Case - Eclampsia Final

I.
Introduction
A. Trends
Hypertension is one of the most common medical complications of pregnancy that affects both fetal and maternal health and is often life threatening.
Multiple maternal organs are affected by hypertension in pregnancy, including the brain in the form of eclampsia.
There are certain types of hypertension in pregnancy/ pregnancy induced-hypertension; Pre-eclampsia is a medical condition where hypertension
arises in pregnancy (pregnancy-induced hypertension) in association with significant amounts of protein in the urine. Pre-eclampsia refers to a set of
symptoms rather than any causative factor, and there are many different causes for the condition. It appears likely that there are substances from the placenta
that can cause endothelial dysfunction in the maternal blood vessels of susceptible women. While blood pressure elevation is the most visible sign of the
disease, it involves generalized damage to the maternal endothelium, kidneys, and liver, with the release of vasoconstrictive factors being secondary to the
original damage. Eclampsia is a leading cause of maternal death, with classic neurologic symptoms that include headaches, nausea, vomiting, cortical
blindness, coma, and convulsions. Although numerous organs are affected by hypertension in pregnancy, cerebrovascular involvement is the direct
mechanism of death in 40% of patients.The major cerebrovascular changes in eclampsia have been shown to be similar to those described for hypertensive
encephalopathy, including loss of cerebral blood flow (CBF) autoregulation, hyperperfusion, and edema.
Eclampsia, a dramatic and often unpredictable complication of pregnancy-induced hypertensive disorders, is characterized by sudden hypertension,
proteinuria, edema, and seizures.
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A relatively rare syndrome, eclampsia complicates approximately 3 in 100 pregnancies, with higher incidence rates in preeclamptic or twin
pregnancies, women of low socioeconomic status or in developing countries, and nulliparous patients younger than 20 years or multiparous patients older
than 35 years of age.
However many medical disorders can occur during pregnancy, childbirth, and in the post delivery time. One of those disorders in pregnancy is
eclampsia.
Eclampsia is a major cause of perinatal morbidity and mortality and can present during the antepartum, intrapartum, or postpartum periods. Late
postpartum eclampsia presents as convulsions, with onset occurring at more than 48 hours postpartum.
WHO
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Our Client Mrs. MSR, 37y/o G7P6, however, is a 17- day postpartum presented to the labor room with complaints of seizures for 14 days. She gave
birth vaginally to a baby boy at home. She didn’t seek any prenatal or medical interventions throughout her pregnancy. She was brought by one of her
neighbors to the hospital. She was assessed and admitted at December 15, 2009.
GENERAL OBJECTIVES
This study aims to develop and broaden our knowledge regarding postpartum eclampsia, thus we can provide competent care and develop a
plan of care that is appropriate for the client.
SPECIFIC OBJECTIVES:
Nurse Centered:
• To gain knowledge about the pathophysiology of eclampsia
• To attain familiarity with regard to signs and symptoms of eclampsia as a postpartum complication.
• To obtain necessary information regarding the patient and her condition through physical examination.
• To analyze medications that was given to the patient through the course of treatment.
• To identify patient’s health care needs through analysis of all the data gathered.
• To be able to give appropriate nursing intervention that will help the patient and other health team member in the fast recovery of client.
• To be able to impart knowledge to the patient about the said incidence and how she can prevent the occurrence of complications.
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Client centered:
• To gain knowledge about the complication she experienced.
• To increase awareness of the patient with regard to possible complications.
• To provide appropriate information on self-care through health teachings.
• To give proper nursing intervention to patient and her situation.
II. Nursing Assessment
A. Personal History
Name: Mrs. MSR
Age: 37 years old
Sex: Female
Civil Status: Married
Position in the family: Mother
Address: City of San Fernando, Pampanga
Date and place of birth: not stated
Race: Malay
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Educational Attainment: First Year High School
Health Care Financing/ Usual source of medical care: Savings
Date of Admission: December 15, 2009
Date of Discharge: December 23, 2009
Initial Diagnosis: S/P NSD G7P7 (7007) postpartum eclampsia
Principal Diagnosis: G7P6 (6016) S/P NSD Postpartum eclampsia
B. Reason for visit/ chief complaint
The client was admitted to the hospital because of seizures.
C. History of Past Illness
The client’s significant other said that her immunization was complete. She hasn’t had chicken pox and measles. Whenever she is ill, like
common colds, cough and flu, she doesn’t consult to a doctor and she prefers to have self medications, such as paracetamol and anti-diarrheals, and
sometimes, medicinal herbs like Oregano. She also doesn’t visit her dentist yearly. She never had any allergies on certain foods or any drugs. Also,
she never had any history of fracture. She doesn’t often get hospitalized and this was her first confinement to a hospital.
D. History of Present Illness
December 15, 2009 client MSR is a 37-year-old G7P6 female at postpartum, status post non-institutional delivery (November 28, 2009). Few
hours prior to arrival at the JBL-MGH, the client is manifesting episodes of convulsions. Thus, she was rushed by her neighbor at Bulaon Hospital
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and hence was transferred at JBL-MGH. She was assessed in the labor room, her vital signs were taken. Her vital signs are as follows: temperature
was 37.3 ˚C, blood pressure was 220/110 mmHg, respiratory rate was 29 cycles per minute and pulse rate was 147 beats per minute.
E. Obstetric History
She has a regular 28-day menstrual cycle lasting for 3 to 5 days consuming at least 4 to 5 moderately soaked pads everyday for the first two
days of her menstruation. Her first menstruation was when she was 13 years old. The client wasn’t able to verbalize her LMP thus; her mother stated
that she had a normal spontaneous vaginal delivery at home on the 22nd of November 2009.
She was pregnant for the 7th time and all her deliveries were done at home with the aid of a traditional midwife via Normal Spontaneous
delivery, where the traditional midwife cuts the cord and performs the first bath on the newborn. She had an abortion on her 4th child.
F. Family Health Illness Pattern
The client’s grandparents died due to aging. Her father had diabetes mellitus that leads to kidney failure and eventually, death. Her mother has
hypertension. Her husband is alcoholic while her second son suffers from asthma. She had a spontaneous abortion on her fourth child.
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LEGEND:
GENOGRAM
- Client
PATERNAL SIDE MATERNAL SIDE
-Male
AC -Female
DC 78
Unrecalled
Unrecalled 67 A - deceased
A
HPN – Hypertension
DM – Diabetes Mellitus
AS LS - Alcoholism
70 71
DM, K HPN A – Aging
AS – Asthma
AR MSR K – kidney failure
35 37 K
client
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AR AR MR
18 14 8 riage 4 3 17
AS days
Gordon’s Functional Health Pattern
Functional Health Prior to Admission During Hospitalization
Pattern
I. Health Perception – Her husband stated that his wife was healthy. He also stated Client doesn’t talk. As her husband had observed, she isn’t healthy
Health Management that she eats ample amount of food and water. When there because she cannot do what she wants to do without any difficulty
Pattern is a sudden change in weather condition, she easily catches or assistance from a person or device. He also observed that her
colds. She doesn’t smoke nor drink alcohol. She sometimes wife tries her best to have a fast recovery and return to her normal
uses herbal medicines. The patient didn’t have general condition.
check-up. When she is sick, she doesn’t consult the doctor
but she will just have a rest and take some over-the-counter
drugs available at home.

II. Nutritional – Client eats any food available at home. Her favorite foods Due to her illness, Mrs. MSR lost her appetite but is trying her best
Metabolic Pattern are sinigang na bangus and adobong manok. She doesn’t to eat adequate amount of food. At first, she was restricted to eat
take any food supplements. She drinks at least 3 to 5 anything. But it was changed to DAT after one day. Her skin is
glasses of water. She doesn’t have the appetite in eating but slighltly moisted and has lesions she made herself whenever she’s
didn’t have any food or eating discomforts. The patient having seizures. She has lesions on hands caused by her long
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didn’t have prenatal check-up during her pregnancies that’s fingernails and has dislodged her IV line a couple of times.
why she doesn’t know any food restrictions during
pregnancy. When she is wounded, it heals well. She has
many lesions in the body due to mosquito and other insect
bites. Her skin is well moistened and has complete number
of teeth. 72 Hour Diet Recall
72 Hour Diet Recall Date Breakfast Lunch Dinner

December NPO NPO NPO
Date Breakfast Lunch Dinner
December 200 ml 250 ml 150 ml 15, 2009
12, 2009 lugaw lugaw lugaw

December 1 pc. 100 ml lugaw 100 ml lugaw
100 ml 100 ml 100 ml
16, 2009 medium- 70 ml water 100 ml water
water water water
December 150 ml 150 ml 100 ml sized mamon
13, 2009 lugaw lugaw lugaw 70 ml water

December 100 ml lugaw 1/2 cup rice ½ cup rice
100 ml 100 100 ml
17, 2009 70 ml milk ½ serving ½ serving
water mlwater water
pork menudo chicken tinola
December 100 ml 80ml lugaw Refused to 100 ml water 100 ml water
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14, 2009 lugaw 50 ml water eat
70 ml water
III.Elimination Pattern The client defecates once a day without any difficulty and Date December December December
has the characteristics of soft, formed, cylindrical and dark 15,2009 16,2009 17, 2009
Urine 3 3 3
brown stool. With regard to her voiding pattern, she voids Stool 0 0 0
The client didn’t defecate during the first 3 days upon admission.
at least four to six times a day with yellow color and
Foley urinary catheter is attached to urine bag with bright yellow
aromatic smell. She has no difficulty in urinating. She
urine output of 10 cc per hour. She perspires excessively and has
doesn’t perspire excessively but has body odor.
foul-smelling breath and body.
IV. Activity – Exercise The client didn’t have sufficient energy for completing full The client is so weak. She has low activity level because of her
Pattern load activities. She doesn’t exercise. When there is spare condition. As her mother had observed, she doesn’t have
time, she plays with her children especially her newborn. sufficiency and endurance to do things on her own. All of her
She also watches television. activities require assistance from person or device.
Perceived ability for code level Perceived ability for code level
Level 0: Full self-care Level 0: Full self-care
Level I: required use of equipment or device Level I: required use of equipment or device
Level II: required assistance or supervision from Level II: required assistance or supervision from another
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another person person
Level III: required assistance or supervision from Level III: required assistance or supervision from another
another person or device person or device
Level IV: is dependent and does not participate Level IV: is dependent and does not participate
0 feeding II feeding
0 bathing N/A bathing
0 toileting I toileting
0 bed mobility III bed mobility
0 dressing II dressing
0 grooming II grooming
0 general mobility III general mobility
0 cooking N/A cooking
II home maintenance N/A home maintenance
II shopping N/A shopping

V. Sleep – Rest Pattern She sleeps for approximately seven to eight hours a day. The client rests or sleeps during most of her/ hospital stay. She
She sleeps at around nine to ten o’clock in the evening and sleeps for eight to ten hours a day. She takes a rest/sleep in the
wakes up at six o’clock in the morning. She has a morning from eight o’clock until before lunch time. She also takes
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continuous sleep and doesn’t take any medications to aid a rest/sleep in the afternoon from two o’clock to seven o’clock in
sleep. In the afternoon, she takes a nap from two o’clock to the evening. She doesn’t have any difficulty in sleeping at the
three o’clock. To relax herself, she watches television or hospital ward.
plays with her young children. Date # of sleep # nap Total Quality
December 8 4 12 Invigorated
Date # of sleep # nap Total Quality
December 7 1 8 invigorated 15, 2009
December 9 5 14 invigorated
12, 2009
December 8 1 9 Invigorated 16, 2009
13, 2009
December 8 1 9 invigorated 17,2009
14, 2009
18, 2009
VI. Cognitive – According to her husband, her senses of sight and hearing Client’s eyes have white cloudiness surrounding her iris which
Perceptual Pattern are functioning well. Mrs. MSR has no difficulty in may be affecting her eyesight.
learning. It was easy for her to learn things. There is also
no change in her memory lately. When she feels any
discomfort, she actually sleeps and doesn’t bother to tell
her husband.
VII. Self-perception – As what her husband had observed, most of the time, she Client isn’t cooperative. She doesn’t answer any of our questions.
Self-concept Pattern feels good about herself. She is a supportive wife to him Instead, her husband or her mother will answer the questions for
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and a loving mother to their six children. She does her. She doesn’t cooperate well even on the physical examination.
everything in order to meet all of the needs of the family. As stated by the significant others, she became anxious since her
She is very patient and doesn’t get angry or annoyed easily. illness started as shown by her emotions and facial expressions.
But when she’s angry, she will shout. She seldom throws
things but not directly on that person. That’s her way of
releasing her anger. When she’s really annoyed, she will
show a sign that she’s annoyed like she walking noisily.
She was really tearful when her father died. She was so
depressed that she didn’t eat for three days.

VIII. Role – She has a nuclear family with her husband, five male and The client is taken care by her husband and her mother during the
Relationship one female children. She likes to keep her family happy by whole hospital stay. Due to her hospitalization, their family
Pattern showing them much love and care. Decisions in the family experienced short in income. And also, her eldest son stands as the
are made between her and her husband. She always kept an second parent to his siblings. In the ward, the client doesn’t
open communication with her husband and children. Her communicate to other patients.
relationship with her neighbors is also good.
But as person, problems are always present, especially with
regard to financial aspect. Their family income is just
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enough for them to buy food. But if there is an emergency
situation that needs cash, she borrows money from her
brothers and sisters. There is also sibling rivalry on their
children for their attention. To handle this, she shows equal
amount of love and care to each child.

IX. Sexuality – According her husband, there was no sexual discomforts. The client’s husband stated that after what happened to her wife,
Reproductive They don’t use any contraceptives. As her mother stated, he thinks that they will abstain from having sex.
Pattern her first mense and her last mense before her last
pregnancy was unrecalled. She doesn’t have any menstrual
problems. She had seven pregnancies in which there were
six children were viable and one was spontaneously
aborted.
X. Coping – Stress According to her mother, the client wasn’t tensed most of When she feels discomfort, she will just look at her husband or her
Pattern the time. She can easily cope with the different changes on mother to give them a sign that she feels discomfort.
her and around her. When there is a problem, she seeks
comfort and advice from her mother, the one who is always
there to comfort her whenever she’s down. The biggest
change in her life for the past two years is when her father
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passed away. She loves her father so much that she wasn’t
able to accept it easily. But as time passes by, she was able
to accept that fact and was able to return to her normal self.
When someone dies that is really closed to her, she
experiences difficulty in accepting but is able to
successfully accept in time whenever the situation occurs.

XI. Values – Beliefs She doesn’t get all the material things that she wants Nothing has changed in her religious beliefs when she was
Pattern because of insufficient financial resources. As stated by her hospitalized.
mother, she and her whole family are still happy together.
Religion is not that important to her. Though she still prays
and asks for God for assistance. She doesn’t go to Church
every Sunday to hear the word of God. She also believes in
herbal and alternative medicines.
GROWTH AND DEVELOPMENT
Developmental Theory Significance

1. Havighurst’s Age Periods and Developmental Tasks
Early Adulthood
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People select a mate and learn to live with a partner. This is also the In our client’s case, she found her significant other. She has a family of her
period in starting a family, rearing children and managing home. They own whom she considers her first priority as of the moment. She takes her
are also getting started in an occupation, taking on civic responsibilities seriously, as a mother and wife. And is conscientiously
responsibilities and finding a congenial social group. taking part in providing family income.
2. Freud’s Five stages of Psychosexual Development
Genital Stage
This stage occurs during puberty and after. Energy is directed toward Our client achieves sexual interest and gratification with her husband.
full sexual maturity, and function and development of skills needed to
cope with the environment. During this stage, separation from
parents, achievement of independence and decision making is
encouraged.
3. Erikson’s Eight Stages of Development
Adulthood
Central task of this stage is generativity versus stagnation. It occurs As for our client, she is very much diligent with regard to her
during twenty-five to sixty-five years of age. Indicators of positive responsibilities. She helps her husband on family expenses by selling
resolution of this stage are creativity, productivity and concern for merienda at home, at the same time this also gives her the opportunity to
others while their negative resolutions are self-indulgence, self- attend to her children’s need.
concern, lack of interest and commitments.
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4. Piaget’s Phases of Cognitive Development
Formal Operations Phase
This phase starts from age eleven and up. People use rational Our client is aware of what happened to her, though she didn’t verbalize it.
thinking. Rational is deductive and futuristic. She wasn’t responsive to specific queries, with that, it is hard to assess if she
fully understand her situation or any procedures she has undergone.

5. Kohlberg’s Stages of Moral Development
Stage 3 – Interpersonal Concordance Orientation
This stage starts from school-age through adulthood. Decisions and With our client, her husband says she is sensitive to the feelings of others
behavior are based on concerns about other’s reactions. The person and is careful in decision-making, especially when her family is involved.
wants other’s approval or a reward. There will be emphatic response,
based on understanding of how another person feels. Emphatic
response is a determinant for decisions and behavior.
II. Anatomy and Physiology
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DATE AND TIME: December 17, 2009; 5:10pm
NAME OF CLIENT: Mrs. MSR
AGE: 37 years old
PHYSICAL ASSESSMENT
Parts to be Examined Technique Normal Findings Actual Findings Interpretation

1. GENERAL SURVEY
Body built, height & weight in Inspection Proportionate, varies with She has a proportionate body built Normal
relation to client’s age, lifestyle and lifestyle which is appropriate with her lifestyle
health
Client’s posture and gait, standing, Inspection Relaxed, erect posture; She is slightly relaxed, has slouched Slouched posture, slight
sitting and walking coordinated movement posture and slightly uncoordinated uncoordinated
movements movements
Client’s overall hygiene and Inspection Clean, neat She is not neat and her dress is dirty. poor hygiene
grooming She also has long fingernails.

Body and breath odor Inspection No body odor or minor body odor There is foul body and breath odor poor hygiene
relative to work or exercise; no
breath odor
Clinical Measurements Underweight-<18.5 overweight
Height Inspection Normal-18.5-24.9 152cm
Weight Overweight-25-29.9 59kg
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Obese->29.9 BMI = 25.5
Vital Signs
Temperature Inspection 36.5-37.5 C 37.5 C high blood pressure
Pulse rate Palpation 60-100bpm 99bpm
Respiratory Rate Inspection 12-21cpm 18cpm
Blood Pressure Auscultation and 120/80mmhg 130/90mmhg
Palpation
BEHAVIOR
Signs of distress, in posture or facial Inspection No distress noted There is some distress noted on the slightly distressed
expression client. She looked unhappy and less appearance
comfortable.
Signs of health or illness Inspection Healthy appearance She does not look that healthy in her poor hygiene
poor hygiene appearance appearance

Client’s attitude Inspection Cooperative, able to follow She is not much cooperative and not not cooperative
instructions able to follow some of the instructions

Client’s affect/mood; Inspection Appropriate to situation She responds to some of the not able to follow some
appropriateness of client’s response instructions appropriately instructions

Quantity of speech, quality Inspection Understandable, moderate pace; She is not speaking not talking
clear tone and inflection; exhibit
thought association
Relevance and organization of Inspection Logical sequence; makes sense; She has some sense of reality. She Slight relevance of
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thoughts has sense of reality sometimes has relevance of thoughts. thoughts
2. INTEGUMENTARY
A. SKIN
Color and uniformity of color Inspection Varies from light to deep brown; She has a deep brown skin which is not Normal
ruddy pink to light pink; from uniform because the areas exposed in
yellow overtones to olive the sun are darker.
Generally uniform except in areas
exposed to the sun; areas of
lighter pigmentation in dark-
skinned people
Presence of edema Inspection No edema She has edema in her face and lower centralized edema
extremities; edema scale of 3+

Presence of lesion according to Inspection Freckles, some birthmarks, some She has flat nevi on her right arm, presence of scars and
location, distribution, color, flat and raised nevi; no abrasions forearm and left foot; she has some bruise
configuration, size, shape, type or or other lesions small dark brown scars on her both
structure legs and bruise on her right elbow

Skin moisture Inspection Moisture in skin folds and axillae She has slight skin moisture in skin Normal
(varies with environmental folds due to warm environment
temperature and humidity and
activity)
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Skin temperature Inspection Uniform; within normal range Her skin temperature is warm and Normal
uniform but within normal range

Skin turgor Inspection Skin springs back to previous She has a good skin turgor Normal
state; has a good skin turgor

B. NAILS
Fingernail’s shape, curvature and Inspection Convex curvature; angle of nail Her nail has a convex curvature Normal
angle plate about 160 ° approximately 160°

Fingernail and toenail texture Inspection No visible lines and cracks She has a smooth nails without any Normal
Smooth texture damages

Fingernail and toenail bed color Inspection Highly vascular and pink in light- Her nail bed color is light pink Normal
skinned people; dark-skinned
may have brown or black
pigmentation in longitudinal
streaks
Tissues surrounding nails Inspection Intact epidermis She has an intact epidermis with no Normal
hangnails
Blanch test of capillary refill Palpation Prompt return of pink or usual There is a prompt return of blood Normal
color resulting to the usual pink color 1 sec.
after the pinch

3. HEAD
A. SKULL
Size, shape and symmetry Inspection Rounded (normocephalic); Her skull is rounded and has a smooth Normal
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smooth skull contour skull contour
Presence of nodules, masses and Palpation Smooth, uniform consistency; She has no nodules and masses Normal
depressions absence of nodules and masses

B. SCALP
Color and appearance Inspection Usually white but it also depends Her scalp is white and has a smooth Normal
on dark-skinned people surface

Areas of tenderness Palpation No tenderness There are no areas of tenderness Normal
C. HAIR
Evenness of growth, thickness and Inspection Evenly distributed thick hair She has a thick hair and it is evenly Normal
thinness distributed
Texture, oiliness over the scalp Palpation Smooth texture; no oiliness She has a dry and oily hair dry and oily hair
D. FACE
Facial features, symmetry of facial Inspection Symmetrical facial features and She has symmetrical facial features but Normal
movements movements she refused to do some facial
movements
4. EYES
A. EYEBROWS
Evenness of distribution and Inspection Hair evenly distributed and the She has evenly distributed hair in her Normal
direction of curl curl is outward eyebrow and they are aligned with
equal movement
B. EYELASHES
Evenness of distribution and Inspection Equally distributed; curls slightly Her eyelashes are equally distributed Normal
direction of curl outward and curled outward

C. EYELIDS
Surface characteristics, position in Inspection Skin intact; no discharge or She has a smooth eyelids with no Normal
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relation to the cornea, ability to blink discoloration; Lids closed discharge; lids closed symmetrically
and frequency of blinking symmetrically approximately 15- and has 15 blinks per minute
20 involuntary blinks per minute

D. CONJUNCTIVA
Bulbar Conjunctiva for color, texture Inspection Transparent; capillaries Her Bulbar Conjunctiva is transparent Normal
and presence of lesions sometimes evident; and has some visible small capillaries
Palpebral Conjunctiva for color, Inspection Shiny, smooth and pink or red Has shiny, smooth and pink palpebral Normal
texture and presence of lesions conjunctiva

E. SCLERA
Color and clarity Inspection Sclera appears white She has white sclera with some visible Normal
capillaries
F. CORNEA
Clarity and texture Inspection Transparent, shiny and smooth; She has a transparent, shiny and Normal
the details of iris are visible smooth cornea

G. IRIS
Shape and color Inspection Rounded shape which are the She has a dark brown iris which is Slight cloudiness
same in each eye; color varies uniform and they are both rounded;
depending on the race and the there are white cloudiness surrounding
color is evenly distributed her iris

H. PUPILS
Color, shape and symmetry of size Inspection Black in color, equal in size and Her pupils are black, equal in size and Normal
smooth border has smooth borders

I. VISUAL ACUITY
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Near Vision Inspection Able to read newsprints She refused Refused
Distant Vision Inspection 20/20 vision Procedure not done No equipment
J. PUPILS
Light reaction and accommodation Inspection Illuminated pupils constricts Her pupils constrict when light passes Normal
Pupils also constricts when and it also converge when near object
looking at near objects, dilate is moved toward her nose
when looking at far objects and
converge when near object is
moved toward the nose

5. LACRIMAL GLAND /
SAC & NASOLACRIMAL
DUCT
Lacrimal Gland Inspection and palpation No edema, tenderness or tearing There are no edema, tenderness and Normal
tearing
A. EXTRAOCULAR MUSCLES
Alignment and coordination Inspection Both eyes coordinated, move in Her both eyes are coordinated, move in Normal
unison, with parallel alignment unison with parallel alignment

B. VISUAL FIELD
Peripheral visual fields Inspection When looking straight ahead, She can see objects in the periphery Normal
client can see objects in the
periphery
6. EARS
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A. AURICLES
Color, symmetry of size and position Inspection Color same as facial skin; Her ears’ skin color is same as the Normal
symmetrical; auricle aligned with surrounding skin and both are
outer canthus of eye about 10 ° symmetrical; the auricles are aligned in
vertical the outer canthus of each eye

Texture, elasticity and areas of Palpation Mobile, firm and not tender; Her auricles are mobile, firm and not Normal
tenderness pinna recoils after being folded tender; her pinna recoils when folded
B. EXTERNAL EAR CANAL
Cerumen, skin lesions, pus and blood Inspection Dry cerumen, grayish-tan color, She had no visible cerumen, has a Normal
sticky or wet cerumen in various grayish color
shades of brown
C. HEARING ACUITY TESTS
Client’s response to normal voice Inspection Normal voice tones audible She can respond to normal voice tones Normal
tone
Watch tick test Inspection Able to hear ticking sound in both She can hear ticking sound in both ears Normal
ears only when the watch is close because
of the noise in the environment

Weber’s test Inspection Sound is heard at both ears or at Procedure not done No equipment
the center (Weber’s negative)

Rinne test Inspection Air conduction is greater than the Procedure not done No equipment
bone conduction (Rinne Positive)

7. NOSE
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Deviations in shape, size or color Inspection Symmetric and straight; no Her nose are uniform in color same as Normal
and flaring or discharge discharge or flaring; uniform with the surrounding skin; there are no
color discharge and flaring

Nasal cavities for presence of Inspection Mucosa pink; clear watery She has a clear watery discharge and Normal
redness, swelling, growths and discharge; no lesions has no apparent lesions
discharge
Nasal septum between the nasal Inspection Nasal septum intact and in Her nasal septum is in the middle Normal
chambers midline
Patency of both nasal cavities Inspection Air moves freely as the client Her nasal cavities are patent Normal
breathes through the nares

Tenderness, masses and Palpation Not tender There are no tenderness, masses or Normal
displacement of bones and cartilage displacement of bones and cartilage

SINUSES
Tenderness Palpation Not tender Her sinuses are not tender Normal
8. MOUTH
A. LIPS
Symmetry of contour, color and Inspection Uniform pink color, soft, moist, She has a uniform pink lips, slightly Refused
texture smooth texture, symmetry of moist and has cracks; it has symmetry
contour, ability to purse lips of contour and refused to purse her lips
B. BUCCAL MUCOSA
Color, moisture, texture and presence Inspection Moist, smooth, soft, glistening She has a moist, soft, glistening and Normal
of lesions and elastic texture elastic texture of her buccal mucosa

C. TEETH
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Color, number, condition and Inspection 32 adult teeth; smooth, white and She has 32 teeth, smooth and yellow teeth
presence of dentures shiny tooth enamel yellowish

D. GUMS
Color and condition Inspection Pink gums; moist and firm She has pink gums, slightly moist and Normal
texture to gums; no retractions firm texture without retractions

E. TONGUE/ FLOOR OF
MOUTH
Color and texture of the mouth and Inspection Central position; Pink color, Her tongue is in the center, pink in Normal
frenulum moist, slightly rough; thin whitish color, it is slightly moist and rough
coating, lateral margins; no without lesions; it has a thin whitish
lesions; raised papillae coating and lateral margins

Position, color and texture, Inspection and palpation Moves freely; no tenderness; Her tongue moves freely without Normal
movement and base of tongue smooth tongue base with tenderness
prominent veins
Presence of nodules, lumps or Palpation Smooth with no palpable nodules It has no nodules Normal
excoriated areas
F. PALATES AND UVULA
Color, shape, texture, and presence Inspection Light pink, smooth, soft palate She has a light pink and smooth soft Normal
of bony prominences Lighter pink hard palate, more palate while lighter pink and irregular
irregular hard palate

Position of uvula and mobility while Inspection Positioned in midline of soft The uvula is in the middle Normal
27 | P a g e
examining the palates. palate
G. OROPHARYNX AND
TONSILS
Color and texture Inspection Pink and smooth posterior walls She has a smooth and pinker posterior Normal
walls
Size of tonsils, color and discharge Inspection Pink and smooth; no discharge; Her tonsils are pink and smooth Normal
of normal size without discharge and of normal size

Presence of Gag reflex Inspection Gag reflex is present She refused Refused
9. NECK
A. LYMPH NODES
Lymph Nodes and tenderness Inspection and palpation Not palpable Her nodes are not palpable Normal
B. TRACHEA
Placement Inspection and palpation Central placement in midline of Her trachea is in the middle with equal Normal
neck; spaces are equal in both spaces on both sides
sides
C. THYROID GLAND
Symmetry and visible masses Inspection Not visible on inspection It is not visible Normal
Smoothness, enlargement and Palpation Glands ascends during Her thyroid glands rise when Normal
nodules swallowing; painless, centrally swallowing; it is smooth and painless
located and smooth

10. THORAX
A. POSTERIOR
Shape, symmetry, compare the Inspection Chest symmetric; anteroposterior Her chest are symmetric; Normal
diameter of anteroposterior to to transverse diameter in ratio of anteroposterior to transverse has a
28 | P a g e
transverse diameter 1:2 diameter ratio of 15cm:32cm
Spinal alignment Inspection Spine vertically aligned Her spine is vertically aligned Normal
Temperature, tenderness and masses Palpation Skin intact; uniform temperature Her skin is intact and has uniform Normal
warm temperature
Respiratory excursion Inspection and palpation Full and symmetric expansion; as She has a full and symmetric Normal
the client breathes, thumbs expansion and as she breathes, thumbs
usually separates 3-5cm usually separate for 3 cm.

Vocal fremitus Palpation Bilateral symmetry of vocal She has a bilateral symmetry of vocal Normal
fremitus; it is heard mostly at the fremitus; it is heard clearly at the apex
apex of lungs
Percuss the thorax Percussion Percussion notes resonance Her percussion notes resonance sound Normal
except over scapula except over the scapula and the lowest
Lowest point of resonance is at resonance heard is at the diaphragm
the diaphragm
Auscultate the thorax Auscultation Vesicular and bronchovesicular There are vesicular and Normal
sounds bronchovesicular sounds heard

B. ANTERIOR
Breathing patterns Inspection Quiet, rhythmic and effortless She has a quiet, rhythmic and Normal
respiration effortless respiration

Temperature, tenderness and masses Palpation Skin intact; uniform temperature Her skin is intact and has uniform Normal
warm temperature
Respiratory excursion Inspection and palpation Full and symmetric expansion; as She has a full and symmetric Normal
29 | P a g e
the client breathes, thumbs expansion and as she breathes, thumbs
usually separates 3-5cm usually separate for 3 cm.

Vocal fremitus Palpation Bilateral symmetry of vocal She has a bilateral symmetry of vocal Normal
fremitus; it is heard mostly at the fremitus; it is heard clearly at the apex
apex of lungs
Percuss the anterios thorax Percussion Percussion notes resonance Her percussion notes resonance sound Normal
except over ribs except over the ribs and the lowest
Lowest point of resonance is at resonance heard is at the diaphragm
the diaphragm
Auscultate the trachea Auscultation Bronchial or tubular breath There are bronchial or tubular sounds Normal
sounds heard
Auscultate the thorax Auscultation Vesicular and bronchovesicular There are vesicular and Normal
sounds bronchovesicular sounds heard

11. CARDIOVASCULAR
Aortic and pulmonic areas Inspection and palpation No pulsation No pulsations felt Normal
Tricuspid area Inspection and palpation No pulsation; no lift or heave No pulsations or lift and heave Normal
Apical area Inspection and palpation Some pulsations visible; no lift or There are some pulsations felt but Normal
heave there are no lift or heave

Epigastric area Inspection and palpation Aortic pulsations There are aortic pulsations Normal
Auscultate aortic, pulmonic, apical, Auscultation S1-usually heard at all sites but There are heart sounds heard in all Normal
tricuspid and epigastric area louder at the apical area sites
S2-usually heard at all sites but
30 | P a g e
louder at the base of heart
12. CAROTID ARTERIES
Palpate with extreme caution Palpation Symmetric pulse volumes; full Her carotid artery has a full symmetric Normal
pulsations pulse volumes and pulsations

Auscultate the carotid arteries Auscultation No sounds heard There are no sounds heard Normal
13. JUGULAR VEINS
Presence of veins Inspection Veins not visible There are no visible veins Normal
14. ABDOMEN
Skin integrity Inspection Unblemished skin, uniform color She has linea nigra, striae gravidarum, Normal in postpartal
stretch marks. Woman

Abdominal contour Inspection Flat, rounded or scaphoid It is suprapubic bulge Normal in Postpartal
Woman
Enlarged liver or spleen Inspection No evidence of enlarged liver and There are no evidence of enlarged liver Normal
spleen and spleen

Symmetry of contour Inspection Symmetric contour She has a symmetric contour Normal
Abdominal movements Inspection Symmetric movements caused by She has symmetric movements Normal
respiration because of respiration

Vascular patterns Inspection No visible vascular patterns There are no visible vascular patterns Normal
Bowel sounds, vascular sounds and Auscultation Audible bowel sounds usually There are audible bowel sounds heard Normal
peritoneal friction rubs occur every 5-20seconds; absence every 5-20 seconds;
of arterial bruits and friction rub

Percuss in each quadrants Percussion Tympany over stomach and gas- There is tympany over her stomach Normal
filled bowels; dullness over the and dull sound over her liver and
liver and spleen or full bladder spleen
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Light palpation of quadrants Palpation No tenderness, relaxed abdomen Her abdomen is relaxed and has no Normal
with smooth, consistent tension tenderness

15. MUSCULOSKELETAL
A. MUSCLES
Size, comparison on one side to Inspection Equal size on both sides of the She has equal muscle size on both Normal
other side body sides of the body

Contractures Inspection No contractures She has no contractures Normal
Fasciculation and tremors Inspection No tremors She has no tremors Normal
Muscle tonicity Palpation Normally firm She has firm muscles Normal
Muscle strength Inspection and Palpation Smooth coordinated movements She has slightly smooth coordinated
movements Slight uncoordinated
movement
B. BONES
Normal structure and deformities Inspection No deformities She has no deformities Normal
Edema and tenderness Palpation No tenderness or swelling She has no edema, tenderness and Normal
swelling
C. JOINTS
Swelling Inspection No swelling There are no swelling Normal
Tenderness, smoothness of Palpation No swelling, tenderness, There are no tenderness, swelling, Normal
movements, crepitation and nodules crepitation or nodules crepitation or nodules;
BUBBLE SHE TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

Breast Inspection and Palpation Dark areola; no nodules, masses She has dark areolas and there are no Normal
or tenderness presence of nodules, masses and it is
32 | P a g e
tender.
Uterus Palpation Firm, contracted and palpated at Her uterus is palpated has descended in Normal
midline midway between the the pelvis
symphysis pubis and umbilicus.

Bladder Palpation Bladder is distended. It is not distended Normal
Bowel Inspection Stool is in normal appearance Her stool is brown and it is not Normal
liquefied or watery.
Lochia Inspection Dark red with small blood clots. Her lochia rubra is bright red with little Normal
blood clots.
Episiorrhapy Inspection It is intact; there is no presence of She has no episiorrapy
tenderness or inflammation
Skin Inspection No lesions; Linea nigra, striae or She has small rounded scars on both of Normal
stretch marks are present. her legs. Linea nigra and striae
gravidarum are present.

Homan’s sign Palpation There is no pain in calf or She felt no pain as the examiner Normal
popliteal region when her foot is dorsiflexed her feet.
dorsiflexed at the ankle while the
knee is flexed to 90degrees.

Emotional Inspection No sign of emotional distress She is not relaxed. Normal
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III.The patient and his illness
1. Schematic Diagram
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2. Review of System
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Eclampsia occurs in the last weeks of gestation, during labor or in the first 48 hours after childbirth. When it occurs days or weeks after delivery, it is
called. Postpartum Eclampsia. There are different effects of the increased blood pressure to the different systems in the body and these are as follows:
A. Reproductive System
Because the placenta has been removed, the client is prone to infection. As the result of her urinalysis, there are bacteria present in her urine which
means she has infection. This infection attracts the inflammatory mediators brought by the leukocytes. So, there is an increase in inflammatory mediators.
B. Cardiovascular System
Postpartum eclampsia affects the cardiovascular system. When there is an increased inflammatory mediators there are effects in:
>Blood Vessels – Endothelium is located in the blood vessels which is responsible for vasoconstriction and vasodilation, blood clotting and inflammation.
The inflammatory mediators released anaphylatoxins which impaired vascular endothelial function. Because the endothelium is responsible for the blood
clotting and coagulation, there is an increased intravascular coagulation and deposition.
36 | P a g e
After having impaired endothelial function, there will be stress response vasospasm which results to Renin-Angiotensin-Aldosterone (RAA)
activation. When angiotensin is activated, there will be vasoconstriction and this will give rise to increase peripheral resistance. After having this, there will
be increase in blood pressure. On the other hand, after activating the angiotensin II, surely, aldosterone will be released by the adrenal cortex of the adrenal
glands in the kidney. It is triggered by increase in the plasma concentration of Angiotensin III, a metabolite of Angiotensin II. Aldosterone is a steroid
hormone (mineralocorticoid family) produced by the outer-section (zona glomerulosa) of the adrenal cortex in the adrenal gland, and acts on the distal
tubules and collecting ducts of the kidney to cause the conservation of sodium, secretion of potassium, increased water retention, and increased blood
pressure.
>Heart – The heart is a muscular organ responsible for pumping blood throughout the body. If there is increased blood pressure due to eclampsia, the heart
will compensate to the change in pressure and pump more. So, there will be cardiac overload due to increased action of the heart to pump. This causes Left
Anterior Hemi-block or Hypertrophy that is manifested by Left Axis Deviation (LAD). It is a cardiac condition that occurs when a cardiac impulse spreads
first through the left posterior fascicle, causing a delay in activation of the anterior and lateral walls of the left ventricle which are normally activated via the
left anterior fascicle. In our client, she had been diagnosed with Left Axis Deviation.
>Blood – It is a specialized fluid that is being transported throughout the body to supply nutrients. When normal renal perfusion is decreased, sodium is
retained which results to increased extracellular volume and decreased intravascular volume. Sodium is also retained due to aldosterone release. This causes
viscosity of blood and a corresponding rise in hematocrit level.
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Due to increased intravascular coagulation by endothelium there is an increased platelet count. The inner surface of blood vessels is lined with a thin
layer of endothelial cells that, in normal hemostasis, acts to inhibit platelet activation by producing nitric oxide, endothelial-ADPase, and PGI2. Endothelial-
ADPase clears away the platelet activator, ADP.
Endothelial cells produce a protein called von Willebrand factor (vWF), a cell adhesion ligand, which helps endothelial cells adhere to collagen in the
basement membrane. Under physiological conditions, collagen is not exposed to the bloodstream. vWF is secreted constitutively into the plasma by the
endothelial cells, and is stored in granules within the endothelial cell and in platelets.
When the endothelial layer is injured, collagen, vWF and tissue factor from the subendothelium is exposed to the bloodstream.
When the platelets contact collagen or vWF, they are activated. They are also activated by thrombin (formed with the help of tissue factor).
C. Urinary System
The urinary system is a group of organs in the body concerned with filtering out excess fluid and other substances from the bloodstream. The
substances are filtered out from the body in the form of urine. Renin is an enzyme that participates in the body's renin-angiotensin-aldosterone system
(RAAS) that mediates extracellular volume (i.e. interstitial fluid), and arterial vasoconstriction. Thus it regulates the body's mean arterial blood pressure.
Since, this renin and aldosterone are secreted by the kidneys, urinary system plays a role in eclampsia.
>Kidney - Urine is a liquid produced by the kidneys, collected in the bladder and excreted through the urethra. Urine is used to extract excess minerals or
vitamins as well as blood corpuscles from the body. During high blood pressure occurrences, the heart works harder and, over time, it can damage blood
vessels throughout the body. The Kidneys receive approximately 20% of the cardiac output. If the blood vessels in the kidneys are damaged, they may stop
removing wastes and extra fluid from the body. The extra fluid in the blood vessels may then raise blood pressure even more.
38 | P a g e
With a reduction of the glumerular filtration rate, serum levels of creatinine and uric acid begin to rise from normal pregnant levels, while urine
output decreases. There will also be albuminuria which means the proteins are being secreted due to altered filtration. This will decrease plasma oncotic
pressure, there is increased in extracellular volume that results to edema. Since there is altered filtration, there is also glycosuria which increases the pH of
the urethra. Because of this, there is increased susceptibility to infection that may lead to Urinary Tract Infection (UTI).
>Glomerular endothelial cells in the kidney – its capillary walls are being stretched that allows large protein molecules, primarily albumin, to escape in the
urine, decreasing serum albumin levels because if decreased renal perfusion brought by increased blood pressure. There will be decreased glomerular blood
flow that will also decreased the excretion of metabolic wastes. This will increased Blood Urea Nitrogen (BUN) and Uric Acid.
D. Gastrointestinal System
In this system, the most affected organ is the liver. The liver is the vital organ metabolism and has a number of functions in the body, including
glycogen storage, decomposition of red blood cells, plasma protein synthesis, hormone production, and detoxification. It produces bile, an alkaline
compound which aids in digestion, via the emulsification of lipids. It also performs and regulates a wide variety of high-volume biochemical reactions
requiring highly specialized tissues, including the synthesis and breakdown of small and complex molecules, many of which are necessary for normal vital
functions.
>Liver – As we said earlier in the endothelium, there is an increase intravascular coagulation which results in protein deposition in the sinusoids of the liver.
Due to this, there will be decreased hepatic blood flow and will result to decrease hepatic function. When it is present, there will be epigastric pain due to
damage of tissues in the liver. As a response to this, Lactose Dehydrogenase (LDH) will increase. LDH is often used as a marker of tissue breakdown as
LDH is abundant in red blood cells and can function as a marker for hemolysis and tissue breakdown.
39 | P a g e
HELLP syndrome: A syndrome featuring a combination of "H" for hemolysis (breakage of red blood cells), "EL" for elevated liver enzymes,
and "LP" for low platelet count (an essential blood clotting element). The HELLP syndrome is a recognized complication of preeclampsia and eclampsia
(toxemia) of pregnancy. Common symptoms in women with the HELLP syndrome include a general feeling of feeling unwell (malaise), nausea and/or
vomiting, and pain in the upper abdomen (epigastric pain). Increased fluid in the tissues (edema) is frequent.
E. Nervous System
Central Nervous System associated with eclampsia are hyperreflexia, headache and seizures. Hyperreflexia is an overactive or overresponsive
reflexes. It is may be due to increased intracellular sodium and decreased intracellular potassium levels. And because the metabolic wastes are not excreted
and they will be deposited, it will lead to altered cerebral perfusion. This will brought seizures.
F. Respiratory System
Eclampsia also affects the respiratory system due to hypoxia or deprived adequate supply of oxygen because of vasoconstriction. After mixing
with water vapour and expired CO2 in the lungs, oxygen diffuses down a pressure gradient to enter arterial. Arterial blood flow delivers oxygen to the
peripheral tissues, where it again diffuses down a pressure gradient into the cells and into their mitochondria. These bacteria-like cytoplasmic structures strip
hydrogen from fuels (glucose, fats and some amino acids) to burn with oxygen to form water. The fuel's carbon is oxidized to CO2, which diffuses down its
partial pressure gradient out of the cells into venous blood to finally be exhaled by the lungs. But because of the increase in pressure, the water remains in the
lungs that cause pulmonary edema.
G. Senses
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Scotoma is a result of increased intracranial pressure. It is the blind gaps in visual fields, areas of blindness. When there is eclampsia, there is
also increased blood pressure that results to increased intracranial pressure brought by altered cerebral perfusion.
DIAGNOSTIC LABORATORY RESULTS
Complete Blood Count
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Diagnostic Date Indications or Purpose Result Normal Values Analysis and Nursing
Laboratory Ordered Interpretation of the Responsibilities
Procedure and Date results
result
CBC December The CBC provides Components Actual Findings Normal Findings Analysis/Interpretation Increased
Blood Typing “O” Rh Positive
15, 2009 valuable information Hemoglobin 125 115 - 155 g/L Normal Neutrophils
Hematocrit 0.39 0.38 - 0.48 Normal
about the blood and to WBC count 3.44 3.5 –10.0 Abnormal/ slightly > Instruct the
Neutrophils 0.87 0.45 - 0.65
some extent the bone Lymphocytes 0.13 0.20 - 0.35 decreased due to acute significant
Platelet 640 150-400
marrow, which is the infection others to wash
Abnormal/ Increased
blood-forming tissue. hands before
due to physical stress
The CBC is used for the contact with
(seizures) and acute
following purposes: patient.
infection.
• as a preoperative test Abnormal/ slightly >Administer
to ensure both decreased due to acute Antimicrobial as
adequate oxygen infection ordered

Abnormal/ Increased
carrying capacity and
due to intravascular
hemostasis
deposition
• to identify persons Decreased WBC
who may have an and
infection Lymphocytes
• to diagnose anemia > Instruct

42 | P a g e
• to identify acute and patient to
chronic illness, consume a low-

result
CBC Decembe The CBC provides Components Actual Findings Normal Findings Analysis/Interpretation > Monitor the
r 18, valuable information Hemoglobin 129 115 - 155 g/L Normal stability of the
2009 about the blood and to WBC count 9.6 3.5 –10.0 Normal laboratory
Neutrophils 0.62 0.45 - 0.65 Normal
some extent the bone Lymphocytes 0.27 0.20 - 0.35 Normal results.
marrow, which is the
blood-forming tissue.
The CBC is used for the
following purposes:
• as a preoperative test
to ensure both
adequate oxygen
carrying capacity and
hemostasis
• to identify persons
who may have an
infection
43 | P a g e • to diagnose anemia
• to identify acute and
chronic illness,
Diagnostic Date Indications or Result Normal Values Analysis and Nursing
Laboratory Ordered Purpose Interpretation of the Responsibilities
result
CBC December The CBC provides Components Actual Findings Normal Findings Analysis/Interpretation > Monitor the
19, 2009 valuable information Hemoglobin 128 115 - 155 g/L Normal stability of the
about the blood and to WBC count 9.6 3.5 –10.0 Normal laboratory
Neutrophils 0.62 0.45 - 0.65 Normal
some extent the bone Lymphocytes 0.27 0.20 - 0.35 Normal results.
marrow, which is the
blood-forming tissue.
The CBC is used for
the following purposes:
to ensure both
adequate oxygen
carrying capacity
and hemostasis
• to identify persons
who may have an
infection
44 | P a g e • to diagnose anemia
• to identify acute and
chronic illness,
Urinalysis
45 | P a g e
result
Urinalysis December The urinalysis includes Components Actual Findings Normal Findings Analysis/Interpretation Prevent and
Color Light Yellow Straw Yellow – Normal
15, 2009 the color, transparency, hinder infection:
Amber Color
specific gravity, pH, Transparency Clear Transparent Normal
Sugar +1 Abnormal/ Glycosuria
protein, glucose, ketones, Albumin +3 0/negative > Administer
pH 2 4.5 – 8 due to altered
blood, bilirubin, nitrite, Specific 1.025 1.003 – 1.030 Antibiotics as
glomerular filtration
leukocyte esterase, Gravity Abnormal/Albuminuria ordered
Pus Cells 4-6 0/negative
transparency, protein and due to altered > Instruct client
blood. Urinalysis is done RBC 30-40 0/negative glomerular filtration and significant
Bacteria Few Abnormal / Acidic due
for the following others to
to glycosuria
purposes: Normal practice
• General health infection control

Abnomal / Pus cells
screening to detect techniques
present due to presence
renal and metabolic >Avoid crowds
of infection
diseases. Abnormal / Hematuria and people with
• Diagnosis of diseases due to urinary tract infection
or disorders of the infection
kidneys or urinary Monitor client’s

46 | P a g e
tract. vital signs and
• Monitoring of patients proper

Blood Chemistry
47 | P a g e
result
Blood Decembe The Blood Chemistry Components Actual Findings Normal Findings Analysis/Interpretation Increased RBS
RBS 8.96 mmol/L 8.85–9.0 mmol/L Normal
Chemistry r 15, provides valuable Uric Acid 0.440 mmol/L 0.145–0.357mmol/L Abnormal/ Increased > Instruct client
LDH 1129 IU/L 225-450 IU/L
2009 information about the due to decreased to observe low-
blood needed to assess a excretion of metabolic sugar diet
wide range of conditions wastes > Teach patient

Abnormal/ Increased
and the function of signs of
due to decreased hepatic
organs. Blood tests are hyperglycemia/
function
used for the following hypoglycemia
purposes:
• as a preoperative test Increased Uric
to examine the general Acid
health of a patient > Administer
• Screen for diabetes prescribed
mellitus: Glucose, medications
Fructosamine, > Teach patient
Hemoglobin AIC to observe low
• Screen for kidney purine diet

48 | P a g e
disorders: BUN,
Creatinine Increased LDH

result
Blood Decembe The Blood Chemistry Components Actual Findings Normal Findings Analysis/Interpretation Increased LDH
Chemistry r 16, provides valuable Uric Acid 0.255 mmol/L 0.145–0.357mmol/L Normal > Advice patient
LDH 1404.5 IU/L 225-450 IU/L Abnormal/ Increased
2009 information about the to continue
blood needed to assess a proper
function
wide range of conditions management of
and the function of hypertension
organs. Blood tests are
used for the following
purposes:
to examine the general
health of a patient
• Screen for diabetes
mellitus: Glucose,
Fructosamine,
Hemoglobin AIC
49 | P a g e • Screen for kidney
disorders: BUN,
Creatinine
result
Blood Decembe The Blood Chemistry Components Actual Findings Normal Findings Analysis/Interpretation Increased LDH
Chemistry r 17, provides valuable Uric Acid 0.253 mmol/L 0.145–0.357mmol/L Normal > Advice patient
2009 information about the to continue
blood needed to assess a proper
function
wide range of conditions management of
and the function of hypertension
purposes:
health of a patient
mellitus: Glucose,
Fructosamine,
Hemoglobin AIC
disorders: BUN,
Creatinine
result
Blood December The Blood Chemistry Components Actual Findings Normal Findings Analysis/Interpretation > Monitor the
Chemistry 16, 2009 provides valuable Uric Acid 0.252 mmol/L 0.145–0.357mmol/L Normal stability of the
information about the laboratory
blood needed to assess a results.
function
wide range of conditions
and the function of
purposes:
health of a patient
mellitus: Glucose,
Fructosamine,
Hemoglobin AIC
disorders: BUN,
Creatinine
V. The patient and his care
A. Medical Management
Medical Management Date Ordered/ Date General Description Indications/Purpose Client’s Response to Nursing
Treatment Performed/ Date treatment Responsibilities
change
5% Dextrose in December 15, 2009 Lactated Ringer's and Fluid replacement and Client is well hydrated • If an adverse reaction
Lactated Ringer’s 9:05am 5% Dextrose is a caloric supplementation and has slightly does occur,
Solution with sterile, non-pyrogenic in patient who can’t decreased energy, discontinue the
Hydralazine solution for fluid and maintain adequate oral though she does not infusion, evaluate the
52 | P a g e
Hydrochloride electrolyte intake or who is eat. patient, institute
replenishment and restricted from doing so. appropriate
caloric supply in a therapeutic
single dose container countermeasures, and
for intravenous save the remainder of
administration. the fluid for
examination if
deemed necessary
• Use cautiously in
cardiac or pulmonary
disease,
hypertension, renal
insufficiency urinary
obstruction and
hypovolemia.
• Never infuse
concentrated
53 | P a g e
solutions rapidly,
may cause
hyperglycemia and
fluid shift.
• Monitor glucose
level carefully.
Prolonged therapy
can cause depletion
of pancreatic insulin
production and
secretion.
Medical Management Date Ordered/ Date General Description Indications/Purpose Client’s Response to Nursing
Treatment Performed/ Date treatment Responsibilities
change
Oxygen Inhalation December 15, 2009 Inhalation of oxygen Prevention of tissue Client is well hydrated • Using the
aimed at restoring hypoxia and resultant and has adequate prescription and
toward normal any cellular dysfunction in energy even though she taking into
54 | P a g e
pathophysiologic patient whose gas does not eat. account the
alterations of gas exchange is impaired. patient's clinical
exchange in the condition and
cardiopulmonary their preference,
system, as by the use of select the most
a respirator, nasal appropriate
catheter, tent, chamber, delivery system
or mask. • Set the
prescribed flow
rate/oxygen
concentration
according to the
prescription and
the device
instructions.
• Assess the
effectiveness of
55 | P a g e
the treatment as
needed
b. Drugs
Name of the Drug Indications and Action Contraindications Adverse Effects/ Nursing
Dosages Side Effects Responsibilities
56 | P a g e
Generic Name: • Vasospastic Inhibits calcium transport into myocardial • Hypersensitivity to CNS: headache, • Monitor blood
Nifedipine angina; chronic and vascular smooth muscle cells, drug dizziness, fatigue pressure
stable angina suppressing contractions. Dilates main regularly,
Brand name: Adults: Initially, coronary arteries and arterioles and CV: peripheral especially in
Afeditab CR, 10 mg P.O t.i.d inhibits coronary spasm, increasing edema, chest pain patients who take
Procardia, Nu- titrated over 7 to oxygen delivery to heart and decreasing beta blockers or
Nifed 14 days; usual frequency and severity of angina attacks. GI: nausea, antihypertensive.
effective range is constipation • Watch for
Pharmacologic 10 to 20 mg t.i.d, symptoms of
class: not to exceed 180 Route Onset Peak Duration heart failure.
P.O 20 min. unknown 6-8 hr
Calcium- channel mg/day. Patient • Although
blocker may be switched to rebound effect
extended- release hasn’t been
Therapeutic class: daily dosage. Total observed when
Antianginal, extended- release drug is stopped,
Antihypertensive dosage should not reduce dosage
57 | P a g e
exceed 90 mg/day slowly under
prescriber’s
• Hypertension supervision.
Adults: 30-60
mg/day P.O
titrated over 7 to
14 days to a
maximum of 120
mg/day
Generic name: • Status epilepticus Produces anxiolytic effect and CNS • Hypersensitivity to CNS: dizziness, • Warn patient to
Diazepam and severe recurrent depression by stimulating gamma other drowsiness, lethargy avoid
convulsive seizures aminobutyric acid receptors. Relaxes benzodiazepine, disorientation, breastfeeding.
58 | P a g e
Brand name: Adults: 5 to 10 mg skeletal muscles of spine by alcohol, or tartrazine depression, light- • Instruct patient to
Dizac, Valium, IV slowly, repeated inhibiting polysynaptic afferent headedness, move slowly
Diazepam Intensol as needed q 10 to 15 pathways. Controls seizures by restlessness, when sitting up or
mins, to a maximum enhancing presynaptic inhibition. paresthesia, standing, to avoid
Pharmacologic of 30 mg; may headache, slurred dizziness from
class: repeat regimen if speech blood pressure
Benzodiazepine needed kin 2 to 4 decrease. Advise
hours. May give IM CV: bradycardia, her to dangle legs
Therapeutic class: if IV delivery is tachycardia, briefly before
Anxiolytic, impossible. hypertension, getting out of bed.
Anticonvulsant, palpitations • Avoid alcohol
Sedative- hypnotic, • Adjunct while taking drug.
Skeletal muscle treatment for seizure EENT: blurred
relaxant disorders vision
Adults: 2 to 10 mg
PO b.i.d to q.i.d GI: nausea,
Children age 6 constipation,
59 | P a g e
months and older: 1 increased salivation
to 2.5 mg P.O t.i.d
or q.i.d initially; GU: urinary
increase as needed retention or
and as tolerated incontinence
Generic name: Unknown. May cause bactericidal • Contraindicated in GI: nausea • Advise patient to
Metronidazole Bacterial vaginosis: effect by interacting with bacterial patient clean area
Adults: 1 DNA. Drug-active against many hypersensitive to GU: vaginitis thoroughly before
Brand name: applicatorful anaerobic gram-negative bacilli, drugs or to its use and to wait 15
Metrocream intravaginally daily anaerobic gram-positive cocci, components. to 20 minutes
Metrogel vaginal or b.i.d. for 5 days. Gardnerrella vaginalis, • Use cautiously in after cleaning skin
60 | P a g e
Metrolotion For once-daily use Campylobacter fetus. patients with burns before applying
give h.s. or large open wounds drug to minimize
Pharmacologic and in those with risk of local
class: impaired renal irritation.
Nitroimidazole functions because • Advise patient to
derivative serious renin toxicity avoid sexual
may occur. intercourse while
using vaginal
Therapeutic class: preparation.
Anti-infective, • If local reactions
Antiprotozoal occur, advise
patient to apply
less frequently or
stop using it and
notify prescriber.
Name of the Drug Indications and Action Contraindications Adverse Effects/ Side Nursing
61 | P a g e
Dosages Effects Responsibilities
Generic name: >eclampsia Unknown. A direct-acting vasodilator • Contraindicated CNS: headache, • Monitor patients
Hydralazine Adults: initially, 5-10 that relaxes arteriolar smooth muscle. in patients dizziness. blood pressure,
mg I.V. doses (ranges hypersensitive to pulse rate, and
Brand name: 5 to20 mg) q 20-30 drugs. G.I: nausea, vomiting, body weight
Alphapress, minutes p.r.n. or, 0.5 • Contraindicated in constipation. frequently.
apresoline, Novo- to 10 mg/hour I.V those with coronary Hydralazine may
hylazine, infusion. artery disease or be given with
mitral valvular diuretics and
Pharmacologic rheumatic heart beta-blockers.
class: disease. • Alert: Monitor
Nitroimidazole • Use cautiously in patients closely
derivative patients with for signs and
suspected disease, symptoms of
CVA, or severe lupuslike
Therapeutic class: renal impairment syndrome (sore
62 | P a g e
Anti-infective, and in those taking throat, fever,
Antiprotozoal other hypertensives. muscle and joint
aches, rash)and
notify the
prescriber
immediately if
they develop.
• Improve patient
compliance by
giving drug b.i.d.
Check with the
prescriber.
• Alert: Don’t
confuse
hydralazine with
hydroxine or
Apresoline with
63 | P a g e
Apresazide.
Name of the Drug Indications and Action Contraindications Adverse Effects/ Side Nursing
Dosages Effects Responsibilities
64 | P a g e
Generic name:
Cefuroxime Sodium - serious lower Second generation cephalosporin that Contraindicated in G.I: nausea >Before
respiratory tract inhibits cell-wall synthesis, promoting patients administration, ask if
Brand name: infection s, UTIs, skin osmotic instability; usually bactericidal. hypersensitive to . patient is allergic to
Zinacef and skin-structure drugs or other penicillins or
infections, bone and Route Onset Peak Duration cephalosporins. cephalosporins.

I.V. Immed Imme Unknown
Pharmacologic joint infections, Use cautiously in
iate diate
class: septicemia, patients
Second generation meningitis, and hypersensitive ro
cephalosporin gonorrhea. penicillin because of
Adults and children possibility of cross-
age 12 and older: 750 sensitivity with other
Therapeutic class: mg to 1.5 g of bet-lactam
Anti-infective cefuroxime sodium antibiotics.
I.M. or I.V q 8hours
for 5 to 10 days. For
life-threatening
65 | P a g e
infections and
infections caused by
less susceptible
organisms, 1.5 I.M or
I.V q 6 hours for
bacterial meningitis up
to 3 g I.V q 8 hours.
66 | P a g e
Generic name: - to prevent or May decrease acetylcholine released by - Parenteral CNS: drowsiness, - if use to treat
Magnesium sulfate control seizures in nerve impulses, but its anticonvulsant administration depressed reflexes seizures, take
Brand name: pre eclampsia or mechanism is unknown. contraindicated in appropriate seizure
Epsom salts eclampsia patients with heart Skin: diaphoresis precautions.
Route Onset Peak Duration block or myocardial

I.V. 1-2 Rapid 30 min
Pharmacologic Women: initially, 4 calcium level. Alert:
min
class: g I.V in 250 ml, - Contraindicated in Watch for
Mineral D5W or normal Patients with respiratory
saline and 4 to 5 g toxemia of depression and
Therapeutic class: deep I.M. into pregnancy during 2 signs and symptoms
Electrolyte alternative buttock hours preceding of heart block.
replacement, q 4 hours , p.r.n. delivery. Don’t confuse
Laxative, Antacid, Or, 4g IV loading - Use cautiously in magnesium sulfate
Anticonvulsant dose: then 1 to 3 g patients with with manganese
67 | P a g e
hourly as I.V. impaired renal sulfate.
infusion. Total function.
dose shouldn’t - use cautiously in
exceed 30 to 40 g pregnant women
daily. during labor.
c. Diet
Type of diet Date started General Indications/ Specific foods Client response to Nursing
Date changed Description Purpose taken diet Responsibilities

NPO December 15, 2009; Nothing per Orem it is usually because Any kinds of food The client has no -Maintain the client
9:40am (NPO), the person has a are not allowed to response due to the in NPO until the
procedure coming be eaten. sedatives doctor ordered so.
that requires them to administered.
be sedated. If you
have a full stomach,
you could vomit
while you are
sedated and aspirate
68 | P a g e
the vomit into your
lungs
DAT December 16, 2009; Given when the For faster healing -Note to the patient
8:00am patient can tolerate and nutrients that and family members
any kinds of food will aid the return of the foods that are not
that is not the normal function allowed to be eaten
contraindicated to of his body. by the patient.
his condition.
d. Activity/ Exercise
Type of exercise Date ordered, Date General Description Indications/ Purpose Client response to Nursing
stared, changed activity/ exercise Responsibilities

Ambulatory December 17, 2009 able to walk and not -to promote circulation -Has facial grimace upon -Explain to the patient
bedridden -prevents muscular movement and and relatives the need for
atrophy abdominal guarding early ambulation and
-Cannot tolerate walking state its purposes.
69 | P a g e
for prolonged period. -Monitor V/S
-Assist the patient in
ambulation or instruct the
relatives to assist the
patient when walking or
going to the comfort
room or other places.
-Provide a safe
environment for the
patient.
-Provide canes, crutches
if necessary to assist the
client in ambulation.
-Provide rest periods for
the client, so that fatigue
will be minimized
-Observe for
70 | P a g e
complications such as
evisceration
Active ROM (range of December 18, 2009 Able to perform mild - helps muscles in current - Has facial grimace -Explain to the client and
motion) range of motion exercises strength upon movement relatives the importance
- promote circulation - The client refused and objectives of range
- mild activity also helps doing some movements. of motion.
burn unneeded calories -Monitor V/S
-Provide an appropriate
environment for the
patient.
-Provide rest periods so
that fatigue is minimized.
Nursing Prioritization
Nursing Problem Priority Justification

1. Excess fluid volume related to High This problem is a high priority because it is
71 | P a g e
dysfunctional kidneys as manifested by categorized on the first level of Maslow’s
edema 4+ and urine output of 10 cc/hr hierarchy of Needs, the Physiologic Needs
(Water). Physiologic needs are crucial for
survival.
2. Self-Care Deficit: hygiene, Medium This problem is a medium priority because it is
dressing/grooming related to decreased categorized on the second level of Maslow’s
motivation as manifested by dirty clothes, Hierarchy of Needs, specifically the safety and
long fingernails, foul body and breath odor. security needs. Safety and security needs
(Activity, Manipulation) both has physiologic and
psychologic aspects, both in physical environment
and relationships. Thus in need of the client and
significant other’s cooperation.

3. Risk for injury related to integrative Medium This problem is a medium priority because it is
dysfunction secondary to altered cerebral categorized on the second level of Maslow’s
perfusion Hierarchy of Needs, specifically the safety and
security needs. Safety and security needs both has
physiologic and psychologic aspects, both in
physical environment and relationships. Thus in
72 | P a g e
need of the client and significant other’s
cooperation.
B. Nursing Care Plan
Name of Patient: MSR December 15, 2009
Age: 37y/o
DX: Excess Fluid Volume
Assessment Diagnosis Background Planning Intervention Rationale Evaluation Health
knowledge Teaching
S>Ǿ Excess fluid dysfunctional Short-term Goal: Independent: Goal met.  Identify
O>edema 4+ volume related to kidneys  After 6-8  Measure vital  After 8 “danger’ signs
>BP=220/110 dysfunctional hours of nursing signs and hours of nursing requiring
>UO=10cc/hr kidneys as increased isotonic intervention, the hemodynamic intervention, the notification of
>sudden manifested by fluid retention client will be parameters client was able to healthcare
73 | P a g e
weight gain edema 4+ and able to  Compare demonstrate provider to
>Change in urine output of 10 excess fluid demonstrate current weight understanding of ensure timely
mental status cc/hr volume understanding with admission individual evaluation/
>restlessness of individual and/or dietary/fluid intervention
dietary/fluid previously restrictions.  Discuss
restrictions. stated weight importance of
 Measure  may fluid
Long-term Goal: abdominal indicate restriction and
 After 5-7 girth for increasing Partially met. “hidden
days of nursing changes fluid retention/  After 7 days of sources” of
intervention  Assess edema nursing intake such as
client is able to neuromuscular intervention foods high in
stabilize fluid reflexes client was water content
volume as  Record I/O partially able to  Suggest
evidenced by accurately; stabilize fluid to SO
balanced I/O, calculate fluid volume as interventions,
vital signs balance evidenced by such as
74 | P a g e
within client’s  Evaluate balanced I/O, frequent oral
normal limit, edematous  to reduce vital signs within care, use of lip
stable weight extremities, tissue pressure client’s normal balm to reduce
and free of signs change and risk of skin limits, stable discomforts of
of edema. position breakdown weight and fluid
frequently presence of restrictions
edema.  Instruct
Dependent: SO to provide
 Restrict quiet
sodium/fluid environment,
intake as limiting
indicated. external
 Weigh daily stimuli
or on a regular  provides a  Promote
schedule as comparative early mobility
indicated baseline
 Administer
75 | P a g e
medication
such as
diuretics
Collaborative:
 Consult
dietitian if
needed
Age: 37y/o
DX: Self-Care Deficit: Hygiene, Dressing or Grooming
Assessment Diagnosis Background Planning Implementation Rationale Evaluation Health Teaching
Knowledge
76 | P a g e
Subjective Data Self-Care Deficit: Presence of illness Short-term goal: Independent: The goal was met. Advice the client
 Ǿ hygiene, After 1 – 2 hours After 1 hour and 30 to perform
dressing/groomin Slight relevance of of nsg intervention,  Assess  To minutesof nsg hygiene every
Objective data g related to thoughts the ct will be able barriers to determine the intervention, the ct day.
 Di decreased to: participation in specific was able to:
rty clothes motivation as Decreased self- regimen (lack barriers of
 L manifested by awareness  Verbalize of information, the client in  Verbalize Teach the client
ong dirty clothes, long knowledge of insufficient rendering knowledge of on how to care
fingernails fingernails, foul Decreased health care time for proper self health care for:
 F body and breath motivation practices discussion, care. practices a. Ears,
oul body odor. regarding to intimate family regarding to her face.
and breath Poor hygiene her hygiene, problems, fear hygiene, fingernails,
odor dressing/ of appearing dressing/ skin
Self-care deficit grooming. ignorant, grooming like b. Teeth –
social/economi proper care of proper
 Determine c, home nails, hair, teeth brushing
techniques/lifes environment and ears. c. Hair and
tyle changes to problems) Body –

77 | P a g e
Age: 37y/o
DX: Risk for Injury
78 | P a g e
Assessment Diagnosis Background Planning Implementation Rationale Evaluation Health
Knowledge Teaching
S>Ǿ Risk for injury vasoconstriction Short-Term Independent:
related to of blood vessels Goal:  Assess  To evaluate Goal Met  Encourag
O>weakness integrative  After 15-30 fine motor degree of risk  After 30 minutes, e client to
>slightly dysfunction decreased renal minutes, the coordination the client was have adequate
uncoordinated secondary to perfusion client will be  Ascertain  To evaluate able to rest periods.
movements altered cerebral able to knowledge of source of risk demonstrate  Advice
perfusion decreased demonstrate safety inherent in the understanding of SO to
excretion and understanding of needs/injury client’s factors that promote
deposition of factors that prevention. situation contribute to quiet,
metabolic wastes contribute to possibility of therapeutic
possibility of Dependent: injury environment.
altered cerebral injury  Provide  To assist  Advice
perfusion information client or SO to SO to
regarding reduce increase
seizures condition that individual risk awareness of
may result factors safety
risk for injury risk for injury measures and
resources
79 | P a g e available to
client
D. Health Teaching
Client: 37 yr old client.
DATE and OBJECTIVES LEARNING CONTENT STRATEGIES TARGET RESOURCES EVALUATION EXPECTED
VENUE POPULATION OUTCOME
The health After 1 hour of I. Definition of Hypertension The group will The target > Materials We measured the After 1 hour of
teaching was Health teaching, be utilizing population of needed: knowledge of the Health teaching,
Hypertension is a chronic
held at Jose B. the client’s discussion & this health significant others the significant
medical condition in which the - bond paper
Lingad significant others blood pressure is elevated. It is lecture in slow teaching is the by asking the others (her
- ball pen
Memorial (her husband and also referred to as high blood manner as well significant other following husband and
- all health
General mother) will be as of our client questions: mother) will be
pressure.
teachings are
Hospital. able to: demonstration (MSR) able to:
Blood pressure readings are derived from
in executing
>have adequate >have adequate
measured in millimeters of 1. What is
textbook like
knowledge about mercury (mmHg) and usually Health teaching. knowledge about
hypertension?
Maternal and
hypertension hypertension
given as two numbers. For
80 | P a g e
example, 120 over 80 (written Child Nursing a. increased in
as 120/80 mmHg). Care blood pressure

a. to know the a. to know the
definition of • The top number is your b. effect of high definition of
hypertension systolic pressure, the cholesterol intake hypertension.

> Manpower:
pressure created when your 2. Enumerate the
Group 5
heart beats. It is considered classifications of
b. to determine b. to apply the
high if it is consistently hypertension?
the causes of following
over 140. > Expenses:
hypertension 3. State some of treatment or
• The bottom number is - no expenses
the factors that prevention
your diastolic pressure, the noted for this
affect the blood needed to prevent
C. to apply the
pressure inside blood health teaching
pressure of a hypertension
following
vessels when the heart is at person.
treatment or
rest. It is considered high if
e.g. age
prevention
it is consistently over 90.
needed to 4. What are the
prevent physical
II. Classification
hypertention symptoms of
81 | P a g e Normal- 120/80 hypertension?

VI. Discharge Planning
Our client went home against medical advice (HAMA).
GENERAL CONDITION OF THE CLIENT UPON DISCHARGE
The client can tolerate light activities and was able to ambulate.
MEDICATIONS
The client was instructed to continue her oral medications for treatment of infection and hypertension:
Nifedipine 20mg TID
Metronidazole 250mg BID
EXERCISES
The client was instructed to ambulate and do light exercises. Ambulation is for normal circulation and light exercises to limit fatigue.
TREATMENT
Voiding on timed schedule is indicated for bladder emptying. Stress the need for adequate fluid intake, including ingestion of vitamin C to discourage
the growth of bacteria and formation of stone.
HEALTH TEACHING
82 | P a g e
-Continuous intake of oral meds based on the doctor’s order
-Eat food with low-salt and low-fat
-Practice proper hygiene to prevent infection.
OUT-PATIENT
Return to the hospital after one week for follow-up check-up
DIET
The client is on DAT diet with emphasis to low-salt and low-fat diet.
SPIRITUAL
Emphasize to the client the importance of making God the center of his life and always seeking God’s guidance and wisdom.
VII. Conclusions
In doing this case study of postpartum eclampsia, we, as a group have acquired knowledge which supported the information we have gathered from
the case. It broadened our limited knowledge regarding the patient’s condition which may help the group handle properly this kind of condition, if possibly
handled again.
83 | P a g e
Regarding the client, we can say that we have been effective providers of care. We have imparted information which led to client’s awareness and
knowledge on how to take care of her condition which indeed helped the client a lot.
VIII. Bibliography
Fundamentals of Nursing Concepts, Process and Practices by Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder (Seventh Edition)
Essentials of Human Anatomy & Physiology” 7th Edition Marieb 2004
Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family by Adele Pillitteri (Fifth Edition)
Fundamentals of Maternal and Child Nursing Care by Marcia L. London (Second Edition)
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales by Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr (Tenth
Edition)
Nursing 2008 Drug Handbook by Wolters Kluwer (28th Edition)
84 | P a g e

Case - Eclampsia Final

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Case - Eclampsia Final

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I.

proteinuria, edema, and seizures.

than 35 years of age.

plan of care that is appropriate for the client.

• To gain knowledge about the pathophysiology of eclampsia

• To gain knowledge about the complication she experienced.

• To increase awareness of the patient with regard to possible complications.

• To provide appropriate information on self-care through health teachings.

• To give proper nursing intervention to patient and her situation.

II. Nursing Assessment

Name: Mrs. MSR

Age: 37 years old

Civil Status: Married

Position in the family: Mother

Address: City of San Fernando, Pampanga

Date and place of birth: not stated

Health Care Financing/ Usual source of medical care: Savings

Date of Admission: December 15, 2009

Date of Discharge: December 23, 2009

Initial Diagnosis: S/P NSD G7P7 (7007) postpartum eclampsia

Principal Diagnosis: G7P6 (6016) S/P NSD Postpartum eclampsia

B. Reason for visit/ chief complaint

The client was admitted to the hospital because of seizures.

C. History of Past Illness

D. History of Present Illness

F. Family Health Illness Pattern

Functional Health Prior to Admission During Hospitalization

uses herbal medicines. The patient didn’t have general condition.

check-up. When she is sick, she doesn’t consult the doctor

drugs available at home.

why she doesn’t know any food restrictions during

pregnancy. When she is wounded, it heals well. She has

many lesions in the body due to mosquito and other insect

bites. Her skin is well moistened and has complete number

of teeth. 72 Hour Diet Recall

72 Hour Diet Recall Date Breakfast Lunch Dinner

12, 2009 lugaw lugaw lugaw

13, 2009 lugaw lugaw lugaw 70 ml water

December 100 ml 80ml lugaw Refused to 100 ml water 100 ml water

Level 0: Full self-care Level 0: Full self-care

another person or device person or device

0 bathing N/A bathing

0 bed mobility III bed mobility

0 general mobility III general mobility

0 cooking N/A cooking

II home maintenance N/A home maintenance

II shopping N/A shopping

three o’clock. To relax herself, she watches television or hospital ward.

learning. It was easy for her to learn things. There is also

no change in her memory lately. When she feels any

discomfort, she actually sleeps and doesn’t bother to tell

things but not directly on that person. That’s her way of

releasing her anger. When she’s really annoyed, she will

show a sign that she’s annoyed like she walking noisily.

depressed that she didn’t eat for three days.

relationship with her neighbors is also good.

But as person, problems are always present, especially with

regard to financial aspect. Their family income is just

situation that needs cash, she borrows money from her

brothers and sisters. There is also sibling rivalry on their

children for their attention. To handle this, she shows equal

amount of love and care to each child.