Republic of the Philippines

PALAWAN STATE UNIVERSITY

College of Nursing and Health Sciences
Puerto Princesa City

In Partial Fulfilment of the Requirements

In NCM 104- B Care of Clients with Problems in Inflammatory and Immuno Response,
Perception and Coordination
(Related Learning Experience)

MMG-PPC Cooperative Hospital (Delivery Room)

GROUP CASE STUDY

PRE-ECLAMPSIA

Presented by:
BUAYA, GEJADDAH GRACE
CAYAO, JOAQUIN A.
CERVANTES, LIANA S.
DAGANTA, PATRICE JANE A.
GONZALES, SALIHJANH KHAN S.
MAYUGA, KATE L.

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1
 ACKNOWLEDGEMENT

Preparing this Group Case Study Presentation is a difficult task to do. This requires much
work, knowledge, skills, focus, and industry. Upon completion of the task, we Group 2-DR
would like to express our gratitude to the following people who have made great contributions to
this group case study possible.

To the Almighty Father, for His unceasing guidance and blessings, for constantly giving
wisdom, hope, courage, and patience. Truly, none of this is possible without Him.

To our Clinical Instructor Mrs. Sonia D. Ygloria, RN, MAN for patiently supervising and
assisting with her knowledge, support, effort and assistance that always giving not only during
hospital exposure but also for her teachings and pieces of advice.

To the staff and administrators of MMG-PPC Cooperative Hospital, who also guided and
helped to adjust and gave opportunity to enhance our knowledge, skills and attitude during the
hospital exposure.

To the patient and family for the generous time extended for them to explore this case,
for the trust they give during physical assessment and interview, and making them available for
the study. This case study will not exist without their consent in giving the information needed.

To our parents, for supporting all the way, providing with everything we need, financially
and emotionally. All of those things are genuinely appreciated.

And to the people who make this project come into fruition yet fail to mention.

The members of Group 2-DR gave honour to all the people mentioned above for their
contributions, time, and efforts towards the success of this grand case study.

Thank you and God Bless!

GROUP 2-DR

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SCOPE AND DELIMITATION

This case study was chosen during the exposure of Nursing Students in their second
semester 2018-2019 at the Operating Room/Delivery Room of MMG-PPC Cooperative Hospital
last January 8, 2019. The case primarily focuses at delivery room (DR) not limited regarding DR
assessment for better evaluation.

Information was gathered primarily through interview from the patient and also thorough
Physical assessment and patient’s chart while secondary information was gathered from
significant others.

SIGNIFICANCE OF THE CASE STUDY

This case study has a great impact to the Student Nurse because through this Student
Nurses learned about the disease process such as occurrence of the disease and manifestations.

This study may be beneficial to the following:

1. Student nurses - Exposing in new cases will impart knowledge and ideas that can be
used for future needs. Nursing student will be able to have a background information
regarding the case that can be used for better care and better assessment for future
clienteles.

2. College of Nursing and Health Sciences - the results of this case study could be
incorporated to classroom teaching as additional knowledge and information that would
benefit both students and lecturers that may improve their knowledge and skills on
rendering care to clients.

3. Researchers - this case study could play an important role as reference point for those
who are planning to conduct studies related on these topics in the future.

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 TABLE OF CONTENTS

Front Page………………………………………………………………………………. 1

Acknowledgement ……………………………………………………………………... 2

Scope and Delimitation ………………………………………………………………… 3

Significance of the Study ………………………………………………………………. 3

Table of Contents …………………………………………….…………………............ 4

Introduction …………………………………………………………………………...... 6

CHAPTER 1: Demographic Data and History

A. Patient’s Profile ……………………………………………………………. 9

B. Present Illness………………………………………………………………. 10
C. Past Health History………………………………………………………… 10
D. Family Health History ……………………………………………………... 10

CHAPTER 2: Growth and Development

ERIK ERIKSON………………………………………………………………... 13
SIGMUND FREUD’S………………………………………………………….... 14
JEAN PIAGETS…………………………………………………………………. 15

CHAPTER 3: Patterns of Functioning and Clinical Examination

Patterns of Functioning…………………………………………………………. 17

CHAPTER 4: Physical Assessment

Physical Assessment……………………………………………………………. 26

CHAPTER 5: Anatomy and Physiology

Anatomy and Physiology of Cardiovascular System …………………………… 34

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CHAPTER 6: Pathophysiology

Pathophysiology of Pre-Eclampsia …………………………………………… 37

CHAPTER 7: Laboratory and Diagnostic Procedures …………………………….. 38

CHAPTER 8: Drug Study ……………………………………………………………. 46

CHAPTER 9: Nursing Care Plan…………………………………………………….. 56

CHAPTER 10: Discharge Plan……………………………………………………….. 64

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 INTRODUCTION
Preeclampsia is a condition that occurs only during pregnancy. Some symptoms of
preeclampsia may include high blood pressure and protein in the urine, occurring after week
20 of pregnancy. Preeclampsia is often precluded by gestational hypertension. While high
blood pressure during pregnancy does not necessarily indicate preeclampsia, it may be a sign of
another problem.

Preeclampsia affects at least 5-8% of pregnancies. If you have severe preeclampsia, your
doctor may try to treat you with blood pressure medication until you are far enough along to
deliver safely, along with possibly bed rest, dietary changes, and supplements. If preeclampsia is
not treated quickly and properly, it can lead to serious complications for the mother such as liver
or renal failure and future cardiovascular issues.

Treatment depends on how close you are to your due date. If you are close to your due
date, and the baby is developed enough, your health care provider will probably want to deliver
your baby as soon as possible. Preeclampsia can prevent the placenta from getting enough blood.
If the placenta doesn’t get enough blood, your baby gets less oxygen and food. This can result in
low birth weight. Most women still can deliver a healthy baby if preeclampsia is detected early
and treated with regular prenatal care.

There are two kinds of preeclampsia the mild and severe, mild preeclampsia: high
blood pressure, water retention, and protein in the urine. Severe preeclampsia: headaches,
blurred vision, inability to tolerate bright light, fatigue, nausea/vomiting, urinating small
amounts, pain in the upper right abdomen, shortness of breath, and tendency to bruise easily.
Contact your doctor immediately if you experience blurred vision, severe headaches, abdominal
pain, and/or urinating very infrequently.

Formerly called toxemia, preeclampsia is a condition that pregnant women develop. It's

marked by high blood pressure in women who haven't had high blood pressure before.
Preeclamptic women will have a high level of protein in their urine and often also have swelling
in the feet, legs, and hands. This condition usually appears late in pregnancy, though it can
happen earlier.

If undiagnosed, preeclampsia can lead to eclampsia, a serious condition that can put you
and your baby at risk, and in rare cases, cause death. Women with preeclampsia who
have seizures are considered to have eclampsia.

There's no way to cure preeclampsia except for delivery, and that can be a scary prospect
for moms-to-be. Even after delivery, signs and symptoms of preeclampsia can last for 1 to 6
weeks.

PRE-ECLAMPSIA
6
 But you can help protect yourself by learning the symptoms of preeclampsia and by
seeing your doctor for regular prenatal care. Catching preeclampsia early may lower the chances
of long-term effects for both mom and baby.

During pregnancy, it’s important to keep you and your baby as healthy as possible. This
includes eating a healthy diet, taking prenatal vitamins with folic acid, and going for regular
prenatal care check-ups. But even with proper care, unavoidable conditions like preeclampsia
can sometimes occur, during pregnancy or after delivery. This can be dangerous for both you and
your baby. Talk with your doctor about things you can do to reduce your risk of preeclampsia
and about the warning signs. If necessary, they may refer you to a maternal-fetal medicine
specialist for additional care.

Last January 8, 2019, we encountered a patient with such kind of problem. This patient
has caught our attention because that the only case that available to the delivery room and has the
opportunity to study her study her case. The objective of this study is to help us understand the
disease process of preeclampsia and to orient ourselves for appropriate nursing intervention that
we could offer to the patient.

This approach enables us to exercise our duties as student nurses which is to render care.
We was given the chance to improve the quality of care we can offer and to pursue our chosen
profession as future nurses.

The following information presented is the case of a 29 years old women who has a
Preeclampsia.

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 CHAPTER 1:
Demographic Data
and History

PRE-ECLAMPSIA
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 PALAWAN STATE UNIVERSITY
College of Nursing and Health Sciences
Puerto Princesa City

A. PATIENT PROFILE

PATIENT’S NAME: Mrs. R

GENDER: Female

STATUS: Married

ADDRESS: Narra, Palawan

AGE: 29 y/o

EDUCATIONAL ATTAINMENT: College Graduate

OCCUPATION: Housewife

RELIGION: Roman Catholic

DATE AND TIME ADMITTED: January 8, 2019 at 1 pm

CHIEF COMPLAINTS: Epigastric Pain

ATTENDING PHYSICIAN: Dr. F

ADMITTING DIAGNOSIS: G2P1

FINAL DIAGNOSIS: G2P2

PRE-ECLAMPSIA
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 B. PRESENT ILLNESS

Around 7:45 am at the patient house, she suddenly feels epigastric pain with positive vomiting
and negative amniotic fluid. By a referral from Narra hospital. She was rushed to coop hospital
via ambulance and arrived at 1:00 pm. The patient received in OR via stretcher at 3:10 pm with
IVF at left hand. She received epidural anaesthesia at 3:20 pm, the patient’s feels dizzy and
vomits even before the operation started. The operation started at 3:35 pm, at exactly 3:36 pm the
baby was out and the placenta follow through at 3:37 pm. The patient vomits during and after the
operation.

C. PAST HEALTH HISTORY

Mrs. R perceived herself as a healthy person, although she experienced chicken pox when
she was 10 years old, aside from it, she didn’t experiences other childhood diseases. When she
experience common cough and colds, she drinks herbal meds and calamansi juice and a lot of
water as home remedy. She stated that she completed her immunization and had 5 doses of
tetanus toxoid.

D. FAMILY HISTORY

Mrs. R stated that her parents and siblings are alive and well. Her father is apparently
alive and well. Her mother is alive and well. They are 4 children in their family. Mrs. R older
brother, 31 years old, who has asthma, next is Mrs. R, who is 29 years old, next is Mrs. R
younger sister, who is 27 years old and last is her youngest brother, who is 25 years old, who
also had asthma. Her father side has history of hypertension, diabetes and asthma, and the oldest
and youngest sibling then inherited asthma from their father.

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E. GENOGRAM

LEGEND: PX’S FATHER PX’S MOTHER HPN DM ASTHMA

MALE FEMALE GRANDFATHER (FATHER SIDE)

GRANDMOTHER (FATHERS SIDE) GRANDFATHER (MOTHER’S SIDE)

GRANMOTHER (MOTHER’S SIDE) UNCLE (FATHER’S SIDE)

PRE-ECLAMPSIA AUNT ( FATHER’S SIDE) UNCLE (FATHER’S SIDE) AUNT(MOTHER’S SIDE

11 BROTHER SISTER PATIENT PATIENT’S HUSBAND CHILD
CHAPTER 2:
Growth
And
Development

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 ERIK ERIKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT
STAGE TASK MANIFESTATION
Erik Erikson’ s
psychosocial theory Intimacy vs. Isolation Mrs. R and her husband live apart
(18-40 years old) from their parents and they have a
Erikson’s (1959) During this period, the major mutual understanding with each
theory conflict centers on forming other to make their family
of psychosocial intimate, loving relationships knitted. She also stated that they
development has eight with other people. argue but not often and if they
Distinct stages. Like argue, they always come up to
During this period, we begin to
Freud, Erikson understand each other. They had
share ourselves more intimately
assumes a successful and happy
with others. We explore
that a crisis occurs at relationship as stated by the
relationships leading toward
each stage of patient.
longer-term commitments with
Development. For
someone other than a family
Erikson
member.
(1963), these crises
are Successful completion of this

of a psychosocial stage can result in happy

nature relationships and a sense of

because they involve commitment, safety, and care

Psychological needs within a relationship.

of the individual (i.e. Avoiding intimacy, fearing

psycho) conflicting commitment and relationships
with can lead to isolation, loneliness,
The needs of society. and sometimes depression.
Success in this stage will lead to
the virtue of love.

SIGMUND FREUD’S OF PSYCHOSEXUAL THEORY

PRE-ECLAMPSIA
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 STAGE TASK MANIFESTATION
Sigmund Freud’s Genital Stage Mrs. R is married to her husband.
psychosexual theory: (12 years old and onwards) In terms of current sexual life, as
stated by the patient she is not
Freud (1905) Physical sexual changes sexually active She took care of
proposed that reawaken repressed needs. her husband and her first born
psychological Direct sexual feelings towards child. Regarding of gratification
development in others lead to sexual he showed that she is a
childhood takes place gratification. responsible wife and especially to
in a series of fixed her children.
stages.
These are called
psychosexual stages
because each stage
represents the fixation
of libido (roughly
translated as sexual
drives or instincts) on
a different area of the
body. As a person
grows physically
certain areas of their
body become
important as sources
of potential frustration
(erogenous zones),
pleasure or both.

JEAN PIAGET’S THEORY OF COGNITIVE DEVELOPMENT

PRE-ECLAMPSIA
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 STAGE TASK MANIFESTATION

Piaget's (1936) theory Formal Operational

of cognitive The patient perceives hereself as
development Stage (11 years and over)
a full-grown woman who knows
how to handle matters as an adult,
Explains how a child The formal operational stage
did her job as a housewife
constructs a mental begins at approximately age
diligently to take care of her child
model of the world. eleven and lasts into adulthood.
and husband as every mother
He disagreed with the During this time, people develop
should. Socially conditioned
idea that intelligence the ability to think about abstract
manners such as smoking &
was a fixed trait, and concepts, and logically test
drinking vices are not rooted.
regarded cognitive hypotheses.
development as a
process which occurs
due to biological
maturation and
interaction with the
environment.

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 CHAPTER 3:
Patterns of
Functioning and
Clinical Examination

Date of Examination: January 8, 2019

PRE-ECLAMPSIA
16
 PATTERNS OF CLINICAL OTHER SOURCES
FUNCTIONING EXAMINATION

1. RESPIRATORY RR: 22 bpm NONE

Does not have difficulty of (-) DOB
breathing

Non-smoker

2.CIRCULATORY BP: 130/ 100 mmHg CBC Results:

No History of hypertension and PR: 95 bpm Hemoglobin- 120 g/L
any heart problems tightness of chest: None Haematocrit-0.365vol%
Capillary refill: <2 secs. WBC -12.89
(-) Edema

3. FOOD AND FLUID General state of health.

INTAKE Nutritional status of Skin:
Usual foods taken are vegetables, hydrated.
fruits, fish and milk.

Patient eats her meal three times

a day.
Breakfast at 6:30 AM, Lunch at
12:45 AM and Dinner at 8:00
PM

Consumes 1 glass of milk every

day.

Drinks 8 to 12 glassses of water

from deep well each day.

Food Allergies
with Chicken and Seafood

4. ELIMINATION
Patient voids one to two times a
day every morning and NONE
sometimes evening. Her stool is Yellowish Urine
usually brownish to darker and (-) Stool
she has a yellowish urine.

She has history of indigestion

PRE-ECLAMPSIA
17
while she is pregnant and had
nausea a d vomiting as well
during her first trimester.
Constipation (Cause): Lack of
water and after eating too much
bananas and other foods that can
trigger constipation
relief done: __ate pineapple
and other fiber rich fruits or
foods

Shiny and evenly distributed

5. REGULATORY hair Dry skin: no
MECHANISMS color of skin: fair skin
Texture: soft
Menarche: 12 years old Temp. & moisture of skin:
Interval: (Regular) once a month warm and soft
No. of days: 3-5 days Scalp/hair: Medications taken.
LMP: April 28,2018 dandruff: (+)
Birth control: None Brittle hair: no
EDC:2/2/2019 scaly dry: no
Lice infestation:NONE
Pain scale of 6 out of 10. swallowing difficult: None
Have membranes ruptured: abdominal pain(scale 1-10): 6
Negative out of 10

Temp.: 36.8 °C (Axilla)

skin : Yes
pale : Yes
hot to touch : Yes
perspiration noted: Yes
Face :
flushed rashes: None
twitching: None
paralysis: None

OB-GYNE
FHT: 148 bpm
(ultrasound) 
Vaginal bleeding : none

Appearance of Placenta:
Rubra
Breast enlargement: Yes
tenderness: Yes

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 HEAD:
hair distribution and texture: Toiletries use.
6. HYGIENE evenly disytibuted but is Brand of soap,
How often does patient take a brittle and dry toothbrush/toothpaste,
bath? Time? Scalp- secretions: Shampoo use.
once to thrice a day every slight Lesions, Dandruff and
morning and afternon/ evening no lice infestation
Skull: contour, size
Shampoo use: Yes Often: Nails: Short and clean
Yes Mouth:- clean: Yes, but with
dental carries noted
Brush teeth: Yes, after meals Odors: Slight odor
Halitosis: None
Change clothes, etc.: Yes Unpleasant odor of patient:
no odor
Allergies to soap, shampoo:
None
Any beliefs/practices related to
personal hygiene: None

Physical bearing, stature, gait,

posture, movement, extent of
7. ACTIVITY & EXERCISE range of joint motion: Normal
Limitations of movements:
Usual exercise: walking in while limited during operation and
working because she works in the after operation. NONE
office Fractures: None
Joint stiffness: None
frequency & time done: Every Contracture deformities: None
Morning at 6: 30 Am to 7: 30 am. Dislocation: no
Muscle pain: Yes
Joint stiffness experienced: Cramps: Abdominal
None Amputated parts: None
Use of crutches, cane, or other
Paralysis: None walking aids: None
Neck:
Prosthetic:None symmetry of musculature:
Symmetrical
Aids to mobility: None Abnormal masses: None
Swelling: None
Enlargement of thyroid
glands,esence of lymph nodes,
vein prominence, scars, moles

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 stiffness of neck: none

Rest prescription of
physician
Looks tired: yes
sleepy: yes
8. REST AND SLEEP eye bags/puffiness around :
Yes
She usually sleeps at 9:00 PM difficulty in sleeping: Yes
and wake up at 6:00 AM Possible cause: Due to her
pregnancy
Favorite sleeping position: Actual no. of hours slept: 7
side-lying hours
Interrupted sleep: Yes
No. of pillows used: 1 piece frequent yawning: No NONE
decreased attention span: No
use Mosquito net: Yes

Bedtime rituals Describe:

taking a half bath or full bath
before bed

snores: NONE

teeth grinding: NONE

talks when asleep: NONE

EYE
Her eyes are symmetrical,
9.COMMUNICATION AND black in color, almond shape.
SPECIAL SENSES Pupils constricts when
Right handed : YES diverted to light and dilates
when she gazes afar,
Use of eye glasses: NONE conjunctivas are pink.
Eyelashes are equally
Hearing aids: NONE distributed and skin around
the eyes is intact. The eyes
Visual and auditory involuntarily blink. No eye
disturbances: NONE infection, presence of
  ulcerations or cataract noted.
Speech disturbances: None NONE
Dialect or language spoken: EARS:
Tagalog and English Color of the auricle is pale
symmetrical
No presence of Heavy earwax
and any discharges.

VOICE:
Able to responds when asked

PRE-ECLAMPSIA
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 in a soft voice

Responds to verbal and tactile

stimulant

Physician’s record for

10.COGNITION & symptoms of which the
PERCEPTION (sensory) She is oriented to place time patient complains.
and person
HX of convulsions: NONE
Hx of loss of consciousness: She oriented to place time and
NONE person
Hx of epilepsy: NONE
Medications taken: NONE Responds to verbal and tactile
stimulant

Oriented:
person: Yes
time: Yes
place: Yes
Level of consciousness :
Alert
comatose(GCS) : No
Suffering from seizures while
in your care? No
Response to stimuli:
Tactile : yes
Verbal: yes
coherence of expression:
yes

Medications taken.

11. PAIN AND DISCOMFORT

Pain and discomforts frequently Facial grimace: No

experienced: epigastric pain guarding: No
Pain scale (0-10): 6/10
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21
Relief done: " tiniis ko lang" as affect other patterns: No
stated by the patient Discomfort felt: None
Mefenamic acid as
prescribed by the doctor
Does he know the cause: Yes

12. RECREATION AND Patient just tried to sleep and

DIVERSION endured it before she gets to
the hospital and after the
What is done for fun: operation she just goes to
sleep due to the effect of
Hobbies: anesthesia

Interest she would like to pursue: Any evidence of boredom:

None
Describe: To become a good
working mother and wife to her Describe: Patient R remains
baby and husband. alert the whole time of
interview. She is also positive
in her views.

What does she want to do to

pass his time? She just take a
sit and rest cause she works
and don’t get a lot of past
time.

13. RELIGIOUS LIFE

Religious affiliation: Church of Religious medals worn:

Christ NONE
Need for religious counselor:
Religious belief and practices No
(esp. those that may affect his Ability to meet own spiritual
care and health), diet, days of needs: Yes
worship, holy day: describe:
What are the patient’s
She is active in their church attitudes? Mood?
Patient R remains happy and
She went to church every Sunday alert the whole time of
together with her interview. She is also positive
husband’s family in her views.

How she is coping with his

She prays before she had her illness?
meals as well as before sleeps. She talks out her emotions
with her husband and seeks
advises from them especially
when it comes to coping with
stress.
She stated that she sees
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22
 herself being a good mom and
that her husband will be her
main supporter in caring for
her newborn baby.

Reports of psychiatric
14. COPING MECHANISMS evaluation: NONE

What is done when facing

stressful situation? : Support of family/friends: Her
Staying positive and expressing family is very supportive with
out her problems and feelings to the patient and her pregnancy.
their close or loved ones such as They are open to visitors and
parents, sisters and friends. is very cooperative with the
medical staffs even to medical
What do you do when: students conducting
Angry: Goes silent and avoid interviews.
encounters from the person or
things or situations she is angry
with.

Frightened: Ask for a company

and express their feelings.

Whose advise is sought when

problems occur?
Parents, siblings, partner and
close friends

15. ROLE AND

RELATIONSHIPS (for Adult
client)
She has a good relationship with
her co-workers and family.

While she was admitted at the NONE

She has a good relationship with hospital she was with her
her husband. family and husband.

Family roles
Members of household: 4
members
1. PA- Px husband
2. MA – Patient
PRE-ECLAMPSIA
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3. Kua- Px first born
4. bunso- Px newborn

CHAPTER 4:
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24
Physical Assessment

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25
ASSESSMENT PRE-OPERATION INTRA-OPERATION P
(January 8, 2019) (January 8,2019)
1:00 PM - 3:00 PM 3:10 PM -4:15 PM
*Dress, Grooming and hygiene *Dress, Grooming and *Dress, Grooming and hygiene
Contraptions: Hygiene Contraptions:
 D5LR 1 L on left hand Contraptions: • D5LR on left hand
• Foley Catheter inserted • D5LR on left hand • Foley Catheter inserted
• Foley Catheter inserted
• Patient wear surgical gown • The patient was skin prepped *Speech patterns, posture, gait,
which is appropriate to the • Patient has surgical drapes coordination and balance
occasion • Patient is still lying on bed;
• Patient looks untidy upon *Speech patterns, posture, gait, patient was able to hear sounds
GENERAL observation; Skin color is fair; coordination and balance and able to reply
APPEARANCE no presence of foul odor on the • Patient is lying on bed; • Patient looks pale and
skin patient wasn’t able to speak weak.
• Short clean fingernails and because of consistent vomitting
toe nails *level of consciousness
• Hair is long, unkempt, color *level of consciousness
of hair is black, straight and • Patient is conscious • Patient is conscious;
wavy; no presence of white during the operation due to patient is coherent on the time,
hair. Epidural anesthesia date, and place.

(-) halitosis, dry pale lips, gums

are pinkish.

* Speech patterns, posture, gait,

coordination and balance.
• She could clearly hear audible
sounds 3 feet away, and no
speech disturbances;
• Mobility is very limited having
the nurse assist the patient upon
walking and transferring the
client.

*level of consciousness
• Patient is conscious, alert and
coherent, oriented by name,
time, and place. PRE-ECLAMPSIA
26
PRE-ECLAMPSIA
27
 • Fair in color ; • Skin is pallor
• Skin is pallor, cold and clammy. • With 5 inches abdominal Inc
• No lesions, drainage, and fresh • Incision deepened to explore
bruises on the skin. peritoneum noted
SKIN • (-) callous on his both palm in the • Perimetrium, Myometrium an
hand; Endometrium incision noted
• (-) Presence of foul odor upon
observation
• Axillary temperature of 36.8˚C.

Hair Hair
• Hair is black with no presence of • Hair in the symphysis pubis w
white hair, long and unkempt, shave
• No hair loss noted
HAIR, SCALP AND NAILS
Nails
• Short smooth clean fingernails and
toenails. Color of nail beds are pale
• Capillary refill in 2 seconds. No
clubbing of fingers.
• Texture is thickened and white
Head is symmetrical, round in shape, Head is lying on bed. No lesio
and in midline. No involuntary swelling noted
movement upon observation. No Face:
lesions, scars and swelling noted. • Facial movements evident
Face:
• The color of the face is fair
• The face is oval in appearance.
HEAD • No lesions and scars noted;

• No swelling or edema noted.

• No pimples noted
PRE-ECLAMPSIA
28
 • No presence of wrinkles or fine
lines on the forehead and the eyes.
• No involuntary movements evident.

• Eye lashes evenly distributed; • Eyelashes are evenly distribu

• Sclera is white • eye blinking noted due to sed
EYES • Conjunctiva are pale in color; no • eye movement are present
tenderness in the lacrimal gland
• Pupils are round, black in color.
• No edema noted

• Pinna are aligned with the outer • Pinna are aligned with the ou
canthus of the eyes. Heard audible canthus of the eyes. (-) earwax
EAR sound 3 feet away on both ears, (-) yellowish in color.
earwax yellowish in color.

• No nasal flaring observed • with oxygen inserted

• No presence of nasal discharge
NOSE noted
• No lesions and scars noted
• Color is same as the face
• Able to breathed on both nares

• Lips are dry, pale without any N/A

lesions, scars and swelling
MOUTH • Oral mucous membrane is moist
• Gums are pinkish
• No presence of halitosis noted.
• Teeth is white in color
• Neck has symmetrical musculature N/A
located at midline of the body.
• No lesions, swelling and
NECK enlargement noted.
• Trachea is in the middle line.
• Able to do flexion, extension,

PRE-ECLAMPSIA
29
 hyperextension

BP- 160/110 mmHg BP-150/100 mmHg

PR- 98 beats per minute PR-95 beats per minute
RR- 22 cycles per minute RR- 22 cycles per minute
T – 36.8 C • Patient lying on bed;
• Good skin turgor • Both arms are at rest lying on
• Cold, clammy skin upon • Patient is under sedation duri
UPPER EXTREMITIES observation operation
• No lesions, drainage, and fresh • With 5 inches abdomin
bruises on the skin. incision
• No edema or swelling noted • Incision deepened to explore
• (-) of callous on the palm; peritoneum noted
• Nails are clean short and pale with • Perimetrium, Myometrium an
capillary refill of < 2 sec. Endometrium incision noted

ABDOMEN
• pregnant
• Skin is fair N/A
• Fairly distributed hair on skin;
LOWER EXTREMITIES Moist skin without lesions
• No edema noted on both feet

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CHAPTER 5:
Anatomy
and
Physiology

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31
 ANATOMY AND PHYSIOLOGY

The Circulatory System

The Circulatory system is designed to deliver oxygen and nutrients to all parts of the
body and pick up waste materials and toxins for elimination. This system is made up of the heart,
the veins, the arteries, and the capillaries.

Circulation is achieved by a continuous one-way movement of blood throughout the

body. The network of blood vessels that flew through the body is so extensive that blood flows
within close proximity to almost every cell.

Heart

The heart is a muscular pump that propels blood throughout the body. The heart is
located between the lungs, slightly to the left of center of the chest. The heart is broken down
into four chambers including:

 The Right Atrium, which is a chamber which receives oxygen-poor blood from
the veins.
 The Right Ventricle which pumps the oxygen-poor blood from the right atrium to
the lungs.
 The Left Atrium which receives the now oxygen-rich blood that is returning from
the lungs.
 The Left Ventricle, which pumps the oxygenated blood through the arteries to the
rest of the body.

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Blood Vessels

Blood vessels are broken down into three groups: the arteries which carry blood out of
the heart to the capillaries, the veins which transport oxygen-poor blood back to the heart, and
the capillaries which transfer oxygen and other nutrients into the cells and removes carbon
dioxide and other metabolic waste from these body tissues.

Blood Pressure

Blood pressure is the force exerted by the blood against the walls of the blood vessels.
The output or direct pumping of the heart and the resistance to blood flow in the vessels
determines blood pressure. Resistance is determined by blood viscosity and by friction.

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 CHAPTER 6:
Pathophysiology

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Predisposing Factor: Precipitating Factor:
Present to client Present to client:
Age: 35-40 y/o 29 y/o Multi-gravida = G₂P₂
Sex: Female Female
Family History: Hypertension
on Father side

Vasospasm

Peripheral
Arteriole
Vasoconstri

Epigastric
Pain

PRE-ECLAMPSIA
35 Headache, Pregnancy
Increased Nausea Induced
Blood
and Hypertensi
 CHAPTER 7:
Laboratory and
Diagnostic Procedure

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36
 PALAWAN STATE UNIVERSITY
College of Nursing and Health Sciences
Puerto Princesa City

LABORATORY STUDY

DATE LABORATORY RESULT NORMAL INTERPRETATION SIGNIFICANCE

EXAMS VALUES

HEMATOLOGY

JAN. 120 g/L F= 120- NORMAL Hemoglobin is

8, HEMOGLOBIN 160g/L The result is within main intracellular
2019 (Hgb) normal protein of
range, this indicates erythrocytes. It
that the carries oxygen
supply of oxygen in and remove
the blood is carbon dioxide.
sufficient therefore the
organs and tissues
inside the body
received sufficient O2.

NORMAL The hematocrit

HEMATOCRIT 0.365vol F= 0.370- Indicates normal measures the
(HCT) % 0.470 vol% percentage of RBC in percentage of
the blood plasma. RBC in the blood
plasma. This
determines if the
patient is at risk
for anemia,
dehydration and
low amount of
oxygen in the
blood.

NORMAL RBCs contain

RED BLOOD 3.83 M= 3.50- The result is within hemoglobin,
CELL 5.50 X 1 normal range, this which carries
(RBC) indicates that the oxygen to your
supply of oxygen in body’s tissues.

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 The number of
the blood is sufficient RBCs you have
therefore the organs can affect how
and tissues inside the much oxygen
body received your tissues are
sufficient receiving. Your
tissues need
oxygen to
function
effectively

4.3-10.0X Producing
WHITE BLOOD 12.89 10 9/ ABOVE NORMAL antibodies to
CELL elevated values may develop immunity
indicate (leukocytosis): against infections.
infection, common It defends the
cold, tuberculosis, body against
allergy, and glandular bacteria, parasites,
fever viruses and
tumors.

(WBC) the cells of the

immune system
that are involved in
protecting the body
against both
disease and foreign
invaders.

BELOW .
PLATELET 92 140-440 X NORMAL Needed for normal
10 9/L - A low platelet blood
count known as clotting; initiating
thrombocytopenia clotting
. It can also cascade by
indicate other clinging to turn
types of disease area; helps to
such as control blood
Leukemia, Some loss
types of anemia,
Viral infections,
such as hepatitis
C or HIV,

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 Chemotherapy
drugs and Heavy
alcohol
consumption

NORMAL They help protect

EOSINOPHILS 1.0 00.0-5.0% the body
against disease and
infections
by moving around
and eating
some types of
bacteria, foreign
substances, and
other cells.
They are very
helpful in
defending the body
against
parasites.

LYMPHOCYT 13.0 20.0- Below normal. It Responsible for

ES 40.0% indicates that immune response
the patient is against microbial
immunocompromis invasion.
ed They are also
and wasn’t able to responsible for
fight the fighting tumors
possible presence and viruses and
of microbes or inactivation of B
infection in the cells.
blood.

NORMAL Monocytes’ main

MONOCYTES 4.0 00.0-7.0% Normal. This function is to
indicates that the remove cellular
patient have active debris and
phagocytic microorganisms, a
response process called
phagocytosis.

BLOOD TYPE: “B”

RH: POSITIVE
REMARKS: PLATELET DOUBLE CHECKED

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 BLOOD CHEMISTRY/ SEROLOGY

DATE TEST RESULT REFERE INTERPRETATI SIGNIFICANCE

NCE ON
VALUES

JANUAR ALBUMIN 30.90 34-48 NORMAL To determine if

Y 8, 2019 mmo1/L there is
It means there is presence of protein
no protein in on the
the urine. urine

POTASSI 333 3.40-5.50 BELOW Helps maintain

UM mmo1/L NORMAL fluid balance
and works on
If potassium level nerve and muscle
is too low may function.
indicate
muscular weakness
and fatigue

SODIUM 137.90 125-140 NORMAL Helps maintain

mmo1/L mmo1/L fluid balance
There is normal and works on
sodium level nerve impulse
which is essential transmission.
to your body. Deficiency may
Sodium is result to muscle
particularly cramps and
important reduced appetite
for nerve and while if
muscle function excess could result
to high
blood pressure.

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40
 URINALYSIS
DATE URINALYSIS RESUL REFERE INTERPRETATION SIGNIFICAN
T NCE CE
VALUES

A dark brown or tea- Color of urine

January STRAW colored is affected by
8,2019 TO DARK urine may indicate eating certain
COLOR YELLO
YELLOW liver food or the
W
disorder or a side presence of
effect of bile or blood in
certain medicine. The the urine. To
bile determine if
excretion in the urine the
may give urochrome, a
the dark color pigment that
result from the
body’s
destruction of
hemoglobin
still
in its normal
state.

SPECIFIC 1.013 1.010- WITHIN NORMAL Urea and uric

GRAVITY 1030 acid have the
The urine is diluted greatest
and normally influence on
concentrated. specific
gravity of
urine. The
specific
gravity
increases with
conditions that
increase the
loss of fluids
from the body.
Decreases in
the specific
gravity result
from renal
disease.

CREATINE 0.80 0.50-1.00 WITHIN NORMAL Creatinine

levels help

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41
 The kidney filters determine how
creatinine out of the well your
blood and kidneys
send them out of the function. When
body creatinine
through urine. levels increase,
your kidney
function may
be
impaired.

ULTRASOUND REPORT OBSTETRICS

SECOND & THIRD TRIMESTER

GENERAL SURVEY
No. Of Fetuses : Singleton live
Presentation: Cephalic
FHB: 148b/min
Placenta Location: Postero Fundal
Total AFI: 3.8cm SVP

BIOMETRY
BPD: 6.6cm AOG: 26W 6D
AC: 23.1 cm AOG: 27W 2D
FL: 5.2 cm AOG: 28W 1D
AVE-ULTRASONIC AGE: 27W 3 DAYS
ULTRASONIC EDC: FEB. 03,2019
EFW: 1.1 Kg

DIAGNOSIS:
Pregnancy, uterine 27 w 3 days sonar age by fetal biometry. Cephalic singleton live. Good
cardiac and somatic activity noted. Placenta is postero fundal grade 11.
Amniotic fluid is adequate. Male genitalia noted.

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CHAPTER 8:
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43
Drug Study

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44
 Name of Drug Classification Dose, Freq. Mechanisms of Indications Contraindications Side Effects and Nursing
and Route Action Adverse Responsibilities
Reactions
Generic name; 1 tab 500mg, Second- Pharyngitis,  Contraindicated  Diarrhea  Determine
Cefuroxime PO, BID generation tonsillitis, in patients  nausea history of
cephalosporin that infections of the hypersensitivity  rash hypersensitivity
Antibiotic inhibits cell-wall urinary and lower to drug.  urticaria reactions to
synthesis, respiratory tracts,  Use cautiously in  pruritus cephalosporin,
promoting and skin and skin- patients penicillin and
osmotic structure hypersensitivity history of
instability; infections caused to penicillin allergies
usually bacterial by streptococcus because of particularly to
pneumoniae and S. possibility of drugs before
pyogenes, cross-sensitivity therapy is inited.
Haemophillus with caution in  Report onset of
influenza, breast feeding loose stools
Brand name; staphylococcus women and in  Absorption of
Zoltax aureus, patients with cefuroxime is
Escherichia coli. history of colitis enhanced by food
or renal  Notify prescriber
sufficiency. about rashes or
super infections.

Name of Drug Classification Dose, Freq. and Mechanisms of Indications Contraindications Side Effects and Nursing
Route Action Adverse Reactions Responsibilities
Generic name; Antifibrinolytic 250 -500 mg Tranexamic acid Treatment of •Hypersensitivity  Dizziness,  Check the
PRE-ECLAMPSIA
45
Tranexamic acid and Hemostatic tid;qid competitively excessive •Active visual doctor’s order
agent injection;250- inhibits activation bleeding resulting Intravascular abnormalities,  Observe the 15
500mg IM or by of from systematic clotting hypotension, rights of drugs
slow IV inj. Bid- plasminogen( via or local •acquired defective thromboemlism administration
Qid binding to the hyperfibronolysis color vision , thrombosis,  do skin testing
kringle domain), •subarachnoid nausea,  cautions
thereby reducing Hemorrhage vomiting. patients to
conversion of avoid products
plasminogen to Use cautiously containing
plasmin Treatment of with renal aspirin or
Brand name; ( fribronolysin), excessive impairment, NSAIDs
Hemostan enzyme that bleeding resulting hematuria  for women who
degrades fibrin from systematic originating in the are taking to
clots, firbronogen, or local upper urinary tract; control heavy
and other plasma hyperfibrinolysis and condition bleeding, the
proteins, associated with medication
including the increased thrombus should only be
procoagulant formation taken during
factors. the menstrual
Tranexamic acid period.
also directly  Administer the
inhibits plasmin drug at the
activity, but right dosage
higher doses are and route in the
required than right time
needed to reduce  check the
plasmin patency of the
formation. IV site and IV
line
 advise pt. to
take
medication
exactly as
directed.

PRE-ECLAMPSIA
46
Name of Drug Classification Dose, Freq. and Mechanisms of Indications Contraindications Side Effects and Nursing
Route Action Adverse Responsibilities
Reactions
Anti-pyretic Dosage: 30mg Anit- Short-term Contraindicated with CNS:  Keep
NSAID Route: IVTT inflamatory and management of significant renal Headache, emergency
Generic name: Frequency: every analgesic pain( up to 5 days) impairment, aspirin dizziness, equipment
Ketorolac 6 hours activity; inhibits allergy, recent GI insomnia, fatigue, readily
prostaglandins bleed or perforation somnolence, available at
and leukotriene use cautiously with ophthalmologic time of
PRE-ECLAMPSIA
47
 synthesis impaired hearing; effect initial, dose,
allergies; hepatic in case of
Brand name: conditions severe
Toradol hypersensiti
vity
reaction.
 Be aware
that patient
may be at
risk for CV
events, GI
bleeding,
renal
toxicity,
monitor
 accordingly
 Administer
every 6 hrs
to maintain
serum levels
and control
pain.

Name of Drug Classification Dose, Freq. and Mechanisms of Indications Contraindications Side Effects and Nursing
Route Action Adverse Reactions Responsibilities

PRE-ECLAMPSIA
48
Generic Name: Analgesic  Carbamazepin  Tramadol may  Headache,  Assess type,
Tramadol ( centrally e ( tegretol increase central nausea, location, and
acting) XR, Equetro nervous system, constipation, intensity of pain
carbatrol) and respiratory dizziness, before and 2-3hr
reduces the depression when drowsiness and (peak) after
Brand effect of combined with vomiting. administration
Name: tramadol by alcohol,  Asses BP &
Ultram, Ultram increasing its anesthetics, RR
ER inactivation in narcotics, before and
the body. tranquilizer ore periodically during
sedative administration,
hypnotics, respiratory
depression has not
occurred with
recommended
doses.
 Assess bowel
function routinely.
Prevention of
constipation
should be
instituted with
increased intake of
fluids and bulk and
with laxative to
min imize
constipating
effects.
 Assess
previous
analgesic
history.
Tramadol is
not
recommended
PRE-ECLAMPSIA
49
 for patients
dependent on
oploids.

Name of Drug Classification Dose, Freq. and Mechanisms of Indications Contraindications Side Effects and Nursing
Route Action Adverse Responsibilities
Reactions
Generic name; Antihypertensive 250mg 1tab TID, Mechanism of General; Contraindicated CNS: Sedation,  check
Methyldopa PO action not  Hypertension with hypersentivity head ache, doctors order
conclusively  IV to methyldopa, asthenia, weakness  assess
demonstrated; methyldopate: active hepatic CV; Bradycardia sensitivity to
probably due to acute disease, previous methyldopa,
drug’s metabolism, hypertensive methyldopa therapy GI; nausea, hepatic
which lowers crisis; not drug associated with vomiting, disease, renal
arterial BP by of choice liver disorders distention, failure,
stimulating the because slow constipation, dialysis
alpha-adrenergic onset of action heaptic necrosis  assess
receptors, which in  unlabeled use: weight, skin,
turn decrease hypertension of color,
sympathetic pregnancy lesions,
outflow from the orientation
CNS  administer at
the right dose
at the right
time

PRE-ECLAMPSIA
50
  discontinue
drug if
fever,abnorm
alities in
liver function
test, ore
jaundice
occur.
 monitor
hepatic
fuction

Name of Classificati Dose, Freq. Mechanisms of Indications Contraindication Side Effects and Nursing Responsibilities
Drug on and Route Action s Adverse
Reactions

PRE-ECLAMPSIA
51
Generic Is an Oral Route: Oral Inhibits the  Treatm  Hypersensi
Name: drug that actions of ent and tivity,  Constipati  Instruct patient not to take
Ranitidine blocks the Dosage:50mg histamine, prevent cross- on new medication, w/o
production at the H2 ion, of sensitivity  diarrhea consulting physician
of acid by Time OD receptors heartbu may occur,  fatigue  Advice patient to report
Brand acid site located rn, acid some oral  headache onset of black, tarry stools;
Name: producing primarily, indigest liquids  muscle fever, sore throat; diarrhea;
Zantac cells in the in gastric ion, contain pain dizziness; rash; confusion.
stomach. It parietal and alcohol and  nausea  Instruct patient to monitor
belongs to a cells, sour should be and for and report occurrence
class of resulting stomac avoided in vomiting adverse-induced adverse
drugs called inhibition h. patients reaction.
 confusion
H2(histamin of gastric  Prophyl with
e-2) acid axis of known
blockers. secretion GI intolerance.
has some hemorr
antibacteri hage
al action from
against H. ulcerati
pylori on

PRE-ECLAMPSIA
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 CHAPTER 9:
Nursing Care Plan

PRE-ECLAMPSIA
53
 ASSESSMENT NURSING RATIONALE EXPECTED NURSING RATIONALE EVALUATION
CUES DIAGNOSIS OUTCOMES AND INTERVENTION
OBJECTIVES

Subjective data: Activity Intolerance Pain limits patient’s STG:  Establish  Rapport is After 4 of the
“Mejo related to pain activity. Individual has rapport important to client demonstrate
nahihirapan pa secondary to insufficient physiological Within 4 hours of gain patient’s activity tolerance.
akong gumalaw postpartum delivery. or psychological energy nursing intervention cooperation and Absence of signs
dahil sa tahi ko” to endure or complete and management, the reduce anxiety. and symptoms, and
as verbalized by required or desired daily patient will able to:-- has no shortness of
the patient. activities thereby identify activities and  Monitor Vital  Baseline data is breath and fatigue
affecting the physical factors that contribute signs important to during any activity.
Objective data: activity. to activity intolerance. help determine
 Facial patient’s current
grimace health status and
when evaluate
moved effectiveness of
 Pain scale nursing
6/10 intervention
 Guarded rendered.
movement
 Limited  Establish  Motivation is
mobility guidelines and enhanced if the
 Needs goals of activity patient
assistant in with the patient participates in
ADL and caregivers. goal setting.

 Observe for pain  Pain restricts the

before activity client from
and, if possible achieving a
treat pain before maximum
activity. activity level
PRE-ECLAMPSIA
54
 and is often
Vital signs: exacerbated by
movement.
BP: 160/100
RR: 22
T: 36.8
PR: 98

PRE-ECLAMPSIA
55
 `
ASSESSMENT CUES NURSING RATIONALE EXPECTED NURSING RATIONALE EVALU
DIAGNOSIS OUTCOMES AND INTERVENTION ATION
OBJECTIVES

Subjective: Acute pain related to Pain is defined as After 1 – 2 hours of  Establish  To have a good Goal
“Medyo masakit po yung disruption of skin and unpleasant sensory and nursing intervention, rapport nurse – client met.
incision site” tissue secondary to emotional experience patient will verbalize relationship After
caesarean section. arising from actual or decrease intensity of 2hrs. of
Objective: potential tissue damage pain from 7/10 to 4/10.  Monitored vital  To established a nursing
 Pain scale: 6/10 or described in terms of signs baseline data interventi
 (+) Facial grimace such damage. on, the
 (+) Guarding  Assessed  To established patient
behaviour quality, baseline data for verbalize
 Irritable characteristic, comparison in d pain
 Skin warm to touch and severity of making decrease
pain. evaluation and d from
Vital signs: to assess for scale of
BP: 160/100 possible internal 6/10 to
RR: 22 bleeding. 4/10 as
T: 36.8 evidence
PR: 98  Provided  Calm by:
comfortable environment (-) facial
environment. helps to grimace
decrease the (-)
anxiety of the guarding
patient and behaviou
promote r
likelihood of
decreasing the
pain.
 Instructed to put  To protect the
pillow on the area of incision
PRE-ECLAMPSIA
56
 abdomen when to improve
coughing or comfort. And
moving. initiate non
stressful muscle
setting
techniques and
progress as
tolerated, based
on the degree of
separation.

 Instructed  For pulmonary

patient to deep ventilation,
breathing and especially when
coughing exercising, and
exercise. to relieve stress
and promote
relaxation.

EXPECTED
NURSING OUTCOMES AND NURSING EVALU
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57
 ASSESSMENT CUES DIAGNOSIS RATIONALE OBJECTIVES INTERVENTION RATIONALE ATION

Subjective data: Impaired Skin/Tissue Skin is the body’s first After 8 hours of nursing  Establish  To gain trust Goal met
“ Integrity related to line of defence against interventions, the rapport with the patient as
mechanical trauma of foreign materials that patient will be able to: evidence
Objective data: surgical removal of skin can be considered as  Perform bedside  To enhance d by the
and subcutaneous tissue injuring agents. Once  Participate in care patient’s self- patient
Destruction of skin layers. secondary to Caesarean the skin is disrupted, prevention esteem and to has able
Disruption of tissue layers. section. this will put a person at measures and provide comfort to display
(+)Redness on the incision risk since it may treatment to the patient. timely
site. become a good medium program healing
for bacterial growth.  Maintain  Inspect skin on  To determine of skin
Caesarean section, like physical well- daily basis and unusual ties and lesions/w
any other surgical being. observe for report it to ounds
procedures, includes  Ability to changes and physician for without
invasion of the inside manage unusual ties. prompt complica
body, specifically the situation. treatment. tion.
skin and subcutaneous
area. the skin and  Keep the area  This will assist
subcutaneous area. clean, carefully body’s natural
dress wound, process of
support incision, repair.
prevent
infection.

 Encourage client  Maintaining

to demonstrate clean, dry skin
good skin provides a
hygiene, e.g., barrier to
wash thoroughly infection.
and pat dry Patting skin dry
carefully after instead of
teaching. rubbing reduces
PRE-ECLAMPSIA
58
 risk of dermal
trauma to fragile
skin.

PRE-ECLAMPSIA
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Date Identified the Problems and Solved Problem Prioritization Maslow’s Hierarchy of Needs Level of Priority

January 8, 2019 Acute pain related to disruption of skin Physiology 1st

and tissue secondary to caesarean section.

January 8, 2019 Impaired Skin/Tissue Integrity related to Physiology 2nd

mechanical trauma of surgical removal of
skin and subcutaneous tissue secondary to
Caesarean section.

Activity Intolerance related to pain

January 8, 2019 secondary to postpartum delivery Physiology 3rd

PRIORITIZATION OF THE PROBLEMS

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CHAPTER 10:
Discharge Plan

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61
 NURSING DISCHARGE INSTRUCTION RATIONALE
ORDERS
MEDICATION  Instruct to take prescribe home  To ensure
medication on time according to the optimum
schedule specifically, Ranitidine, recovery of the
Methyldopa, Ketorolac, Tranexamic, patient.
Tramadol, Cefuroxime.

 Emphasize the correct dosage, time and  To avoid drug

other special instruction. toxicity, to
minimize the side
effects of the drugs
and factors that
contributes to it.
EXERCISE  Encourage the client to take a walk as  To regain strength
tolerated when she get home.
TREATMENT  Instruct the patient to clean the incision  To avoid infection
site.
HYGIENE  Instruct the patient to change her  To prevent
sanitary gauze every 4 hours. contamination and
infection
 Encourage the patient to take a daily  It facilitates good
shower avoiding direct water spray and healing and
soap on nipples. prevent harbouring
microorganism
that will cause
infection.
OPD  Advise the patient to go to OPD after 7  For follow up
days or as recommended by the check-up and to
physician. check if the mother
and the baby are
healthy.
DIET  Encourage the patient to eat food rich in  To soften the stool
fiber like whole grain, cooked dried and regulate bowel
beans, fruits and vegetables. movement.

 Encourage the patient to drink clean

water and if water pump can’t avoid,  To avoid acquiring
encourage client to boil the water first. microorganism
that may harm
your body and
water also helped
for milk
SPIRITUALITY  Encourage the patient to pray for her  To gain optimism
good health and also to her baby. and avoid
depression.

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