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I. INTRODUCTION Description of the Disease Preeclampsia, also referred to as toxemia, is a condition that pregnant women can get. It is marked by high blood pressure accompanied with a high level of protein in the urine. Women with preeclampsia will often also have swelling in the feet, legs, and hands. Preeclampsia, when present, usually appears during the second half of pregnancy, generally in the latter part of the second or in the third trimesters, although it can occur earlier. In addition symptoms of preeclampsia can include: • Rapid weight gain caused by a significant increase in bodily fluid • Abdominal pain • Severe headaches • A change in reflexes • Reduced output of urine or no urine • Dizziness • Excessive vomiting and nausea The exact causes of preeclampsia are not known, although some researchers suspect poor nutrition, high body fat, or insufficient blood flow to the uterus as possible causes. The only real cure for preeclampsia and eclampsia is the birth of the baby. Mild preeclampsia (blood pressure greater than 140/90) that occurs after 20 weeks of gestation in a woman who did not have hypertension before; and/or having a small amount of protein in the urine can be managed with careful hospital or in-home observation along with activity restriction. The group chose the case for the reason that they wanted to show the readers the process on how pre-eclampsia occurs and for them to fully understand and be reminded on one of the complications associated with pregnancy. In developing countries: preeclampsia/eclampsia impact 4.4% of all deliveries (1) and may be as high as 18% in some settings in Africa (2) If the rate of life threatening eclamptic convulsions (0.1% of all deliveries) is applied to all deliveries from countries considered to be the least developed, 50,000 cases of women experiencing this serious complication can be expected each year. According to Safe Motherhood.org of the 585,000 maternal annually (3), 13%, or 76,050, are due to eclampsia. II. NURSING HISTORY

Mrs. Ob, a 39 years old housewife and first time mother, who currently resides at Guagua Pampanga with her husband Mr. Gyne. She was born a Filipina on November 9, 1969 in Sta. Rita Guagua Pampanga. The patient was admitted at a Regional Hospital with a chief complaint of abdominal pain, last November 15, 2008 at around 3:00 p.m. b.) Socio-Economic and Cultural Factors Mrs. Ob is plain housewife and her husband is an extra laborer on a construction site. She graduated at a Public High School. And she didn’t continue her college level due to financial problem. Mrs. Ob was raised as a Roman Catholic, were she learned about religious values but she still believes in super natural forces and superstitious beliefs. When it comes in health matters, she seeks the help of a albularyo and uses herbal medicines to treat any member of the family who has an ailment. But when serious matters arise she still refers to medical professionals for help. c.) Environmental factors

Ms. Ob resides at Guagua Pampanga and occupies the ancestry house of her family. The location of their house is not easily accessible to hospitals, health centers and other government institutions. Mrs. Ob did not report any problems regarding her environment which interfered to her pregnancy. Maternal-child Health History

a.) Maternal – Obstetric record (for OB cases) Mrs. Ob was married to Mrs. Gyne at the age of 33 years old. She has a record of T1P0A0L1M0 at her 39th week of gestation. She underwent low transverse ceasarian section under a certain obstetrician at the regional hospital last November 18, 2008 at around 10:00 in the evening, she delivered her 1st child who is term baby with hyperbilirubinemia. b.) Antepartal/ Prenatal Preparation When Mrs. Ob was still pregnant, she only consulted once in a district hospital all throughout. c.) Significant Trimestral Changes (1st to 3rd trimester) Mrs. Ob rxperienced some changes in her pregnancy, such as striae gravidarum, linea nigra, and melasma. She also experienced nausea and vomiting, dizziness, and headache.

a.) Demographic Data DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic or Laboratory Procedure

Indication or Purpose

Date Ordered and Date Results were released

Results

Normal Values

Analysis and Interpretation of Results

WBC Count

To determine infection or inflammation Pre-operation assessment of the patient.

November 16, 2008

8.0

5-10 x 109/L

RBC Count

Pre-operation assessment of the patient.

November 16, 2008

3.3

4.2-5.4 x 1012 /L

Decreased RBC count on pregnant is normal because of the increase in plasma volume during pregnancy.

Hemoglobin

Pre-operation assessment of the patient.

November 16, 2008

96

120-160g/L

Hematocrit (%)

Pre-operation assessment of the patient.

November 16, 2008

0.29

0.37-0.47 g/L

The result indicates that a 1000 ml sample of blood contains 96 g of hemoglobin. Decreased hemoglobin on pregnant is normal because of their increase in plasma volume. The result indicates that a 1000 ml sample of blood contains .29 g of hemoglobin. Decreased hematocrit on pregnant is normal because of their increase in plasma volume.

Nursing Responsibilities Laboratory Procedures

During

Different

White Blood Cell Count Before • Explain to the patient that the WBC test is used to detect an infection or inflammation. • Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. • Explain to the patient that he may experience slight discomfort from the needle puncture and the tourniquet. • Inform the patient that he should avoid strenuous exercise for 24 hours before the test. Also tell him that he should avoid eating a heavy meal before the test. • If the patient is being treated for an infection, advise him that this test will be repeated to monitor his progress. • Notify the laboratory and physician of medications the patient is taking that may affect test results: they may need to be restricted. During • Ensure subdermal bleeding has stopped before removing pressure.

No infection or inflammation is present.

After • If a hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is large, monitor pulses distal the venipuncture site. • Inform the patient that he may resume his usual diet, activity and medications discontinued before the test, as ordered. • A patient with severe leucopenia, they have little or no resistance to infection and requires protective isolation. Red Blood Cell Count Before • Explain to the patient that RBC count is used to evaluate the number of RBCs and to detect possible blood disorders. • Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. • Explain to the patient that he may experience slight discomfort from the needle puncture and the tourniquet. • Inform the patients that he need not restrict foods and fluids During • Ensure subdermal bleeding has stopped before removing pressure.

After • If a hematoma develops at venipuncture site, apply warm soaks.

• the

Hemoglobin Before • Explain to the patient that the hbg test is used to detect anemia or polycythemia or to assess his response to treatment. • Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. • Explain to the patient that he may experience slight discomfort from the needle puncture and the tourniquet. During

•

Ensure subdermal bleeding has stopped before removing pressure.

After • If a hematoma develops at the venipuncture site, apply warm soaks. Hematocrit Before

• • •

Explain to the patient that hct is tested to detect anemia and other abnormal conditions Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. Explain to the patient that he may experience slight discomfort from the needle puncture and the tourniquet. Inform the patients that he need not restrict foods and fluids

During • Ensure subdermal bleeding has stopped before removing pressure. After • If a hematoma develops at venipuncture site, apply warm soaks. III. THE PATIENT AND HIS ILLNESS

the

Efforts to unravel the pathogenesis of preeclampsia have been hampered by the lack of clear diagnostic criteria for the disease and its subtypes. Consequently, several studies have included a variety of other conditions that do not necessarily reflect an adverse pregnancy outcome.

Abnormal placentation (stage 1), particularly lack of dilatation of the uterine spiral arterioles, is the common starting point in the genesis of pre-eclampsia, which compromises blood flow to the maternal–fetal interface. Reduced placental perfusion activates placental factors and induces systemic hemodynamic changes. The maternal syndrome (stage 2) is a function of the circulatory disturbance

cascade and loss of vascular integrity. Preeclampsia has effects on most maternal organ systems, but predominantly on the vasculature of the kidneys, liver and brain. Nursing Responsibilities:

• Check the doctor’s order • Explain the procedure to the patient • Tell the patient that she might feel a discomfort from the tourniquet and the IV insertion

• Check and monitor IVF regulation and level of fluid

• Check if there is a need for removal and replacement of fluid

• Check if the tube is in the vein and signs of edema

caused by systemic maternal endothelial cell dysfunction resulting in vascular reactivity, activation of coagulation VIII. Discharge Plan General Condition of client upon discharge During nurse-patient interaction upon discharge, the patient was wearing a comfortable pair of white shirt and white pajama and a pair of flat slip-ons while being sealed on a chair cuddling her baby boy. Her hair was untidy and up in a ponytail with visible infestations. She was oriented enough to follow instructions and answers questions asked by the student nurse. Methods M- Instructed the patient to take the following home medication as ordered by the physician: Mefenamic Acid 500mg PRN Ferrous Sulfate OD Nifedipine 10mg BID E- Instructed patient to avoid strenuous activities. And practice deep breathing exercise. T- n/a H- Instructed patient to take a bath everyday. Emphasize the importance of breast feeding. O- Advice to visit or have a follow up check-up with her attending physician. D- Low fat, Low salt diet.

• Check if there is a back-flow of blood • Check if there is bubbles present in the tube • Always Monitor V/S.

With this study, the student nurses were able to gain more knowledge and wider view and perspective of the complication of pregnancy which is pre-eclampsia. Thus, the student nurses would like recommend and share some pointers on how to deal with different diseases with pregnancy specifically pre-eclampsia. To the government, primarily they should allocate sufficient budget to sustain and provide better facilities. They must be responsible enough to create awareness program for care and management for all the Filipino people. To the health care team, they should righteously implementing basic and ideal procedures regardless of the health care facilities where they belong. They must observe and always remember to keep in line with their duties towards both the mother and the child during the pregnancy. To the community and the family, that they must be insufficient coordination with the government and the health care team regarding promotion of health before, during, and after the delivery of the baby.

IX. Conclusion Nurses can help the nation achieve National Health Goals. These goals speak directly to both fetus and the mother because pregnancy is a high risk factor for them. Close monitoring in pregnant women and health teaching as much as possible about pregnancy could definitely reduce life threatening complications. Studies shows that there is no certain facts that will give us the idea where pre-eclampsia arise. But there so many factors that could prevent this complication such as diet modifications, proper compliance with the health care providers, proper exercise. And if the complication is already present, proper monitoring, proper diet and drug compliance should be ruled in. X. Recommendations

Chapter IV Discharge Planning Medication Drug to be continued, Hydralazine (Apresoline) oral. For maintenance, adjust dosage to the lowest effective levels. Exercise The client should limit the no. of stairs she climbs to one flight/dayfor the first week at home. Beginning the second week, if her lochial discharge is normal, she may start to increase this activity. Limit stair climbing to only when necessary for first two weeks. Treatment Advice client to monitor blood pressure, take prescribed medications and perform wound care as needed.

Health Teaching Teaching should focus on action to maintain comfort, to promote healing and restore wellness.  avoid heavy work (lifting or straining) for at least first 3 weeks after birth. (it is usually advised that she doesn’t return to an outside for at least 3 weeks (better 6 weeks) not only for her own health but also for enjoyment of the early weeks with her newborn. Explore with th client what she consider heavy work)  get lots of sleep. Sleep when baby sleeps. (Client should at least 1 rest period a day and try to get a good night’s sleep. She can rest during the day when her newborn is sleeping.)  take advantage of help from others.  avoid having sexual intercourse at least a month  call your health care provider if you have any of the warning signs of sickness: (fever greater than100F, severe pain, redness or swelling in the incision site, foul smelling vaginal discharge, increase bleeding, back ache or severe abdominal pain or cramping (unrelieved by medication).)  report increasing pain, swelling, or opening or gaping of wound edges.  teach the client how to change wound dressings and perform wound care.  instruct client to use pain medication as ordered.  emphasize the importance of hygiene and hand washing to prevent infection Out Patient follow-up The client should return to her physician 2-4 weeks after. Diet The client’s diet is high protein and low sodium diet.

Cues S-“sumasakit nga daw ung tahi niya at sumusigaw siya” as the SO verbalized

Nursing diagnoses Acute pain related to postparum

O- facial grimaces Rated pain as 8 in a pain scale of 110, 10 being the highest Guarding behavior

Cues S-“ayoko na muna dapat mabuntis kc papangit ung katawan ko tsaka bat ang itim ng pek-pek ko” as pt verbalized

Scientific Explanation Unpleasant sensory experience arising from post surgical incision from cesarean section.

VI. NURSING CARE PLAN Objective After 2-4 hr of nursing intervention, the pt rate the pain from 8 to 3 in a pain scale of 1-10

Nursing diagnoses Disturbed body image related to pregnancy AEB changes in appearance

Scientific Explanation Severity of the abdominal wound due to surgery, a new type of tissues develops that eventually will causes scar formation

Objective After 2-4 hrs of nursing intervention, the patient will able to understand the change of body image.

S: “bumibilis nga

Nursing diagnoses Decreased

Scientific Explanation Pregnancy Induced

Objective After 4 hrs of

Rationale -to promote pain management.

-Encouraged to do deep breathing exercise

-to reduce tension

- Encouraged adequate rest period

-to prevent fatigue

- Encouraged to support the affected area upon movement

O-presence of melasma -presence of bipedal edema

Cues

Nursing intervention - Provide quite environment

-to reduce pressure on the affected area

Nursing intervention -Encouraged client to looked/ touch the affected body area

-to begin to incorporate changes into body image.

-Encourage the client to have a daily exercise.

-to bring back the usual physical images.

-Advised the SO to give support to the pt (especially emotional feelings)

-to feel that the patient still worthy.

-Assist pt to identify positive behavior

-to aid in recovery.

Nursing intervention -Keep client on

Expected outcomes Goal Partially met AEB pt rated the pain from 8 to 5 in a pain scale of 110

Rationale

Rationale - decreases

Expected outcomes Goal met the patient recognized and verbalized understanding of body changes.

Expected outcomes Goal Met AEB

tibok ng puso ko” verbalized by the patient

O: -with the tenderness of abdominal are -facial grimaces

cardiac output related to altered heart rate (111 bpm) AEB tachycardia, pt’s report of palpations; (r/t) decreased venous return AEB edema (ankle), SOB (28)

-BP= 160/100 mmhg RR= 28 cycles per min.

Hypertension is a condition in which vasospasms occur. It is caused by altered cardiac output that injures endothelial cells of the arteries. Blood vessels become less resistant to pressor substances. This results to vasoconstriction and increases BP dramatically

nursing intervention, the patient will display hemodynamic stability (heart rate will decrease from 111 bpm to 100 bpm, BP from 140/100 to 120/80)

bed and in position of comfort

oxygen consumption

-decrease stimuli; provide quiet env’t

-to promote adequate rest -to reduce anxiety

-Encouraged deep breathing exercise -Encouraged changing positions slowly -give information about positive signs of improvement

PR= 111 bpm

-Instruct client to avoid or limit activities that may stimulate valsalva response (rectal stimulation, bearing down B.M) Cues SO- decreased ambulation of the patient bcs of pain and the complete bed rest ordered of the physician.

Nursing diagnoses Risk for constipation related to post CS delivery.

Scientific Explanation Constipation may happen due to disturbance of normal bowel movements because intestines were displaced during surgical procedure.

Objective After 4 hrs of nursing intervention, the patient will verbalize understanding the etiology and appropriate intervention if constipation may occur.

Nursing intervention - Educate patient/ SO about safe and risky practices for managing constipation. - Instruct balance fiber and bulk in diet and fiber supplements.

within 4 hrs. of nursing intervention the pt. HR decreased from 111 bpm to 100 bpm, BP from 140/100 to 120/80 (Normal BP)

-to reduce risk for orthostatic hypotension -to provide encouragement -to prevent in changes in cardiac pressures or impede blow flow

Rationale - Information can help client to make beneficial choices when need arises. - To improve consistency of stool and facilitate passage

Expected outcomes Goal Met AEB the patient verbalized understanding about constipation and gained knowledge of appropriate intervention.

- Promote adequate fluid intake, also suggest drinking warm fluids. - Encourage activity within limits of individual ability. Cues O- postpartum surgery

Nursing diagnoses Impaired Skin Integrity related to surgery

Scientific Explanation The incision from the cesarean section altered the skin integrity making it more susceptible to pathogens and even the pt’s normal flora

Objective After 2-4 hrs of nursing intervention, the patient will able to know the preventive measures of wound healing

Nursing intervention -stress proper hand hygiene. -Encouraged to increase foods that are rich in protein

through colon. - To promote soft stool and stimulate bowel activity. -To stimulate constrictions of the intestines Rationale - to control the spread of infection. - to aid in tissue repair

-Encouraged proper clothing

-to maintained the proper skin moisture.

-Apply appropriate dressing

-to help in wound healing

Expected outcomes Goal Met AEB the patient was able to knew the preventive measures of wound healing