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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
Rationale Evaluation
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
Rationale Evaluation
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/