OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
Name: Alfaro, Christine Mae M., Blanco, Allysha Marie J., Calimquim, Christine Mae B., Cortes, Lourdes Angelika D.
Year/ Section: BSN 2 -Y2- 5
I. Case Study Title:
23-year-old pregnant female present with pre-eclampsia with severe features.
II. OBJECTIVES:
a. To determine the health status and the complications of our client through assessment in order to
develop a database about the patient’s overall state to render an individualized nursing care.
b. To know the appropriate interventions and differentiate the medications indicated to the patient’s
condition promoting evidenced-based nursing care.
c. Evaluate the identified and distinguished goals and expected outcomes if these has been met.
III. INTRODUCTION:
Pregnancy-related hypertensive disorders, also referred to as pregnancy-associated hypertensive disorders or
pregnancy-induced hypertension, are the most frequent complications that develop during pregnancy (more
specifically, after 20 weeks), and they are the leading cause of maternal and fetal morbidity and mortality. It
frequently results in high blood pressure and may have an impact on a number of bodily organs, including the liver,
kidney, and brain. If left untreated, it may cause serious complications of the mother and the unborn child. Preeclampsia is the most typical serious medical condition that can develop during pregnancy. Pregnancies with mild
pre-eclampsia can happen in up to 1 in 10 cases, and those with severe pre-eclampsia in up to 1 in 100 cases. Around
the world, preeclampsia alone is thought to complicate 2-8% of pregnancies.
Patient Licuanan who is a 23-year-old woman G1P0 at 37 weeks and 1 day of gestation. She has been
experiencing high blood pressure and bilateral leg edema. She has a family medical history of hypertension from
her father’s side.
She was admitted on March 8, 2023 at 7:12 PM with a BP of 160/100, HR: 103, RR: 20, T: 36.3, O2: 98%, FHT:
131. No continuous contractions, in cephalic position, and not in labor. Her admitting diagnosis is pre-eclampsia
with severe features. She denied experiencing headache, blurring of vision, and vomiting.
Patient’s blood pressure is monitored regularly, and she is given medications to help lower it. She is also put on
bed rest to minimize any occurrence of seizures and reduce the risk of complications. Her baby is monitored with
frequent ultrasounds and fetal monitor to ensure fetal well-being.
After several days of hospitalization, patient’s condition restricted her to have vaginal delivery, hence, with the
consent of the mother, they decided to perform an emergency cesarean section to deliver the baby safely. She
delivered a healthy baby girl who weighs 2.3 kg. Having a final diagnosis of pre-eclampsia with severe features and
abruptio placenta.
Patient and her baby require close monitoring and care after the delivery due to the potential complications
associated with preeclampsia. Her blood pressure is closely monitored, and she continues to receive medication to
control it. She is counseled about the importance of follow-up care after discharge to monitor her blood pressure
and ensure that her condition does not worsen
IV. BIOGRAPHICAL DATA:
a. Patient Profile: (Name: Initials Only, Age, Gender, Religion, Marital Status, Occupation)
Name: Licuanan, SS
Age: 23 years old
Gender: Female
1
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
Religion: Roman Catholic
Marital Status: Married
Occupation: N/A
b. History of Present Illness:
Prior to admission patient was noted to have elevated blood pressure.
c. Obstetrical and Menstrual History
Last Menstrual Period – June 21, 2022
d. Past Medical History:
N/A
e. Family History:
Hypertension – Father’s side
f.
Social History:
N/A
g. Developmental Stage: (Erick Erickson)
STAGE 6 Intimacy vs Isolation
(Young Adult Years from 18 to 40)
The major conflict at this stage of life centers on forming intimate, loving relationships with other people.
Success at this stage leads to fulfilling relationships. Struggling at this stage, on the other hand, can result
in feelings of loneliness and isolation.
V. Physical Assessment: (Cephalocaudal)
Findings
General Appearance: (Contraptions)
Conscious coherent with cardiorespiratory distress
a. Head
N/A
b. Upper Extremities
Diminished peripheral pulses
c. Chest
Symmetrical Chest Expansion
Clear Breath Sounds
d. Abdomen
No contractions
Not in labor
e. Lower Extremities
f. Others:
Bilateral Edema
N/A
VI. Medical Management: (Indicate Findings and Interre)
a. Laboratories: (CBC, UA, Fecalysis etc.)
N/A
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OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
b. Diagnostics: (ECG, X- Ray etc.)
N/A
VII. Drug Study:
Drugs/Classificatio
n
Dose/Route/Time
CEFUROXIME
750MG
o Antibiotics
o Second
Generation
cephalosporins
o IV q8 x 2 doses
Indication/Action
Contraindication
Action: Inhibits callwall synthesis,
promoting osmotic
instability; usually
bactericidal
•
Indication:
➢ Serious
lower
respiratory
tract
infection,
skin or skinstructure
infection,
septicemia,
and
meningitis.
➢ Preoperative
prophylaxis
➢ Uncomplicat
ed skin and
skinstructure
infection
•
•
•
•
HYDRALAZINE
5 MG
o Antihypertensiv
e
o Peripheral
vasodilators
o Slow iv push
now
Action: Not fully
understood. A directacting peripheral
vasodilator that
relaxes arteriolar
smooth muscle.
Indication:
➢ HTN
➢ Hypertensive
emergency
•
•
Contraindicate
d in patients
hypersensitive
to drug or
other
cephalosporins
Use cautiously
in patients
hypersensitive
to penicillin
because of
possibility of
crosssensitivity with
other betalactam
antibiotics
Use cautiously
in patients with
history of
colitis and in
those with
renal
insufficiency
Some drugs
may contain
phenylalanine
or sodium
Contraindicate
d in patient
hypertensive to
drug
Drug may
contain
tartrazine and
cause allergic
reactions,
especially in
patients
sensitive to
aspirin
Adverse Reaction/
Side Effect
CV: phlebitis,
thrombophlebitis
Nursing
Considerations:
•
GI: Diarrhea, anorexia,
nausea, vomiting
HEMATOLOGIC:
thrombocytopenia,
hemolytic anemia,
eosinophilia
SKIN: maculopapular
and erythematous
rashes, urticarial, tissue
sloughing at IM
injection site
•
•
Monitor
patients for
signs and
symptoms of
superinfection
and diarrhea
and treat
appropriately
Drug may
increase INR
and risk of
bleeding.
Monitor
patient
OTHERS: anaphylaxis,
hypersensitivity
reactions, serum
sickness
CNS: anxiety,
headache, depression,
dizziness, peripheral
neuritis, increased ICP,
psychosis
•
CV: angina pectoris,
palpitations,
tachycardia, edema
•
EENT: conjunctivitis,
nasal congestion
•
Monitor
patient’s BP
standing and
sitting, HR, and
bpdy weight
frequently
Elderly patients
may be more
sensitive to
drugs
hypotensive
effect
Obtain CBC,
lupus
3
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
•
•
DICLOFENAC 75
MG
• NSAID
-LOADING DOSE
ACTION: Produces
anti-inflammatory
and analgesic effects
by ability to inhibit
prostaglandin
synthesis.
•
INDICATION:
➢ Acute pain
due to minor
strains,
sprains, and
contusions.
•
•
Drug may
produce a
clinical picture
consistent with
SLE
Use cautiously
in patients with
suspected
cardiac disease,
stroke, or sever
renal
impairment
and in those
taking other
antihypertensiv
e.
Contraindicate
d in patients
hypersensitive
to diclofenac.
Diclofenac 3%
sodium gel is
also
contraindicated
in patients with
a known
hypersensitivit
y to benzyl
alcohol,
polyethylene
glycol
monomethyl
ether 350, or
hyaluronate
sodium.
Contraindicate
d in patients
with a history
of asthma,
urticaria, or
other allergic
reactions after
taking aspirin
or other
NSAIDs.
Flector patch is
contraindicated
for use on
GI: nausea, vomiting,
diarrhea, anorexia,
constipation,
serythematosu
s cell before
preparation,
and ANA titer
determination
before therapy
and
periodically
during long
term therapy
GU: difficult urination
Hematologic: anemia,
leukopenia, eosin philia
Muscuskeletal: muscle
cramps, arthralgia
Respiratory: dyspnea
Skin: diaphoresis,
pruritus, rash
Other: hypersensitivity
raections, chills
CNS: paresthesia,
headache, pain, asthenia, migraine,
hypokinesia.
•
CV: chest pain, HTN.
EENT: conjunctivitis,
eye pain, sinusi-tis,
pharyngitis, rhinitis.
Gl: diarrhea, dyspepsia, abdominal pain,
flatulence, nausca.
CU: heraturia, renal
impairment. Hepatic:
liver impairment.
METABOLIC:hyperchol
es-terolemia,
hyperglycemia.
MUSCOSKELETAL:
arthralgia, arthrosis,
back pain, myalgia,
neck pain.
RESPIRATORY: asthma,
dyspnea, pneumonia.
•
Avoid use in
patients with
recent MI
unless benefits
are expected
to outweigh
risk of
recurrent CV
thrombotic
events. If used
in patients
with recent MI,
watch for signs
and symptoms
of cardiac
ischemia.
Avoid use in
patients with
severe HF
unless benefits
are expected
to outweigh
risk of
worsening HF.
If used in
patients with
severe HF,
watch for signs
and symptoms
of worsening
HF.
4
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
nonintact or
damaged skin,
including from
exudative
dermatitis,
eczema,
infected lesions, burns, or
wounds.
SKIN: reaction at
application site, contact
dermatitis, dry skin,
exfoliation, localized
pain, pruritus, rash,
localized edema, acne,
alopecia,
photosensitivity
reactions, skin ul-cer.
OTHER: anaphylaxis,
flulike syndrome,
infection, allergic
reaction.
•
•
•
METHYLDOPA 250
MG /CUP
o Antihypertensi
ve
-ORAL TID
ACTION: May inhibit
the central
vasomotor centers,
decreasing
sympathetic outflow
to the heart,
kidneys, and
•
Contraindicate
d in patients
hypersensitive to drug
and in those
with active
CNS: decreased mental
acuity, sedation,
headache, weakness,
dizziness, paresthesia,
parkinsonism,
involuntary
choreoathetoid
•
Evaluate
patient with
signs or
symptoms of
liver
dysfunction or
with abnormal
LFT results for
development
of more severe
hepatic
reaction while
taking drug.
If clinical signs
or symptoms
of liver disease
develop, or if
systemic
manifestation
(cosinophilia,
rash) occurs,
discontinue
drug.
Safety and
effcctiveness
of sunscreens,
cos-metics, or
other topical
medications
used with drug
are unknown. •
Complete
healing or
optimal
therapeutic
effect may not
be seen until
30 days after
therapy is
complete. •
Reevaluate
lesions that
don't respond
to therapy
Monitor
patient's BP
regularly.
Elderly patients
are more likely
to experience
hypoten-sion,
5
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
peripheral
vasculature.
INDICATION:
➢ HTN,
Hypertensive
crisis
•
•
hepatic disease
(such as acute
hepatitis) or
active cirrhosis.
Contraindicate
d in those
whose previous
methyldopa
therapy caused
liver problems
and in those
taking MAO
inhibitors.
Use cautiously
in patients with
history of
impaired
hepatic
function or
sulfite
sensitivity.
movements, psychic
disturbances, depression, nightmares.
CV: orthostatic
hypotension, edema,
bradycardia, HF,
myocarditis,
aggravated angina.
EENT: nasal congestion.
Gl: dry mouth,
pancreatitis, nausea,
vomiting, diarrhea,
constipation, flatus,
sore or "Black" tongue,
abdominal distention,
colilis.
GU: amenorrhea,
impotence.
ACTION: Unknown.
Binds with opioid
receptors in the CNS,
altering perception
of and emotional
response to pain
INDICATION:
➢ Moderate to
severe pain (
• Contraindicated
in patients
hypersensitive to
drug or its
components and in
those with
significant
respiratory
depression, known
or suspected GI
•
Hematologic:
thrombocytopenia,
leukopenia, bone
marrow depression,
hemolytic anemia.
Hepatic: hepatic
necrosis, hepatitis,
jaundice.
NALBUPHINE
HYDROCHORIDE
(NUBAIN) 5MG +
PHENERGAN 25
MG
-IV
Opioid Analgesics
•
Metabolic:
hyperprolactinemia,
weight gain.
Musculoskeletal:
arthralgia, myalgia.
Skin: rash. Other: druginduced fever, breast
en- largement.
CNS: dizziness,
headache, sedation,
vertigo.
CV: bradycardia,
hypotension.
EENT: dry mouth.
GI: nausea, vomiting.
•
syncope, and
sedation.
Occasionally,
tolerance may
occur, usually
between the
second and
third months
of therapy.
Adding a
diuretic or
adjusting
dosage may be
needed. If
patient's
response
changes
significantly,
notify
prescriber.
After dialysis,
monitor
patient for HTN
and notify
prescriber, if
needed.
Patient may
need an extra
dose of drug.
Monitor CBC
with
differential
counts before
therapy and
periodically
thereafter.
• Reassess
patient's level of
pain at least 15 and
30 minutes after
parenteral
administration.
• Carefully monitor
vital signs, pain
level, respiratory
6
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
non-opioidtolerant
patients)
➢ Adjunct to
balanced
anesthesia;
preoperative
and
postoperativ
e analgesia;
obstetric
analgesia
during and
delivery.
FUROSEMIDE 20
MG
ACTION: Inhibits
sodium and chloride
reabsorption at the
proximal and distal
tubules and the
ascending loop of
Henle.
INDICATION:
➢ Acute
pulmonary
edema
➢ Edema
➢ HTN
obstruction
(including paralytic
ileus), and acute or
severe asthma in
anunmonitored
setting or in the
absence of
resuscitative
equipment.
• Use cautiously
and at low doses in
patients with
preexisting
respiratory
compromise.
• Contraindicated
in patients
hypersensitive to
drug and in those
with anuria.
• Use cautiously in
patients with
hepatic cirrhosis
and in those
allergic to
sulfonamides.
Respiratory:
respiratory depression.
Skin: clamminess,
diaphoresis.
status, and
sedation level in all
patients receiving
opioids, especially
those receiving IV
drugs, even those
given
postoperatively.
CNS: vertigo, headache,
dizziness, paresthesia,
weakness, restlessness,
fever.
•
CV: orthostatic
hypotension,
thrombophlebitis with
IV administration.
•
EENT: blurred or
yellowed vision,
transient deafness,
tinnitus.
•
GI: abdominal
discomfort and pain,
diarrhea, anorexia,
nausea, vomiting,
constipation,
pancreatitis.
GU: azotemia, nocturia,
polyuria, frequent
urination, oliguria.
Hematologic:
agranulocytosis,
aplastic anemia,
leukopenia,
thrombocytopenia,
anemia.
Hepatic: dysfunction,
•
Monitor
weight, BP, and
pulse rate
routinely with
long-term use.
Monitor fluid
intake and
output and
electrolyte,
BUN, and
carbon dioxide
levels
frequently.
Monitor
patients with
severe
symptoms of
urine retention
due to bladder
emptying
disorders,
prostate
enlargement,
or urethral
narrowing or
worsening of
symptoms,
especially
during initial
treatment.
Drug may
increase fetal
birth weight.
Monitor fetal
7
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
jaundice, increased
liver enzyme levels.
•
Metabolic: volume
depletion and
dehydration,
asymptomatic
hyperuricemia,
impaired glucose
tolerance,
hypokalemia,
hypochloremic
alkalosis,
hyperglycemia,
dilutional
hyponatremia,
hypocalcemia,
hypomagnesemia.
•
growth during
pregnancy.
Nephrocalcinos
is and
nephrolithiasis
have occurred
in premature
infants and in
children
younger than
age 4 on longterm
furosemide
therapy.
Monitor renal
function and
renal
ultrasounds.
Musculoskeletal:
muscle spasm.
Skin: dermatitis,
purpura,
photosensitivity
reactions, transient
pain at IM injection
site, toxic epidermal
necrolysis, SJS,
erythema multiforme.
Other: gout.
8
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
VIII. Nursing Management: Course in the Ward
F
D
A
R
F
D
A
Date/ Day: March 9, 2023
7:00 AM – 8:00 AM
Shift:___________________
Date/ Day: March 9, 2023
7:00 AM – 8:00 AM
Shift: ___________________
FOCUS:
Decreased Cardiac Output/ Elevated Blood Pressure
FOCUS: Edema
R
DATA:
BP: 130/100
RR: 18
PR: 64
Temp: 36
(+) Urine Output
(+) Lower extremities edema
DATA:
BP: 130/100
RR: 18
PR: 64
Temp: 36
-Pre eclampsia
-Elevated Blood Pressure
-Edema
ACTION:
• Monitor the patient’s blood pressure every
one hour, record and graph vital signs, and
administer antihypertensive medications as
ordered by the physician.
• Provide frequent rest periods with bed rest.
• Monitor fetal heart rate and movements.
• Encourage bed rest and provided calm
environment.
RESPONSE:
• Blood pressure is maintained within normal
limits. Any seizure activity did not occur. Fetal
well being is maintained.
________________________
Name/ Signature
ACTION:
• Monitor signs of worsening edema and
preeclampsia including headache and vision
changes.
• Maintain normal blood pressure and monitor for
sign of hypertension.
• Administer medication as prescribed by the
physician (antihypertensive, diuretics, and
analgesics).
• Monitor fluid balance or fluid intake & output and
adjust fluids as needed.
• Provide frequent position changes to promote
circulation.
• Encourage ambulation as soon as possible to
prevent blood clots.
• Assess pain level and administer pain medication as
needed.
• Provide education on signs & symptoms of
preeclampsia and instruction for follow-up care.
RESPONSE:
- Blood pressure decreases to after administering antihypertensive medication.
- Improved urine output after fluid intake is increased.
- Patient demonstrates understanding of the
importance of monitoring blood pressure and reporting
any changes in condition to healthcare providers.
- Physician is notified of the patient’s condition and
appropriate intervention are initiated.
________________________
Name/Signature
9
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
VIII. Nursing Management: Course in the Ward
F
D
A
R
F
D
Date/ Day: March 9, 2023
Date/ Day: March 9, 2023
7:00 AM – 8:00 AM
Shift: __________________
7:00 AM – 8:00 AM
Shift: _________________
FOCUS:
FOCUS:
Risk for injury
DATA:
Patient stated that she was experiencing dizziness.
ACTION:
•
•
•
•
Subjective: Mother verbalized that: “Hindi
dumedede ang anak ko sa aking suso, hindi ko alam
ang aking gagawin”
ACTION:
Assess for central nervous system (CNS)
involvement.
Assess for alterations in level of consciousness.
Assess for signs of labor at every visit.
Assess the client’s vital signs.
Palpate for uterine tenderness or rigidity;
check for vaginal bleeding—review
RESPONSE:
•
R
Ineffective Breastfeeding
DATA:
•
A
•
•
•
The client participates in treatment and/or
environmental modifications to protect herself
and enhance safety.
Perform physical assessment, noting
appearance of breasts and nipples, marked
asymmetry of breasts, obvious inverted or flat
nipples, or minimal or no breast enlargement
during pregnancy.
Discuss/demonstrate breastfeeding aids (e.g.,
infant sling, nursing footstool/pillows, hand
expression, manual and/or piston -type
electric breast pumps).
Encourage mother to obtain adequate rest,
maintain fluid and nutritional intake, continue
to take her prenatal vitamins, and schedule
breast pumping every 3 hr. while awake, as
indicated.
RESPONSE
•
•
•
________________________
Name/ Signature
Mother exhibited different proper
breastfeeding position.
Mother achieved satisfactory breastfeeding
regimen with content after feedings.
Infant displayed effective breastfeeding as
evidenced by appropriate weight gain.
________________________
Name/Signature
10
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
IX. Nursing Care Plan:
ASSESSMENT
NSG.
DIAGNOSIS
PLANNING
Impaired tissue
perfusion
related to
preeclampsia
as evidenced
by edema
After hours of
nursing
intervention,
the patient will
be able to
manifest
increased
tissue
perfusion as
evidenced by:
- blood
pressure
within normal
range
- absence of
edema
•
Subjective:
Objective:
BP: 130/100
RR: 18 PR: 64
Temp: 36
Lower
extremities
edema
INTERVENTION
•
•
•
•
•
•
•
Date:______________________
RATIONALE
EVALUATION
Monitor signs of
worsening edema
and preeclampsia
including
headache and
vision changes.
Maintain normal
blood pressure
and monitor for
sign of
hypertension.
Administer
medication as
prescribed by the
physician
(antihypertensive,
diuretics, and
analgesics).
Monitor fluid
balance or fluid
intake & output
and adjust fluids
as needed.
Provide frequent
position changes
to promote
circulation.
Encourage
ambulation as
soon as possible
to prevent blood
clots.
Assess pain level
and administer
pain medication
as needed.
Provide education
on signs &
symptoms of
preeclampsia and
instruction for
follow-up care.
- After hours of
nursing
intervention,
the patient
was able to
manifest
increased
tissue
perfusion as
evidenced by:
- blood
pressure is
slightly above
normal range
- edema is still
present (from
grade 2 to
grade 1)
11
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
IX. Nursing Care Plan:
ASSESSMENT
Subjective:
“Nahilo po ako
sa bahay,” as
stated by the
client.
NSG.
DIAGNOSIS
Decreased
cardiac output
related to
elevated blood
pressure as
evidenced by
the changes in
blood pressure
and edema.
PLANNING
INTERVENTION
The goals of
nursing care for
this patient with
pre-eclampsia
are:
Monitor the
patient's blood
pressure every
one hour and
administer
antihypertensive
medications as
ordered by the
physician
- Maintain
maternal blood
pressure within
normal limits to
prevent further
organ damage
-Prevent seizure
activity
Objective:
BP: 130/100 RR:
18
PR: 64
Temp: 36
-Pre eclampsia
-Elevated Blood
Pressure
-Edema
-Promote fetal
well-being
-Provide
education and
support to the
patient and her
family about
pre-eclampsia
and its
management
Monitor fetal
heart rate and
movement
Encourage bed
rest and restrict
activity and
provide a quiet
and calm
environment.
Provide
emotional
support and
education to the
patient and her
family about preeclampsia, its
management,
and the signs and
symptoms of
worsening
disease.
Date:______________________
RATIONALE
EVALUATION
To assess fetal
well-being.
To prevent
further organ
damage and to
reduce stress
and prevent
seizure activity.
To prevent
further maternal
and fetal injury
and promote a
positive
pregnancy
outcome.
To ensure
appropriate care
is provided.
The nursing care
plan for preeclampsia will be
evaluated based
on the
achievement of
the following
goals:
Blood pressure is
maintained
slightly above
within the
normal range
and
administered
appropriate
medications. No
occurrence of
seizure. Fetal
well-being is
maintained.
Patient and
family are
educated about
pre-eclampsia
and its
management.
Collaborate with
other members
of the healthcare
team, such as the
obstetrician and
neonatologist, to
ensure
appropriate care
is provided.
12
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
IX. Nursing Care Plan:
ASSESSMENT
NSG.
DIAGNOSIS
PLANNING
INTERVENTION
Date:______________________
RATIONALE
EVALUATION
Subjective:
Patient stated
that she was
experiencing
dizziness.
Objective:
BP: 130/100
RR:18 PR: 64
Temp : 36 PREECLAMPSIA
RISK FOR
SHORT TERM
INJURY RELATED - After 2-3 hours
TO SEIZURES
of nursing
interventions,
the patient will
be able to
verbalize
understanding of
individual
factors that
contribute to the
possibility of
injury.
LONG TERM
- After 2-4 days
or nursing
interventions,
the patient will
be able to
demonstrate
behaviors,
lifestyle changes
to reduce risk
factors and
protect self from
injury.
- Assess/Monitor
the client's vital
signs.
- Assess for
central nervous
system (CNS)
involvement.
- Emphasize the
importance of
the client
promptly
reporting
signs/symptoms
of CNS
involvement.
- Provide
education on
signs and
symptoms of
preeclampsia
Explain that
eclampsia is
usually preceded
by prodromal
signs such as
persistent
headache,
blurring of
vision, severe
epigastric strict
pain, altered
mental status,
and abdominal
pain. The client
explains they
may feel restless
during the aural
phase.
Understanding
the importance
of providing for
own safety may
enhance client
cooperation.
- Client was able
to verbalize
understanding
individual
factors that
contribute to the
possibility of
injury
- the patient was
be able to
demonstrate
behaviors,
lifestyle changes
to reduce risk
factors and
protect self from
injury.
13
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
IX. Nursing Care Plan:
ASSESSMENT
NSG.
DIAGNOSIS
PLANNING
Ineffective
Breastfeeding
RT to
knowledge
deficit AEB
verbalization of
“hindi ko alam
ano ang aking
gagawin”
Short term:
After 2 hours of
nursing
intervention
the mother will
be able to:
INTERVENTION
Date:______________________
RATIONALE
EVALUATION
Subjective:
Mother
verbalized that:
“Hindi
dumedede ang
anak ko sa
aking suso,
hindi ko alam
anng aking
gagawin”
Objective:
• BP – 130/100
mmHg
• RR – 18 bpm
• PR – 64 bpm
• T – 36 C
• Verbalizes
understanding
of causative or
contributing
factors of
ineffective
breastfeeding
• Demonstrate
techniques to
enhance
breastfeeding
experience.
• Assume
responsibility
for effective
breastfeeding
Long term:
After 7 days of
nursing
intervention
the mother and
infant will be
able to:
Mother will
exhibit different
proper
breastfeeding
position.
• Mother will
achieve
satisfactory
breastfeeding
regimen with
content after
feedings.
Independent:
• Perform physical
assessment, noting
appearance of breasts
and nipples, marked
asymmetry of breasts,
obvious inverted or
flat nipples, or
minimal or no breast
enlargement during
pregnancy.
• Note previous
unsatisfactory
experience (including
self or others)
• Identify maternal
support systems or
presence and
response of
significant others
(SOs), extended
family, and friends.
•Discuss/demonstrate
breastfeeding aids
(e.g., infant sling,
nursing
footstool/pillows,
hand expression,
manual and/or piston
-type electric breast
pumps).
-type electric breast
pumps).
• Encourage mother
to obtain adequate
rest, maintain fluid
and nutritional intake,
continue to take her
prenatal vitamins, and
schedule breast
pumping every 3 hr.
while awake, as
indicated.
Identifies
existing
problems that
may interfere
with successful
breastfeeding
experience and
provides
opportunity to
correct them
when possible
because it may
lead to negative
expectations
Short term:
After 2 hours of
nursing
intervention
the mother was
able to:
The infant’s
father and
maternal
grandmother
(in addition to
caring
healthcare
providers) are
important
factors that
contribute to
successful
breastfeeding.
• Demonstrated
techniques to
enhance
breastfeeding
experience.
• Assumed
responsibility
for effective
breastfeeding.
This enhances
comfort and
relaxation for
breastfeeding.
When
circumstances
dictate that the
mother and
infant are
separated for a
time, whether
by illness,
prematurity, or
returning to
work or school,
the milk supply
can be
• Verbalized
understanding
of causative or
contributing
factors of
ineffective
breastfeeding.
Long term:
After 7 days of
nursing
intervention
the mother and
infant were
able to:
• Mother
exhibited
different proper
breastfeeding
position.
• Mother
achieved
satisfactory
breastfeeding
regimen with
content after
feedings.
14
OUR LADY OF FATIMA UNIVERSITY
Regalado Avenue, Fairview Quezon City
• Infant will
display
effective
breastfeeding
as evidenced by
appropriate
weight gain.
Dependent:
• Advise the patient
to join lactation
counselor training
course available near
the area or in online.
Collaborative:
• Refer the patient to
a lactating counselor.
maintained by
use of the
pump. Storing
the milk for
future use
enables the
infant to
continue to
receive the
value of breast
milk.
• Infant
displayed
effective
breastfeeding
as evidenced by
appropriate
weight gain.
Sustains
adequate milk
production and
enhances
breastfeeding
process when
mother and
infant are
separated for
any reason.
Designed to
provide up-to
date, researchbased
information
15