,
restful
surroundings,
minimize
environmental
activity/ noise.
Limit the
number of
visitors and
length of stay.
 To obtain baseline
date
 Presence of pallor;
cool, moist skin;
and delayed
capillary refill time
may be due to
peripheral
vasoconstriction or
reflect cardiac
decompensation/
decreased output.
 Helps reduce
sympathetic
stimulation that
promotes
relaxation.
The patient will
demonstrate
adequate
cardiac output
as:
 BP within
individually
acceptable
range.
 No dizziness
and
headache

89
 Implement
dietary sodium,
fat, and
cholesterol
restrictions as
indicated.
Dependent:
 Administer
prescribed
medication as
ordered such as
:
 Catapres 75
mg tab
Sublingual
> 160/90
 These restrictions
can help manage
fluid retention and,
with associated
hypertensive
response,
decrease
myocardial
workload.
 Stimulates alpha-adregenic
receptors in CNS,
decreasing
sympathetic
outflow, inhibiting
vasoconstriction,
and ultimately
reducing blood
pressure. It
generally reduce
BP through the
combined effect of
decreased total
peripheral
resistance,
reduced cardiac
output, inhibited
sympathetic
activity, and

90
suppression of
renin release. (2011
McGraw-Hill Nurse’s Drug
HandBook by Patricia
Dweyer Schull at pages
264-266)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S: “Namamanas
ako” as verbalized
by the patient
91
O:
 With
generalized
edema
 Pale in color
 Capillary refill
of >3
seconds
 With
adventitious
breath sounds
(crackles)
 Dyspnea
 Weaknesses
Fluid volume
excess: interstitial
related to
decrease oncotic
pressure as
manifested by
shinny and
swollen skin and
indentation and
crackles
Short Term
Goal:
Within the 8
hours of shift the
patient will
demonstrate
reduction of fluid
excess.
Long Term
Goal:
Within the 2-3
days of duty the
patient will
stabilize fluid
volume as
evidence by
balanced input
and output, vital
signs within the
client’s normal
limits.
Independent:
 Monitor vital
signs
 Note presence
of medical
conditions or
situations.
 Record Intake
and Output
 Restrict fluids
 To obtain
baseline data.
 To prevent
contribution of
excess fluid
intake or
retention.
 Accurate
Intake and
Output is
necessary
for determining
renal function
and fluid
replacement
needs and
reducing risk of
fluid overload.
 Fluid
management
is usually
calculated
to prevent
further fluid
retention.
The patient will
have reduction of
fluid excess and
stabilize fluid
volume as
evidence by
balanced input
and output, vital
signs within the
client’s normal
limits, and free of
signs of edema.

92
Dependent:
 Administer
Diuretic as
ordered.
 Administer
Antihypertensi
ve as ordered.
 To excrete
excess fluid.
 To treat
hypertension by
counteracting
effects of
decrease renal
blood flow.

93
OUTCOME
S:”Mainit ang
pakiramdam ko” as
verbalized by the
client.
O:
 Temperature: 39˚
 PR: 117
 RR: 34
BP: 140/110
 Flushed skin,
 Warm to touch
 Tachycardia
 Malaise/weakness
 Thirst
 Weakness
 Undocumented
measurement of
urine output
Ineffective
thermoregulation
related to
intravascular
fluid volume
depletion as
manifested by
Temperature of
39˚ C, flushed
skin and warm to
touch.
Short Term Goal:
Within the 4hrs of
shift the patient will
achieve normal
body temperature
within 36 C to
37.5˚ C.
Long Term Goal:
Within 2-3 days
the patient’s
temperature will be
maintained within
normal range of 36
˚C – 37.5 ˚C and
no episode of
fever.
Independent:
 Monitor vital signs
especially the
temperature.
 Perform tepid
sponge bath.
 Promote surface
cooling by means
of undressing.
 Encourage
adequate fluid
intake.
 Advise to maintain
bed rest.
 To have
Baseline
 It will promote
heat loss by
means of
evaporation and
conduction.
 It promotes heat
loss by radiation
and conduction.
 To prevent
dehydration.
 To reduce
metabolic
demands and
oxygen
consumption.
The patient will be
afebrile as:
 T = 36 ˚C –
37.5˚ C

94
Dependent:
 Administer
prescribed
medication as
ordered such as :
 Paracetamol
1 amp. 300
mg for T >
38.6 ˚C
 Administer
replacement fluids
and electrolytes as
ordered.
Collaborative:
 Refer for laboratory
test.
 Through the
produce analgesia
by blocking pain
impulse by
inhibiting
synthesis of
prostaglandin in
CNS that
synthesize pain
receptor
to stimulation
 To support
circulating volume
and tissue
perfusion.
.
 To identify
causative factors.

95
OUTCOME
S:
“Sobrang sakit ng
ulo ko” as
verbalized by the
patient.
O:
 Temp: 39˚c
 PR: 117 b/m
 RR : 34 b/m
 BP: 140/110
mmHg
 Pain R/S of
8/10
 With facial
grimace
 Dizziness
 Restlessness
Acute pain:
headache related
to high blood
pressure as
manifested by
verbal reports of
headache PRS
8/10.
After 1 hour of
nursing
interventions the
client will be able
to verbalize or
report pain is
relieved or
controlled.
Independent:
 Monitor vital
signs.
 Assess for
referred pain
.
 Provide
comfort
measures,
quiet
environment,
and calm
activities
 Instruct in
and
encourage
use of
relaxation
techniques
Dependent:
 Administer
 To obtain
baseline data.
 To help
determine
possibility of
underlying
condition or
organ
dysfunction
requiring
treatment.
 To promote non
pharmacological
pain
management
 To distract
attention and
reduce tension
 To maintain
acceptable level
The client’s
verbalize pain
r/s is 6/10.

96
analgesics as
doctor’s
prescribed.
of pain.

Assessment Diagnosis PLANNING INTERVENTION RATIONALE EXPECTED
97
OUTCOME
S: “Nagigising
ako sa gabi pag
may mga baby
na naiyak tapos
makakatulog na
ko after 4-5
hours.” as
verbalized by the
client.
O:
 BP:140/110
 PR: 67 b/m
 RR: 24 b/m
 With body
malaise
 Restlessness
 Yawning
 Dark circle
under the eye.
Disturbed
sleeping
pattern
related to the
excessive
hospital
stimulation
(noise) as
evidence by
yawning,
restlessness,
dark circle
under the
eye.
Short Term:
Within the shift,
client will have
3-4 hours of
continued and
uninterrupted
rest and sleep.
Long Term:
Client will be
able to
verbalize ways
to promote and
maintain
adequate sleep
and
uninterrupted
sleep at night.
Independent:
 Monitor client’s vital
signs and recorded.
 Manage environment;
perform monitoring and
care activities without
waking client whenever
possible.
 Ensure environment is
quiet and has a
comfortable temperature
by providing fan, etc.
 Listen to reports of sleep
quality and response
from lack of good sleep.
 Encourage to use
earplugs,
 To obtain
baseline data.
 It will allow
patient for
longer periods
of uninterrupted
sleep,
especially
during the
night.
 External stimuli
interfere with
going to sleep
and increase
awakenings.
 Helps clarify
the client’s
perception of
sleep quantity
and quality and
response to
inadequate
sleep.
 To enhance
ability to fall
asleep.
Client is able to
maintain 6 – 8
hours of sleep at
night.
Client is able to
have daytime nap
of 3-4 hours.

99
XII. Recommendation
Our group recommend:
To the patient
 To minimize drinking of alcohol beverages
 To stop using tobacco
 To avoid eating foods high in cholesterol and salt like noodles
 To avoid too much caffeine
 To maintain BMI between 20-24 kg/m2 and increase physical activity like doing
exercise.
To the Family
 To encourage the patient on her proper diet
 Give spiritual support
 Encourage the patient to have a healthy lifestyle
To the students
 Keep informing the patient about her condition
 Provide health teaching
 Give deep empathy

Discharge Plan
101
Medications:
 Catapres 75mg 1tablet as needed for Blood pressure of ≥160/90
 Losartan 10mg 1tablet OD (6am)
 Amlodipine 10mg 1tablet OD (6pm)
 Amoxicillin 500mg 1capsule every 8hours for 7 days
 Metronidazole 500mg 1tablet BID for 7 days
 Ferrous Sulfate 1capsule BID for 1 month
 Mefenamic acid 500mg 1 capsule every 8hours for pain
 Spinorolactone 50mg 1 capsule BID for 7 days
Environment: Client needs clean and safe environment.
Treatment: no follow up treatment.
Health teaching:
 The patient should be instructed to monitor her Blood pressure
 Advise to for a minute of exercise
 Advise to avoid salty and fatty foods
 Explain the action and side effects of the drugs to the patient.
Out-patient department: Follow check-up at OB on August 22, 2014 , Friday at 1pm
Diet:
 Sodium restrictions
- Sodium- restricted diets may vary from 2 to 4 g depending on the degree of
hypertension. The patient should be avoiding high-sodium foods such as
cured meats, canned soups, and soy sauce.

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