Mild Preeclampsia IV. HISTORY OF THE PATIENT A. Past Medical History B. History of Present Illness V.

Assessment of the Patient

Systems Mild Preeclampsia Physical Examination Mild Preeclampsia Review of Systems Problem Identified

General Appearance

A weight gain of more than 2 lb/wk in the second trimester Weight gain of more than 1lb/wk in the third trimester Edema begins to accumulate in the upper part of the body: slight pitting edema +1 Reflexes may be normal (using the reflex hammer, check the biceps, patellar, and ankle deep tendon reflexes.)

Patient may report of headache absent or transient and dizziness

Fluid volume excess Risk for injury

Neurologic

Patient may report for Headache Patient may report for dizziness

Risk for Injury: Fall

Head/Hair/Face

Edema may be noted in the face

Patient may report of headache absent or transient and dizziness

Fluid volume excess Disturbed Body Image Risk for injury

EENT Chloasma is present None Patient may report no visual disturbances at this stage None

No problems identified

Neck

The thyroid may be palpable( normal findings)

No problems identified No problems identified No problems Identified No problems identified

Thorax/Lungs

none

none

Back

none

none

Breast and Axilla

Dark areola The breast are enlarged

none

Cardiovascular/Peripheral Vascular

Blood reading of 140/90 mmHg x 2, 4-6 hr apart, no more than 1 wk apart CRT is > 3 seconds

Patient may report of headache and dizziness

Decreased cardiac output Ineffective tissue perfusion No problems identified

GIT

none

Patient may report no absent epigastric pain at this stage None

GUT

Quantitative 24-hr urine analysis: Proteinuria of 0.3g in a 24-hr specimen Qualitative dipstick: 30 mg/dl (/+) on dipstick

Fluid volume deficit

Urine output: Output matching intake, 30 ml/hr or <650 ml/24hr Serum Creatinine: Normal

Musculoskeletal

Reflexes may be normal

Patient may report limitation of motion due to

Activity intolerance

edema that begins to accumulate in the upper part of the body

Extremities

Edema begins to accumulate in the upper part of the body: slight pitting edema +1 CRT is > 3 seconds

Patient may report limitation of motion due to

Activity intolerance Ineffective tissue perfusion

edema that begins to accumulate in the upper part of the body

None

Hematologic

None

No problems identified

VI. COURSE IN THE WARD A. Brief Description Of The Patient Stay From Admission Until Discharge B. Daily Enumeration of Physicians Order & Procedures Done
Date/Shift/Time June 5, 2012 7-3shift 7:10am Physicians Order Admit under Dr. Dazo/ Dr. Astillo/Dr. Ducducan Consent to Care Vital Signs every 1 hour NPO D5LR 1L at 30 gtts/min Labs: Complete Blood Count(CBC), Blood Typing (BT), Platelet Count(PC), Urinalysis(UA), HbsAg, Creatinine, Serum Urine Albumin(SUA), SGPT EFM Medications: Ampicillin 1gm every 6 hours ANST( ) Hydralazine 5gm PRN IVTT DBP110mmHg Methyldopa 250 mg every 6 hours FHT every hour Retain FBC Refer Dr. Astillo Procedures Done Dependent Nursing Functions: V/S Monitoring: BP RR PR Temp Secured consent for admission Instructed patient to take nothing by mouth Started venoclysis of #1 D5LR 1 Liter regulated at 30 gtts/minute. Follow-up laboratory results. Attached to Electronic Fetal Monitor (EFM). Monitored Fetal Heart Rate Inserted/maintain indwelling catheter, as indicated. Nurses Notes Independent Nsg. Functions Promote proper body positioning to promote comfort, such as semi fowlers position. Advise the patient to sleep 8 hours each night and to nap or rest for 2 hours in the afternoon. Instruct the patient in in basic deep chest breathing, which is similar to normal breathing but slower and deeper. Encourage client to acknowledge and express feelings. Promote bed rest Weigh daily at same time of day, on same scale, with same equipment and clothing.

Date/Shift/Time June 5, 2012 3-11 shift 8:45 pm

Physicians Order For EFM Now Left Lateral Decubitus Position O2 at 2 Liters/minute Dr. Ducducan

9:00 pm

Postpartum Order: (PPO) DAT To HR II (High Risk 2) Incorporate 20 units of Oxytocin @ 30 gtts/minute Medications: Co-Amoxiclav 625 mg TID Ketorolac 10mg TID FeSO4 1 cap OD Nifedipine 5mg q 6 hrs Keep Uterus Well Contracted Perineal Care BID Dr. Dazo

Procedures Done VS Monitored: BP RR PR Temp Monitored EFM. Placed On Left Lateral Decubitus Position Oxygen Therapy Started And Regulated At 2 Liters/Minute. Maintain oxygen therapy as ordered. Delivered By Outlet Forcep Extraction Incorporated Intravenous Fluid With 20 Units Of Oxytocin Regulated At 30 Gtts/Minute Administered Medications Checked For Unusualities Kept Uterus Firm And Contracted Perineal Care Done

Nurses Notes Evaluate edematous extremities, change position frequently. Assess skin, face, and dependent areas for edema. Evaluate degree of edema (on scale of +1+4). Determine pain history, e.g. location of pain, frequency, duration, and intensity using pain scale and relief measures used. Place in comfortable position as appropriate Carefully monitor intake and output at least every 4 hours. Increased patients activity level as tolerated; for example, ambulate and increase self-care measures performed by patient.

Date/Shift/Time June 6, 2012 7-3 shift 7:00 am

Physicians Order Continue Meds Possible MGH tomorrow Refer for Hypertension/BP/Profuse Vaginal Bleeding Dr. Ducducan

Procedures Done IE Done BP 110/80 mmHg Medications given Checked For Unusualities VS monitored

Nurses Notes Inform patient about: Proper use of medication and possible adverse reactions.

 Benefits of low-fat, lowcholesterol diet. Need to avoid straining with bowel movements. Date/Shift/Time June 7, 2012 7-3 shift 8:00 am Physicians Order MGH DAT Medications: Follow-up Check-up 6/13/12 @ OPD Advised Dr. Astillo Procedures Done VS Monitored Intake and output monitored. Nurses Notes Educate Patient regarding: Environmental safety measures. Fluid restriction and diet. Ways to prevent infection.