Pre-eclampsia: A Case Study
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Holy Angel University Angeles City College of Nursing
Pre-Eclampsia
December 05, 2008
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.
Nurse-Centered Objectives Upon completion of this case study, the student nurse should be able to: 1. Identify the risk factor contributing to the occurrence of the disease. 2. Formulate significant nursing diagnosis, with the significantly related nursing care plan. 3. Identify the different medications administered for this disease their indications, contraindications, side effect, and specific responsibility . 4. Identify the laboratory and diagnostic procedure done with the pre-eclamptic
patient, their indication and purposes, and specific nursing responsibilities. Client-Centered Objectives Upon completion of this case study, the client should be able to: 1. Understand awareness of her disease. 2. Know the possible causes of the disease. 3. Learn and understand why such laboratory examinations are being done.
II. NURSING HISTORY a.) Demographic Data
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.
Family Health Illness History
Grandmother
Grandmother
Grandfather
Grandfather
Father Mother
Patient
π
Legend:
hypertension
pneumonia
died of old age
asthma
deceased
π
pre eclampsia
*pink border – mother side *blue border – father side *violet border - patient
Both the grandparents from the mother’s side died from old age. From the father’s side, the grandmother died from Hypertension and the father was died from Pneumonia. The mother is not experiencing any health problems but the father has hypertension and asthma. The patient, upon admission has elevated blood pressure and is suffering from aggravating factors like anxiety, nervousness and fear.
PHYSICAL ASSESSMENT November 27, 2008
SKIN
•
brown skin generally uniform in color except in areas exposed to the sun
•
skin temperature uniform and within the normal range (37°C)
•
when pinched, skin readily springs back to previous state
•
moist skin folds
•
nails with smooth texture
•
nail beds pink
•
prompt capillary refill time (2 seconds)
•
bipedal non-pitting edema
•
absence of nodules or masses
•
symmetric facial features and movements
•
symmetric nasolabial folds
•
evenly distributed black hair
•
no infestations
•
eyebrows symmetrically aligned with equal movement
•
eyelashes equally distributed and curled slightly outward
•
skin of eyelids intact with no discoloration
•
lids close symmetrically
•
bilateral blinking exhibited
HEAD
EYES
•
no discharge, edema or tearing
•
white sclera
•
pink palpebral conjunctiva
•
iris black in color
•
pupils equal in size with smooth borders
•
illuminated pupils constricts
•
pupils converge when near object is moved toward the nose
•
when looking straight ahead, the client can see objects in the periphery
•
both eyes coordinated, move in unison with parallel alignment
•
color same as facial skin
•
symmetrically aligned
•
pinna immediately recoils after it is folded
•
pinna is not tender
•
no lesions or discoloration
•
dry cerumen, grayish-tan color
•
normal voice tones audible
•
able to hear ticking of a watch in both ears
•
symmetric and straight
•
no discharge or flaring
•
absence of lesions and tenderness
•
nasal septum intact and in the midline
EARS
NOSE
MOUTH AND THROAT
•
outer lips uniform pink color with symmetric contour, soft and moist
•
buccal mucosa is of uniform pink color
•
gums are pink
•
tongue pink, moist, at central position
•
head centered
•
lymph nodes not palpable
NECK
BREAST
•
firm
•
generally symmetric in size
CARDIOVASCULAR
•
BP 180/100 mmHg
•
PR 114
•
reported palpitations
•
symmetric pulse strength
RESPIRATORY/CHEST
•
chest symmetric
•
chest wall intact, no tenderness, no masses
•
symmetric chest expansion and excursion
•
RR: 29 breaths per minute
GASTROINTESTINAL/ABDOMEN
•
striae present at hypogastric and iliac regions
•
linea nigra present
•
no tenderness
•
presence of surgical incision
URINARY
•
absence of nocturia, dysuria, urgency, hesitancy,
•
light yellow urine
REPRODUCTIVE
•
regular menstrual cycle
•
G1P1
MUSCULOSKELETAL/EXTREMITIES
•
muscle equal size on both sides of the body
•
no bone deformities
•
no tenderness
NEUROLOGIC
•
can respond to verbal commands
•
oriented
•
conscious
•
displayed anxiety
PHYSICAL ASSESSMENT November 28, 2008 SKIN
•
brown skin generally uniform in color except in areas exposed to the sun
•
skin temperature uniform and within the normal range (37°C)
•
good skin turgor
•
moist skin folds
•
nails with smooth texture
•
nail beds pink
•
prompt capillary refill time
•
bipedal non-pitting edema
•
rounded
•
smooth skull contour
•
symmetric facial features
•
symmetric nasolabial folds
•
symmetric facial movements
•
thick black hair
•
evenly distributed
•
no infestations
HEAD
HAIR
EYES
•
eyebrows symmetrically aligned
•
eyelashes curled slightly outward
•
exhibited bilateral blinking
•
both eyes coordinated, move in unison and with parallel alignment
•
white sclera
•
pink palpebral conjunctiva
•
pupils equally round and reactive to light and accommodation
•
iris black in color
•
pupils equal in size with smooth borders
•
illuminated pupils constricts
•
no discharge
•
color same as facial skin
•
symmetrically aligned
•
pinna immediately recoils after it is folded
•
pinna is not tender
•
no lesions or discoloration
•
dry cerumen, grayish-tan color
•
normal voice tones audible
EARS
NOSE AND SINUSES
•
symmetric and straight
•
no discharge
•
absence of lesions and tenderness
•
nasal septum intact and in the midline
•
sinuses not tender
MOUTH AND THROAT
•
outer lips uniform pink color
•
symmetric contour
•
buccal mucosa is of uniform pink color
•
no abrasions and ulcerations
•
gums are pink
•
tongue pink, moist, at central position
•
tongue moves freely with no tenderness
•
palate surface intact
•
uvula positioned in midline
•
palatine tonsils pink and smooth and not swollen
•
head centered
•
head movement coordinated and smooth with no discomfort
•
lymph nodes not palpable
NECK
BREAST AND AXILLAE
•
rounded, generally symmetric
•
areola rounded and the same shape
•
nipples round, everted and equal in size
•
milk letdown
CARDIOVASCULAR
•
BP 160/100 mmHg
•
PR 106
•
prompt capillary refill time (less than 1 second)
•
symmetric pulse strength
RESPIRATORY/CHEST
•
chest symmetric
•
chest wall intact, no tenderness, no masses
•
full symmetric chest expansion and excursion
•
respiratory rate of 22 breaths per minute
GASTROINTESTINAL/ABDOMEN
•
striae present at hypogastric and iliac regions
•
symmetric movement caused by respiration
•
tender because of suture from cesarean operation
URINARY
•
yellowish urine
REPRODUCTIVE
•
regular menstrual cycle
•
G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
•
muscle equal size on both sides of the body
•
equal strength
•
no bone deformities
•
no tenderness
•
no tenderness on calf muscle when dorsiflexed
NEUROLOGIC
•
can respond to verbal commands
•
oriented
•
conscious
PHYSICAL ASSESSMENT November 29, 2008 SKIN
•
brown skin generally uniform in color except in areas exposed to the sun
•
skin temperature uniform and within the normal range (37.2°C)
•
when pinched, skin readily springs back to previous state
•
moist skin folds
•
nails with smooth texture
•
nail beds pink
•
nail plate angle about 160°
•
prompt capillary refill time
•
bipedal non-pitting edema
•
rounded
•
smooth skull contour
•
no masses, tenderness in the scalp
•
symmetric facial features
•
symmetric nasolabial folds
•
symmetric facial movements
•
thick, evenly districbuted black hair
•
no infestations
HEAD
HAIR
EYES
•
eyebrows symmetrically aligned
•
exhibited bilateral blinking
•
anicteric sclera
•
pink palpebral conjunctiva
•
pupils equally round and reactive to light and accommodation
•
no discharge
•
symmetrically aligned
•
pinna not tender and immediately recoils after folded
•
no lesions or discoloration
•
dry cerumen, grayish-tan color
•
normal voice tones audible
•
able to hear ticking of a watch in both ears
EARS
NOSE AND SINUSES
•
symmetric and straight
•
no discharge or flaring
•
absence of lesions and tenderness
•
nasal septum intact and in the midline
•
both nares patent
MOUTH AND THROAT
•
outer lips uniform pink color
•
symmetric contour
•
buccal mucosa is of uniform pink color
•
gums are pink
•
tongue pink, moist, at central position
•
palate surface intact
•
uvula positioned in midline
•
palatine tonsils pink and smooth and not swollen
•
gag reflex present
•
30 adult teeth, 2 molars missing, 1 with black discoloration of the enamel
•
neck muscles equal in size, head centered
•
head movement coordinated and smooth with no discomfort
•
lymph nodes not palpable
NECK
BREAST AND AXILLAE
•
areola rounded and the same shape
•
nipples round, everted and equal in size
•
milk letdown
CARDIOVASCULAR
•
BP 150/100 mmHg
•
PR 96
•
strong, regular rhythm
•
prompt capillary refill time (less than 1 second)
RESPIRATORY/CHEST
•
chest symmetric
•
right and left shoulders and right and left hips are at the same height
•
chest wall intact, no tenderness, no masses
•
full symmetric chest expansion and excursion
•
respiratory rate is 28 breaths per minute
GASTROINTESTINAL/ABDOMEN
•
striae present at hypogastric and iliac regions
•
rounded contour
•
symmetric movement caused by respiration
•
tender because of suture form cesarean operation
URINARY
•
yellowish urine
REPRODUCTIVE
•
regular menstrual cycle
•
G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
•
muscle equal size on both sides of the body
•
smooth coordinated movements
•
equal strength
•
no tenderness
•
walks aided to maintains balance
•
no tenderness on calf muscle when dorsiflexed
NEUROLOGIC
•
can respond to verbal commands
•
oriented
•
conscious
DIAGNOSTIC AND LABORATORY PROCEDURES
Diagnostic or Laboratory Procedure WBC Count
Indication or Purpose
Date Ordered and Date Results were released
To determine
November
infection or
16, 2008
Results
Normal Values
Analysis and Interpretation of Results
8.0
5-10 x
No infection or
109/L
inflammation
inflammation
is present.
Pre-operation assessment of the patient. RBC Count
Pre-operation
November
assessment of
16, 2008
3.3
4.2-5.4 x 1012 /L
the patient.
Decreased RBC count on pregnant is normal because of the increase in plasma volume during
Hemoglobin
Pre-operation
November
assessment of
16, 2008
the patient.
96
120160g/L
pregnancy. 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 Hematocrit
Pre-operation
November
(%)
assessment of
16, 2008
0.29
0.37-0.47 g/L
the patient.
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 During Different Laboratory Procedures
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.
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 the venipuncture site, apply warm soaks.
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 the venipuncture site, apply warm soaks.
III. THE PATIENT AND HIS ILLNESS
Efforts to unravel the pathogenesis of pre-eclampsia 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 caused by systemic maternal endothelial cell dysfunction resulting in vascular reactivity, activation of coagulation cascade and loss of vascular integrity. Pre-eclampsia has effects on most maternal organ systems, but predominantly on the vasculature of the kidneys, liver and brain.
V. THE PATIENT AND HIS CARE 1. Medical Management a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy
Medical Management IVF
Date Ordered
General
Indication &
Client Response
Date Ordered
Description 5% dextrose in
Purpose D5NM is
to Treatment The patient
November 15,
lactated ringers administered by
responded well
2008
solution
with no signs of
D5LRS 1L intravenous
30gtts/min (Osmolarity of infusion for
irritation and
527-hyprtonic,
parenteral
adverse reactions.
pH of 4.9)
maintenance of
-provides
routine daily fluid
Date d/c November 20, 2008 calories and free and electrolyte water, provides requirement with electrolytes.
minimal
Also contains
carbohydrates
sodium lactate
calories and to
which is used in correct or replace treating mild to fluid losses due to moderate
change in the
metabolic
patient’s diet
acidosis.
(NPO) and during the cesarean operation.
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
•
Check if there is a back-flow of blood
•
Check if there is bubbles present in the tube
•
Always Monitor V/S.
b. Pharmacotherapy
Brand name and Date ordered/
Route of
General action
Client response
Generic name
Date started/
Administration,
Date changed/
Dosage and
Administration P.O., 500mg,
Inhibits
Patient was
TID for pain
prostaglandin
relieved from
synthesis by
pain.
Frequency of Mefenamic
11-19-08
Acid
decreasing the activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin Cephalosporin
11-19-08
I.V., 750mg, q8
precursors Inhibits bacterial
The patient did
Cefuroxime
cell wall
not acquire
sodium
synthesis by
infection and
binding to one or did not more of the
experience any
penicillin-
adverse
binding proteins
reaction.
(PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is
arrested. Ferrous Sulfate
11-19-08
P.O., O.D.
Replaces iron,
The patient
found in
responded well
hemoglobin,
to treatment
myoglobin, and
and did not
other enzymes;
experience any
allows the
adverse
transportation of
reaction.
oxygen via Nifedipine
11-19-08
hemoglobin. P.O., 10mg, BID Inhibits calcium
The patient
ion from
responded well
entering the
to treatment
"slow channels"
and did not
or select
experience any
voltage-sensitive adverse areas of vascular smooth muscle and myocardium during depolarization, producing a relaxation of coronary vascular smooth muscle and coronary vasodilation; increases
reaction.
myocardial oxygen delivery in patients with vasospastic angina
c. Diet
Type of Diet
NPO
Date Ordered,
General
Indication &
Client
Date Performed,
Description
Purpose
Response to
Date Administer 11-17-08
The patient is not
This is done to
Treatment The patient
11-19-08
allowed to take
prevent
complied with
any oral food or
alteration of the
the prescribed
liquid
result of the
diet.
fasting blood sugar.bcs intake of food can increase Clear Liquid
11-19-08
A diet of clear
glucose level This diet reduce
Diet
11-20-08
liquids maintains
stimulation of
complied with
vital body fluids,
the digestive
the prescribed
salts, and
system, and
diet.
minerals; and also
leave no residue
gives some energy
in the intestinal
for patients when
tract. This is
normal food intake why a clear must be
liquid diet is
The patient
interrupted. Clear
often prescribed
liquids are easily
in preparation
absorbed by the
for surgery, and
body. by mouth
is generally the
(NPO) for a long
first diet given
time. This diet is
by mouth after
also used in
surgery. Clear
preparation for
liquids are
medical tests such
given when a
as sigmoidoscopy,
person has been
colonoscopy, or
without food by
certain x-rays.
mouth (NPO) for a long time.
d. Exercise
Activity
General
Purpose
Date Order
Description Complete Bed Rest
Client Response
Prescribed
To provide
maternal
adequate rest
11-18-08
The client adhered to the
complication of
order without
pregnancy
complaints.
VI. NURSING CARE PLAN
Cues S-“sumasakit
Nursing diagnoses Acute pain
Scientific Explanation Unpleasant
nga daw ung
related to
tahi niya at
postparum
Objective After 2-4 hr of
Nursing intervention - Provide quite
Rationale -to promote pain
Expected outcomes Goal Partially
sensory
nursing
environment
management.
met AEB pt
experience
intervention, the
rated the pain
sumusigaw siya”
arising from post pt rate the pain
-Encouraged to
as the SO
surgical incision
from 8 to 3 in a
do deep
pain scale of 1-
verbalized
from cesarean
pain scale of 1-
breathing
10
section.
10
exercise
O- facial
-to prevent
grimaces
- Encouraged
Rated pain as 8
adequate rest
in a pain scale of
period
1-10, 10 being the highest
-to reduce tension
fatigue
-to reduce - Encouraged to
pressure on the
from 8 to 5 in a
Guarding
support the
behavior
affected area
affected area
upon movement
Cues S-“ayoko na
Nursing diagnoses Disturbed body
Scientific Explanation Severity of the
muna dapat
image related to
mabuntis kc
Objective After 2-4 hrs of
Nursing intervention -Encouraged
Rationale -to begin to
Expected outcomes Goal met the
abdominal
nursing
client to looked/
incorporate
patient
pregnancy AEB
wound due to
intervention, the
touch the
changes into
recognized and
papangit ung
changes in
surgery, a new
patient will able
affected body
body image.
verbalized
katawan ko
appearance
type of tissues
to understand the
area
tsaka bat ang
develops that
change of body
itim ng pek-pek
eventually will
image.
ko” as pt verbalized
understanding of -to bring back
-Encourage the
the usual
causes scar
client to have a
physical images.
formation
daily exercise. -to feel that the
body changes.
O-presence of
-Advised the SO
patient still
melasma
to give support
worthy.
-presence of
to the pt
bipedal edema
(especially emotional feelings)
-to aid in recovery.
-Assist pt to identify positive behavior
Cues S: “bumibilis
Nursing diagnoses Decreased
Scientific Explanation Pregnancy
nga tibok ng
cardiac output
Induced
puso ko”
After 4 hrs of
Nursing intervention -Keep client on
- decreases
Expected outcomes Goal Met AEB
nursing
bed and in
oxygen
within 4 hrs. of
related to altered Hypertension is a
intervention, the
position of
consumption
nursing
verbalized by
heart rate (111
condition in
patient will
comfort
the patient
bpm) AEB
which
display
tachycardia, pt’s
vasospasms
hemodynamic
-decrease
-to promote
decreased from
report of
occur. It is caused
stability (heart
stimuli; provide
adequate rest
111 bpm to 100
palpations;
by altered cardiac
rate will decrease quiet env’t
(r/t) decreased
output that injures from 111 bpm to
venous return
endothelial cells
100 bpm, BP
-Encouraged
AEB edema
of the arteries.
from 140/100 to
deep breathing
(ankle), SOB
Blood vessels
120/80)
exercise
(28)
become less
O: -with the tenderness of abdominal are -facial grimaces -BP= 160/100 mmhg
resistant to
Objective
Rationale
intervention the pt. HR
bpm, BP from -to reduce
140/100 to
anxiety
120/80 (Normal BP)
-to reduce risk for -Encouraged
orthostatic
RR= 28 cycles per min.
pressor
changing
substances. This
positions slowly
results to PR= 111 bpm
hypotension
-to provide
vasoconstriction
-give
and increases BP
information
dramatically
about positive
encouragement
signs of
-to prevent in
improvement
changes in cardiac pressures
-Instruct client to or impede blow avoid or limit activities that may stimulate valsalva response (rectal stimulation,
flow
bearing down B.M)
Cues S-
Nursing diagnoses Risk for
Scientific Explanation Constipation
Objective After 4 hrs of
Nursing intervention - Educate
Rationale - Information
Expected outcomes Goal Met AEB
constipation
may happen due
nursing
patient/ SO
can help client to the patient
O- decreased
related to post
to disturbance of
intervention, the
about safe and
make beneficial
verbalized
ambulation of
CS delivery.
normal bowel
patient will
risky practices
choices when
understanding
the patient bcs
movements
verbalize
for managing
need arises.
about
of pain and the
because
understanding
constipation.
complete bed
intestines were
the etiology and
rest ordered of
displaced during
appropriate
- Instruct balance - To improve
knowledge of
the physician.
surgical
intervention if
fiber and bulk in
consistency of
appropriate
procedure.
constipation may
diet and fiber
stool and
intervention.
occur.
supplements.
facilitate passage
constipation and gained
through colon. - Promote adequate fluid
- To promote
intake, also
soft stool and
suggest drinking
stimulate bowel
warm fluids.
activity.
- Encourage activity within
-To stimulate
limits of
constrictions of
individual
the intestines
ability.
Cues O- postpartum
Nursing diagnoses Impaired Skin
Scientific Explanation The incision
surgery
Integrity related
from the
Objective After 2-4 hrs of
Nursing intervention -stress proper
Rationale - to control the
Expected outcomes Goal Met AEB
nursing
hand hygiene.
spread of
the patient was
to surgery
cesarean section
intervention, the
infection.
able to knew
altered the skin
patient will able
-Encouraged to
integrity making
to know the
increase foods
- to aid in tissue
measures of
it more
preventive
that are rich in
repair
wound healing
susceptible to
measures of
protein
pathogens and
wound healing
the preventive
even the pt’s
-Encouraged
-to maintained the
normal flora
proper clothing
proper skin moisture.
-Apply appropriate
-to help in wound
dressing
healing
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.
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 preeclampsia 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
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.
XI. BIBLIOGRAPHY
http:// www.nursingcrib.com http:// www.medicinenet.com http:// www.wrongdiagnosis.com http:// www.umm.edu.com http:// www.doh.gov.ph
Pre-Eclampsia
December 05, 2008
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.
Nurse-Centered Objectives Upon completion of this case study, the student nurse should be able to: 1. Identify the risk factor contributing to the occurrence of the disease. 2. Formulate significant nursing diagnosis, with the significantly related nursing care plan. 3. Identify the different medications administered for this disease their indications, contraindications, side effect, and specific responsibility . 4. Identify the laboratory and diagnostic procedure done with the pre-eclamptic
patient, their indication and purposes, and specific nursing responsibilities. Client-Centered Objectives Upon completion of this case study, the client should be able to: 1. Understand awareness of her disease. 2. Know the possible causes of the disease. 3. Learn and understand why such laboratory examinations are being done.
II. NURSING HISTORY a.) Demographic Data
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.
Family Health Illness History
Grandmother
Grandmother
Grandfather
Grandfather
Father Mother
Patient
π
Legend:
hypertension
pneumonia
died of old age
asthma
deceased
π
pre eclampsia
*pink border – mother side *blue border – father side *violet border - patient
Both the grandparents from the mother’s side died from old age. From the father’s side, the grandmother died from Hypertension and the father was died from Pneumonia. The mother is not experiencing any health problems but the father has hypertension and asthma. The patient, upon admission has elevated blood pressure and is suffering from aggravating factors like anxiety, nervousness and fear.
PHYSICAL ASSESSMENT November 27, 2008
SKIN
•
brown skin generally uniform in color except in areas exposed to the sun
•
skin temperature uniform and within the normal range (37°C)
•
when pinched, skin readily springs back to previous state
•
moist skin folds
•
nails with smooth texture
•
nail beds pink
•
prompt capillary refill time (2 seconds)
•
bipedal non-pitting edema
•
absence of nodules or masses
•
symmetric facial features and movements
•
symmetric nasolabial folds
•
evenly distributed black hair
•
no infestations
•
eyebrows symmetrically aligned with equal movement
•
eyelashes equally distributed and curled slightly outward
•
skin of eyelids intact with no discoloration
•
lids close symmetrically
•
bilateral blinking exhibited
HEAD
EYES
•
no discharge, edema or tearing
•
white sclera
•
pink palpebral conjunctiva
•
iris black in color
•
pupils equal in size with smooth borders
•
illuminated pupils constricts
•
pupils converge when near object is moved toward the nose
•
when looking straight ahead, the client can see objects in the periphery
•
both eyes coordinated, move in unison with parallel alignment
•
color same as facial skin
•
symmetrically aligned
•
pinna immediately recoils after it is folded
•
pinna is not tender
•
no lesions or discoloration
•
dry cerumen, grayish-tan color
•
normal voice tones audible
•
able to hear ticking of a watch in both ears
•
symmetric and straight
•
no discharge or flaring
•
absence of lesions and tenderness
•
nasal septum intact and in the midline
EARS
NOSE
MOUTH AND THROAT
•
outer lips uniform pink color with symmetric contour, soft and moist
•
buccal mucosa is of uniform pink color
•
gums are pink
•
tongue pink, moist, at central position
•
head centered
•
lymph nodes not palpable
NECK
BREAST
•
firm
•
generally symmetric in size
CARDIOVASCULAR
•
BP 180/100 mmHg
•
PR 114
•
reported palpitations
•
symmetric pulse strength
RESPIRATORY/CHEST
•
chest symmetric
•
chest wall intact, no tenderness, no masses
•
symmetric chest expansion and excursion
•
RR: 29 breaths per minute
GASTROINTESTINAL/ABDOMEN
•
striae present at hypogastric and iliac regions
•
linea nigra present
•
no tenderness
•
presence of surgical incision
URINARY
•
absence of nocturia, dysuria, urgency, hesitancy,
•
light yellow urine
REPRODUCTIVE
•
regular menstrual cycle
•
G1P1
MUSCULOSKELETAL/EXTREMITIES
•
muscle equal size on both sides of the body
•
no bone deformities
•
no tenderness
NEUROLOGIC
•
can respond to verbal commands
•
oriented
•
conscious
•
displayed anxiety
PHYSICAL ASSESSMENT November 28, 2008 SKIN
•
brown skin generally uniform in color except in areas exposed to the sun
•
skin temperature uniform and within the normal range (37°C)
•
good skin turgor
•
moist skin folds
•
nails with smooth texture
•
nail beds pink
•
prompt capillary refill time
•
bipedal non-pitting edema
•
rounded
•
smooth skull contour
•
symmetric facial features
•
symmetric nasolabial folds
•
symmetric facial movements
•
thick black hair
•
evenly distributed
•
no infestations
HEAD
HAIR
EYES
•
eyebrows symmetrically aligned
•
eyelashes curled slightly outward
•
exhibited bilateral blinking
•
both eyes coordinated, move in unison and with parallel alignment
•
white sclera
•
pink palpebral conjunctiva
•
pupils equally round and reactive to light and accommodation
•
iris black in color
•
pupils equal in size with smooth borders
•
illuminated pupils constricts
•
no discharge
•
color same as facial skin
•
symmetrically aligned
•
pinna immediately recoils after it is folded
•
pinna is not tender
•
no lesions or discoloration
•
dry cerumen, grayish-tan color
•
normal voice tones audible
EARS
NOSE AND SINUSES
•
symmetric and straight
•
no discharge
•
absence of lesions and tenderness
•
nasal septum intact and in the midline
•
sinuses not tender
MOUTH AND THROAT
•
outer lips uniform pink color
•
symmetric contour
•
buccal mucosa is of uniform pink color
•
no abrasions and ulcerations
•
gums are pink
•
tongue pink, moist, at central position
•
tongue moves freely with no tenderness
•
palate surface intact
•
uvula positioned in midline
•
palatine tonsils pink and smooth and not swollen
•
head centered
•
head movement coordinated and smooth with no discomfort
•
lymph nodes not palpable
NECK
BREAST AND AXILLAE
•
rounded, generally symmetric
•
areola rounded and the same shape
•
nipples round, everted and equal in size
•
milk letdown
CARDIOVASCULAR
•
BP 160/100 mmHg
•
PR 106
•
prompt capillary refill time (less than 1 second)
•
symmetric pulse strength
RESPIRATORY/CHEST
•
chest symmetric
•
chest wall intact, no tenderness, no masses
•
full symmetric chest expansion and excursion
•
respiratory rate of 22 breaths per minute
GASTROINTESTINAL/ABDOMEN
•
striae present at hypogastric and iliac regions
•
symmetric movement caused by respiration
•
tender because of suture from cesarean operation
URINARY
•
yellowish urine
REPRODUCTIVE
•
regular menstrual cycle
•
G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
•
muscle equal size on both sides of the body
•
equal strength
•
no bone deformities
•
no tenderness
•
no tenderness on calf muscle when dorsiflexed
NEUROLOGIC
•
can respond to verbal commands
•
oriented
•
conscious
PHYSICAL ASSESSMENT November 29, 2008 SKIN
•
brown skin generally uniform in color except in areas exposed to the sun
•
skin temperature uniform and within the normal range (37.2°C)
•
when pinched, skin readily springs back to previous state
•
moist skin folds
•
nails with smooth texture
•
nail beds pink
•
nail plate angle about 160°
•
prompt capillary refill time
•
bipedal non-pitting edema
•
rounded
•
smooth skull contour
•
no masses, tenderness in the scalp
•
symmetric facial features
•
symmetric nasolabial folds
•
symmetric facial movements
•
thick, evenly districbuted black hair
•
no infestations
HEAD
HAIR
EYES
•
eyebrows symmetrically aligned
•
exhibited bilateral blinking
•
anicteric sclera
•
pink palpebral conjunctiva
•
pupils equally round and reactive to light and accommodation
•
no discharge
•
symmetrically aligned
•
pinna not tender and immediately recoils after folded
•
no lesions or discoloration
•
dry cerumen, grayish-tan color
•
normal voice tones audible
•
able to hear ticking of a watch in both ears
EARS
NOSE AND SINUSES
•
symmetric and straight
•
no discharge or flaring
•
absence of lesions and tenderness
•
nasal septum intact and in the midline
•
both nares patent
MOUTH AND THROAT
•
outer lips uniform pink color
•
symmetric contour
•
buccal mucosa is of uniform pink color
•
gums are pink
•
tongue pink, moist, at central position
•
palate surface intact
•
uvula positioned in midline
•
palatine tonsils pink and smooth and not swollen
•
gag reflex present
•
30 adult teeth, 2 molars missing, 1 with black discoloration of the enamel
•
neck muscles equal in size, head centered
•
head movement coordinated and smooth with no discomfort
•
lymph nodes not palpable
NECK
BREAST AND AXILLAE
•
areola rounded and the same shape
•
nipples round, everted and equal in size
•
milk letdown
CARDIOVASCULAR
•
BP 150/100 mmHg
•
PR 96
•
strong, regular rhythm
•
prompt capillary refill time (less than 1 second)
RESPIRATORY/CHEST
•
chest symmetric
•
right and left shoulders and right and left hips are at the same height
•
chest wall intact, no tenderness, no masses
•
full symmetric chest expansion and excursion
•
respiratory rate is 28 breaths per minute
GASTROINTESTINAL/ABDOMEN
•
striae present at hypogastric and iliac regions
•
rounded contour
•
symmetric movement caused by respiration
•
tender because of suture form cesarean operation
URINARY
•
yellowish urine
REPRODUCTIVE
•
regular menstrual cycle
•
G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
•
muscle equal size on both sides of the body
•
smooth coordinated movements
•
equal strength
•
no tenderness
•
walks aided to maintains balance
•
no tenderness on calf muscle when dorsiflexed
NEUROLOGIC
•
can respond to verbal commands
•
oriented
•
conscious
DIAGNOSTIC AND LABORATORY PROCEDURES
Diagnostic or Laboratory Procedure WBC Count
Indication or Purpose
Date Ordered and Date Results were released
To determine
November
infection or
16, 2008
Results
Normal Values
Analysis and Interpretation of Results
8.0
5-10 x
No infection or
109/L
inflammation
inflammation
is present.
Pre-operation assessment of the patient. RBC Count
Pre-operation
November
assessment of
16, 2008
3.3
4.2-5.4 x 1012 /L
the patient.
Decreased RBC count on pregnant is normal because of the increase in plasma volume during
Hemoglobin
Pre-operation
November
assessment of
16, 2008
the patient.
96
120160g/L
pregnancy. 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 Hematocrit
Pre-operation
November
(%)
assessment of
16, 2008
0.29
0.37-0.47 g/L
the patient.
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 During Different Laboratory Procedures
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.
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 the venipuncture site, apply warm soaks.
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 the venipuncture site, apply warm soaks.
III. THE PATIENT AND HIS ILLNESS
Efforts to unravel the pathogenesis of pre-eclampsia 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 caused by systemic maternal endothelial cell dysfunction resulting in vascular reactivity, activation of coagulation cascade and loss of vascular integrity. Pre-eclampsia has effects on most maternal organ systems, but predominantly on the vasculature of the kidneys, liver and brain.
V. THE PATIENT AND HIS CARE 1. Medical Management a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy
Medical Management IVF
Date Ordered
General
Indication &
Client Response
Date Ordered
Description 5% dextrose in
Purpose D5NM is
to Treatment The patient
November 15,
lactated ringers administered by
responded well
2008
solution
with no signs of
D5LRS 1L intravenous
30gtts/min (Osmolarity of infusion for
irritation and
527-hyprtonic,
parenteral
adverse reactions.
pH of 4.9)
maintenance of
-provides
routine daily fluid
Date d/c November 20, 2008 calories and free and electrolyte water, provides requirement with electrolytes.
minimal
Also contains
carbohydrates
sodium lactate
calories and to
which is used in correct or replace treating mild to fluid losses due to moderate
change in the
metabolic
patient’s diet
acidosis.
(NPO) and during the cesarean operation.
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
•
Check if there is a back-flow of blood
•
Check if there is bubbles present in the tube
•
Always Monitor V/S.
b. Pharmacotherapy
Brand name and Date ordered/
Route of
General action
Client response
Generic name
Date started/
Administration,
Date changed/
Dosage and
Administration P.O., 500mg,
Inhibits
Patient was
TID for pain
prostaglandin
relieved from
synthesis by
pain.
Frequency of Mefenamic
11-19-08
Acid
decreasing the activity of the enzyme, cyclooxygenase, which results in decreased formation of prostaglandin Cephalosporin
11-19-08
I.V., 750mg, q8
precursors Inhibits bacterial
The patient did
Cefuroxime
cell wall
not acquire
sodium
synthesis by
infection and
binding to one or did not more of the
experience any
penicillin-
adverse
binding proteins
reaction.
(PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is
arrested. Ferrous Sulfate
11-19-08
P.O., O.D.
Replaces iron,
The patient
found in
responded well
hemoglobin,
to treatment
myoglobin, and
and did not
other enzymes;
experience any
allows the
adverse
transportation of
reaction.
oxygen via Nifedipine
11-19-08
hemoglobin. P.O., 10mg, BID Inhibits calcium
The patient
ion from
responded well
entering the
to treatment
"slow channels"
and did not
or select
experience any
voltage-sensitive adverse areas of vascular smooth muscle and myocardium during depolarization, producing a relaxation of coronary vascular smooth muscle and coronary vasodilation; increases
reaction.
myocardial oxygen delivery in patients with vasospastic angina
c. Diet
Type of Diet
NPO
Date Ordered,
General
Indication &
Client
Date Performed,
Description
Purpose
Response to
Date Administer 11-17-08
The patient is not
This is done to
Treatment The patient
11-19-08
allowed to take
prevent
complied with
any oral food or
alteration of the
the prescribed
liquid
result of the
diet.
fasting blood sugar.bcs intake of food can increase Clear Liquid
11-19-08
A diet of clear
glucose level This diet reduce
Diet
11-20-08
liquids maintains
stimulation of
complied with
vital body fluids,
the digestive
the prescribed
salts, and
system, and
diet.
minerals; and also
leave no residue
gives some energy
in the intestinal
for patients when
tract. This is
normal food intake why a clear must be
liquid diet is
The patient
interrupted. Clear
often prescribed
liquids are easily
in preparation
absorbed by the
for surgery, and
body. by mouth
is generally the
(NPO) for a long
first diet given
time. This diet is
by mouth after
also used in
surgery. Clear
preparation for
liquids are
medical tests such
given when a
as sigmoidoscopy,
person has been
colonoscopy, or
without food by
certain x-rays.
mouth (NPO) for a long time.
d. Exercise
Activity
General
Purpose
Date Order
Description Complete Bed Rest
Client Response
Prescribed
To provide
maternal
adequate rest
11-18-08
The client adhered to the
complication of
order without
pregnancy
complaints.
VI. NURSING CARE PLAN
Cues S-“sumasakit
Nursing diagnoses Acute pain
Scientific Explanation Unpleasant
nga daw ung
related to
tahi niya at
postparum
Objective After 2-4 hr of
Nursing intervention - Provide quite
Rationale -to promote pain
Expected outcomes Goal Partially
sensory
nursing
environment
management.
met AEB pt
experience
intervention, the
rated the pain
sumusigaw siya”
arising from post pt rate the pain
-Encouraged to
as the SO
surgical incision
from 8 to 3 in a
do deep
pain scale of 1-
verbalized
from cesarean
pain scale of 1-
breathing
10
section.
10
exercise
O- facial
-to prevent
grimaces
- Encouraged
Rated pain as 8
adequate rest
in a pain scale of
period
1-10, 10 being the highest
-to reduce tension
fatigue
-to reduce - Encouraged to
pressure on the
from 8 to 5 in a
Guarding
support the
behavior
affected area
affected area
upon movement
Cues S-“ayoko na
Nursing diagnoses Disturbed body
Scientific Explanation Severity of the
muna dapat
image related to
mabuntis kc
Objective After 2-4 hrs of
Nursing intervention -Encouraged
Rationale -to begin to
Expected outcomes Goal met the
abdominal
nursing
client to looked/
incorporate
patient
pregnancy AEB
wound due to
intervention, the
touch the
changes into
recognized and
papangit ung
changes in
surgery, a new
patient will able
affected body
body image.
verbalized
katawan ko
appearance
type of tissues
to understand the
area
tsaka bat ang
develops that
change of body
itim ng pek-pek
eventually will
image.
ko” as pt verbalized
understanding of -to bring back
-Encourage the
the usual
causes scar
client to have a
physical images.
formation
daily exercise. -to feel that the
body changes.
O-presence of
-Advised the SO
patient still
melasma
to give support
worthy.
-presence of
to the pt
bipedal edema
(especially emotional feelings)
-to aid in recovery.
-Assist pt to identify positive behavior
Cues S: “bumibilis
Nursing diagnoses Decreased
Scientific Explanation Pregnancy
nga tibok ng
cardiac output
Induced
puso ko”
After 4 hrs of
Nursing intervention -Keep client on
- decreases
Expected outcomes Goal Met AEB
nursing
bed and in
oxygen
within 4 hrs. of
related to altered Hypertension is a
intervention, the
position of
consumption
nursing
verbalized by
heart rate (111
condition in
patient will
comfort
the patient
bpm) AEB
which
display
tachycardia, pt’s
vasospasms
hemodynamic
-decrease
-to promote
decreased from
report of
occur. It is caused
stability (heart
stimuli; provide
adequate rest
111 bpm to 100
palpations;
by altered cardiac
rate will decrease quiet env’t
(r/t) decreased
output that injures from 111 bpm to
venous return
endothelial cells
100 bpm, BP
-Encouraged
AEB edema
of the arteries.
from 140/100 to
deep breathing
(ankle), SOB
Blood vessels
120/80)
exercise
(28)
become less
O: -with the tenderness of abdominal are -facial grimaces -BP= 160/100 mmhg
resistant to
Objective
Rationale
intervention the pt. HR
bpm, BP from -to reduce
140/100 to
anxiety
120/80 (Normal BP)
-to reduce risk for -Encouraged
orthostatic
RR= 28 cycles per min.
pressor
changing
substances. This
positions slowly
results to PR= 111 bpm
hypotension
-to provide
vasoconstriction
-give
and increases BP
information
dramatically
about positive
encouragement
signs of
-to prevent in
improvement
changes in cardiac pressures
-Instruct client to or impede blow avoid or limit activities that may stimulate valsalva response (rectal stimulation,
flow
bearing down B.M)
Cues S-
Nursing diagnoses Risk for
Scientific Explanation Constipation
Objective After 4 hrs of
Nursing intervention - Educate
Rationale - Information
Expected outcomes Goal Met AEB
constipation
may happen due
nursing
patient/ SO
can help client to the patient
O- decreased
related to post
to disturbance of
intervention, the
about safe and
make beneficial
verbalized
ambulation of
CS delivery.
normal bowel
patient will
risky practices
choices when
understanding
the patient bcs
movements
verbalize
for managing
need arises.
about
of pain and the
because
understanding
constipation.
complete bed
intestines were
the etiology and
rest ordered of
displaced during
appropriate
- Instruct balance - To improve
knowledge of
the physician.
surgical
intervention if
fiber and bulk in
consistency of
appropriate
procedure.
constipation may
diet and fiber
stool and
intervention.
occur.
supplements.
facilitate passage
constipation and gained
through colon. - Promote adequate fluid
- To promote
intake, also
soft stool and
suggest drinking
stimulate bowel
warm fluids.
activity.
- Encourage activity within
-To stimulate
limits of
constrictions of
individual
the intestines
ability.
Cues O- postpartum
Nursing diagnoses Impaired Skin
Scientific Explanation The incision
surgery
Integrity related
from the
Objective After 2-4 hrs of
Nursing intervention -stress proper
Rationale - to control the
Expected outcomes Goal Met AEB
nursing
hand hygiene.
spread of
the patient was
to surgery
cesarean section
intervention, the
infection.
able to knew
altered the skin
patient will able
-Encouraged to
integrity making
to know the
increase foods
- to aid in tissue
measures of
it more
preventive
that are rich in
repair
wound healing
susceptible to
measures of
protein
pathogens and
wound healing
the preventive
even the pt’s
-Encouraged
-to maintained the
normal flora
proper clothing
proper skin moisture.
-Apply appropriate
-to help in wound
dressing
healing
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.
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 preeclampsia 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
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.
XI. BIBLIOGRAPHY
http:// www.nursingcrib.com http:// www.medicinenet.com http:// www.wrongdiagnosis.com http:// www.umm.edu.com http:// www.doh.gov.ph
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