Case Study

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Tel: 757-55-88 / 818-09-45 / 818-09-46

Pre-Eclampsia Case StudyRLE

(N- 211)

Submitted By:

Adriel Apolinario

Submitted To:

Arnold Peralta, R.N.

2nd Semester 2012

A. Nursing HistoryAna Santos, 33 y/o, female, R.C., Fil, born in Antipolo, presently residing in #29 Atoside Western Bicutan, Taguig City, was admitted at TPDH on February 26, 2012.

On March 1, 2012 at 3:00pm, the patient’s husband Mr. Ronie Sudaria was interviewed with 100% reliability.

General Data:Name: Ana SantosAge: 33 y/oSex: FemaleMarital Status: MarriedReligion: Roman CatholicRace: FilipinoOccupation: HousewifeDate of Birth: 07/15/1978Place of Birth: AntepoloResidence: #29 Atoside Western Bicutan, Taguig CityDate of Admission: February 26, 2012Place of Admission: TPDH-ERNumber of Admission: 1

Chief Complaint: Blurry Vision

History of Present Illness:Informant/Source of Information: Mr. Ronie Sudaria (patient’s husband).Date of Interview: 03/01/2012 at TPDH-OB WARD

The patient was brought to Taguig Pateros District Hospital for the following reason: blurry vision, and headache. Symptoms started 38 days prior to first admission (January 19, 2012) in sudden occurrence. The patient would experience intermittent yellow productive cough with no sign of blood, and headache for one week. The patient took Ambroxol and the cough went away after a week. 7 days prior to admission (February 19, 2012) the patient complained of blurry vision and headache. No medical attention was done. On the day of admission (February 26, 2012) the patient was first admitted to FTI, Manila at the Clinic Ward for the blurry vision. The patient had a blood pressure of 210/100, no medication was given, and the attending physician referred the patient to TPDH-ER. The patient commuted to the referred hospital. Upon admission to TPDH-ER, the patient had a blood pressure of 230/100 and was given 5 grams of Magnesium Sulfate on each buttock to prevent seizure and 0.5 grams of Hydralazine to lower the blood pressure. The patient was placed on a low sodium and low fat

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diet. The fetal heart rate was checked and ECG, CBC, Urinalysis was ordered. The patient was then transferred to the OB ward. One day after admission (February 27, 2012) the patient was continually monitored and given medication. The patient vomited 5-8 times throughout the day after eating or medication starting at 5AM. The second day after admission (February 28, 2012) the patient continued to vomit 5-8 times throughout the day after eating or medication. An ultra sound and x-ray was ordered. Three days after submission (February 29, 2012), the patient’s baby was confirmed as stillbirth at 8AM and was delivered at 11:50PM. The placenta cotyledons were complete and minimal vaginal bleeding. Four days after admission (March 1, 2012) the patient continued experiencing blurry vision, headache and lethargic.

Past History:Childhood Illness: The patient had no known childhood illnesses or hospitalization. The patient reported that she was complete of all vaccination as a child. She has no known allergies or any foods or certain days of the season. The only medication she took was Tylenol for fever.

Personal And Social History

The patient is Roman Catholic living with a family of 4 people. They live in a 2 bedroom single story home. There are no smokers residing in their residence. The patient spends most of the time with house chores such as cleaning and cooking. The patient is a non smoker/alcohol user. During pregnancy the patient did not go out of town.

Family History

The patient’s parents did not have any known history of illness. The patient’s mother is living and the father is deceased of unknown cause. The patient is the youngest and only daughter of six children. The patient does not know of any illness or smoking/alcohol use of her brothers. The patient’s husband’s mother died of a stroke and the father died of unknown cause. The patient’s husband the eldest. He is a non smoker and drinks beer occasionally with no known illnesses. His brother regularly smokes and drinks alcohol with no known illnesses. The patient has two children, a daughter the eldest and son. The children do not have any known illnesses or complications during delivery.

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GENOGRAM

Gordon’s Functional Health Patterns

Health pattern Past Condition Present ConditionAnalysis and

Interpretation

a. Health Interpretation and Maintenance

Patient is a 33 years old female. She has no history of high blood pressure and no complication of during in her 2 previews pregnancies. She is a non smoker and alcohol user. The

The patient is lethargic due to poor blood perfusion and blurry vision. She states that every time she switches position she feel dizzy and sleepy. The patient is afebrile with 35-36 degree temp on the right outer surface axilla arm. Patient continues to experiences blurry vision,

I: Client’s health perception is not altered.

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patient and her husband do not allow smoking in the house. She considers herself very healthy. She does not like going to hospitals especially when she is sick.

During her first trimester of pregnancy she only went to the health center ones for checkup. She never back because it is too far (30 min. away). She has never had any ultrasound or blood exams during her pregnancy. In addition, she has received her tetanus toxoid vaccines.

headache, oriented to time, place and person. She perceived her health is not that well and is aware of her condition. Her long stay at the hospital made her realize the importance of eating healthy by consuming less sodium and fat, especially during her pregnancy. Her husband is more supportive of her health than before. The patient is in complete bed rest.

A: Because of her condition, the client feels that her illness is not severe. She assumes total responsibility for decision-making and self-care.

Reference:

Kozier and Erb’s Fundamentals of Nursing 8th

edition, vol.1, page 295-307.

b. Nutrition and Metabolic pattern

Patient eats on time since 3-5 meals a day. She loves to eat fish and chicken which her husband prepares when he is home. During times when her husband is at work she enjoys eating fried foods three times a week and eats salty foods three times a week. The patient’s favorite dish is adobo. Her husband states

Patient is currently on a low salt and low fat diet. She needs assistance in eating every time. She cannot hold her spoon and fork and her husband is the one who feeds her. She eats small meals a day at different times and drinks 2,500ccs of water every day as ordered by the doctor. She is not allowed to drink soda. Most of her diet consists of noodles, fish, vegetables, crackers and rice. The patient displays no appetite to eat. The patient switches position in bed every hour because she

I: Client’s nutrition is hindered because she needs help in eating every time. She cannot do activities of daily living as important as eating.

A: The nutritional–

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that she has a stronger taste than him because she puts too many salt.

She also eats heavy meals with her husband when he gets home from work in the evening and sleeps an hour after.

She drinks (250cc/8oz/glass) more than 3-4 glasses every day. She enjoys drinking soda with her meals and consumes 1,000 to 2,000cc per day.

During pregnancy she took daily vitamins but she cannot recall if she took folic acid.

Her weight is stable at 200lbs. She has not experience any increase or decrease in weight.

When the patient is sick she usually gets better the next day.

feels warm all the time. Her skin is moist but cool to touch.

metabolic pattern focuses on food and fluid intake, however the client has problems in eating and that might influence intake.

Reference:

Cox’s Clinical Applications of Nursing Diagnosis 5th edition, page 120

c. Elimination pattern

Patient has no problem in defecating and urinating. She usually defecates once a day at nighttime and urinates 5-8 times a day with

The patient has not defecated since she was admitted. She urinates in approximately 500-800cc in 24 hours with small amounts of light yellow urine. The patient does not have any pain or

I: Client’s elimination pattern is not altered however client needs assistance in doing

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yellow colored urine. She drinks approximately 3-4 of 250 cc each glass of water and 1,000-2,000cc of soda per day. Client’s stool is brown and loose in consistency.

difficulty urinating. so.

A: Medications like Methyldopa affects the central nervous system that interferes with the normal urination and elimination process and may cause retention. In addition, her water intake is regulated at 2,500cc/day.

Reference:



d. Activity and Exercise pattern

Patient does not require any help and is completely independent in performing activities such as feeding, bathing, dressing, toileting and ambulation. She usually walks around outside the house in the morning as a form of her daily exercise. During spare time she walks around the

Patient is unable to perform activities of daily living due to lethargic and blurry vision. When the patient moves around she feels very dizzy which makes her feels sleepy. She also has difficulty sleeping because her blood pressure is checked every hour. The patient is in complete bad rest.

Patient is a level 2: Requires assistance or supervision from another person, her husband.

I: The client needs assistance when performing all daily living activities. Her husband is her primary care taker.

A: Because of her condition, the client is unable to do her tasks alone such as eating. A

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basketball court outside her house. She states that she has enough energy throughout the day. She has not experienced any musculoskeletal impairment. A week before admission she had difficulty sleeping because of a cough and dizziness.

Patient is Level 0: Full self-care.

problem in the activity–exercise pattern may be the primary reason for the patient entering the health-care system or may arise secondary to problems in another functional pattern.

Reference:


e. Sleep and Rest pattern

Patient usually sleeps 5-8 hours at 1AM and wakes up usually at 6AM and does take naps in the morning at usually 6-9AM for 3 hours after the husband leaves for work.

During rest time, she usually walks outside at the basketball court. Although most of the time she is at home doing house work.

Patient has no difficulty in sleeping and usually sleeps 8-12 hours at night. Throughout the day the patient also takes naps because of the dizziness she feels when she switches position and from her blurry vision. Her rest is disturbed because her vital signs are checked every hour.

The patient appears weak because of her slow movements, drowsiness and restlessness from her medications (Metronidazole, Mefenamic acid, Amlodipine, Nifedipine and Furosemide.

I: The client is having prolonged sleep at night and daytime sleepiness due to her dizziness and blurry vision.

A: The patient’s drowsiness and restlessness maybe due to medications like Furosemide, mefenamic acid, Amlodipine,

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Nifedipine and metronidazole that may cause excessive daytime sleepiness.

Reference:



f. Cognitive and Perceptual pattern

The patient has no problem with her hearing and in the past. She use to wear glasses but they were 5 years ago and never worn corrective lenses since.

Her memory from her past and condition is still accurate. She can remember names of most of the drugs she took, and her regiment before hospitalization. She usually learns best hands on and has no problems learning new things.

When she feels sick she usually uses natural methods such as herbs. She rarely takes medication because of

She is lethargic due to her medication yet responds to questions and has no signs of looseness of association or any flights of ideas.

She answers in full sentences when asked questions. She recalls most information about her condition before hospitalization.

She does not experience any chills.

The patients eyes are round and symmetrical, reactive to light and pupils constricts. When light is off, her pupils dilate. Her pupils are 5mm dilated because of dizziness and restlessness. The patient reacts to accommodation when looking close and far.

I: The client is coherent, cooperative, and alert with no problems with her sensors.

A: Client manifests intact sensory mechanisms and perception.

Reference:


edition, vol.2, page 981.

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their financial situation.

There are no problems in her senses.

g. Self Perception and Self Control pattern

The client would then view herself as someone who regards life to the fullest. She rarely worries about her problems. She is a hard worker and is rarely immobilized.

She focuses on her husband and children, especially when her husband is at work.

The patient feels that she has enough energy throughout the day and rarely rests.

She does not believe that she unhealthy since she eat frequently and abundantly since she incorporates vegetable and fruits in her diet.

She rarely gets mad or irritated when she is at home. Her relationship with her family and husband is peaceful.

She only worries when her husband is at work

During the assessment the patient was responsive yet answered every question with ease and depth. She defined that her hospitalization caused a big impact on her life that changed the way she viewed life. She is more focused on eating less fat and salty foods. She Also realizes that eating late at night and sleeping immediately is should be avoided.

I: The client has positive views on her condition. She thinks that her hospitalization only affected her body and lifestyle. She is still calm and positive about things.

A: The patient’s behavior is affected not only by experiences prior to interactions with the health-care system, but also by interactions with the health-care system.

Reference:


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and her children at school.

h. Role and Relationship pattern

The patient lives with her two children and her husband.

Most of their problems are financial reasons. They manage by saving money and eating what they could afford.

The patient would view herself as a kind, and responsible mother to her children and a loving wife to her husband. When they have problems in the family they solve it by talking between the members.

She has no problems raising her children since they help around the house and are studios at school.

The patient does not affiliate or take part in any community organizations. Most of her friends are her neighbors.

She involves herself in decision-making for the household and major decisions. Her

The relationship of her family remains strong. They remain firm and gather strength from each other. They support each other and exude strength to the patient.

Her husband is her main source of support. Since the patient’s admission to TPDH, he has not left the hospital for work. He said that it is his turn to take care of her.

The children were sent to the patient’s province where her brothers would take care of them until she recoveres.

I: The client’s relationship with her family remains strong.

A: The client’s hospitalization made their family become stronger. They used each as a source of energy and hope.

Reference:


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husband usually has the final say on things.

i. Sexual and Reproductive pattern

The patient and her husband are into sexual activity when they have time and energy.

Most of the time they show love to each other through action and care, such cooking for one another and helping in the house.

On the patient’s last menstruation, she did not experience any problems or pain. Her cycle is regular.

They are not aware or take part in family planning.

Patient and her husband are still intimate with each other. They ensure that they have time with each other since the patient is in complete bed rest.

Her husband provides comfort by hugging and showing care to his wife, anything to make her feel comfortable.

I: The client has sexual activity with her husband when there is time and energy. Usually this is when her husband comes home from work. Although at their age and schedule, they are not as active as before.

A: Sexuality patterns involve sex role behavior, gender identification, physiologic and biologic functioning and the ability to express sexual feelings. Client is able to fulfill sexual needs.

Reference:

Cox’s Clinical Applications of Nursing Diagnosis 5th edition, page

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715

j. Copping-Stress Tolerance Pattern

She is not the type of mother/wife that gives up easily. She views stresses as challenges to keep her firm and grounded.

According to the patient, she faces stressors of life such as financial crisis, and emotional conflicts by talking with her husband at all times.

She does not worry often or use alcohol/drugs for comfort.

She deals with her problems as a family and it makes her feel better when her husband is involved is all circumstances.

Patient tackles stress by resting.

Her husband is her source of outlet. He continues to care and converse with her everyday concern and worry on her well being as well as her children.

The patient’s short-term and Long-term coping strategies is supported by her conversing with her husband.

I: The client’s coping mechanism is not hindered because of the continued support of her husband. Whenever she experiences stress, the client would take time to rest.

A: Her ability to respond to stress is affected by a complex interaction of supportive social and emotional reactions.

Reference:


edition, vol.2, page 1068.

k. Values and Belief pattern

The patient is satisfied with her life and dreams. She feels that her place and family is where she should be.

The client is Roman Catholic and the client

During hospitalization the client prays to God every day and believes that God has plans for her and her husband.

She and her husband view her condition as a sign to eat healthier. They both agree that

I: The patient’s faith in God is evident in hospitalization. She values her husband’s support.

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believes that she generally gets things she likes out of life. She doesn’t go to mass regularly but she makes sure that she says her daily prayers and puts strong faith in God especially during times of conflict or suffering.

she would lessen the amount of salt and fat in her food; also limit the amount of soda she drinks.

She is very thankful for her husband’s continued support and love. Although they are worried financially since he has not went to work since her hospitalization, they are happy to have each other and they continue to show care and love everyday she is at the hospital.

A: The patient finds great solace in her spirituality.

Reference:Cox’s Clinical Applications of Nursing Diagnosis 5th edition, page 803

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B. Global city Innovative CollegeCollege of Nursing and Allied Health Sciences

Physical Examination

Name of Client: Ana SantosUnit/Ward: 206 Bed F/ OB WARDAge: 33 y/o Sex: Female

Date of Physical Assessment: March 1, 2012BMI: 37.8, Obese (BMI 30+ = Obese)Height: 5’ 1”Weight: 200 lbs.Vital Signs:

BP: 140/60, regular (right arm)Temp: 35.8, axilla (right outer surface axilla arm)P.R: 68/min, regular (right arm radial pulse)R.R: 17/min, regular

General Appearance

Appearance:

Level of consciousness: Development: Nutritional State:

Lethargy Oriented, but slowed metal reponses. Speech sluggish, sleeps often, but easily awaken.

Well Developed

Well Nourished

Body Parts Method of Assessment

Normal Findings Actual findings Analysis and Interpretation

Skin Inspection Uniform skin color with slightly darker exposure areas. No jaundice, cyanosis, pallor, erythema, or hyper/phypopigmentation.

Skin is fair in complexion, cool to touch and moist.

No erythma (rash).

Client manifests warm and dry skin due to nausea and vomiting as fluids are lost, most of the

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( Kozier and Erb’s. techniques in clinical nursing. Physical health examination. P.58)

remaining fluids are drawn to maintain fluids to more vital areas of the body such as the blood and various vital organs requiring fluids.

(Deglin, et al. Davis’s Drug Guide For Nurses. 9th ed. P. 796)

Palpation No presence of edema

Temperature is uniform

Moisture in skin folds and axillae.

When pinched, skin springs back to previous state.

No presence of edema

Temperature is uniform

Moisture in skin folds and axillae.

When pinched, skin springs back to previous state.

Client manifests

Normal findings

Nails Palpation Smooth, firm and non-tender

Capillary refill within three to four seconds

When palpated, the nails are smooth, firm and non-tender and its capillary refill is three seconds.

Eyes Inspection Positioned symmetrical to The eyes of the

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each other

There are no pigmentations, cloudiness or any presence of abnormal discharges in the eyes

Pupils equally rounded and appear normal in size

Pupillary activity appears normal

patient are positioned symmetrically to each other. No pigmentations, cloudiness or any presence of abnormal discharges are seen in the patient’s eyes. Anicteric sclera

Pupillary is 5mm dilated and is reactive to light and accommodation.

Head and Face Inspection The parts of the head and face is proportion to each other and symmetric

Shape is gently curved with prominences at the frontal and parietal bones

Symmetric facial movements

The parts of the head and face are proportion to each other and are symmetrical. The shape is gently curved with prominences at the frontal and parietal bones. The patient has symmetric facial movements.

Client manifests normal findings

Palpation Smooth uniform consistency; absence of nodules or masses

Smooth uniform consistency; absence of nodules or masses


Mouth, Throat,

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Neck Palpation There is no significant or palpable mass at the thyroid area

Jugular vein is not distended

The lymph nodes are not distended

The trachea is palpable at the midline of the neck.

No significant or palpable mass was reported at the thyroid area, jugular vein is not distended. Lymph nodes when palpated were not palpable or significantly distended.

Client manifests normal findings.

Upper Extremities

Inspection No venous patterns, varicosities, rashes and ulcers.

No venous patterns, varicosities, rashes and ulcers


Thorax and Lungs

Inspection Chest is symmetric and skin is intact

Quiet, rhythmic, and effortless respirations

Chest is symmetric and skin is intact, the respiratory rate of the patient is 17 cpm.

Palpation Temperature is uniform

Chest wall is intact; no tenderness; no masses

Patient refused to be palpated

Unable to assess

Auscultation No adventitious breath sounds

Heart Inspection No visible lifts or heaves

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Peripheral veins in dependent position, distention and nodular bulges at calves are present

Palpation Full Pulsation at 60-100 bpm

Full Pulsation at 68 bpm

Client manifest normal findings

Auscultation S1; usually heard at all sites, usually louder at apical area

S2; Usually heard at all sites, usually louder at base of heart

Systolic; silent interval. Slightly shorter duration than diastole at normal heart rate

Diastolic; silent interval. Slightly longer duration than systole at normal heart rates.

Abdomen Palpation No tenderness, relax abdomen with smooth, consistent tension, bladder and liver is not palpable.

Patient experiences pain in deep palpation in the lower right quadrant.

Lower Extremities

Inspection No venous pattern, varicosities, rashes, ulcers

No venous pattern, varicosities,


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rashes, ulcers.

Palpation Uniform temperature Uniform temperature

Strong peripheral pulsation.


Kidneys

Inspection Urine color is straw, amber or transparent; urine consistency clear liquid; urine glucose not present.

Urine is light yellow colored, urine consistency is clear liquid.

Neurologic System

Inspection Glasgow coma scale is 15

Positive reflexes such as biceps reflex, triceps reflex, brachioradialis, patellar reflex and Achilles reflex

Glasgow coma scale of the patient was scored as 14 wherein the eye response has the score of 3, 5 for verbal response and 6 for motor response.

The patient was able to perform all of the said reflexes such as biceps and triceps reflex, brachioradialis, patellar and Achilles reflex.

Cranial Nerves

I Olfactory By asking patient to close his eyes

Identify different mild aromas such as coffee, vanilla, peanut butter,

The patient was able to determine different mild


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II Optic

III Oculomotor

IV Trochlear

V Trigeminal

and identify different mild aromas.

By asking to read snellen chart; check visual fields by confrontation

The nurse will be assessing the six ocular movements and pupil reaction of a patient

The nurse will be assessing the six ocular movements of a patient.

The nurse lightly touches the lateral sclera of the

orange, lime, chocolate

Ability to clearly visualize the snellen chart; check visual fields by confrontation

Able to perform extraocular eye movement (EOM); movement of sphincter of pupil; movement of ciliary muscles of lens

Able to perform extra eye movements specifically movements of eyeballs downward laterally

Presence of blink reflex; can feel the sensation of skin of face and nasal mucosa; able to feel the sensation of

aromas such as alcohol, sweets and water.

A snellen chart was not available.

The patient was able to perform the six ocular movements; movement of sphincter of pupil and movement of ciliary muscles of lens.

The patient was able to perform extra eye movements, specifically the six ocular movements wherein eyeballs can move downward laterally

The patient was able to elicit blink

Was not able to perform.




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VI Abducens

VII Facial

VIII Auditory

eye while the patient is looking upward. To test light sensation, have the client close eyes, wipe a wisp of cotton over patient’s forehead and paranasal sinuses. Ask client to clench teeth.

The nurse will be assessing the directions of gaze.

By asking the patient to smile, raise eyebrows, frown, and puff out cheeks, close eyes tightly. Identifying various tastes placed on tip and sides of tongue.

anterior oral cavity; mastication of muscles

Ability to move eye balls laterally

Ability to perform different facial expressions; able to identify different tastes

Ability to clearly hear spoken words and vibrations of tuning fork

reflex; can feel the sensation of skin of face and nasal mucosa. Patient was able to feel the sensation of anterior oral cavity and was able to clench teeth for mastication.

The patient was able to move eye balls laterally.

The patient was able to perform different facial expressions by doing the method of assessment and was able to identify various tastes placed on the tongue.




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IX Glossopharyngeal

X Vagus

XI Accessory

The nurse will be assessing the patient’s ability to hear spoken word and vibrations of tuning fork.

The nurse will be applying tastes on posterior tongue for identification. Asking the patient to move tongue from side to side and up and down.

The nurse will do palpation on the pharynx and larynx, assessing the gag reflex with the use of tongue depressor and assess the presence of hoarseness.

Able to move the tongue from side to side and up and down; no difficulty in swallowing;; able to identify different taste on posterior tongue

Palpable pharynx and larynx; presence of gag reflex; no presence of hoarseness in the client’s speech

Able to shrug shoulders against resistance and able to turn to side against

The patient was able to clearly hear spoken words and vibrations of tuning fork.

The patient was able to move tongue from side to side and up and down. The patient did not show any difficulty in swallowing and able to identify different taste on posterior tongue.

The pharynx and larynx of the patient was able to palpate, positive gag reflex and no presence of hoarseness on client’s speech.




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XII Hypoglossal

The nurse will apply pressure on patient’s shoulders and ask patient to shrug shoulders against resistance and turn head to side against resistance from the nurse hand.

By asking patient to protrude tongue at midline and move it side to side and up and down

resistance without any difficulty

Ability to protrude tongue at midline and move up and down and side to side

The patient was able to shrug shoulders against the resistance of the nurse and was able to turn head to side against resistance without having any difficulty.

The patient was able to protrude tongue at midline without any difficulty and was able to move it up and down and side to side.


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D. LABORATORY STUDY

Examination Normal Reference Actual Findings

Analysis & Interpretation (including references)

CBC: WBC Count 4,800-10,800 28,500 mm/3

CBC: Neutrophils 2,000-7,500 26,220 CBC: Lymphocytes 1,500-4,000 1,425 CBC: Monocytes 40-500 0CBC: Basophils 10-100 0

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