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Questions and Answers
What is the primary goal of the nursing process?
What is the primary goal of the nursing process?
Which step of the nursing process involves validating and documenting data?
Which step of the nursing process involves validating and documenting data?
In which step of the nursing process are goals and desired outcomes formulated?
In which step of the nursing process are goals and desired outcomes formulated?
What is included in the evaluation of nursing interventions?
What is included in the evaluation of nursing interventions?
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Which component of a nursing health history covers a patient's lifestyle habits?
Which component of a nursing health history covers a patient's lifestyle habits?
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What is analyzed during the diagnosing step of the nursing process?
What is analyzed during the diagnosing step of the nursing process?
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What action is taken during the implementing step of the nursing process?
What action is taken during the implementing step of the nursing process?
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Which option describes a common aspect of effective nursing documentation?
Which option describes a common aspect of effective nursing documentation?
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What occurs in an inevitable abortion?
What occurs in an inevitable abortion?
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What is the management for incomplete abortion?
What is the management for incomplete abortion?
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Which of the following is a sign of septic abortion?
Which of the following is a sign of septic abortion?
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What defines a complete abortion?
What defines a complete abortion?
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What is the primary characteristic of a missed abortion?
What is the primary characteristic of a missed abortion?
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During a threatened abortion, which symptom is NOT typically present?
During a threatened abortion, which symptom is NOT typically present?
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What is the typical risk associated with habitual or recurrent pregnancy loss?
What is the typical risk associated with habitual or recurrent pregnancy loss?
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What symptom is a hallmark of an incomplete abortion?
What symptom is a hallmark of an incomplete abortion?
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What is the main goal of therapeutic abortion?
What is the main goal of therapeutic abortion?
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Which condition is a common predisposing cause of ectopic pregnancy?
Which condition is a common predisposing cause of ectopic pregnancy?
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What symptom is indicative of a possible tubal rupture during an ectopic pregnancy?
What symptom is indicative of a possible tubal rupture during an ectopic pregnancy?
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What is Cullen's sign and its significance?
What is Cullen's sign and its significance?
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Which diagnostic aid uses aspiration to detect bleeding in ectopic pregnancy?
Which diagnostic aid uses aspiration to detect bleeding in ectopic pregnancy?
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What is the primary purpose of salpingostomy in the context of ectopic pregnancy?
What is the primary purpose of salpingostomy in the context of ectopic pregnancy?
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Which of the following is NOT a suggested method to prevent abortion?
Which of the following is NOT a suggested method to prevent abortion?
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What is a common sign of hemorrhage in the context of ectopic pregnancy?
What is a common sign of hemorrhage in the context of ectopic pregnancy?
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What is the primary symptom of pseudocyesis?
What is the primary symptom of pseudocyesis?
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Which of the following is an indication of hyperemesis gravidarum?
Which of the following is an indication of hyperemesis gravidarum?
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What defines gestational hypertension?
What defines gestational hypertension?
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Which risk factor is associated with developing pregnancy-induced hypertension?
Which risk factor is associated with developing pregnancy-induced hypertension?
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Which treatment is prioritized for managing hyperemesis gravidarum?
Which treatment is prioritized for managing hyperemesis gravidarum?
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What distinguishes chronic hypertension from gestational hypertension?
What distinguishes chronic hypertension from gestational hypertension?
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How can one differentiate between pseudocyesis and actual pregnancy based on symptoms?
How can one differentiate between pseudocyesis and actual pregnancy based on symptoms?
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Which of the following is NOT associated with hyperemesis gravidarum?
Which of the following is NOT associated with hyperemesis gravidarum?
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Which of the following is NOT one of the components of HELLP syndrome?
Which of the following is NOT one of the components of HELLP syndrome?
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What criteria must be met for a patient to be managed at home for HELLP syndrome?
What criteria must be met for a patient to be managed at home for HELLP syndrome?
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During a convulsion, what is one of the main responsibilities of the nurse?
During a convulsion, what is one of the main responsibilities of the nurse?
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Which statement about bed rest in the management of HELLP syndrome is true?
Which statement about bed rest in the management of HELLP syndrome is true?
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Which of the following is a stage in the convulsion process?
Which of the following is a stage in the convulsion process?
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What dietary considerations should be included in the management of HELLP syndrome?
What dietary considerations should be included in the management of HELLP syndrome?
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What may occur as a complication of HELLP syndrome?
What may occur as a complication of HELLP syndrome?
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What symptom is considered an impending sign of convulsion?
What symptom is considered an impending sign of convulsion?
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Study Notes
Nursing Process
- A systematic, rational method of planning and providing care.
- Cyclical, with components following a logical sequence.
- Terminated if the goal is achieved.
- Cycle may continue with reassessment or modification of the plan of care.
Goal of Nursing Process
- Identify the client's healthcare status, actual or potential health problems.
- Establish plans to meet identified needs.
- Deliver specific nursing interventions to address these needs.
Steps of the Nursing Process
Assessment
- Collect, organize, validate, and document data.
- Includes subjective and objective data.
Diagnosing
- Analyze data
- Identify health problems, risks, and strengths.
- Formulate diagnostic assessments. (Example: Ineffective airway clearance related to accumulated mucus obstructing airways)
Planning
- Prioritize problems/diagnoses.
- Formulate goals/desired outcomes.
- Select nursing interventions.
- Write nursing orders. (Example: restore effective breathing and lung ventilation, develop a care plan)
Implementing
- Reassess the client.
- Determine the nurse's need for assistance.
- Implement the nursing interventions.
- Supervise delegated care.
- Document nursing activities.
Evaluating
- Collect data related to planned outcomes.
- Compare data with outcomes.
- Relate nursing actions to client goals/outcomes.
- Draw conclusions about problem status.
- Continue, modify, or terminate the client's care plan.
Components of a Nursing Health History
- Chief complaint/reason for visit.
- History of present illness.
- Biographic data. (Example: When did symptoms start? Was the onset sudden or gradual?)
- Phenomena or symptoms associated with the chief complaint
- Factors that aggravate or alleviate the problem.
- Past History
- Family History of Illness
- Lifestyle
Severe Malnutrition
- Happens before 16 weeks gestation.
Late Abortion
- Happens between 16 - 20 weeks gestation.
Types of Abortion
- Inevitable Vaginal bleeding or rupture of membranes before 20 weeks gestation, with advanced dilation of the cervix.
- Incomplete Dilation of the cervix and expulsion of some products of conception.
- Complete Closed cervix after expulsion of all products of conception.
Types of Abortion (Continued):
- Spontaneous Unintended termination of pregnancy at any time before the fetus has attained viability.
Threatened Abortion
- Possible loss of the products of conception.
- Symptoms: Slight bleeding, mild uterine cramping, but no cervical dilation on vaginal examination, no passage of tissue.
- Management: Bed rest, save all pads, no coitus up to 2 weeks after bleeding has stopped
Inevitable or Imminent Abortion
- Loss of pregnancy that cannot be prevented.
- Clinical Manifestations: Moderate to profuse bleeding, moderate to severe uterine cramping, dilated cervix, rupture of membranes.
- Management: Hospitalization, D&C, Oxytocin after D & C, emotional support
Complete Abortion
- All products of conception are expelled.
- Symptoms: Moderate bleeding, mild uterine cramping, passage of tissue.
- Management: Sympathetic understanding and emotional support
Incomplete Abortion
- Not all products of conception are expelled from the uterus.
- Symptoms: Profuse vaginal bleeding, severe uterine cramping, open cervix, passage of tissue, other products retained.
- Treatment and Management: D & C, Oxytocin after D & C, emotional support.
Missed Abortion
- Retention of all products of conception after the death of the fetus in the uterus.
- Symptoms: No fetal heart tones, signs of pregnancy disappear.
- Management: D&C.
Septic Abortion
- Abortion complicated by infection.
- Symptoms: Foul-smelling vaginal discharge, uterine cramping, fever.
- Management: Treat abortion and administer antibiotics.
Habitual or Recurrent Pregnancy Loss
- Spontaneous abortion in three or more successive pregnancies.
- Usually due to incompetent cervix.
Induced Abortion
- Intentional loss of pregnancy through direct chemical or mechanical stimulation.
Types of Induced Abortion
- Therapeutic Abortion To preserve the life of the mother.
- Elective Abortion
Reasons for Induced Abortion
- Therapeutic To end a pregnancy that is life-threatening to the mother.
- To end a pregnancy of a fetus found to have severe congenital abnormalities that may be incompatible with life.
- To end an unwanted pregnancy that is a result of rape or incest.
- To end a pregnancy because of a woman's choice not to have a child yet.
Prevention of Abortion
- Pre-pregnancy correction of maternal disorders.
- Immunization against infectious diseases.
- Proper early antenatal care.
- Treatment of pregnancy complications.
- Correction of cervical incompetence.
Ectopic Pregnancy
- Any pregnancy that occurs outside of the uterine cavity.
- Second leading cause of bleeding in early pregnancy.
- Types: Ampullar, Intestinal, Ovarian, Cervical, Abdominal
Predisposing Causes of Ectopic Pregnancy
- Salpingitis
- Peritubal adhesions
- Previous Ectopic Pregnancy
- Previous Tubal Surgery
- Multiple previous abortions
- Tumors that distort the tubes
- External migration of the ovum
- Intrauterine device (IUD)
Signs and Symptoms of Ectopic Pregnancy
- Vaginal spotting or bleeding.
- Cul de sac mass.
- Absence of an amniotic sac.
- Amenorrhea or abnormal menstruation followed by slight uterine bleeding.
Signs of Tubal Rupture
- Severe sharp knife-like pain in the lower quadrant of the abdomen.
- Abdominal rigidity.
- Nausea and vomiting.
- Low Hemoglobin and hematocrit.
- Sharp localized pain in the cervix on internal examination (wiggling sign).
Signs of Hemorrhage
- Cullen’s Sign Bluish discoloration of the umbilicus due to the presence of blood in the peritoneal cavity.
- Hard or rigid boardlike abdomen.
Signs of Shock
- Falling BP, rapid pulse.
- Lightheadedness.
- Pallor
- Cyanotic Nailbeds
- Cold clammy skin.
Diagnostic Aids for Ectopic Pregnancy
- Culdocentesis
- Ultrasound
Treatment and Management of Ectopic Pregnancy
- If not yet ruptured:
- Salpingostomy
Cord Compression
- Fetal hypoxia as a result of cord compression.
- Prolonged labor
Pseudocyesis
- Spurious pregnancy, occurs in women nearing menopause or women with an intense desire to become pregnant
- Women develop the belief they are pregnant when they are not.
- These women experience subjective symptoms of pregnancy (fatigue, amenorrhea, tingling sensations, fullness of the breast, nausea, and vomiting). Some women report feeling fetal movements, which are actually movement of air in the intestines or muscular contractions of the abdominal wall.
- Management: Explain pregnancy test results, clarify misconceptions and false beliefs, provide referrals when necessary, psychological counseling, provide emotional support and understanding.
Hyperemesis Gravidarum
- Excessive nausea and vomiting that persists beyond 12 weeks gestation.
- Leading to complications like dehydration, weight loss, starvation, and fluid and electrolyte imbalance.
- Etiology unknown.
Symptoms of Hyperemesis Gravidarum:
- Excessive nausea and vomiting not relieved by ordinary remedies persisting beyond 12 weeks
- Signs of dehydration: thirst, dry skin, increased pulse rate, weight loss, concentrated, and scanty urine.
Management of Hyperemesis Gravidarum
- D10NSS 3000 ML in 24 hours is the priority of treatment.
- Rest.
- Antiemetics (Ex. Plasil).
Hypertensive Disorders in Pregnancy
- Gestational Hypertension: Hypertension that develops during pregnancy or during the first 24 hours after delivery, not accompanied by edema, proteinuria, or convulsions, and disappears within 10 days after delivery.
- Chronic Hypertension: The presence of hypertension before pregnancy or hypertension that develops before 20 weeks gestation in the absence of H-mole and persists beyond the postpartum period.
- Pregnancy-Induced Hypertension (Toxemia): Hypertension that develops after the 20th week of gestation in a previously normotensive woman.
Risk Factors for Pregnancy-Induced Hypertension
- Primiparas Higher incidence in primiparas below 17 and above 35 years old.
- Low socioeconomic status Low protein intake.
- History of chronic hypertension on the mother, H-mole, diabetes mellitus, multiple pregnancy, polyhydramnios, renal disease, heart disease.
- Hereditary History of preeclampsia in mothers or sisters.
HELLP Syndrome
- Hemolysis - Red blood cells break down.
- Elevated liver enzymes - Damage to liver cells cause changes in liver function lab tests.
- Low platelets - Cells found in the blood that are needed to help clot the blood to control bleeding.
Complications of HELLP Syndrome
- Anemia - Breakdown of RBC’s may cause anemia
- DIC - May lead to severe bleeding
- Placenta abruptio - May also occur.
Management of Hypertensive Disorders in Pregnancy
-
Ambulatory Management
- Home management is allowed if:
- BP is 140/90 or below.
- There is no proteinuria.
- There is no fetal growth retardation.
- The patient is not a young primipara.
- Bed rest
- Consult the clinic as often as necessary.
- Diet should be high in protein, and carbohydrates with moderate sodium restriction.
- Hospitalization is necessary if the condition worsens.
- Provide detailed instructions about warning signs:
- Epigastric pain - Aura to convulsion.
- Visual disturbances
- Severe continuous headache.
- Nausea and vomiting.
- Home management is allowed if:
-
Hospital Management
- BP goes above 140/90 mm Hg
- Bed rest is one of the most important principles of care:
- Rest in the left lateral position to promote blood supply to the placenta and the fetus.
Stages of a Convulsion
- Stage of Invasion Facial twitching, rolling of the eyes to one side, staring fixedly in space
- Tonic Phase Body becomes rigid, as all muscles go into violent spasms or contractions, eyes protrude, hands are clenched, woman stops breathing for 15-20 seconds.
- Clonic Phase Jaws, and eyelids close, and open violently, foaming of the mouth, face becomes congested and purple, muscles of the body contract and relax alternately. The contractions are so violent that the woman may throw herself out of bed. Lasts for about a few minutes.
- Post Ictal Phase Woman is semicomatose, no more violent muscular contractions. The patient will not remember the convulsion, and the events immediately before and after.
Responsibilities During a Convulsion
- Always monitor the patient for impending signs of convulsion:
- Epigastric pain.
- Severe headache.
- Nausea and vomiting.
- Maintenance of a patent airway and protection of the patient from injury.
- Turn patient to her side to allow drainage of saliva and prevent aspiration.
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Description
Explore the systematic method of planning and delivering nursing care through the nursing process. This quiz covers the critical steps including assessment, diagnosis, planning, and implementation of interventions, helping you understand how to identify and meet client healthcare needs effectively.
