preeclampsia

I. INTRODUCTION

Pre-eclampsia, formerly called toxemia of pregnancy is an abnormal condition of

pregnancy characterized by the onset of an acute hypertension after the 24 th week of gestation.

The classic triad of preeclampsia is proteinuria and edema. The cause of the disease remains

unknown despite 100 years of research by thousands of investigators. Pre-eclampsia commonly

causes abnormal metabolic function, including negative nitrogen balance, increase central

nervous system irritability, hyperactive reflexes, compromised renal function,

hemoconncentration, and alteration of the fluids and electrolytes balance. It occurs in 5-7% of

pregnancies. Most often in primigravida and is more common in some areas of the world than

others, the incidence is particularly high in the southern part of the U.S. The incidence increases

with increasing gestational age and it is more common in cases of multiple gestation, H. Mole or

hydramnios. A typical lesion in the kidney, glomerulo endotheliosis is pathognomonic

termination of the pregnancy results in the resolution of the signs and symptoms of the disease

and in healing of the renal lesion. Preeclampsia is classified as mild or severe. Mild eclampsia is

diagnosed if one or more of the following signs develop after 24 th week of gestation. Systolic BP

of140 mmHg or more or an increase of 30 mmHg of more above the woman’s systolic BP;

proteinuria and edema. Severe preeclampsia is diagnosed if one or more of the following signs is

present.; systolic BP 160 mmHg and above, diastolic Bp of 110 mmHg above on two occasions 6

hours apart with the woman on bed rest; proteinuria of 5g or more within 24 hours; oliguria of

less than 400cc in 24 hours; ocular or cerebral vascular disorders; and cyanosis or pulmonary

edema. Complications include premature separation of the placenta, hemolysis, cerebral

hemorrhage, ophthalmologic damage, pulmonary edema, hepatocellular changes, fetal

malnutrition and lower birth rate. The most common complication is eclampsia, which can

results to both maternal and fetal death. Healthy living conditions including a diet with high in

proteins, calories and essential nutritional elements, rest and exercise are associated with

decrease incidence of pre-eclampsia. Treatments include rest sedation, magnesium sulfate, and

antihypertensive. Ultimately if eclampsia threatens delivery by induction of labor or CS may be

necessary. (Mosby’s dictionary of Medicine, Nursing and Health Professions,)

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In developing countries, preeclampsia impact 4.4% of all deliveries. The incidence of

preeclampsia as of 2002 up to present raises to 146, 320 cases annually. It affects 5% of

pregnancies worldwide. In United States, approximately 1 in 1858 cases or 0.05% equivalent to

146,320 people in the U. S have preeclampsia. (cureresearch.com/p/preeclampsia/stats-

country.htm). In the Philippines, cases of preeclampsia exceeds up to 0.05% of pregnancies

annually or 46,392 cases out of 86,241,697 as of 2009. (www.doh.gov.ph). In local setting, 25

cases of preeclampsia were recorded at the Tarlac Provincial Hospital from January-December of

the year 2008. (TPH records).

As of May 18, 2009, there was an article posted about the cure of preeclampsia entitled

“A possible cure for pre-eclampsia”, this article talks about the new trends about preeclampsia

treatment.

Article: “A possible cure for pre-eclampsia”

A condition which affects one in every ten pregnancies and is responsible for 1,000 baby

deaths in Britain each year may have a genetic cause. Scientists in the United States say they

have discovered in studies with mice, a gene which may be linked with pre-eclampsia in some

women. The researchers from Harvard Medical School found mice, genetically-engineered to be

deficient in an enzyme called COMT (catechol-O-methyltransferase), developed pre-eclampsia.

The research team say low levels of COMT are also seen in pregnant women with the condition

which presents dangers for both mother and baby. The discovery could lead in the future to a

diagnostic test for the condition and possibly some form of preventative treatment. Of all

premature deliveries in the UK, pre-eclampsia accounts for 15% of them because the only way to

safely deal with pre-eclampsia is to deliver the baby. It causes rapid rises in blood pressure and if

the condition is untreated it can lead to convulsions, kidney failure, serious liver problems and

death. Pre-eclampsia is triggered by oxygen starvation caused by leaky blood vessels in the

placenta and the researchers examined the proteins possibly involved in pre-eclampsia by

affecting the level of oxygen delivered to the placenta. Dr. Raghu Kalluri, the study leader says if

a gene is responsible for pre-eclampsia in some families then it could be a useful genetic test.

COMT is an enzyme involved in the development of new blood vessels and a compound it

produces called 2-methoxyoestradiol (2-ME), normally increases during the last three months of

human pregnancy. They realised that mice without any COMT also failed to produce 2-ME, but

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when the COMT was restored the pre-eclampsia was cured. The researchers say as well as the

potential for a genetic test to identify women at risk, this has important implications for a

potential treatment. They say it is possible to measure 2-ME in blood or urine, which could

identify those who need more close monitoring, and those at risk can be treated with a

supplementary pill. Dr. Kalluri says this would give the mothers back what is missing. A large

clinical trial to look at the effect of COMT in women is now on the cards and experts say even

though all women are closely monitored for signs of pre-eclampsia a good test would remove

that need and would be very useful.(www.themedicalnews.com)

IMPORTANCE OF THE CASE STUDY

We chose this case because we are aware that pregnancy - related complications or

abnormalities, is not a simple problem, which can even lead to both fetal and maternal death that

is why this case in very significant. Knowing that Mrs. X is experiencing hypertension during

her pregnancy (preeclampsia) and is at risk for complications such as eclampsia (a life

threatening condition), we, as the student nurses in charge of taking care and rendering

healthcare services to her, must know well about the course of her condition and the possible

nursing interventions we can provide to manage her condition. This case is also significant in the

actual practice of our nursing profession.

Nursing research is also important to nursing profession because new researches helps

people especially those who were engaged on the medical field to know new things and update

their knowledge about certain things which they can use in practicing the nursing profession.

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GENERAL OBJECTIVE:

To come up with a detailed clinical case study of pre-eclampsia and to identify as well

as provide an appropriate and accurate nursing measure and different responsibilities to

consider while taking care of the client.

SPECIFIC OBJECTIVES:

This study aims to:

1. Assess properly to determine the contributing factors regarding the client’s disease and

identify any present abnormalities.

a. Personal Data

b. Family history of health and illness

c. History of past illness

d. History of present illness

e. 13 areas of assessment

2. Gather the needed data that can help to understand how and why the disease occurs

f. Diagnostic and Laboratory Procedures

g. Anatomy and Physiology

h. Pathophysiology book base and client centered

3. Develop an individualized plan considering client characteristics or the situation and setting a

specific, measurable, attainable, realistic and time bounded plan that reflect the onset, date of

problem identified

i. Planning (nursing care plan)

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4. Provide appropriate interventions for every problem encountered and monitor the client’s

response to treatment and therapies through means of physical assessment and communication

with the client

j. Medical management

k. Surgical management

l. Nursing management

5. Judge the effectiveness of chosen interventions, nursing care, and the quality of care provided

m. Client’s daily program in the hospital

6. Describe the general condition of the client upon discharge and know the take home

medications, exercise, and treatment for the client, provide health teachings and inform client for

OPD follow-ups

n. Discharge Planning

7. Broaden the knowledge of each member through further research about the latest news articles

and journals regarding to the client disease

a. Related literature

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II. NURSING PROCESS

A. ASSESSMENT

1. Personal Data

A. Demographic data

Date: September 19, 2009

Name: Mrs X Age: 37 y/o

Sex: female Civil status: married

Occupation: no permanent job Religion: Roman Catholic

Role in the family: mother Address: Tarlac City

Date & place of birth: August 17, 1972 Nationality: Filipino

Tarlac City

Source of referral: husband & other relatives

Usual source of care: hospital

Admitting diagnosis or impression: Pregnancy Uterine 40 2/7 week AOG, Preeclampsia with gestational HTN, G1P0,

Final Diagnosis: Pregnancy Uterine 40 2/7 weeks delivered to term, cephalic live baby boy, APGAR 8/9 via primary low transverse segment caesarean section dor proploged 2nd stage of labor, arrest in fetal head descent, G1P1 (1001)

B. Environmental Status

The patient lives in a mixed-type bungalow, it has two doors, one front door and one back door, has 2 rooms each with two windows. Their house is about 8 kilometres away from the nearest health center. They have their own water pump located in the kitchen inside their house. They have chickens and ducks in their backyard, where a vegetable garden is also found. When it comes to garbage disposal, they use burning system. She also stated that her husband is a chain smoker and usually smokes even inside their house.

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C. Lifestyle

Mrs X. Usually wakes up at around 4:00 in the morning. Upon waking up, she takes her first cup of coffee while preparing their breakfast which usually consists of dried fish and instant noodles. After breakfast, she goes to the backyard to clean their garden or she will immediately proceed to washing their dirty clothes. After doing the chores, she prepares their lunch which also consists of instant noodles and sometimes. Their dinner consists of what is left from their lunch. According to her she loves eating fatty foods such as chicharon, fried pork and many more. The patient usually sleeps at around nine - ten o’clock in the evening.

2. Family History of Health and Illness

See genogram – next page

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GENOGRAM

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87

89

72

74

69 6

5

65 6

8

58

53

49

90 8

4

37

39

42

40

393

032AW

AW AW AW HP AST

HP HP

AW

AW

CVA

AST

AW HPN HPN

HPN AW HPN

DM

LEGEND: - POINTS TO THE PATIENT AW – ALIVE & WELL HPN – HYPERTENSION AST – ASTHMA DM- Diabetes Mellitus CVA - STROKE P-E - PREECLAMPSIA -DECEASED FEMALE

- DECEASED MALE

AS

P-E *BASED ON THE DIAGRAM, WE CAN SAY THAT THE PATIENT HAS HISTORY OF HYPERTENSION, STROKE, ASTHMA AND DIABETES MELLITUS.

*BASED ON THE GENOGRAM, WE CAN SAY THAT THE CLIENT’S PRESENT CONDITION IS GENETICALLY ACQUIRED.

MATERNAL PATERNAL

3. HISTORY OF PAST ILLNESS

According to the patient, she always experiences cough and colds and fever as a child. Her mother usually treats this illnesses using over-the-counter drugs and with herbal medicines. She denies any history of allergies and injuries in the past.

4. HISTORY OF PRESENT ILNESS

The client is on her 40th week AOG. Few days before her confinement, the client experienced blurring of vision and pounding headache while preparing their breakfast. She stated “Biglang nanlabo ang paningin ko tapos parang pinupukpok ung ulo ko”. According to her, she just lied down for a few minutes and she took a pain reliever and the headache alleviated a little but the blurring of vision persisted for the whole day.

The next day, she went to the health center for her weekly pre-natal check-up. It was that day when she discovered that she has an elevated blood pressure of 140/90 mmhg. According to her, she ignored that fact, thinking that it will not do any harm to her and her baby so she just went home and continued her daily chores.

Few hours before her confinement, while cleaning their house, she experiences the same symptoms but this time, it was more intense. She described the headache as crashing headache. She also felt light to moderate uterine contractions. She immediately called her husband who was inside the house at that time and she was rushed to the emergency department of the Tarlac Provincial Hospital on the16th day of September two thousand and nine.

5. 13 AREAS OF ASSESSMENT

Date assessed:

Pre – op: September 19, 2009

Post – op: September 21, 2009

1. Social Status

The 37 year old patient was nine months pregnant at the time of her confinement. She is happily married to her husband of two years. According to her, she has a good working relationship with her in-laws as well as with their other relatives. Her husband works as a jeepney driver. The patient also denies any conflicts among their neighbours.

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Norms:

Family members should perform their roles. Good communication within the family must be maintained to obtain a healthy relationship with one another. Social support is a perception that one has an emotional and tangible resource to call on when needed; perceived social support is being followed by the family to express the love and care to the family. Financial aspect is one of the normal constraints in the family.(Kozier, Copyright 2004)

Analysis:

The patient has a harmonious relationship among the people around her. She is well-supported by her relatives.

2. Mental Status

Level of consciousness

Pre – op:

The patient responds appropriately to the questions asked. She can also recall the names of her family members. She is also oriented to the date, time, and place she is in.

Post – op:

The patient refused to answer some of our questions, but still she knows the date, place, and time where she is in.

NORMS:

Level of Consciousness determines whether a person is oriented to the things that are happening. Response to verbal stimuli indicates that the patient is oriented to the place he or she is in. (Kozier, Copyright 2004)

ANALYSIS:

Pre – op:

The client is alert and well oriented as she responds appropriately with the questions that were asked to her.

Post – op:

The patient was hesitant to answer some of our questions, but she is well oriented.

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Mood

Pre – op:

During the interview, the patient appears attentive but there are times that she appears irritable but she still manages to answer our questions appropriately. A tinge of anxiety was also noted.

Post – op:

Upon interview to the client, the patient appears to be attentive but sometimes she seems to be not interested to answer our questions.

NORMS:

Moods are dependent on a person’s view of what is happening around him for example person who is lacking of sleep may not be approachable. (Kozier, Copyright 2004)

ANALYSIS:

Pre – op:

The client can still manage her emotions despite her condition.

Post – op:

The patient was a little bit hesitant to answer our questions because of the pain she experiences caused by her operation.

Thought processes and perception

Pre – op:

The client freely expresses her feelings about her condition. She can identify the reality from not as she states the possible outcomes of her pregnancy,”sabi ng doctor puwedeng malagay sa peligro ang buhay namin ng anak kaya lagi talaga akong nagdadasal” as verbalized by the patient.

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Pre – op:

The client seems to be quiet about what she feels. She can still identify reality from not by stating that she will be fine after few days.

NORMS:

Thought processes is the person’s ability to identify the reality from not. Feelings need to be explored to determine whether they are based on reality or interpretations memories or fears. (Kozier, Copyright 2004)

ANALYSIS:

Pre – op:

The client knows what is reality from not, as she talked to as about things that really happens in reality.

Post – op:

The client still knows what is reality from not.

Cognitive Abilities

Pre – op:

The client is well oriented on the place, time, and date. She also knows about her condition. She responded normally to the neurological test performed but because she is on bed rest, the Romberg’s test was not performed.

Post – op:

The client is still well oriented on the date, time and place. She also knows her present condition. Romberg’s test was not performed because she is still on bed rest.

NORMS:

Clients undertaking a Romberg’s test should be able to stand upright while the eyes closed then with eyes open. It is a negative Romberg if the client sways slightly but is able to maintain upright posture. It is positive if the client cannot maintain an upright position. (Kozier, Copyright 2004)

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ANALYSIS:

Pre – op:

The client has normal cognitive abilities as the outcomes of the neurological tests shown.

Post – op:

The client has normal cognitive abilities.

3. Emotional Status

Pre – op:

The client remains calm even though she knows about what will happen to her child if her condition was not given enough attention. Despite that, she exhibits poor eye contact during the interview. Her voice pitch is slightly increased and shaky. She also shows a strong faith in God as she stated that whatever happens to is within the will and accordance of God.

Post – op:

The client remains calm in spite of her present condition. She still shows strong faith in God as she stated that God will help her to be strong again.

NORMS:

A person’s emotional status depends much on his ability to cope up with the happenings in his/her life. He or she may not be in the right mood if some unnecessary things had happened. (Nursing CEU.com: The process of human development)

ANALYSIS:

Pre – op:

The client is emotionally stable. The poor eye contact is a manifestation of the anxiety that she gets because of too much worrying.

Post – op:

The client is emotionally stable.

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4. SENSORY PERCEPTION

Sense of taste

Pre – op:

The patient can determine taste. As she verbalized “matamis yung mangga na kinain ko kanina”. No lesions or abnormalities were found in the tongue and oral cavities and it is symmetrical.

Post – op:

The patient sense of taste was not assessed because she is on NPO status.

NORMS:

Normal sensation would be accurate perceptions of sweet, sour, salty, and bitter taste. (Estes, Third edition, Copyright 2006)

ANALYSIS:

Pre – op:

The client has a normal sense of taste.

Post – op:

The client sense of taste was not able to assess.

Auditory Acuity

Pre – op:

Hearing test was performed in the patient to check if he has a good auditory acuity. We whispered words 3 inches away from her, she was able to repeat the words correctly and clearly as we asked her to repeat it; we call her name and claimed if she clearly heard us under 10 and 20 feet away. She was able to answer our question correctly. No bleeding, wounds found on his external ear.

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Post – op:

Hearing test was performed in the patient to check if he has a good auditory acuity. We whispered words 3 inches away from her; she was able to repeat the words correctly and clearly as we asked her to repeat it. No bleeding, wounds found on his external ear.

NORMS:

Patient should hear whispered words or watch tick test and ear must free from lesions and masses. (Estes, Third edition, Copyright 2006)

ANALYSIS:

Pre – op:

The patient’s auditory sense is intact and has no problem.

Post – op:

The patient’s auditory acuity was normal.

Sense of Smell

Pre – op:

She can distinguish different odors. She was able to differentiate the smell of a cologne, and alcohol that we provided. She told to us that she is irritated in deleterious odor in the hospital especially in the comfort room. Her nose lies on the midline of her face and it is symmetrical and nostrils are intact, no bleeding and wounds found.

Post – op:

The patient can distinguish different odors. She can smell the alcohol we asked her to smell. Her nose lies on the midline of her face and it is symmetrical and nostrils are intact, no bleeding and wounds found.

NORMS:

Patient must able to identify different smell; nose should be at the midline position of the face, free from lesions and intact nostrils. (Estes, Third edition, Copyright 2006)

ANALYSIS:

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Pre – op:

The patient’s sense of smell has no problem.

Post – op

The patient’s sense of smell has no problem.

Sense of Sight

Pre – op:

The client can read well through the reading materials provided by the examiners even without the use of corrective lenses/glasses. Visual Acuity test was not performed due to the patient’s condition; she was always on bed rest. She also reported that blurring of vision occurs during episodes or increased blood pressure.

Post – op:

The client can read well through the materials we asked her to read without the use of eye glasses. Visual acuity test was not performed because the patient is on bed rest. No blurring of vision reported.

NORMS:

The patient who has a visual acuity of 20/20 in a Snellen chart test is considered to have a normal visual acuity. (Estes, Third edition, Copyright 2006)

ANALYSIS:

Pre – op:

The patient’s vision has no problem except for the blurring during increased blood pressure.

Post – op:

The patient’s visual acuity was normal.

Pain Sensation

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Pre – op:

The patient rated her uterine contraction as 7/10 while the headache she felt before was rated as 9/10.

Post – op:

The patient complains pain on her incision site and rated it as 7/10.

NORMS:

Reacting with a stimulus is a sign of good sensation. (Estes, Third edition, Copyright 2006)

ANALYSIS:

Pre – op:

The patient’s pain sensation has no problem.

Post – op:

The patient’s pain sensation is normal.

5. MOTOR STABILITY

Pre – op:

The patient was not able to walk due to imposed bed rest but she can still move or flex and extend her hands, elbows, joints and foot.

Post – op:

The patient was not able to walk due to imposed bed rest. She can move her hands, elbows, joints and foot but she complains difficulty when moving her legs.

NORMS:

Normal motor stability includes the ability to perform the different steps in doing range of motion. It should be firm with smooth and coordinated movements (Estes, Third edition, Copyright 2006)

ANALYSIS:

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Pre – op:

The patient motor stability is impaired but she can still perform range of motion even though she was on bed rest.

Post – op:

The patient motor stability is impaired due to imposed bed rest.

6. BODY TEMPERATURE

Pre – op:

The patient has cold and clammy skin upon assessment on the first few hours of assessment.

The following body temperatures were obtained:

Date Time Temperature (°C)

PRE – OP:

September 19, 2009 10:00am 36.7

12:00pm 37

2:00pm 37

September 20, 2009 10:00am 37.2

12:00pm 37.2

2:00pm 37.4

POST – OP:

September 21, 2009 10:00am 37.5

12:00pm 37.3

2:00pm 37.5

September 22, 2009 10:00am 37.2

12:00pm 37.3

2:00pm 37.1

September 23, 2009 10:00am 37.3

12:00pm 37.1

NORMS:

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36.5 C to 37.5 ◦C is the normal body temperature (Kozier, Seventh edition, Copyright

2004)

ANALYSIS:

Pre – op:

The patient has normal body temperature.

Post – op:

The patient has normal body temperature.

7. RESPIRATORY STATUS

Pre – op:

On the first day of our assessment on the patient, she has a slightly elevated respiratory

rate. She was on Oxygen Therapy via nasal cannula regulated at 3L/min.\

Table below shows the respiratory rate of the patient.

Date Time Respiratory Rate (cpm)

PRE – OP:

September 19, 2009 10:00am 22

12:00pm 20

2:00pm 21

September 20, 2009 10:00am 18

12:00pm 18

2:00pm 17

POST – OP:

September 21, 2009 10:00am 20

12:00pm 19

2:00pm 18

September 22, 2009 10:00am 18

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12:00pm 15

2:00pm 17

September 23, 2009 10:00am 16

12:00pm 17

NORMS:

Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of pattern,

normal respiration must be regular and even in rhythm. The normal depth of respirations is none

exaggerated and effortless (Health Assessment and Physical Examination 3rd Edition Mary Ellen

Zator Estes).

ANALYSIS:

Pre – op:

The patient has a deviation from normal respiratory status during first few days of stay in

the hospital but achieved a normal respiratory condition as day’s progresses.

Post - op:

The patient has normal respiratory status.

8.) CIRCULATORY STATUS

Pre – op:

The patient nail color turns back within 4 seconds and she has +2edema on face, hands,

and feet. Her pulse is weak and thready upon assessment with regular interval.

The following pulse rate and blood pressure were obtained:

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Date Time Pulse Rate(bpm) Blood

Pressure(mmHg)

PRE – OP:

September 19, 2009 10:00am 102 bpm 140/90

12:00pm 98bpm 130/90

2:00pm 91 bpm 130/80

September 20, 2009 10:00am 93 bpm 130/90

12:00pm 96 bpm 120/80

2:00pm 90 bpm 120/90

POST –OP:

September 21, 2009 10:00am 98 bpm 130/90

12:00pm 95 bpm 120/80

2:00pm 91 bpm 120/80

September 22, 2009 10:00am 89 bpm 120/90

12:00pm 90 bpm 120/80

2:00pm 92 bpm 120/90

September 23, 2009 10:00am 90 bpm 120/80

12:00pm 86 bpm 120/80

NORMS:

The average heart rate and blood pressure of an adult are 60-120bpm and 120/90mmHg.

No edema should be observed on the extremities because it indicates venous insufficiency, the

pulse is regular in interval, not weak and thread, not bounding.(Kozier, Seventh edition,

Copyright 2004). The normal range of capillary refill test is within 2-3 sec.(Estes, Third edition,

Copyright 2006)

ANALYSIS:

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Pre – op:

With regard to his circulatory status, it shows that his pulse rate is normal and her blood

pressure was elevated. She also has insufficient venous return and abnormal capillary refill. Her

pulse characteristics did not meet normal findings for weak and thread assessment.

Post –op:

The client’s circulatory status is within normal limits.

9.) NUTRITIONAL STATUS

The client claimed to as that her weight is 63 kg and 5”2’. She also told us that she eat 4

times a day. She prefers eating fatty foods than vegetables. Her family has the ability to provide

her nutritional needs. She has no food and drug allergies and her body mass index (BMI) was

25.56.

NORMS:

BMI is a measurement that indicated body composition. The degree of overweight or

obesity as well as the degree of underweight can be determined. A balanced diet consist of

variety of foods from meat, fish, vegetables and fruits.(Estes, Third edition, Copyright 2006)

Standard Body Mass Index for Adults

Underweight = <18.5

Normal weight = 18.5-24.9

Overweight = 25-29.9

Obesity = BMI of 30 or greater

ANALYSIS:

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The patient has an above than normal BMI related to her present maternal condition. Her

diet put her on a greater risk for developing ailment.

10. ELIMINATION STATUS

Upon assessment diaphoresis was noted to the client due to the humid and crowded

environment in the ward she is in. The patient usually defecates one to two times a day, brown in

color, and soft but formed. The patient has yellow-colored urine with turbid appearance. Her

urine output is 20-25cc/hr. For urinalysis results, please see: Laboratory Results.

NORMS:

Normal bowel movement is usually 2-3 times a week which help in elimination of

unnecessary waste material in the body in the GI tract. It should be soft but formed and brown in

color. Urine output of an adult is usually 1200-1500mL per day. The color is pale yellow or

yellow and has turbid appearance.(Kozier Seventh edition, Copyright 2004)

ANALYSIS:

The patient has a normal bowel movement. Her urine characteristics were normal but her

urinary output is decreased.

11.) REPRODUCTIVE STATUS

The patient has a recorded LMP of December 7, 2008. She said her menstrual cycle was

regular and stated have interval of 24-26 days that lasts for 6-7days. She consumed

approximately 2 pads per day. Her recorded menarche was on 1983 at age 11. She got married at

the age of 27 in the year 1999.

September 19, 2009 = G1 P0 T0 P0 A0 L0

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September 20, 2009 = G1 P1 T1 P0 A0 L1

NORMS:

Sexual activity/status can be determined through the presence or absence of sexual urge.

Age is also one of the factors that affect one’s reproductive status because of the hormonal

changes. Length of duration vary from 2-7 days depending on the duration of the cycle.(Outline

in Obstetrics, 3rd edition)

ANALYSIS:

The patient has a normal reproductive status.

12.) STATE OF PHYSICAL REST AND COMFORT

Before admission, the patient usually slept at 10:00 pm and woke up at around 6:00am to

do the house chores and cook breakfast for her family. But upon admission in the hospital she

could not sleep properly because of the environmental stimulus. She also appears irritable upon

assessment.

NORMS:

A normal sleep hour of an adult per day is 6 - 8 hours without being disturbed and

normally is not irritable, restless and other feature indicating uncomfortable situation. (Kozier,

Seventh edition, Copyright 2004)

ANALYSIS:

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The patient has adequate rest and sleep. But this was aggravated when she was admitted

in the hospital. This indicates that she has an abnormal sleep and rest upon her admission.She

also appears irritable which one of the features signifying uncomfortable.

13. STATE OF SKIN APPENDAGES

Pre – op:

The patient skin was light brown and uniform in color. The scalp has no flakes and free

from lesions. The hair was properly distributed, black and free from infestations. Nails are in

normal angle of 160o characterized as intact but pale in color and no lesions found. No bleeding

or wounds found in the extremities which are cold and clammy especially on hands. Pitting

edema on extremities and face +2.

Post –op:

The patient skin was light brown and uniform in color. The scalp has no flakes and free

from lesions. The hair was properly distributed, black and free from infestations. Nails are in

normal angle of 160o characterized as intact but pale in color and no lesions found. No bleeding

or wounds found in the extremities. No edema was noted.

NORMS:

Skin varies from light to brown from ruddy pink to light pink. Generally, uniform except

in areas exposed to the sun, areas of lighter pigmentation in palms, nail beds, and lips. The hair

should be evenly distributed, thick, shiny and free from infestation. The nails should be 160◦ and

smooth in texture. Edema in any part in the body could not be considered normal. The skin is

slightly warm but not flushed.(Kozier, Seventh edition, Copyright 2004)

ANALYSIS:

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Pre – op:

The patient indicates that she has normal skin and appendages except for edema found on

her extremities and face, and a cold clammy skin especially on hands.

Post –op:

The patient has normal state of skin and appendages.

ANATOMY AND PHYSIOLOGY

THE PLACENTA

The placenta is an organ unique to mammals that connects the developing fetus to the

uterine wall. The placenta supplies the fetus with oxygen and food, and allows fetal waste to be

disposed of via the maternal kidneys. Protherial (egg-laying) and metatherial (marsupial)

mammals produce a choriovitelline placenta that, while connected to the uterine wall, provides

nutrients mainly derived from the egg sac. The placenta develops from the same sperm and egg

cells that form the fetus, and functions as a fetomaternal organ with two components, the fetal

part (Chorion frondosum), and the maternal part (Decidua basalis). In humans, the placenta

Page | 26

averages 22 cm (9 inch) in length and 2–2.5 cm (0.8–1 inch) in thickness (greatest thickness at

the center and become thinner peripherally). It typically weighs approximately 500 grams (1 lb).

It has a dark reddish-blue or maroon color. It connects to the fetus by an umbilical cord of

approximately 55–60 cm (22–24 inch) in length that contains two arteries and one vein. The

umbilical cord inserts into the chorionic plate (has an eccentiric attachment). Vessels branch out

over the surface of the placenta and further divide to form a network covered by a thin layer of

cells. This results in the formation of villous tree structures. On the maternal side, these villous

tree structures are grouped into lobules called cotelydons. In humans the placenta usually has a

disc shape but different mammalian species have widely varying shapes. The placenta begins to

develop upon implantation of the blastocyst into the maternal endometrium. The outer layer of

the blastocyst becomes the trophoblast which forms the outer layer of the placenta. This outer

layer is divided into two further layers: the underlying cytotrophoblast layer and the overlying

syncytiotrophoblast layer. The syncytiotrophoblast is a multinucleate continuous cell layer which

covers the surface of the placenta. It forms as a result of differentiation and fusion of the

underlying cytotrophoblast cells, a process which continues throughout placental development.

The syncytiotrophoblast (otherwise known as syncytium), thereby contributes to the barrier

function of the placenta. The placenta grows throughout pregnancy. Development of the

maternal blood supply to the placenta is suggested to be complete by the end of the first trimester

of pregnancy (approximately 12–13 weeks). The placenta functions in two purposes. The

perfusion of the intervillous spaces of the placenta with maternal blood allows the transfer of

nutrients and oxygen from the mother to the fetus and the transfer of waste products and carbon

dioxide back from the fetus to the mother. Nutrient transfer to the fetus is both actively and

passively mediated by proteins called nutrient transporters that are expressed within placental

cells. In addition to the transfer of gases and nutrients, the placenta also has metabolic and

endocrine activity. It produces, among other hormones, progesterone, which is important in

maintaining the pregnancy; somatomammotropin (also known as placental lactogen), which acts

to increase the amount of glucose and lipids in the maternal blood; estrogen; relaxin, and beta

human chorionic gonadotrophin (beta-hCG).

PLACENTAL CIRCULATION

Page | 27

Maternal placental circulation

In preparation for implantation, the uterine endometrium undergoes 'decidualisation'. Spiral arteries in the decidua are remodelled so that they become less convoluted and their diameter is increased. This increases maternal blood flow to the placenta and also decreases resistance so that shear stress is reduced. The relatively high pressure as the maternal blood enters the intervillous space through these spiral arteries bathes the villi in blood. An exchange of gases takes place. As the pressure decreases, the deoxygenated blood flows back through the endometrial veins. Maternal blood flow is approx 600–700 ml/min at term.

Fetoplacental circulation

Deoxygenated fetal blood passes through umbilical arteries to the placenta. At the junction of umbilical cord and placenta, the umbilical arteries branch radially to form chorionic arteries. Chorionic arteries also branch before they enter into the villi. In the villi, they form an extensive arteriocapillary venous system, bringing the fetal blood extremely close to the maternal blood; but no intermingling of fetal and maternal blood occurs ("placental barrier").

PATHOPHYSIOLOGY (Book-Based)

Page | 28

PATHOPHYSIOLOGY (Client-Based)

Page | 29

RISK AND PREDISPOSING FACTORS

MODIFIABLE↑ Sodium intake, Poor Nutrition,

Hypercholesterolemia, lack of activities during pregnancy, inadequate prenatal

care

NON - MODIFIABLE

Age (<20,>35 years old), family history of Hypertension, primipara, Diabetes Mellitus,

Chronic Renal Disease, heart diseases, multi –gestation (twins)

Damage to the endothelium cells (cells that line in the blood vessels)

Endothelium cells releases endothelin (a potent

vasoconstrictor)

Injury to uterine vessels

Placental ischemia

↑renin, ↓ prostaglandin production

↑ Sensitivity of arterioles to angiotensin

↑ BLOOD PRESSURE

↓ Renal perfusion

Impaired kidney function

Activation of renin-angiotensin system

↓ Glomerular Filtration Rate

↑ Na retention & water reabsorption

EDEMA

↓ Permeability of renal tubules

PROTEINURIA

Headache Visual disturbances

Weak thready pulse

Cold-clammy skin

Delayed capillary refill

RISK AND PREDISPOSING FACTORS

MODIFIABLE↑ Sodium intake, Poor Nutrition,

Hypercholesterolemia, lack of activities during pregnancy

NON - MODIFIABLE

Age (<20,>35 years old), family history of Hypertension, primiparaDamage to the endothelium cells (cells that line in

the blood vessels)Endothelium cells releases endothelin (a potent

vasoconstrictor)Injury to uterine vesselsPlacental ischemia↑renin, ↓ prostaglandin

production

↑ Sensitivity of arterioles to angiotensin↑ BLOOD PRESSURE ↓ Renal perfusionImpaired kidney function

Activation of renin-angiotensin system

↓ Glomerular Filtration Rate

↑ Na retention & water reabsorptionEDEMA

↓ Permeability of renal tubulesPROTEINURIA

Headache Visual disturbances Weak thready pulseCold-clammy skin Delayed capillary refill

DIAGNOSTIC AND LABORATORY PROCEDURES

Page | 30

Diagnostic/ Laboratory Procedures

Date Ordered and date Result/s In

Indication/s or Purposes

Result/s Normal Values (Units used in the Hospital)

Analysis and Interpretation of results

CBC

>WBC

>LYM

>MID

>GRAN

>RBC

Sept. 16, 2009

Result:

Sept. 17, 2009

CBC is used as abroad screening test to determine the values of formed elements of the blood.

9.6

1.7

0.3

7.6

4.24

4.1 – 10.9 g/dL

0.6 – 4.1

0.0 – 1.8

2.0– 7.8

4.20 – 6.30 T/L

Normal>No indicative abnormalities noted.

Normal> No indicative abnormalities noted




Page | 31

>HGB

>HCT

>MCV

>MCH

>MCHC

>PLT

112

0.372

87.8

26.4

301

231

120 – 180 g/dL

0.370 – 0.510 L/L

80.0 – 97.0 fl

26.0 – 32.0 pg

310 – 360 g/dL

140 -440 g/L

Decreased>There is a marked decreased in HGB.




Decreased>There is a marked decreased in MCHC.


NURSING RESPONSIBILITIES:

Page | 32

Before:

Determine the clients understanding of the procedure Determine the clients response to previous testing

During:

Ensure client’s comfort until the procedure will be done

After:

Document the method of testing and results on the clients record Immediately reached the blood sample on the laboratory. Follow-up result from laboratory






BLOOD CHEMISTRY

Sept. 16, 2009

Result:

Sept. 17, 2009

Blood tests are used to determine physiological and biochemical states such as disease, mineral content, drug effectiveness, and organ function

FBS:4.84

BUN:8.0

Creatinine:105.6

EnzymesSGOT/ AST4.2

SGPT/ALT1.9

FBS:3.9-6.1 mmol/L

BUN:2.9-8.2 mmol/L

Creatinine:53-106 mmol/ l

Enzymes8-33 U/L

4-36 U/L

Normal

Normal

Normal

Not normalDecrease amount of SGOT/AST

Not normalDecrease amount of SGPT/ALT

Page | 33


Before:

1. Explain the purpose of the test and the procedure for collection of blood. Client mat

experience anxiety about the procedure, especially if it is perceived as being intrusive or

if they fear unknown to the result. A clear explanation will facilitate cooperation on the

part of the client.

2. Inform the client of the time period before the results will be available.

During:

1. Use the correct procedure for obtaining the blood.

2. Aseptic technique should be use in collection to prevent contamination that can cause

inaccurate results.

3. Ensure correct labelling, storage and transportation of the specimen to avoid invalid test

results.

After:

1. Report results to the appropriate health team members.

2. Compare the previous and current test results and modifies nursing interventions as needed






Urinalysis Sept. 16, 2009

Result:

Sept. 17, 2009

> To determine the presence of micro organism, the type of organism, and the antibiotics

Color: yellow

Appearance:

Color:

straw amber transparent

Normal

Normal

Page | 34

to which the organism are sensitive.

> Assess the color, odor, and consistency of the urine and the presence of clinical signs of UTI. ( frequency, urgency, dysuria, hematuria, flank pain, cloudy urine with foul odor.

Turbid

Pus cells:

3-4

RBC:

0-1

Epithelial cells:

moderate

Mucus threads:

many

Specific gravity:

1.015

Albumin:

++

Glucose:

negative

Appearance:

Amber transparent

Pus cells:

0/HPF

RBC:

Red blood cells: 0–2/HPF

Epithelial cells:

None to few

None

Specific gravity:

1.010-1.020

Albumin:

Negative

Glucose:

Negative

Not Normal, pus cells are present.

Normal

Not Normal, moderate epithelial cells are present.

Not Normal, mucus threads are present.

Normal

Abnormal, albumin is present

Normal


Page | 35

Before:

1. Explain the purpose of the specimen collection and the procedure for collection of the

specimen. Client mat experience anxiety about the procedure, especially if it is perceived

as being intrusive or if they fear unknown to the result. A clear explanation will facilitate

cooperation on the part of the client.

2. Provide proper instruction if client will be the one to collect the specimen.

During:

1. Provide client comfort, privacy and safety. Client may experienced embarrassment or

discomfort when providing a specimen.

2. The nurse needs to be judgemental and sensitive to possible socio cultural beliefs that

might affect client’s condition.

3. Use the correct procedure for obtaining the specimen.

4. Aseptic technique should be use in collection to prevent contamination that can cause

inaccurate results.

5. Note relevant information on the laboratory requisition slip like medications the client is

taking that can affect the result of the specimen.

6. As much as possible collect the specimen at the first void in the morning.

After:

1. Make sure that the specimen label and the laboratory requisition carry the correct

information.

2. Attach the label securely.

3. Transport the specimen to the laboratory promptly. Fresh specimens provide more

accurate results.

4. Report abnormal laboratory findings.

VI. PLANNING.

Page | 36

NURSING CARE PLANS

See next page. . .

Page | 37

September 19, 2009

Assessment Diagnosis Planning Intervention Rationale Expected Outcome

S> OO> with an ongoing IVF of 1L D5LR, received @ the level of 750cc @ right hand regulated 30-31 gtts/min, infusing well> pale in appearance > cold and clammy skin> noted pitting edema on extremities and face (+2)> weak pulse> with delayed capillary refill of 4 seconds > FHT of 162 bpm @ 10:00 am> blood pressure of 140/90 mmHg @ 10:00 am> pulse rate of 102bpm @ 10:00 am> respiratory rate of 22cpm @ 10:00 am> temperature of 36.7 C @ 10:00 am

Decreased cardiac output related to decreased venous return.

Scientific Explanation:Prolonged vascular constriction increases hemo concentration and fluid shifts decrease cardiac output.

Within 5hrs of nursing intervention, the client will demonstrate adequate cardiac output.

> Monitor maternal vital signs and fetal heart rate closely.

> Assess changes in mental status.

> Position client in left lateral position.

> Institute bed rest.

> Provide quiet environment and limit visitors.

> Elevate edematous extremities and avoid restrictive clothing.

> The following should be encouraged to pt:a. Eat foods that are low in sodium and fats but high in protein and carbohydrate.b. Eat small meals and rest after wards.

c. Report any visual disturbances, severe headache, nausea and vomiting, epigastric pain and abdominal pain. d. relaxation such as deep breathing exercise.> Administer supplemental oxygen as indicated.

> Alteration in vital signs may signify the client risk for eclampsia and the high risk newborn.

> Changes in mental status may indicate decrease cerebral perfusion or hypoxia.

> To increase renal and placental perfusion.

> To decrease oxygen demand and increase cardiac output.

> To decrease stimuli or stressors.

> To promote venous return.

> Sodium intake increases the risks in forming edema. Protein intake replaces the loss of proteins. > Larger meals increases myocardial workload> It signify signs and symptoms of impending eclampsia

> To reduce anxiety

> To increase oxygen available to tissues.

After 5hrs of nursing intervention, the client will demonstrate adequate cardiac output as evidenced by:>blood pressure, pulse rate and rhythm are within normal parameters> Capillary refill of 2 seconds.

Page | 8Page l 38

September 19, 2009


S>OO> with an ongoing IVF of 1L D5LR, received @ the level of 750cc @ right hand regulated 30-31 gtts/min, infusing well> pale in appearance > cold and clammy skin> noted pitting edema on extremities and face (+2)> weak pulse> with delayed capillary refill of 4 seconds > FHT of 162 bpm @ 10:00 am> blood pressure of 140/90 mmHg @ 10:00 am> pulse rate of 102bpm @ 10:00 am> respiratory rate of 22cpm @ 10:00 am> temperature of 36.7 C @ 10:00 am> urine output of 170cc from 7:00 am to 3:00 pm

Ineffective tissue perfusion related to vasoconstriction of blood vessels.

Scientific Explanation: Vasoconstriction is due to the presence of endothelin in the blood vessels which is a potent vasoconstrictor. Blood vessels lumens are constricted thus small amount of blood can pass through.

After 6 hrs of nursing intervention, the client will demonstrate adequate tissue perfusion.

> Monitor maternal vital signs and fetal heart rate closely.

> Monitor urine output

> Assess changes in mental status.

> Position client in left lateral position.

> Institute bed rest.

> Provide quiet environment and limit visitors.> Elevate edematous extremities and avoid restrictive clothing.

> The following should be encouraged to pt:a. Eat foods that are low in sodium and fats but high in protein and carbohydrate.b. Eat small meals and rest after wards.

c. Report any visual disturbances, severe headache, nausea and vomiting, epigastric pain and abdominal pain. d. relaxation such as deep breathing exercise.> Administer supplemental oxygen as indicated.

> Alteration in vital signs may signify the client risk for eclampsia and the high risk newborn. > Further decreased in urine output can indicate kidney damage and eclampsia.> Changes in mental status may indicate decrease cerebral perfusion or hypoxia.> To increase renal and placental perfusion.

> To decrease oxygen demand and increase cardiac output.> To decrease stimuli or stressors.

> To promote venous return.

> Sodium intake increases the risks in forming edema. Protein intake replaces the loss of proteins. > Larger meals increases myocardial workload> It signify signs and symptoms of impending eclampsia

> To reduce anxiety

> To increase oxygen available to tissues.

After 6 hrs of nursing intervention, the client will demonstrate adequate tissue perfusion as evidenced by:> capillary refill of 2 seconds> Adequate urine output.

Page | 9

Page l 39

September 19, 2009


S>”Nag-aalala ako sa magiging kalagayan ng anak ko”

O> > with an ongoing IVF of 1L D5LR, received @ the level of 750cc @ right hand regulated 30-31 gtts/min, infusing well > poor eye contact> voice changes in pitch> fetal heart rate: 162 bpm> irritable> blood pressure of 140/90 mmHg @ 10:00 am> pulse rate of 102bpm @ 10:00 am

Anxiety related to actual threats to self/ fetus.

Scientific Explanation:During extreme emotion, the body tends to compensate and in the feeling of anxiety, the body tends to affect all of the system

Within 1 hour of nursing intervention, the patient will be able to identify healthy ways to deal with and express anxiety.

Establish a therapeutic relationship, conveying empathy and unconditional positive regard.

Provide information about pre eclampsia

Explain the need for stress management to prevent further problems by encouraging patient to pray for the safety of the baby and herself.

Encourage patient to acknowledge and to express feelings.

Provide comfort measures such as back rub and therapeutic touch.

Instruct and encourage to do deep breathing exercises

To gain the trust of the patient

To give patient knowledge about pre eclampsia

To reduce stress.

Acknowledging and expressing feelings help to reduce anxiety.

Relieves muscle tension and fatigue.

Increase oxygen supply, thus help the patient relax.

After 1 hour of nursing intervention, the patient would be able to identify healthy ways to deal with and express anxiety as evidenced by verbalization of feelings about her anxiety.

September 21, 2009Page | 10

Page l 40


S> “Masakit and tahi ko.”> Pain scale of 7 out of 10.O> with an ongoing IVF of 1L D5LR, received @ the level of 800 cc @ right hand, regulated 30-31 gtts/min, infusing well.> with IFC, patent> with grimace> with guarding behaviour> irritable> wound dressing dry and intact> Respiratory rate of 20 cpm @ 10:00 am> Pulse rate of 98bpm @ 10:00am> BP of 130/90 mmHg @ 10:00 am

Pain related to incision.

Scientific Explanation:After the tissue damage done on the incision site, inflammation is commonly seen, one of the signs of inflammation is pain.

Within 30 minutes of nursing intervention, the client pain scale of 7/10 will decrease.

> Monitor vital signs.

> Provide comfort measures such as touch therapy and straightening linens.

> Identify ways of avoiding/minimizing pain by splinting incision during coughing.

> The following should be encouraged to the client:a. Verbalization of feelings about pain.b. the use of relaxation exercises such as deep breathing and coughing exercise.> Administer medications as ordered

> Clients who experience pain may have an alteration in vital signs.

> To provide non pharmacological pain management.

> To minimize pain.

> To lessen anxiety.

> To reduce muscle tension.

> To lessen the pain.

After 30 minutes of nursing intervention, the client pain scale of 7/10 will decrease to 3/10 as evidenced by absence of grimace and irritability.

September 21, 2009Page | 11

Page l 41


S> OO> with an ongoing IVF of 1L D5LR, received @ the level of 800 cc @ right hand, regulated 30-31 gtts/min, infusing well.> with IFC, patent> presence of suture> wound dressing dry and intact> Respiratory rate of 20 cpm @ 10:00 am> Pulse rate of 98bpm @ 10:00am> BP of 130/90 mmHg @ 10:00 am> Temperature of 37 C @ 10:00am

Risk for infection related to postoperative site.

Scientific Explanation:Improper care in the postoperative site will lead to infection because of the breakage in the skin.

Within 8hrs of nursing intervention, the client will be free from signs of infection.

> Monitor vital signs especially temperature.

>Observe and report signs of infection such as redness, warmth and increased body temperature.

>Use appropriate hand hygiene.

> The following should be instructed to the client:

a.Complete any course of prophylactic antibiotic unless experiencing adverse reaction.

b. Promptly reported signs and symptoms of infection such as redness, warmth, swelling, tenderness or pain and increased body temperature.

> Change dressing as ordered.

>Administer medications as prescribed.

> Elevated body temperature may indicate infection

> Fever of unknown origin is the most common sign of nosocomial infection.

>To reduce transmission of antimicrobial resistant microorganism and reduced infection rate.

> Prophylactic antibiotic therapy decreases the risk of infection.

> 2/3 of wound infection occur after discharge.

> To prevent and check for signs of infection.

> To prevent infection.

After 8hrs of nursing intervention, the client will be free from signs of infection as evidenced by absence of redness, swelling and other signs of infection.

Page | 12

Page l 42

C. IMPLEMENTATION

1. Medical Management

i. IVF Therapy

Name/s of Drug/s (generic

and Brand name)

Date Ordered/ Date taken/Given, Date

Changed/Discontinue

Route of Admin.

And Dosage and Frequency of Admin.

General Action,

Mechanism of Action

Indication/s, Purpose/s

Client’s Response to Med with actual S/E

D5LR

D5NM+ 100 mg tramadol

Sept. 16, 2009Date change:Sept. 18, 2009Sept. 20, 2009

Sept. 23, 2009

Intravenous

Intravenous

>contains sodium, chloride, potassium and calcium that can maintain balanced fluid and electrolytes.

>provides the major intracellular electrolytes (potassium, magnesium, and phosphorus) as well as sodium and chloride.

>used to restore vascular volume and to replace fluid and electrolytes that were loss in the patient

> used to replace fluid loss from the large intestine.

The patient felt better after the administration of the I.V meds.

The patient felt better after the administration of the I.V meds.

Nursing Responsibilities:

Before:

> Assess patient’s patency for insertion

>Observe sterile technique upon insertion

Page | 43

After:

>Assess for patient’s a reaction.

> Assess for pain, redness, swelling in the insertion site

ii. Drugs

Name/s of Drug/s

(generic and Brand name)


Changed/Discontinue

Route of Admin. And Dosage and Frequency of Admin.

General Action,

Mechanism of Action



Generic

Name:

oxytocin

Brand Name:

Oxytocin

Classification:

Uterine-active

agent

Sept. 16, 2009

Started at 6:50 am

10 units, 10-

15 gtts/ min

>thought

directly

stimulate

uterine

muscle

contractions.

>to induce or

stimulate

labor.

>nausea and

vomiting.


BEFORE:

>Explain the action and scientific explanation of drugs to the patient and family members

>Assess pt’s condition at starting therapy & regularly thereafter to monitor the drug’s effectiveness.

Page | 44

>Monitor patient closely for toxicity such as tremor, palpitations, increased heart rate, decreased BP, seizures, hypokalemia, muscle cramps, headache, and hyperglycemia.

AFTER:

>Proper disposal of syringe and other waste materials

>Check for infiltrations and thrombophlebitis

Name/s of Drug/s



Changed/Discontinue

Route of Admin.

And Dosage and Frequency of Admin.

General Action,

Mechanism of Action



Generic Name: Cefuroxime

Brand name: Zinacef

Classsification: Antibiotic

Sept. 16, 2009 750 mg IVP q 8 hr.

Interferes with bacterial cell wall, causing cell to die.

Gynaecologic Infections

>hyperactivity>headache>nausea and vomiting


BEFORE:


>Assess pt’s condition at starting therapy & regularly thereafter to monitor the drug’s effectiveness.

>Monitor patient closely for toxicity such as tremor, palpitations, increased heart rate, decreased BP, seizures, hypokalemia, muscle cramps, headache, and hyperglycemia.

AFTER:

>Proper disposal of syringe and other waste materials

>Check for infiltrations and thrombophlebitis

Page | 45

Name/s of Drug/s



Changed/Discontinue

Route of Admin. And Dosage and Frequency of Admin.

General Action,

Mechanism of Action



Generic

Name:

Ketorolac

Brand Name:

Toradol

Classification:

Analgesic

Sept. 16, 2009 30 mg IVP q

6 hr. times 6

doses

>Interferes

with

prostaglandin

biosynthesis

by inhibiting

cyclogenase

pathway

arachidonic

acid

metabolism.

>Moderately

severe pain

>the patient

experience

drowsiness

headache.

iii. Diet

Type of Diet Date OrderedDate StartedDate Changed

General Description

Indications or Purposes

Specific Foods taken

Client’s response and/or reaction to the diet.

SODIUM-RESTRICTED DIET

Sept. 16, 2009 Mildly restrictive 2 g sodium diet to extremely

Diet can be prescribed for patients with heart failure,

Foods allowed are fresh fruits and vegetables such as banana

>The patient was able to eat well.>the patient

Page | 46

Before:


> Assess patient’s infection before therapy

After:

>Assess patient’s condition after therapy.

>Be alert for adverse reactions & drug interactions

iii. Diet

LOW-FAT, CHOLESTEROL-RESTRICTED DIET

Sept. 16, 2009

restricted 200 mg sodium diet.

Low in fat foods

hypertension, renal disease, cirrhosis, toxemia of pregnancy, andcortisone therapy.

Diet can be prescribed for patients with hyperlipedimia, atherosclerosis, pancreatitis, cystic fibrosis, sprue (disease of

intestinal tract

characterized by malabsorption), gastrectomy, massive resection of small

intestine, and cholecystitis.

and cabbage.

Such as:

nonfat milk; low-carbohydrate, low-fat vegetables; most fruits; breads; pastas;

cornmeal; lean meats;

nsaturated fats

consumed 1 fresh fruits

>the patient gained appetite after the diet was ordered.>the patient was able to consume given foods.

Nursing Responsibilities:

Before:

> Assess patient’s appetite

After:

>Assess patient’s reaction after eating her meals

> Document any difficulty of eating

Page | 47

iv. Activity / Exercise

The patient is strictly on a bed rest thus restriction of work is implemented. The client has limited activity and performed ROM exercise such as shoulder and elbow exercises, hand and finger exercises, hip and knee exercises, , and ankle and foot exercises.

2. SURGICAL MANAGEMENT

The pt. undergone Low transverse segment Cesarian Section.

3. NURSING MANAGEMENT (SOAPIE)

See next page . . .

Page | 48

SOAPIES

September 19, 2009

Subjective Objective Assessment Planning Intervention Evaluation

S> O > pale in appearance

> cold and clammy skin

> noted pitting edema on

extremities and face (+2)

> weak pulse

> with delayed capillary

refill of 4 seconds

> FHT of 162 bpm @

10:00 am

> blood pressure of

140/90 mmHg @ 10:00

am

> pulse rate of 102bpm @

10:00 am

> respiratory rate of

22cpm @ 10:00 am

> temperature of 36.7 C

@ 10:00 am

Decreased cardiac

output related to

decreased venous

return

Within 5hrs of nursing

intervention, the client

will demonstrate

adequate cardiac output.

> Monitored maternal vital signs and fetal heart rate closely.

> Assessed changes in mental status.

> Positioned client in left lateral position.

> Instituted bed rest.

> Provided quiet environment and limit visitors.

> Elevated edematous extremities and avoid restrictive clothing.

> The following were encouraged to pt:a. Eat foods that are low in sodium and fats but high in protein and carbohydrate.b. Eat small meals and rest after wards.

c. Report any visual disturbances, severe headache, nausea and vomiting, epigastric pain and abdominal pain. d. relaxation such as deep breathing exercise.

> Administered supplemental oxygen as indicated.

After 5hrs of

nursing

intervention, the

client

demonstrated

adequate cardiac

output as

evidenced by:

>blood pressure,

pulse rate and

rhythm are within

normal

parameters

> Capillary refill

of 2 seconds.

Page | 49

September 19, 2009


S> O > pale in appearance

> cold and clammy skin

> noted pitting edema on

extremities and face (+2)

> weak pulse

> with delayed capillary

refill of 4 seconds

> FHT of 162 bpm @

10:00 am

> blood pressure of

140/90 mmHg @ 10:00

am


10:00 am

> respiratory rate of

22cpm @ 10:00 am

> temperature of 36.7 C

@ 10:00 am

> urine output of 170cc

from 7:00 am to 3:00 pm

Ineffective tissue

perfusion related

to vasoconstriction

of blood vessels.

After 6 hrs of nursing


will demonstrate

adequate tissue

perfusion.

> Monitored maternal vital signs and fetal heart rate closely.

> Monitored urine output

> Assessed changes in mental status.

> Positioned client in left lateral position.

> Instituted bed rest.

> Provided quiet environment and limit visitors.

> Elevated edematous extremities and avoid restrictive clothing.

> The following were encouraged to pt:a. Eat foods that are low in sodium and fats but high in protein and carbohydrate.b. Eat small meals and rest after wards.c. Report any visual disturbances, severe headache, nausea and vomiting, epigastric pain and abdominal pain. d. relaxation such as deep breathing exercise.

> Administered supplemental oxygen as indicated.

After 6 hrs of

nursing

intervention, the

client

demonstrated

adequate tissue

perfusion as

evidenced by:

> capillary refill

of 2 seconds

> Adequate urine

output.

Page | 50

September 19, 2009

SUBJECTIVE Objective Assessment Planning Intervention Evaluation

S>”Nag-aalala

ako sa magiging

kalagayan ng

anak ko”

O> > with an ongoing IVF

of 1L D5LR, received @

the level of 750cc @ right

hand regulated 30-31

gtts/min, infusing well

> poor eye contact

> voice changes in pitch

> fetal heart rate: 162 bpm

> irritable

> blood pressure of

140/90 mmHg @ 10:00

am


10:00 am

Anxiety related to

actual threats to

self/ fetus.

Within 1 hour of nursing

intervention, the patient

will be able to identify

healthy ways to deal with

and express anxiety.

> Established a therapeutic relationship, conveying empathy and unconditional positive regard.

> Provided information about pre eclampsia

>Explained the need for stress management to prevent further problems by encouraging patient to pray for the safety of the baby and herself.

> Encouraged patient to acknowledge and to express feelings.

> Provided comfort measures such as back rub and therapeutic touch.

>Instructed and encourage to do deep breathing exercises

After 1 hour of

nursing

intervention, the

patient would be

able to identify

healthy ways to

deal with and

express anxiety

as evidenced by

verbalization of

feelings about her

anxiety.

Page | 51

September 21, 2009


> “Masakit and

tahi ko.”

> Pain scale of 7

out of 10.

> with an ongoing IVF of 1L D5LR, received @ the level of 800 cc @ right hand, regulated 30-31 gtts/min, infusing well.

> with IFC, patent

> with grimace

> with guarding behaviour

> irritable

> wound dressing dry and intact

> Respiratory rate of 20 cpm @ 10:00 am

> Pulse rate of 98bpm @ 10:00am

> BP of 130/90 mmHg @ 10:00 am

Pain related to

incision.

Within 30 minutes of

nursing intervention, the

client pain scale of 7/10

will decrease.

> Monitored vital signs.

> Provided comfort measures such as touch therapy and straightening linens.

> Identified ways of avoiding/minimizing pain by splinting incision during coughing.

> The following were encouraged to the client:

a. Verbalization of feelings about pain.

b. the used of relaxation exercises such as deep breathing and coughing exercise.

> Administered medications as ordered

After 30 minutes

of nursing

intervention, the

client pain scale

of 7/10 decreased

to 3/10 as

evidenced by

absence of

grimace and

irritability.

September 21, 2009

Page | 52


S> O > with an ongoing IVF of

1L D5LR, received @ the

level of 800 cc @ right

hand, regulated 30-31

gtts/min, infusing well.

> with IFC, patent

> presence of suture

> wound dressing dry and

intact

> Respiratory rate of 20

cpm @ 10:00 am

> Pulse rate of 98bpm @

10:00am

> BP of 130/90 mmHg @

10:00 am

> Temperature of 37 C @

10:00am

Risk for infection

related to

postoperative site.

Within 8hrs of nursing


will be free from signs of

infection.

> Monitored vital signs especially temperature.

>Observed and reported signs of infection such as redness, warmth and increased body temperature.

>Used appropriate hand hygiene.

> The following were instructed to the client:

a.Complete any course of prophylactic antibiotic unless experiencing adverse reaction.

b. Promptly reported signs and Symptoms of infection such as redness, warmth, swelling, tenderness or pain and increased body temperature.

> Changed dressing as ordered.

>Administered medications as prescribed.

After 8hrs of

nursing

intervention, the

client manifested

free from signs of

infection as

evidenced by

absence of

redness, swelling

and other signs of

infection.

Page | 53

D. EVALUATION

1. Discharge Planning

Daily Program Saturday

Sept. 19,2009

Sunday

Sept. 20, 2009

Monday

Sept. 21, 2009

Nursing Problems

1. Decreased cardiac output related to decreased venous return.

2. Ineffective tissue perfusion related to vasoconstriction of blood vessels.

3. Anxiety related to actual threats to self/ fetus.

4. Pain related to incision site.

5. Risk for infection related to postoperative site

Identified

Identified

Identified

Resolved

Resolved

Resolved

Resolved

Resolved

Resolved

Identified/Resolved

Identified/Resolved

Vital signs T: 36.7 C

PR:102bpm

RR:22cpm

BP:140/90 mmHg

T: 37.2 C

PR:93bpm

RR:18cpm

BP:130/90 mmHg

T: 37 C

PR:98bpm

RR:21cpm

BP:130/90mmHg

Diagnostic & Lab. ProceduresMedical and Surgical Mgt.

N/A Cesarian Section N/A

Drugs - Cefuroxime750 mg IVP q 8 hr.

- Cefuroxime 750 mg IVP q 8 hr.

Page | 55

-Methyldopa

-HNBB

Ketorolac 30 mg IVP q

6 hr. times 6 doses

Diet Low fat and low sodium diet

NPO Low fat and low sodium diet

Activity / Exercise Passive ROM Flat on bed for 8 hours

May turn side to side

2. METHOD

The following is a discharge plan that is needed to be implemented by the client with the help of her significant others.

MEDICATIONS EXERCISE TREATMENT HEALTH

TEACHINGS

OPD

FOLLOW-UP

DIET

>Continue taking maintenance medications w/c includes the ff:- Cefalexin

- Mefenamic

acid

- Ferrous Sulfate

-Ascorbic Acid

>Perform Activities of Daily Living (ADL’s) as tolerated

> N/A- The patient has no further prescribed treatments.

>Instructed the patient to eat a well-balanced diet, low in fat and sodium to provide proper nourishment.

>Instructed the client to go on follow-up check-ups.

>Diet as tolerated.>foods low in fat and salt.

Page | 56

III. CONCLUSION

Choosing this case made the group more familiar about the things related to Pre-eclampsia. The group met the goal of this case. Now the group fully understand what Pre-eclmapsia is, its signs and symptoms, and the treatments for this condition. The group was able to apply the appropriate interventions needed by the patient. With our proper explanations, Mrs. X now understands what her condition is and how it is so crucial that it needs strict monitoring. In addition, the group, together with our patient, now increased our level of awareness and gained lots of knowledge with regard to Pre-eclampsia.

IV. RECOMMENDATION

As the patient was about to be discharged, our group recommended the following

health teachings to our client:

Adequate rest

Advise patient to have adequate sleep (6-8 hours).

Refrain doing strenuous activities like lifting heavy objects such as fetching water.

Advise client to take her medications regularly.

Implement ROM exercises

Avoid getting angry because it may trigger hypertension.

Eat nutritious foods especially those low in fat and sodium such as fruits, milk and

vegetables.

For the future researchers, the group recommends the following to:

Use appropriate assessment techniques to come up with a good assessment

Formulate a comprehensive health history

Make a comprehensive Pathophysiology of the condition

Develop good nursing care plans that are patient – oriented

Page | 57

V. BIBLIOGRAPHY

Carroll SG, Ville Y, Greenough A, Gamsu H, Patel B, Philpott-Howard J, Nicolaides

KH. Preterm prelabour amniorrhexis: intrauterine infection and interval between membrane rupture and delivery. Arch Dis Child 1995

COPAR by Untalan book

cureresearch.com/p/preeclampsia/stats-country.htm

Fundamentals of Anatomy and Physiology by Donald Rizzo

Fundamentals of Nursing by Barbara Kozier

Health Assessment and Physical Examination 3rd Edition Mary Ellen Zator Estes

Maternal and Child Health Nursing, Fourth Edition by Piliterri

Medical and Surgical Nursing by Brunner and Suddarth’s book

Medical and Surgical Nursing by Hawk and Black

Mosby medical, nursing and allied health dictionary, sixth edition

Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions

NANDA Book

Nutrition and Diet therapy, 9th edition, Ruth Roth

Wigglesworth JS, Desai R. Female reproductive system. Early Hum Dev 1979; 3:51–65

www.doh.gov.ph

www.themedicalnews.com

www.who.int

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Page | 59

preeclampsia

Documents

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mild eclampsia

cases of preeclampsia

incidence of preeclampsia

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