Ms. B was admitted at OBW - BRTTH last April 7, 2022 at 1:20 am, cervix 1 cm dilated. Her BP was 160/100 and her pain level of 0/10. IVF of D5LR 1L was inserted at the right hand, regulated at 20 gtts/min. Laboratories such as Complete Blood Count (CBC) with typing, Blood Urea Nitrogen (BUN), Hepatitis B Surface Antigen (HBsAg), Creatinine, Platelet count, and Urinalysis were done to the pregnant mother. The Admitting Diagnosis was Pre-eclampsia with superimposed chronic hypertension, and the final diagnosis was Pre-eclampsia with severe features. Monitoring of V/S and FHT q 4hrs was ordered and done. At 9:45 pm, delivered to a baby boy with AS of 8, 9. Several hours after delivery, the mother was ordered to undergo laboratory tests. The findings are normal results in CBC with typing, platelet count, and creatinine. Non-reactive HBsAg and high levels of BUN and oliguria in urinalysis. Upon checking the mother, she exhibited edema around her hands, has severe dehydration, decreased urine output, and her uterus is still boggy. The V/S of the mother is BP: 140/90 mmHg, T: 37.0ºC, RR: 15 breaths/min, PR: 65 beats/min, and the mother verbalize pain and discomfort. Monitor V/S every 2 hours and record.
The physician’s order prior to discharge is to have low salt and low-fat diet, use the MgS04 four (4) gms in 90cc of D5W to run at 100 cc/hr for 10 mins via soluset, and give the following:
- Amlodipine 10mg/tab 1 tab for 2 weeks
- Amoxicillin 500mg 1cap TID
- FeS04 1 tab OD at bedtime
- Mefenamic Acid 1 cap q 8hrs for pain
In addition, to monitor V/S q 2 hours and record. Furthermore, the doctor instructed the mother for follow-up at OB-OPD on April 14, 2022
Based from this patient-based scenario:
- Make a Gordon's Health Assessment
- Make a three (3) Nursing Diagnosis and nursing care plan
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