Case Study Ob Ward

8/10/2019 Case Study Ob Ward

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ST. MARYS COLLEGE

NURSING PROGRAM

Tagum City

CASE STUDY

on

Preeclampsia

Presented to

Ms. Lesley Cadua RN,MN

Ms. Joan Calzada RN, MNIn Partial Fulfillment of the Requirements

In

Related Learning Experience

(RLE)

By

BSN 2-A

Pinky Rose Jean Marfil

Yvonne Obra

Axel Mae Abarico

Zhendy Solis

Holly Eve Pasuquin

Ian mizzelDulfina

RondelDadula

Jose Mari Bernardino

John Occeo

Niel Sabino

February 2013

TABLE OF CONTENTS


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INTRODUCTIONI

ASSESSMENT..II

A. BIOGRAPHICAL DATA

B. CHIEF COMPLAINT

C. HISTORY OF PRESENT ILLNESS

D. PAST MEDICAL AND NURSING HISTORY

E. PERSONAL, FAMILY AND SOCIO ECONOMIC HISTORY

F. PATIENT NEED ASSESSMENT

G. COURSE IN THE WARD

LABORATORY AND DIAGNOSTIC EXAM INATIONSIII

REVIEW OF ANATOMY AND PHYSIOLOGY.IV

SYMPTOMATOLOGYV

ETIOLOGY OF THE DISEASEVI

PATHOPHYSIOLOGY..VII

A. Written

B. Diagram

PLANNING

A. Nursing Care Plan

B. Discharge Plan

PHARMACOLOGICAL MANAGEMENTIX

SYNTHESIS OF CLIENTS CONDITION/STATUS FROM ADMISSION TO PRESENT.X

EVALUATION OF THE OBJECTIVES OF THE STUDYXI

BIBLIOGRAPHYXII


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I. Introduction

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

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

week of

gestation. The classic triad of preeclampsia is elevated BP 140/90, proteinuria and

edema. The cause of the disease remains unknown despite 100 years of research by

thousands of investigators. Pre-eclampsia commonly causes abnormal metabolic

function, including negative nitrogen balance, increase central nervous system

irritability, hyperactive reflexes, compromised renal function, hemoconcentration, and

alteration of the fluids and electrolytes balance. It occurs in 5-7% of pregnancies. Most

often in primigravida and is more common in some areas of the world than others, the

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

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

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

pathognomonic termination of the pregnancy results in the resolution of the signs andsymptoms of the disease and in healing of the renal lesion. Preeclampsia is classified

as mild or severe. Mild eclampsia is diagnosed if one or more of the following signs

develop after 24 th week of gestation. Systolic BP of140 mmHg or more or an increase of

30 mmHg of more above the womans systolic BP; proteinuria and edema. Severe

preeclampsia is diagnosed if one or more of the following signs is present.; systolic BP

160 mmHg and above, diastolic Bp of 110 mmHg above on two occasions 6 hours apart

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

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

pulmonary edema. Complications include premature separation of the placenta,


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hemolysis, cerebral hemorrhage, ophthalmologic damage, pulmonary edema,

hepatocellular changes, fetal malnutrition and lower birth rate. The most common

complication is eclampsia, which can results to both maternal and fetal death. Healthy

living conditions including a diet with high in proteins, calories and essential nutritional

elements, rest and exercise are associated with decrease incidence of pre-eclampsia.

Treatments include rest sedation, magnesium sulfate, and antihypertensive. Ultimately if

eclampsia threatens delivery by induction of labor or CS may be necessary. (Mosbys

dictionary of Medicine, Nursing and Health Professions,)

In developing countries, preeclampsia impact 4.4% of all deliveries. Theincidence of preeclampsia as of 2002 up to present raises to 146, 320 cases annually. It

affects 5% of pregnancies worldwide. In United States, approximately 1 in 1858 cases

or 0.05% equivalent to 146,320 people in the U. S have preeclampsia.

(cureresearch.com/p/preeclampsia/stats-country.htm). In the Philippines, cases of

preeclampsia exceeds up to 0.05% of pregnancies annually or 46,392 cases out of

86,241,697 as of 2009. (www.doh.gov.ph). In local setting, 25 cases of preeclampsia

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

2008 . (TPH records) .


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IMPORTANCE OF THE CASE STUDY

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

complications or abnormalities, is not a simple problem, which can even lead to both

fetal and maternal death that is why this case in very significant. Knowing that Mrs. X is

experiencing hypertension during her pregnancy (preeclampsia) and is at risk for

complications such as eclampsia (a life threatening condition), we, as the student

nurses in charge of taking care and rendering healthcare services to her, must know

well about the course of her condition and the possible nursing interventions we can

provide to manage her condition. This case is also significant in the actual practice of

our nursing profession.

Objectives

Define what is preeclampsia

Trace the pathophysiology of preeclampsia

Enumerate the different signs and symptoms of preeclampsia

Formulate and apply nursing care plans utilizing the nursing process

To learn new clinical skills as well as sharpen our current clinical skills

required in the management of the patient with preeclampsia.

To develop our sense of unselfish love and empathy in rendering nursing

care to our patient so that we may be able to serve future clients with

higher level of holistic understanding as well as individualized care.


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II. ASSESSMENT

A. BIOGRAPHICAL DATA

Patients Name: Mrs. X

Address: Prk. 5, Sindahon, Panabo City, Davao del Norte

Sex: Female

Age: 39 years old

Civil Status: Married

Birthdate: 03/05/1973

Birthplace: MATI, DAVAO ORIENTAL

Nationality: Filipino

Religion: Catholic

Occupation: House keeper

B. CHIEF COMPLAINT

Dyspnea

C. History of present illnessMorning prior to admission patient notice onset of labor pains 6hours prior

to admission patient had persistent labor pains associated with dyspnea.

D. Past medical and Nursing HistoryPositive outer neck mass for 3 years

E. Personal, family and socio-economic history

Mrs. X is plain housewife and her husband is a farmer. She graduated at aPublic Elementary School. And she didnt continue her studies due to financialproblem. On prenatal care with poor compliance.


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F. Patient need assessment

I. OXYGENATION

BP__160/110__ RR 49 cpm____CR___149bpm

(CHARACTER)tachypnia___

LUNGS (per auscultation: character, lung sound, symmetry of chest

expansion, breathing character and pattern):crackles sounds heard upon

auscultation, with symmetrical chest expansion, intercostals retraction

noted, use of accessory muscles noted.

CARDIAC STATUS (per auscultation) sounds, character, chest pain.

__ Lub-dubb sound heard with increased intensity pe r auscultation,

chest pain not noted

CAPILLARY REFILL 4-5 sec._

SKIN CHARACTER AND COLOR_skin is brown, dry, flaky and

wrinkled.

II. TEMPERATURE MAINTENANCE

TEMPERATURE: 36.8 oC_

SKIN CHARACTER_Skin is dry, flaky, wrinkled and not warm to touch_

III NUTRITIONAL FLUID

HEIGHT/WT 52/45 kg _ AMT. FOOD CONSUMED: with good appetite, able to

consumed the OF served

PRESCRIBED DIET: low salt low fat

EATING PATTERN: 3x a day_

INTAKE (IVF; FLUID/WATER: with IVF of D5LR 1L@30cc/hr, water = 300cc


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Other OBSERVATION (related): Skin is dry, has poor skin turgor

IV ELIMINATION

Last BOWEL MOVEMENT(frequency, amount, character)__able to defecate,

NORMAL PATTERN 1- 2x a day

URINATION(Frequency, character, sensation)_able to urinate

V REST-SLEEP

BED TIME _6-7 pm_WAKING UP__5:30 am_

SLEEP (pattern, amount of sleep)_5-6hrs_

PROBLEM AS VERBALIZED dili ko kayo makatulog - OTHER OBSERVATION (related)_Patient can easily be distracted, thus, having

difficulty in sleeping back again

VI PAIN AVOIDANCE

RATE PAIN_- cant able to verbalize- TIME STARTED__7:30 PM_

LOCATION _abdomen__BEHAVIOR (restlessness, facial expression, irritable,

diaphoretic)frequent change of position noted, grimace face and guarding

behavior noted on abdomen area

FREQUENCY_intermittent_

CHARACTER ca nt able to describe, cant able to verbalize

OTHER observation (related) Patient has difficulty in sleeping due to pain felt

VII SEXUALITY REPRODUCTIVE

LMP__N/A__

GRAVIDA/PARITY__G7P6__

FMILY PLANNING METHOD USE: calendar method


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CHILDREN (no.) __6__

VIII STIMULATION ACTIVITY

WORK: Before: plain housewife During: needs assistance in performing

activities

HOBBIES/VICES: sleeping, a moderate smoker and drinker before

SAFETY AND SECURITY

MENTAL STATUS (Coherent, Responsive, conscious, unconscious) conscious,

able to respond by making incomprehensible sounds

EMOTIONAL PROBLEM (diaphoretic, trembling, restless)_restlessness: frequentchange of position due to pain felt________

LOVE BELONGING NEED

CHILDREN (living with?) Patient is loving and supportive

Wife (living with) husband. Due respect and care was given to her

SELF ESTEEM NEED

she is a good person and a loving mother. she has a moderate selfesteem, also because she is a friendly type of person and being loved by familymembers.

GENERAL SURVEY

Date of Assessment: January 24, 2013

On bed, awake, responsive and tachypneic. Pale conjunctiva of the eye noted.

With IVF of # 4 D5LR 1L @ KVO rate @ Left metacarpal vein. Pale nailbeds noted with

capillary refill returns within 4-5 seconds. Bladder distention noted. Bipedal edema

noted.

Nutritional Status


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Mrs. X stands 51 and weighs 49 kilos. On low salt, low fat diet. With IVF of #4

D5LR 1L @ KVO rate infusing well at Left metacarpal vein. With poor skin turgor.

Denies malnutrition during childhood.

Physical Assessment

Skin

Brown skin generally uniform in color except in areas exposed to the sun

Skin temperature uniform and within the normal range (36.8 0C)

Dry skin folds

Nails with smooth texture

cyanotic nail beds

Prompt capillary refill time (4-5 seconds)

Head

Present of nodules or masses

Symmetric facial features and movements

Symmetric nasolabial folds

Evenly distributed black hair

No infestations

Eyes

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


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Presence of discharge,

Yellowish sclera

Pale 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

Eyeballs protruding

Ears

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

Nose

Symmetric and straight

Nasal septum intact and in the midline

Mouth and Throat


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Outer lips uniform bluish in color with symmetric contour,

Buccal mucosa is of uniform pale in color

Gums are pink

Tongue slightly pale, not so moist, at central position

Neck

Head centered

Lymph node palpable

Breast

Firm

Generally symmetric in size

Cardiovascular

BP 160/110

PR 149

Symmetric pulse strength

Respiratory/Chest

Chest symmetric

Chest wall intact, no tenderness, no masses

Symmetric chest expansion and excursion

RR: 49bpm

Gastrointestinal/Abdomen

Straie present at hypogastric and iliac regions

Linea nigra present

No tenderness


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Urinary

Absence of nocturia, dysuria, urgency, hesitancy

Light yellow urine

Reproductive

Regular menstrual cycle

G7p6

Musculoskeletal/Extremities

Muscle equal size on both sides of the body

No tenderness

Presence of edema

Smooth coordinated movements

Neurologic

Can respond to verbal commands

Oriented

Conscious

G. COURSE IN THE WARD

DATE SHIFT NURSES

ASSESSMENT

NURSES

INTERVENTION

MEDICAL

MANAGEMENT

01-18-13 7 3 Repiratory rate

49

Encourging

position

changes(semi-

fowlers)

Oxygen

theraphy

Elevated BP Ecourging Antihypertensive


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160/110 bedrest theraphy

III. Laboratory and Diagnostic examinations

LAB EXAM NORMAL VALUE RESULT INTERPRETATION/IMPLICATIONWBC Count 5-10x 10g/L 16.8 Abnormally high due to presence

of inflammationRBC Count 4.20-6.30 T/L 1.49 Decreased RBC due to

generalized vasospasmHemoglobin 115-155g/L 34g/L Decreaseed hemoglobin due to

liver injury

Hematocrit 0.370-0.47g/L 0.123 decreased due to liver injuryPlatelet count 140-440 G/L 120g/L Endothelial injury occurs, leading

to subsequent platelet adherenceUrine proteincollection

0 +4 Abnormally high due to severepreeclampsia


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IV. REVIEW OF ANATOMY AND PHYSIOLOGY

THE PLACENTA

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

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

fetal waste to be disposed of via the maternal kidneys. Protherial (egg-laying) and

metatherial (marsupial) mammals produce a choriovitelline placenta that, while

connected to the uterine wall, provides nutrients mainly derived from the egg sac. The

placenta develops from the same sperm and egg cells that form the fetus, and functions

as a fetomaternal organ with two components, the fetal part (Chorion frondosum), and

the maternal part (Decidua basalis). In humans, the placenta averages 22 cm (9 inch)

in length and 2 2.5 cm (0.8 1 inch) in thickness (greatest thickness at the center and

become thinner peripherally). It typically weighs approximately 500 grams (1 lb). It has a

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

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


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The umbilical cord inserts into the chorionic plate (has an eccentiric attachment).

Vessels branch out over the surface of the placenta and further divide to form a network

covered by a thin layer of cells. This results in the formation of villous tree structures.

On the maternal side, these villous tree structures are grouped into lobules called

cotelydons. In humans the placenta usually has a disc shape but different mammalian

species have widely varying shapes. The placenta begins to develop upon implantation

of the blastocyst into the maternal endometrium. The outer layer of the blastocyst

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

divided into two further layers: the underlying cytotrophoblast layer and the overlyingsyncytiotrophoblast layer. The syncytiotrophoblast is a multinucleate continuous cell

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

fusion of the underlying cytotrophoblast cells, a process which continues throughout

placental development. The syncytiotrophoblast (otherwise known as syncytium),

thereby contributes to the barrier function of the placenta. The placenta grows

throughout pregnancy. Development of the maternal blood supply to the placenta is

suggested to be complete by the end of the first trimester of pregnancy (approximately

12 13 weeks). The placenta functions in two purposes. The perfusion of the intervillous

spaces of the placenta with maternal blood allows the transfer of nutrients and oxygen

from the mother to the fetus and the transfer of waste products and carbon dioxide back

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

mediated by proteins called nutrient transporters that are expressed within placental

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

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


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disturbances perfusion leads tosmall cerebralhemorrhages andsymptoms of arterialvasospasm

Hyperreflexia of DTRs Decreased brainperfusion leads toarterial vasospasm

Elevated liver enzymes

Decreased liverperfusion

Pulmonary edema withcyanosis

Reduces plasmacolloid osmoticpressure and movesmore fluid intoextracellular spaces

Fetal growth restiction Poor placental

perfusion(S.Ricci, Essentials of maternity, newborn, and womens health Nursing (2 nd ed.))

VI. ETIOLOGY OF THE DISEASE

Gestational hypertension remains an enigma. The condition can be devastating to

both the mother and her unborn child, and yet the etiology still remains a mystery to

medical

science, despite decades of research. Many different theories regarding it exist, but

none have truly explained the widespread pathologic changes that result in pulmonary

edema, oliguria, seizures, thrombocytopenia, and abnormal liver enzymes (Sibai, 2003).

Despite the results of several research studies, the use of aspirin or supplementation

with calcium, vitamins C and E, magnesium, zinc, or fish oils has not proved to prevent

this destructive condition.


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Factors associated with an increase risk for developing gestational hypertension have

been identified and include

Primigravida status

History of preeclampsia in a previous pregnancy

Excessive placental tissue, as is seen in women with GTD and multiple gestations

Family history of preecl ampsia (mother or sister)

Lower socioeconomic group

History of diabetes, hypertension, or renal disease

Women with poor nutrition African -American ethnicity

Age extremes of younger than 17 years or older than 35 years old

Obesity (Green & Wilkinson, 2004)

((S.Ricci, Essentials of maternity, newborn, and womens health Nursing (2 nd ed.))


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hemoconcentration (resulting from decreased intravascular volume) causes increased

blood viscosity and elevated hematocrit (ACOG, 2002).


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B. Diagram of the pathophysiology

PATHOPHYSIOLOGY (Book-Based)

RISK AND PREDISPOSING FACTORS

MODIFIABLE

Sodium intake, Poor Nutrition,Hypercholesterolemia, lack of activitiesduring pregnancy, inadequate prenatal

care

NON - MODIFIABLE

Age (35 years old), family history ofHypertension, primipara, Diabetes Mellitus,

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

Damage to the endothelium cells

(cells that line in the blood vessels)

Endothelium cells releases

endothelin (a potent

vasoconstrictor)

Injury to uterine vessels

Placental ischemia

renin, prostaglandinroduction

Sensitivity of arterioles toangiotensin

BLOOD PRESSURE

Renal perfusion

Impaired kidney function

Activation of renin-angiotensin system

GlomerularFiltration Rate

Na retention &water reabsorption

EDEMA

Permeability ofrenal tubules

PROTEINURIA

Headache Visual

disturbances

Weak thready pulse

Cold-clammy skin

Delayed capillary refill


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PATHOPHYSIOLOGY (Client-Based)

RISK AND PREDISPOSING FACTORS

MODIFIABLE

Sodium intake, Poor Nutrition, lack ofactivities during pregnancy

NON - MODIFIABLE

Age (39 years old), family history ofHypertension

Damage to the endothelium cells (cells that line in

the blood vessels)

Endothelium cells releases endothelin (a potent

vasoconstrictor)

Injury to uterine vessels

Placental ischemia

renin, prostaglandinroduction

Sensitivity of arterioles toangiotensin

BLOOD PRESSURE

Renal perfusion

Impaired kidney function

Activation of renin-angiotensin system

GlomerularFiltration Rate

Na retention &water reabsorption

EDEMA

Permeability ofrenal tubules

PROTEINURIA

Headache Visual

disturbances

Weak thready pulse

Cold-clammy skin

Delayed capillary refill


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VIII. Planning

A. Nursing Care Plan

Assessment NursingDiagnosis

Objective NursingIntervention

Rationale Evaluation

SubjectiveCues:medyo naglisod koog ginhawalabi na kungmag uboko,

as verbalizedby the client

ObjectiveCues:> (+) crackles>rapid,shallow,irregularrespiration> use of

accessorymuscleswhencoughing> abnormalblood gases> abnormalchest x-rayresult

Ineffectivebreathingpattern r/tlungcompliance as aresult of

accumulation of fluidin thepulmonaryinterstitium

At the endof thenursingshift, thepatient willbe able toexperienc

eadequaterespiratoryfunction.

INDEPENDENT> place patientin a semi tohigh fowlerposition if notcontraindicated

> instruct &assist patient tochangeposition, deepbreathe, &cough or huffevery 1-2 hours

> implementmeasures toreduce pain splint incision

>this positionallowincreaseddiaphragmatic excursion &maximum

lungexpansion,whichpromotesoptimalalveolarventilation>frequentrepositioninghelps loosensecretions &

promotes amoreeffectivecough. It alsopromotesmaximumlungexpansion &stimulatessurfactantproduction.Coughing orhuffingmobilizessecretions &facilitatesremoval ofthesesecretions

At the endof thenursingshift, thepatient wasable toexperience

adequaterespiratoryfunction. asevidencedof the ff.:> normalrate, rhythm& depth ofrespiration> improvedbreath

sounds> (-)crackles> bloodgaseswithinnormalranges>Patientverbalizesrelief fromdifficulty ofbreathing


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with pillowduring coughing& deepbreathing

DEPENDENT> implementmeasures tofacilitateremoval ofpulmonarysecretions

suction asorders> maintainO2therapy asordered

> administermeds that maybe ordered toimprove patientrespiratorystatus

from therespiratorytract> a patientwith pain

often guardsrespiratoryefforts painreductionenables theclient tobreathe moredeeply whichenhancesalveolarventilation&

O2/CO 2 exchange> excessivesecretionsand inabilityto clearsecretionsfrom therespiratorytract lead tostasis of

secretions>supplementalO2 increasestheconcentrationof oxygen inthe alveoli,whichincreases thediffusion ofO2 across thealveolar capillarymembrane> medicationtherapy is anintegral partof treating


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manyrespiratorycondition

Assessment NursingDiagnosis

Objective

NursingInterventio

ns

Rationale

Evaluation

Subjective Cues:nahadl ok judk o, kayingon sa doctor naadaw koy high blood.

Unya cge pa jud kogka lipong. Mao nangpaminaw nako laing

jud kayo ako lawas. Dilipa jud ko katulog ogtarong sa cge huna-huna, as verbalized bythe client

Objective Cues:> disturbed sleep

pattern> weak appearance

Fear r/tpersistentheadache

At theend ofthenursingshift,

thepatientwill beable toexperience areduction offear

INDEPENDENT>encourageverbalizatio

n offeelings &concerns

> assurepatient thatstaffmembersare nearby;respond to

call signalas soon aspossible

> reinforcephysiciansexplanation

s & clarifymisconceptions thepatient hasabout thediagnostictests,disease

>verbalization offeelings

&concernshelpsclientidentifyfactorsthat arecausinganxiety> closecontact

& apromptresponsetorequestsprovide asense ofsecurity&facilitates the

development oftrust,thusreducingtheclientsanxiety

At the endof thenursingshift, thepatient

will beable toexperience areductionof fear asevidencedby the ff:>verbalization of

decreased fear &understanding ofthemedicalprocedures


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condition,treatmentplan &prognosis>

implementmeasuresto reducedistress

DEPENDENT

>administerprescribedanti anxietyagents ifindicated

> factualinformation & anawareness of

what toexpecthelpdecreasetheanxietythatarisesfromuncertainty

>improvement ofrespiratory statushelpsrelieveanxiety

associated withthefeeling ofnot beingable tobreathe

> helpsreducethepatients anxiety


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Assessment NursingDiagnosi

s

Objective NursingInterventio

ns


Ojective cues:Weak and pale in

appearance- Capillaryrefill of 3-4seconds

- RBCLevel=1.49

- Hgb level=34g/L

- Bp=160/110mmHg

Ineffectivetissue

perfusionrelated todecreasein RBC,hemoglobin andhematocritlevel

After 4hours of

nursinginterventions, the clientwill exhibitdecrease inoxygendemandand abilityto conserveenergy.

Assist clientin

performing ADL

Place theclient intrendelenbur g position.

Maintainadequateventilation.

Instructclient to sitand danglethe feetbeforestanding.

Advise clientto increase

intake offood rich iniron andfolate suchas liver andgreen leafyvegetables.

Topromote

safety

Topromotevenousreturn

To

promoteoxygenation andgoodbloodcirculation

To preventorthostatic

hypotension

Iron andfolate arenecessaryfor redblood cellproduction.

After 4hours of

nursingintervention, theclient willexhibitdecreasein oxygendemandand abilitytoconserve

energy.


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Assessment

NursingDiagnosis

Objective Nursinginterventions


Subjective:wala kokabalo ko

unsa ngamgapagkaonang gapataas ogbloodpressure

Objective:>Cohorent>Responsiv

e>conscious>Edemanoted atLowerextremeties>PallorNoted>Afebrile>cyanosisnoted at

LowerextremitiesV/SBP: 160/110Temp: 36.6ocPR:149bpmRR:49cpm

Knowledge Deficitrelated to

BloodPressureasevidencedby walako kabaloko unsanga mgapagkaonang gapataas og

bloodpressure

Rationale:

Knowledge deficitabsenceordeficiencyof

cognitiveinformation relatedto patienthasincapacitytounderstand hercondition

General:

After 8 hours

of renderingnursinginterventionsthe patient willbe able acqureknowledgeabout hercondition.

Specific:

After 8 hoursof nursinginterventionsthe patient willbe able to:>participate innursingprocess.>identify theinconvenienceto her learning

and specificaction to them.>exhibitincreaseinterest/assume responsibilityto own learningby beginning tolook forinformationand ask andquestion.>verbalizedunderstandinglearningcondition.>initiatenecessarylifestyle

>Build rapport

>Check andmonitor vitalsigns

>determine theclientability/readiness andanticipatory

needs>provideinformationrelevant only tothe situation topreventoverload.

>identifyinformation

what needs toberemembered.

>recognizedlevel ofachievement,time factors,short term &long.

>discuss topicat a time,avoiding givingto muchinformation.

>providemutual goal

>to gainpatientcooperation

.

>forbaselinedata

>todeterminefactorspertinent &the learning

process.>to assessthe clientmotivation.

>toestablished

the contentto included

Todevelopedlearnersobjectives

>tofacilitatelearning

>to identifyteaching

Goadpartiallymet, has

slightlyacquiredknowlegedabout herconditionsas patient.Verbalized ah amodin asilang mgapagkaona.


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changes andparticipate intreatmentregimen.

setting &learningcontacts.

>provide asses

information forcontact personto answerquestions.

methods tobe used

>to

promotedwellness

B. Discharge plan

Medicines:

Diuretics: This medicine is given to remove excess fluid from

around your lungs and decrease your blood pressure. You may

urinate more often when you take this medicine.

Heart medicine: These medicines may be given to make your

heartbeat stronger or more regular, or to lower your blood pressure.

Vasodilators: Vasodilators may improve blood flow by making the

blood vessels in your heart and lungs wider. This may decrease the

pressure in your blood vessels and improve your symptoms.

Take your medicine as directed: Call your primary healthcare

provider if you think your medicine is not helping or if you have side

effects. Tell him if you are allergic to any medicine. Keep a list of

the medicines, vitamins, and herbs you take. Include the amounts,

and when and why you take them. Bring the list or the pill bottles to


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follow-up visits. Carry your medicine list with you in case of an

emergency.

Follow up with your primary healthcare provider or pulmonologist in 7 to

10 days or as directed.

You may need to return for more tests. Write down your questions

so you remember to ask them during your visits.

Manage pulmonary edema

Limit your liquids as directed. Follow your primary healthcare

provider or pulmonologists directions about how much liquid youshould drink each day. Too much liquid can increase your risk for

fluid buildup.

Weigh yourself daily. Weigh yourself at the same time every

morning after you urinate, but before you eat. Weight gain can be a

sign of extra fluid in your body.

Rest as needed. Return to activities slowly, and do more each day.

You may have trouble breathing when you are lying down. Use

foam wedges or elevate the head of your bed. This may help you

breathe easier while you are resting or sleeping. Use a device that

will tilt your whole body, or bend your body at the waist. The device

should not bend your body at the upper back or neck.

Use a device that will tilt your whole body, or bend your body at the

waist. The device should not bend your body at the upper back or

neck.


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Limit or avoid alcohol: You will need to limit the alcohol you drink,

or avoid alcohol completely. Alcohol can worsen your symptoms

and increase your blood pressure. If you have heart failure, alcohol

can make it worse.

Do not smoke or take drugs: If you smoke, it is never too late to

quit. Do not take street drugs, such as cocaine. Smoking and drugs

can make your condition and symptoms worse. Ask for information

if you need help quitting.

limb to high altitudes slowly: Go slowly to allow your body to getused to a higher altitude. Ask your primary healthcare provider

about the symptoms of high altitude pulmonary edema (HAPE). Ask

what to do if you get these symptoms.

Contact your primary healthcare provider or pulmonologist if:

you have a fever

you gain weight for no known reason

you urinate more than usual

you have new or increased swelling when you breathe

you have questions or concerns about your condition or care.


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IX. PHARMACOLOGICAL MANAGEMENT

Drug study

Drug Action Indications NursingResponsibilities

magnesium sulfateBlockage of

neuromusculartransmission,vasodilation

Prevention and

treatment ofeclamptic seizures,reduction in blood

pressure inpreeclampsia and

eclampsia

Administer IVloading dose of 4-6

over 30 minutes,continue

maintenanceinfusion of 2-

4g/hour as orderedmonitor serum

magnesium levels

closely assessDTRs and check forankle clonus havecalcium gluconatereadily available in

case of toxicitymonitor for signsand symptoms oftoxicity, such as

flushing, sweating,hypotension, and

cardiac and centralnervous systemdepression

hydralazinehydrochloride

(Apresoline)

Vascular smoothmuscle relaxant,thus improving

perfusion torenal, uterine,and ce

Reduction in blood

pressure

Administer 5 10 mgby slow IV bolusevery20 minutesUse parenteral formimmediately afteropeningampule

Withdraw drugslowly to preventpossiblereboundhypertensionMonitor for adverseeffects such aspalpitations,


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headache,tachycardia,

anorexia, nausea,vomiting, and

diarrhea

labetalolhydrochloride

(Normodyne) Alpha 1 and betablocker Reduction in bloodpressure

Be aware that druglowers bloodpressurewithout decreasingmaternal heart rateorcardiac output

Administer IV bolusdose of 10 20 mgand thenadminister IV

infusion of 2mg/minute untildesired bloodpressure valueachievedMonitor for possibleadverse effectssuch asgastric pain,flatulence,constipation,

dizziness, vertigo,and fatigue

nifedipine(Procardia)

Calcium channelblocker/dilationof coronaryarteries,arterioles, andperipheral

arterioles

Reduction in bloodpressure,stoppage of

preterm labor

Administer 10 mgorally for threedoses andthen every 4 8hoursMonitor for possibleadverse effectssuch asdizziness,

peripheral edema,angina,diarrhea, nasal

congestions, cough

Sodiumnitroprusside

Rapid vasodilation(arterial and

venous)

Severehypertensionrequiring rapidreduction in blood

Administer viacontinuous IVinfusion with dosetitrated according to


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pressurePulmonary

blood pressurelevelsWrap IV infusionsolution in foil oropaque

material to protectfrom lightMonitor for possibleadverse effects,such asapprehension,restlessness,retrosternalpressure,palpitations,diaphoresis,

abdominal pain

furosemide(Lasix)

Diuretic action,inhibiting thereabsorption ofsodium andchloride fromthe ascending

loop of Henle

Pulmonary edema

Administer via slowIV bolus at a doseof10 40 mg over 1 2minutesMonitor urine outputhourly

Assess for possibleadverse effectssuch as

dizziness, vertigo,orthostatichypotension,anorexia, vomiting,electrolyteimbalances,muscle cramps, and

muscle spasms


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X. SYNTHESIS OF CLIENTS CONDITION/STATUS FROM ADMISSION TOPRESENT

Conclusion

We therefore conclude that the study portrayed its importance and helped us

know all about preeclampsia. It also helped us understood the causes and effects of the

diseases that enabled us to determine the predisposing and precipitating factors and

traced the pathophysiology of these disorders. This also had given us the knowledge to

identify where and when it had started and how the disease progressed and we had

also interpreted the laboratory and diagnostic exam results of the client and recognizedthe implication of it. We also identified the different pharmacologic treatments indicated

to the condition, considering the effects, actions and different nursing considerations

with regards to the administration of the medications. We have also identified and

formulated the nursing interventions that we could render to the patient that will help us

attain our goal of care to our patient basing from the nursing care plan we have

formulated.

Patients prognosis

After some point in time, as the medical and the nursing management of

the patient is constantly done, a development of her present health status is anticipated.

Continuous administration of medications will result to termination of the signs and

symptoms that was caused by the patients disease such as shortness of breaths,

paleness, swelling, high blood pressure, face and hand edema, and dyspnea.

Furthermore, vital signs are expected to stabilize.


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Recommendation

On the basis of the findings of this study, the following measures are

recommended:

1. Client should take his prescribed medications religiously. He must create a

schedule in order for him to be guided as when to take the medicines and for him

not to be able to forget in doing so.

2. Follow the prescribed diet. His prescribed diet is a low-salt, low-fat diet, therefore

client should avoid salty and fatty foods and client must take note that all cannedgoods are high in sodium even if it says that it is good for the heart.

3. Have an oral fluid intake with in cardiac tolerance.

4. Lifestyle modification is also important in order to prevent the severity of the

condition that will further contribute complications such as cessation of smoking

and drinking alcoholic beverages.

5. Visit his doctor regularly for constant check-ups and to continuously monitor his

condition.

XI. Evaluation of the objectives of the study

After few days of conducting study about the case of Mrs. X, we were able to trace the

history of her disease locally, nationally and globally. We have come up with a

comprehensive assessment of the patients biographical data, cephalo -caudal physical

assessment as well as pe rtinent medical information with regards to the clients health

condition. Apart from that, we were also able to have a clearer view on how the disease

affects the patients body by tracing the pathophysiology of the disease process and


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identifying the different organs involved by reviewing its anatomy and physiology. By

understanding fully the mechanism and effects of the disease to the patient, we have

interpreted different laboratory results related to her condition. We have also identified

and traced so me medications and how these drugs affect the patients physiological

functioning. Appropriate therapeutic care was well planned and provided to the client.

And lastly, we have come up with a discharge plan pertaining to the patients early

recovery.


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XII. BIBLIOGRAPHY

BOOKS

1. Pillitteri, Maternal & Child Health Nursing, 4th Edition

2. Lippincott Williams & Wilkins,Nursing Student Drug Handbook 2009

3. Doenges, Moorhouse, Geissler-Murr Nurses Pocket Guide 9 th edition

4. Mosbys dictionary of Medicine, Nursing and Health Professions

5. S.Ricci, Essentials of maternity, newborn, and womens health Nursing

2nd edition

Internet

1. (cureresearch.com/p/preeclampsia/stats-country.html )February 24,2013

2. (www.doh.gov.ph ) February 24, 2013

3. (www.nursingcrib.com ) date February 24, 2013
http://www.doh.gov.ph/http://www.doh.gov.ph/http://www.doh.gov.ph/http://www.nursingcrib.com/http://www.nursingcrib.com/http://www.nursingcrib.com/http://www.nursingcrib.com/http://www.doh.gov.ph/

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