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Ms. Grace S. Dimaguyod, 18yrs old primigravida, single, 22 weeks age of gestation arrived at the ER complaining low back pain and persistent abdominal pain few hours prior to consultation. She also complaint of persistent headache for three days. 

LMP- Nov. 18 ,2020

Date of Consultation- may 3, 2021

On interview, she verbalized, she loss her appetite 2 days ago, then experience abdominal pain and low back pain. Edema is evident on her face. She took Paracetamol 500mg needed for the pain but it doesnt subside.

 

at 10:00am, VS were taken as follows:

BP: 140/90mmHg

RR: 20bpm

PR: 88bpm

T:36.8 degree C

 

Doctor's Order

-Admit to OB ward

-Magnesium Sulfate 4 grams SIVP STAT, then followed by 2 grams in 90cc PNSS per soluset q1 hour x 24 hours (90mg/ml in 20ml)

-Low salt and low fat 

-Keep on left side lying position

-Hook to CTG

-Watch out for episode of SZ

-Diagnostic procedure

-CBC STAT, BUN Creatinine Test

-ABO typing, HBSag, UA

-Monitor VS q 15 minutes, record

-Refer Accordingly

MAKE A NCP

Nursing Assessment:

? Subjective: 

? Objective: 

 

List of Nursing Diagnosis: (at least 3)

Nursing Diagnosis (PES Format):

? Problem:

? Etiology: 

? Signs and Symptoms:

Nursing Inference:

Nursing Goal (Outcome):

 

Nursing Interventions  Rationale
 

 

 

   
   

Nursing Evaluation:

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