Pih Case Final .docx

I.

Introduction It was the fourth (4th) day of our hospital exposure at Tarlac Provincial Hospital-Delivery Room when we found our prospect patient for our case study. For the purpose of confidentiality we will call our prospect, Mrs. Rosalinda. She 39 years of age and presently residing at San Miguel, Tarlac with her husband Carlos Miguel. Mrs. Rosalinda was admitted on June 29, 2009 complaining of epigastric and labor pains. On admission, she was diagnosed with preeclampsia at 38 weeks AOG and a BP of 160/100 Definition Preeclampsia is a complication of pregnancy. In preeclampsia, the woman has dangerously high blood pressure, swelling (edema) and protein in the urine (proteinuria). Blood pressure rises from 140/90 mm Hg to 160/110 mm Hg. High blood pressure is first noted sometime after week 20 of pregnancy and is accompanied by protein in the urine (2g of protein in 24 hour urine or 2+ to 3+ on qualitative examination) Risk Factors Preeclampsia is most common among women who have never given birth to a baby (called nulliparas). About 7% of all nulliparas develop preeclampsia. The disease is most common in mothers under the age of 20 or over the age of 35. Other risk factors include poverty, multiple pregnancies (twins, triplets, etc.), pre-existing chronic hypertension or kidney disease, diabetes, excess amniotic fluid, and a condition of the fetus called nonimmune hydrops. The tendency to develop preeclampsia appears to run in families.The daughters and sisters of women who have had preeclampsia are more likely to develop the condition. Causes and symptoms Experts are still trying to understand the exact causes of preeclampsia and eclampsia. It is generally accepted that preeclampsia and eclampsia in general are problematic because these conditions cause blood vessels to leak. The effects are seen throughout the body. • General body tissues. When blood vessels leak, they allow fluid to flow out into the tissues of the body. The result is swelling in the hands, feet, legs, arms, and face. While many pregnant women experience swelling in their feet, and sometimes in their hands, swelling of the upper limbs and face is a sign of a more serious problem. As fluid is retained in these tissues, the woman may experience significant weight gain (two or more pounds per week). • Brain. Leaky vessels can cause damage within the brain, resulting in seizures or coma.

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

1

• Eyes. The woman may experience problems seeing, and may have blurry vision or may see spots. The retina may become detached. • Lungs. Fluid may leak into the tissues of the lungs, resulting in shortness of breath. • Liver. Leaky vessels within the liver may cause it to swell. The liver may be involved in a serious complication of preeclampsia, called the HELLP syndrome. In this syndrome, red blood cells are abnormally destroyed, chemicals called liver enzymes are abnormally high, and cells involved in the clotting of blood (platelets) are low. • Kidneys. The small capillaries within the kidneys can leak. Normally, the filtration system within the kidney is too fine to allow protein (which is relatively large) to leave the bloodstream and enter the urine. In preeclampsia, however, the leaky capillaries allow protein to be dumped into the urine. The development of protein in the urine is very serious, and often results in a low birth weight baby. These babies have a higher risk of complications, including death. • Blood pressure. In preeclampsia, the volume of circulating blood is lower than normal because fluid is leaking into other parts of the body. The heart tries to make up for this by pumping a larger quantity of blood with each contraction. Blood vessels usually expand in diameter (dilate) in this situation to decrease the work load on the heart. In preeclampsia, however, the blood vessels are abnormally constricted, causing the heart to work even harder to pump against the small diameters of the vessels. This causes an increase in blood pressure. The most serious consequences of preeclampsia and eclampsia include brain damage in the mother due to brain swelling and oxygen deprivation during seizures. Mothers can also experience blindness, kidney failure, liver rupture, and placental abruption. Babies born to preeclamptic mothers are often smaller than normal, which makes them more susceptible to complications during labor, delivery, and in early infancy. Babies of preeclamptic mothers are also at risk of being born prematurely, and can suffer the complications associated with prematurity. Prognosis The prognosis in preeeclampsia (and eclampsia) depends on how carefully a patient is monitored. Very careful, consistent monitoring allows quick decisions to be made, and improves the woman’s prognosis. Still, the most common causes of death in pregnant women are related to high blood pressure. About 33% of all patients with preeclampsia will have the condition again with later pregnancies. Eclampsia occurs in about 1 out of every 200 women with preeclampsia. If not treated, eclampsia is almost always fatal.

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

2

II.

Objectives a. Establish rapport and gain the trust and cooperation of the patient and immediate family members. b. Perform and obtain thorough and complete physical assessment using the assessment techniques following the cephalocaudal approach; obtain complete medical, socio-cultural, and family history related to the patient’s current health condition. c. Analyze and prioritize problems based from the gathered pertinent data to come up with the correct nursing diagnoses. d. Plan the appropriate nursing interventions to address the patient’s health needs. The interventions should address not only the physical well being of the patient but also her emotional, social, and mental welfare. e. Implement the planned nursing interventions to meet the desired outcomes and help improve patient’s condition. f. Impart useful health teachings to the patient and immediate family members to prevent further development of the patient’s condition and other related complications, and for the patient to be able to adjust well and continue with her normal life after being discharged from the hospital.

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

3

III.

Nursing health history a. Biographical information Surname: X First name: Rosalinda Age: 39 Nationality: Filipino Address: Brgy. San Miguel Tarlac City b. Reasons For seeking Health Care

Middle name: Z

Mrs. X seeks for health care because of the chief complains of labor pain c. Client Expectation Mrs. X has expectation in the following areas:  Information needed about his disease process and involvement in decision making.  Caring and compassion expressed by care providers.  Timelines of caregiver’s response to client request.  Relief of pain and symptoms.  Deliver the neonate safely. d. Present Illness Mrs. X came to the emergency room last Tuesday, June 30, 2009 after her client meeting and subsequently complaining of severe epigastric and labor pain.

e. Past Health History Mrs. X has only been hospitalized on her first born delivery. f. Family History Mrs. X has verbalized that the only heredo-familial disease that they have was hypertension on her mother side. g. Immunization She verbalized that she had a complete vaccination. BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

4

h. Nutrition She verbalized that she primarily eats vegetable and meat. i. Environment History Mrs. X leaves at San Miguel, Tarlac City. Their concrete type of house is located in a residential area with good ventilation. Their water source was on water pump but they buy drinking water and their garbage was being burn. j. Psychosocial History Mrs. X stated that she has a lot of support system coming from her family and relatives. k. Spiritual Health Mrs. X is a Roman Catholic and makes it a point to visit and attened a mass every Sunday with her husband. Their beliefs about life. Their source for guidance in acting their beliefs, and the relationship they have in exercising their faith is truly God centered manner.

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

5

IV.

Assessment

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

6

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

7

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

8

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

9

V.

Anatomy and physiology Renal system

The excretory system consists of the kidneys, the ureters, the urinary bladders, and the urethra. The kidneys are the major excretory organs of the body. The skin, liver, lungs, and intestines eliminate some waste products, but if the kidneys fail to function, these other excretory organs cannot adequately compensate. The Urinary system eliminates waste, regulates blood volume, ion concentration and pH; and it is involve with red blood cell production.

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

10

1. Approximately 180 L of filtrate enters the nephrons each day; of that volume 65% is reabsorbed in the proximal tubule. In the proximal tubule, solute molecules move by active transport and cotransport from the lumen of the tubule into the interstitial fluid. Water moves by osmosis because the cells of the tubule wall are permeable to water. 2. Approximately 15% of the filtrate volume is reabsorbed in this segment of the descending limb of the loop of Henle. The concentrated interstitial fluid of the medulla. Because the wall of the descending limb is permeable to water, water moves by osmosis from the tubule into the more concentrated interstitial fluid. By the time the filtrate reaches the tip of the renal pyramid, the concentration of the filtrate is equal to the concentration of the interstitial fluid. 3. The descending limb into the loop of Henle is not permeable to water. Solutes diffuse out of the thin segment. 4. Na+, K+, and Cl- are cotransported across the apical membrane of the thick segment. Na+ is actively transported and K+ and Cl- diffuse across the basal membrane of the epithelial cells of the thick segment into the interstitial fluid. 5. The volume of the filtrate doesn’t change as it passes through the ascending limb, but the concentration is greatly reduced. By the time the filtrate reaches the cortex of the kidney, the concentration is approximately 100 mOsm/L, which less concentrated than interstitial fluid of the cortex. BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

11

6. The distal tubule and collecting are permeable to water if ADH is present. If ADH is present, water moves by osmosis from the less concentrated filtrate into the more concentrated fluid. By the time the filtrate reaches the tip of the renal pyramid an additional 19% of the filtrate is reabsorbed. 7. One percent or less remains as urine. Vascular system

The heart provides the major force that causes blood to circulate, and the peripheral circulation functions to carry blood, exchange nutrients, waste products, and gases, transport hormones, components of the immune system, molecules required for coagulation, enzymes, nutrients, gases, waste products, and other substances are transported in the blood to all areas of the body, regulate blood pressure, and direct blood flow. Blood flows from the heart through elastic arteries, muscular arteries, and arterioles to the capillaries. Blood returns to the heart from the capillaries through venules, small veins, and large vein. Layers of blood vessels The tunica intima consists of endothelium, a delicate connective tissue basement membrane, a thin layer of connective tissue called the lamina propia, and a fenestrated layer of elastic fibers call the internal BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

12

elastic membrane. The internal elastic membrane separates the tunica intima from the next layer, the tunica media. The tunica media, or middle layer, consists of smooth muscle cells arranged circularly around the blood vessel. The amount of blood flowing through a blood vessel can be regulated by contraction or relaxation of the smooth muscle in the tunica media. A decrease in blood flow results from vasoconstriction, an increase in blood vessel diameter because of smooth muscle relaxation. The tunica adventitia is composed of connective tissue, which varies from the dense connective tissue near the tunica media to loose connective tissue that merges with the connective tissue surrounding the blood vessels. Female Reproductive System

The vagina is a muscular, hollow tube that extends from the vaginal opening to the uterus. The vagina is about 3 to 5 inches (8 to 12 centimeters) long in a grown woman. Because it has muscular walls it can expand and contract. This ability to become wider or narrower allows the vagina to accommodate something as slim as a tampon and as wide as a baby. The vagina's muscular walls are lined with mucous membranes, which keep it protected and moist. The vagina has several functions: for sexual intercourse, as the pathway that a baby takes out of a woman's body during childbirth, and as the route for the menstrual blood (the period) to leave the body from the uterus. The vagina connects with the uterus, or womb, at the cervix. The cervix has strong, thick walls. The opening of the cervix is very small (no wider than a straw), which is why a tampon can never get lost inside a girl's body. During childbirth, the cervix can expand to allow a baby to pass. BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

13

The uterus is shaped like an upside-down pear, with a thick lining and muscular walls - in fact, the uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. When a woman isn't pregnant, the uterus is only about 3 inches (7.5 centimeters) long and 2 inches (5 centimeters) wide. At the upper corners of the uterus, the fallopian tubes connect the uterus to the ovaries. The ovaries are two oval-shaped organs that lie to the upper right and left of the uterus. They produce, store, and release eggs into the fallopian tubes in the process called ovulation .Each ovary measures about 1 1/2 to 2 inches (4 to 5 centimeters) in a grown woman. There are two fallopian tubes, each attached to a side of the uterus. The fallopian tubes are about 4 inches (10 centimeters) long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area wraps around the ovary but doesn't completely attach to it. When an egg pops out of an ovary, it enters the fallopian tube. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus. The ovaries are also part of the endocrine system because they produce female sex hormones such as estrogen and progesterone. Placenta

The placenta or afterbirth is a highly vascularized ephemeral organ present in placental vertebrates that connects the developing fetal tissues to the uterine wall. The placenta supplies the fetus with maternal nutrients, and allows fetal waste to be disposed of via the maternal kidneys.

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

14

In humans, the placenta averages 22 cm (9 in.) in length and 2-2.5 cm (0.8-1 in.) in thickness. 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 in.) in length that contains two arteries and one vein. The umbilical cord inserts into the chorionic plate. 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..

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

15

VI.

Pathophysiology

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

16

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

17

VII.

Medical management Doctor’s orders Post partum order On June 29, 2009 at 7:00 pm the doctor ordered to ward and IVF to consume DAT. He also ordered to follow up lab results. Medications prescribed are cefalexin TID, FeSO4 OD, Mefinamic Acid TID. Also ordered is to put ice pack over fundus, massage uterus as needed, perineal hygiene and to watch out for profuse vaginal bleeding, refer. On june 30, 2009 at 3:50pm the doctor ordered to admit patient to OB service charity ward and to secure consent. He also ordered to monitor and record TPR every shift. The patient is also under a DAT diet. The patient is for diagnostic for CBC, U/A, blood typing, and HBsAg, with IVF of D5LRS 1L for 8 hours. Medications prescribed are HNBB 1 amp, for IVP every 4 hours, MgSO4 5g deep IM in each buttocks and Hydralazine 5mg IVP. To Labor Room, for perenial prep, monitor Vital signs FHT POL and record, to refer accordingly. Last july 01, 2009 the doctor ordered NPO at 10pm, for blood chem. tomorrow. July 02, 2009, the doctor ordered to continue medications, start nefedipine 30g stat then OD, carry out blood chem. then refer. With BP of 150/90, negative fever, negative haldz, negative profuse vaginal bleeding, negative pain C/L CBS

July 03, 2009 the doctor ordered continue meds with low, salt low fat diet. Follow up blood chem.

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

18

Drug study

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

19

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

20

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

21

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

22

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

23

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

24

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

25

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

26

Laboratory Analyzed: 06/30/09 19:04 Blood type “A” Test Result

Reference

WBC

14.2 G/L

4.1-10.9 G/L

LYM

1.5 10.3%L

0.6-4.1

10.0-58.5%L

Normal

Increase MID

0.4 2.7%M

0.0-1.8

0.1-24.0%M

Normal

12.4 87.0%G

2.0-7.8

37.0-92.0%L

Above normal values

RBC

3.87 T/L

4.20-6.30 T/L

Below normal values

HGB

117. g/L

120.-180. g/L

Below normal values

HCT

.348 L/L

.370-.510 L/L

Below normal values

MCV

89.9 f/L

80.0-97.0 f/L

Normal

MCH

30.2 pg

26.0-32.0 pg

Normal

MCHC

336. g/L

310.-360 g/L

Normal

PLT

289. G/L

140.-440. G/L

Normal

GRAN

Range (LIMIT 2)

Findings Above normal values

MID cells may include less frequently occurring and rare cells correlating to monocytes, eosinophils, basophils, blasts and other precursor white cells HBsAg – NON REACTIVE

VIII.

Nursing Management a. NCP

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

27

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

28

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

29

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

30

b. NURSE’S NOTES On june 30, 2009, patient was admitted to ER, with the chief complaint of labor pain @ 3:3OPM. Patient’s vital signs were taken and recorded and with BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

31

IVF of D5lr L @ 3Ogtts/min, afebrile, on NPO, with uterine contraction, IE done, cervix fully dilate, and medications are given. At 4:50pm, patient delivered spontaneously alive baby boy attended by Dr.Valdoz, placenta out completely, BP recorded at 170/110, oxytocin incorporated to IVF,and massage uterus till firm & contracted. At 5:30pm administered MgS04 5g deep IM on each buttock,placed ice pack over fundus,latest BP 150/110 At 6:30pm patient y transfered,afebrile,(-) DOB,with ongoing IVF of D5LR 1L infusing well,withminimal vaginal bleedin,DAT instructed.

IX.

METHODS M-Cefalexin, Mefenamic acid, Ferrous sulphate BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

32

E- Early ambulation to promote peristalsis, and circulation T-CBC, BT, Hepa-B screening, UA, B-HCG, CXR-PAT H-Deep breathing exercises- to promote lung expansion Pursed-Lip breathing- to prevent lung collapse Coughing exercise- to remove excess secretion and help prevent air tripping. Educate on avoiding pregnancy for 1yr. or Birth spacing O- Return to TPH-OPD after 1 week from discharge (07-07-09) D- DAT S- Continue activities of daily living

X.

Recommendation

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

33

As a recommendation, the patient is adviced to monitor her blood pressure by having regular visits / check up to her doctor. She is also encouraged to improve her daily diet for her body to obtain the needed nutrients so she could quickly recuperate. Since the patient has verbalized desire to have another baby, she was also adviced to take extra precaution and watch for signs of preeclampsia. She is now aware of her condition and thereby encouraged to maintain a clean healthy lifestyle.

XI.

Evaluation. BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

34

Nurse centered The student-nurses from group 11 section C were able to obtain complete knowledge on the patient’s condition; analyse and prioritize problems; plan the appropriate nursing interventions and were able to implement the nursing care plans. The student-nurses were also able to impart useful health teachings to the patient and her family to be able to perform self-care. Patient centered There was a significant change to the patient’s condition from the time she was admitted up to the present: her blood pressure has decreased from 180/120 mmHg to 130/90 mmHg.

BSN 3F – Delivery Room Area | Case Study: Preeclampsia Group 24

35