University of The East Ramon Magsaysay Memorial Medical Center, Inc. College of Nursing
University of The East Ramon Magsaysay Memorial Medical Center, Inc. College of Nursing
University of The East Ramon Magsaysay Memorial Medical Center, Inc. College of Nursing
NCM109-WORKSHEET
Submitted by:
Ramones, Reina Mae M.
N2A
HYPEREMESIS GRAVIDARUM
A. Description:
- An uncontrollable and persistent vomiting during the first week of pregnancy and
may continue throughout pregnancy. It is associated with loss of 5% or more of
pregnancy weight, dehydration, elevated blood and urine ketones, acidosis from
starvation alkalosis from loss of hydrochloric acid in the gastric fluids and
hypokalemia. The cause of this is still unknown but it is common to unmarried
women during first and multifetal pregnancies
E. Pathophysiology
Subjective: Deficient fluid Deficient fluid Goals: Independent: After the nursing
Thirst volume related to volume is a state or After 2 days of - Assess Vital Signs interventions, the
Weakness excessive vomiting as condition where the nursing interventions, - Maintain accurate patient abled to:
evidenced by fluid fluid output exceeds the patient will be intake and output - Restore her fluid
Objective: and electrolyte the fluid intake. It able to: of the patient and electrolyte
Sudden weight imbalance happens when water - Restore her fluid - Monitor laboratory balance
loss and electrolytes are and electrolyte values and report - Maintain fluid
Elevated lost as they exist in balance deviations from volume at a
hematocrit normal body fluids. - Maintain fluid normal functional level
Change in mental Common sources of volume at a - Monitor daily with normal
state fluid loss are the functional level weight specific gravity,
Dry skin and gastrointestinal tract, with normal - Have the patient stable vital signs,
mucous polyuria, and specific gravity, begin to drink oral moist mucous
membranes increased perspiration stable vital signs, fluid slowly and membranes, and
Decreased skin o moist mucous carefully good skin turgor
tongue turgor Source: membranes, and - Assess and - Verbalize
Nurselabs (2019). good skin turgor document skin understanding of
Deficient Fluid turgor, condition of causative factors
Volume. Retrieved Objectives: mucous and purpose of
from After 1 hour of membranes, vital individual
https://nurseslabs.co nursing interventions, signs and urine therapeutic
m/deficient-fluid- the patient will be specific gravity interventions and
volume/ able to: - Discuss factors medications
- Verbalize related to - Demonstrate
understanding of occurrence and behaviors to
causative factors ways that patient monitor and
and purpose of can prevent from correct deficit as
individual dehydration indicated
therapeutic - Review - Verbalize
interventions and medications, its measures that can
medications interactions and be taken to treat or
- Demonstrate side effects prevent fluid
behaviors to volume loss.
monitor and Dependent:
correct deficit as - Administration of
indicated prescribed
- Verbalize antiemetic
measures that can medications
be taken to treat or
prevent fluid Collaboration:
volume loss. Advice patient to
consult to a dietitian
to develop optimal
diet plan
Subjective: Anxiety related to Vague uneasy feeling Goals: Independent: After 1 hour of
effects of of discomfort by an After 2 days of - Use therapeutic nursing intervention,
hyperemesis on fetal autonomic response. nursing interventions, communication to the patient able to
Objective: well-being as A feeling of the patient will be listen to patient’s exhibit decreased
Su evidenced by client apprehension caused able to: concern incidence of anxiety
statements concern by anticipation of - E - Provide
danger. It is an - information
altering signal that Objectives: regarding any
warns of impending After 1 hour of potential risks to
danger and enables nursing interventions, the fetus
the individual to take the patient will be - Identify patient’s
measures to deal with able to: personal strengths
threat - and previous
coping
Source: mechanisms
Doenges, M., - Identify patient’s
Moorhouse, M. and sources of support
Murr, A. (2010). and mobilize
Nurse’s Pocket Guide support person or
Diagnoses, group of her choice
Prioritized
Interventions and Dependent:
Rationales - Administration of
prescribed anti-
anxiety or sedative
medications
Collaboration:
- Advice patient to
consult to social
service as needed
for ongoing
evaluation and
assistance
Nursing Scientific
Assessment Planning Implementation Evaluation
Diagnosis Rationale
J. Drug Analysis
ECTOPIC PREGNANCY
A. Description
- It is the implantation of fertilized ovum in a site other than the fallopian tube,
abdominal cavity, or cervix.
- This may be caused by tubal damage from pelvic inflammatory disease, previous
tubal surgery, congenital anomalies of the tube, endometriosis, previous EP, presence
of IUD, and in utero exposure to diethylstilbestrol.
- An ectopic pregnancy can't give birth normally as the fertilized egg can't survive, and
when it is left untreated, the growing tissue may cause life-threatening bleeding.
D. Risk Factors
- History of sexually transmitted disease
- History of pelvic inflammatory disease
- History of ectopic pregnancies
- Failed tubal ligation
- Intrauterine device
- Multiple induced abortions
- Maternal age older than 35 years
E. Pathophysiology
E. Pathophysiology
D. Risk Factors
Increased maternal age, congenital or endocrine development such as uterine
abnormalities and genetic disorders affecting a fibrous type of protein that makes up
your body's connective tissues (collagen) and cervical trauma such as might have
occurred with a D& C or traumatic delivery is probably often the cause.
E. Pathophysiology
J. Drug Analysis
Hydroxyprogesterone
Tocolytic- Terbutaline
PLACENTA PREVIA
A. Description:
It is the low implantation of the placenta and attachment of the placenta to the wall of
the uterus in a location that completely or partially covers the uterine outlet
This occurs in four degrees:
1. Implantation in the lower rather than in the upper portion of the uterus
2. Marginal implantation
3. Implantation that occludes a portion of the cervical os
4. Implantation that totally obstructs the cervical os
An increase in congenital anomalies in the fetus may occur if the low implantation
does not allow for optimal fetal nutrition or oxygenation
5. Abdominal Examination
The fetal head may be discovered to be nonengaged but this finding gives little
indication of how much of the placenta is obscuring the os and thus prevent the
head from engaging
6. Speculum Examination
A device named speculum is used to look inside in the vagina and observe the
cervix.
This is to rule out a source of bleeding such as ruptured varices or cervical
trauma and to establish the percentage of placenta covering the os
7. Vaginal Examination
This is the actual investigation of dilation
This is to determine whether placenta previa exists are done in an operating room
so that if hemorrhage does occur with the manipulation, the woman may be
immediately sections to remove the child and the bleeding placenta, contract the
uterus and save the both the woman and child
8. Sonogram/ Ultrasound
Uses high frequency sound waves to visualize the structures within the body
The ultrasonic waves deflect off tissues within the woman's abdomen, showing
structures of varying densities
D. Risk Factors
Risk Factors could be because she had a baby, have scars on the uterus from
previous surgery such as cesarean deliveries, uterine fibroid removal, and dilation
and curettage, she had placenta previa in a previous pregnancy, a multiparous,
maternal age of 35 or older and uses cigarette and cocaine.
E. Pathophysiology
Mckinley, E., James, S., Murray, S. and Ashwill, J. (2005). Matenal – Child Nursing
London, M., Ladewig, P., Ball, J. and Bindler, R. (2007). Fundamentals of Maternal and Child
Nursing Care
Pilliterri, A. (1995). Maternal & Child Health Nursing Care of the Childbearing and
Childbearing Family
https://www.webmd.com/drugs/2/drug-8689/phenobarbital-oral/details
Doenges, M., Moorhouse, M. and Murr, A. (2010). Nurse’s Pocket Guide Diagnoses, Prioritized
Interventions and Rationales