case-study-preeclampsia 3.doc

8/13/2019 Case-Study-PreEclampsia 3.doc

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Pre-Eclampsia

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I. INTRODUCTION

Description of the Disease

Preeclampsia, also referred to as toxemia, is a condition that pregnant women can

get. It is marked by high blood pressure accompanied with a high level of protein in the

urine. Women with preeclampsia will often also have swelling in the feet, legs, and

hands. Preeclampsia, when present, usually appears during the second half of pregnancy,

generally in the latter part of the second or in the third trimesters, although it can occur

earlier.

In addition symptoms of preeclampsia can include:

apid weight gain caused by a significant increase in bodily fluid

!bdominal pain

"evere headaches

! change in reflexes

educed output of urine or no urine

#i$$iness

%xcessive vomiting and nausea

&he exact causes of preeclampsia are not known, although some researchers

suspect poor nutrition, high body fat, or insufficient blood flow to the uterus as possible

causes.

&he only real cure for preeclampsia and eclampsia is the birth of the baby. 'ild

preeclampsia (blood pressure greater than )*+-+ that occurs after /+ weeks of gestation

in a woman who did not have hypertension before0 andor having a small amount of

protein in the urine can be managed with careful hospital or in1home observation along

with activity restriction.


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&he group chose the case for the reason that they wanted to show the readers the

process on how pre1eclampsia occurs and for them to fully understand and be reminded

on one of the complications associated with pregnancy.

In developing countries: preeclampsiaeclampsia impact *.*2 of all deliveries ()

and may be as high as )32 in some settings in !frica (/ If the rate of life threatening

eclamptic convulsions (+.)2 of all deliveries is applied to all deliveries from countries

considered to be the least developed, 4+,+++ cases of women experiencing this serious

complication can be expected each year. !ccording to "afe 'otherhood.org of the

434,+++ maternal annually (5, )52, or 67,+4+, are due to eclampsia.

Nurse-Centered Objectives

8pon completion of this case study, the student nurse should be able to:

). Identify the risk factor contributing to the occurrence of the disease.

/. 9ormulate significant nursing diagnosis, with the significantly related nursing care

plan.

5. Identify the different medications administered for this disease their indications,

contraindications, side effect, and specific responsibility .

*. Identify the different medications administered for this disease their indications,

contraindications, side effect, and specific responsibility .

Client-Centered Objectives

8pon completion of this case study, the client should be able to:

). 8nderstand awareness of her disease.

/. now the possible causes of the disease.

5. ;earn and understand why such laboratory examinations are being done.


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II. NURSING ISTOR!

a. #emographic #ata

'rs.


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"aternal-child ealth istor#

a. 'aternal B


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$a%il# ealth Illness istor#

Legend:

hypertension

died of old age

pneumonia

asthma

deceased pre eclampsia

*pink border mother side*blue border father side

*

Grandmother

Grandfather

Mother

Grandmother

Grandfather

Father

Patient


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Aoth the grandparents from the mother@s side died from old age. 9rom the father@s

side, the grandmother died from >ypertension and the father was died from Pneumonia.

&he mother is not experiencing any health problems but the father has hypertension and

asthma. &he patient, upon admission has elevated blood pressure and is suffering from

aggravating factors like anxiety, nervousness and fear.


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&!SIC'( 'SS)SS")NT

Nove%ber *+, *

S/IN

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

skin temperature uniform and within the normal range (56C?

when pinched, skin readily springs back to previous state

moist skin folds

nails with smooth texture

nail beds pink

prompt capillary refill time (/ seconds

bipedal non1pitting edema

)'D

absence of nodules or masses

symmetric facial features and movements

symmetric nasolabial folds

evenly distributed black hair

no infestations

)!)S

eyebrows symmetrically aligned with eDual movement

eyelashes eDually distributed and curled slightly outward


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bilateral blinking exhibited

no discharge, edema or tearing

white sclera

pink palpebral conEunctiva

iris black in color

pupils eDual in si$e with smooth borders

illuminated pupils constricts

pupils converge when near obEect is moved toward the nose

when looking straight ahead, the client can see obEects in the periphery

both eyes coordinated, move in unison with parallel alignment

)'RS

color same as facial skin

symmetrically aligned

pinna immediately recoils after it is folded

pinna is not tender

no lesions or discoloration

dry cerumen, grayish1tan color

normal voice tones audible

able to hear ticking of a watch in both ears

NOS)

symmetric and straight

no discharge or flaring


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"OUT 'ND TRO'T

outer lips uniform pink color with symmetric contour, soft and moist

buccal mucosa is of uniform pink color

gums are pink

tongue pink, moist, at central position

N)C/

head centered

lymph nodes not palpable

0R)'ST

firm

generally symmetric in si$e

C'RDIO1'SCU('R

AP )3+)++ mm>g

P ))*

reported palpitations

symmetric pulse strength


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chest symmetric

chest wall intact, no tenderness, no masses

symmetric chest expansion and excursion

: /- breaths per minute

G'STROINT)STIN'(2'0DO")N

striae present at hypogastric and iliac regions

linea nigra present

no tenderness

presence of surgical incision

URIN'R!

absence of nocturia, dysuria, urgency, hesitancy,

light yellow urine

R)&RODUCTI1)

regular menstrual cycle

=)P)

"USCU(OS/)()T'(2)3TR)"ITI)S

muscle eDual si$e on both sides of the body

no bone deformities


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N)URO(OGIC

can respond to verbal commands

oriented

conscious

displayed anxiety


13/50

&!SIC'( 'SS)SS")NT

Nove%ber *, *

S/IN


skin temperature uniform and within the normal range (56C?

good skin turgor

moist skin folds


nail beds pink

prompt capillary refill time


)'D

rounded

smooth skull contour

symmetric facial features


symmetric facial movements

'IR


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evenly distributed

no infestations

)!)S

eyebrows symmetrically aligned

eyelashes curled slightly outward

exhibited bilateral blinking

both eyes coordinated, move in unison and with parallel alignment

white sclera


pupils eDually round and reactive to light and accommodation

iris black in color

pupils eDual in si$e with smooth borders

illuminated pupils constricts

no discharge

)'RS

color same as facial skin


pinna immediately recoils after it is folded

pinna is not tender



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NOS) 'ND SINUS)S


no discharge

absence of lesions and tenderness

nasal septum intact and in the midline

sinuses not tender

"OUT 'ND TRO'T

outer lips uniform pink color

symmetric contour


no abrasions and ulcerations

gums are pink


tongue moves freely with no tenderness

palate surface intact

uvula positioned in midline

palatine tonsils pink and smooth and not swollen

N)C/

head centered

head movement coordinated and smooth with no discomfort


16/50

0R)'ST 'ND '3I((')

rounded, generally symmetric

areola rounded and the same shape

nipples round, everted and eDual in si$e

milk letdown

C'RDIO1'SCU('R

AP )7+)++ mm>g

P )+7

prompt capillary refill time (less than ) second

symmetric pulse strength

R)S&IR'TOR!2C)ST

chest symmetric


full symmetric chest expansion and excursion

respiratory rate of // breaths per minute



symmetric movement caused by respiration


17/50

URIN'R!

yellowish urine

R)&RODUCTI1)


=)P) ()1+1+1)1+


muscle eDual si$e on both sides of the body

eDual strength

no bone deformities

no tenderness

no tenderness on calf muscle when dorsiflexed

N)URO(OGIC


oriented

conscious


18/50

&!SIC'( 'SS)SS")NT

Nove%ber *4, *

S/IN


skin temperature uniform and within the normal range (56./C?

when pinched, skin readily springs back to previous state

moist skin folds


nail beds pink

nail plate angle about )7+C

prompt capillary refill time


)'D

rounded


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symmetric facial features


symmetric facial movements

'IR

thick, evenly districbuted black hair

no infestations


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)!)S

eyebrows symmetrically aligned

exhibited bilateral blinking

anicteric sclera


pupils eDually round and reactive to light and accommodation

no discharge

)'RS


pinna not tender and immediately recoils after folded


dry cerumen, grayish1tan color

normal voice tones audible

able to hear ticking of a watch in both ears

NOS) 'ND SINUS)S


no discharge or flaring

absence of lesions and tenderness

nasal septum intact and in the midline

both nares patent


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outer lips uniform pink color

symmetric contour


gums are pink


palate surface intact

uvula positioned in midline

palatine tonsils pink and smooth and not swollen

gag reflex present

5+ adult teeth, / molars missing, ) with black discoloration of the enamel

N)C/

neck muscles eDual in si$e, head centered

head movement coordinated and smooth with no discomfort

lymph nodes not palpable

0R)'ST 'ND '3I((')

areola rounded and the same shape

nipples round, everted and eDual in si$e

milk letdown

C'RDIO1'SCU('R

AP )4+)++ mm>g


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prompt capillary refill time (less than ) second


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R)S&IR'TOR!2C)ST

chest symmetric

right and left shoulders and right and left hips are at the same height


full symmetric chest expansion and excursion

respiratory rate is /3 breaths per minute



rounded contour

symmetric movement caused by respiration

tender because of suture form cesarean operation

URIN'R!

yellowish urine

R)&RODUCTI1)


=)P) ()1+1+1)1+



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eDual strength

no tenderness

walks aided to maintains balance

no tenderness on calf muscle when dorsiflexed

N)URO(OGIC


oriented

conscious


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DI'GNOSTIC 'ND ('0OR'TOR! &ROC)DUR)S

#iagnostic or

;aboratoryProcedure

Indication or

Purpose

#ateemoglobin Pre1operation

assessment of

the patient.

November

)7, /++3

-7 )/+1

)7+g;

&he result

indicates that a

)+++ ml

sample of

blood contains

-7 f


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hemoglobin on

pregnant is

normal

because of

their increase

in plasma

volume.

>ematocrit

(2

Pre1operation

assessment of

the patient.

November

)7, /++3

+./- +.561+.*6

g;

&he result

indicates that a

)+++ ml

sample of

blood

contains ./- g

of hemoglobin.

#ecreased

hematocrit on

pregnant is

normal

because of

their increase

in plasma

volume.


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Aefore

%xplain to the patient that the WA? test is used to detect an infection or

inflammation.

&ell the patient that the test reDuires a blood sample. %xplain who will perform

the venipuncture and when.

%xplain to the patient that he may experience slight discomfort from the needle

puncture and the tourniDuet.

Inform the patient that he should avoid strenuous exercise for /* hours before the

test. !lso tell him that he should avoid eating a heavy meal before the test.

If the patient is being treated for an infection, advise him that this test will be

repeated to monitor his progress.

Notify the laboratory and physician of medications the patient is taking that may

affect test results: they may need to be restricted.

#uring

%nsure subdermal bleeding has stopped before removing pressure.

!fter

If a hematoma develops at the venipuncture site, apply warm soaks. If the

hematoma is large, monitor pulses distal the venipuncture site.

Inform the patient that he may resume his usual diet, activity and medications

discontinued before the test, as ordered.

! patient with severe leucopenia, they have little or no resistance to infection and

reDuires protective isolation.


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%xplain to the patient that A? count is used to evaluate the number of A?s and

to detect possible blood disorders.





Inform the patients that he need not restrict foods and fluids

#uring


!fter

If a hematoma develops at the venipuncture site, apply warm soaks.

e%o5lobin

Aefore

%xplain to the patient that the hbg test is used to detect anemia or polycythemia or

to assess his response to treatment.






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#uring


!fter


e%atocrit

Aefore

%xplain to the patient that hct is tested to detect anemia and other abnormal

conditions





Inform the patients that he need not restrict foods and fluids

#uring


!fter



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III.T) &'TI)NT 'ND IS I((N)SS

%fforts to unravel the pathogenesis of pre1eclampsia have been hampered by the

lack of clear diagnostic criteria for the disease and its subtypes. ?onseDuently, several

studies have included a variety of other conditions that do not necessarily reflect an

adverse pregnancy outcome.


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!bnormal placentation (stage ), particularly lack of dilatation of the uterine

spiral arterioles, is the common starting point in the genesis of pre1eclampsia, which

compromises blood flow to the maternalBfetal interface. educed placental perfusion

activates placental factors and induces systemic hemodynamic changes. &he maternal

syndrome (stage / is a function of the circulatory disturbance caused by systemic

maternal endothelial cell dysfunction resulting in vascular reactivity, activation of

coagulation cascade and loss of vascular integrity. Pre1eclampsia has effects on most

maternal organ systems, but predominantly on the vasculature of the kidneys, liver and

brain.


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1. T) &'TI)NT 'ND IS C'R)

7. "edical "ana5e%ent

a. I1$s, 0T, NGT feedin5, Nebuli8ation, T&N, O9#5en Therap#

'edical

'anagement

#ate


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%xplain the procedure to the patient

&ell the patient that she might feel a discomfort from the tourniDuet and the IF

insertion

?heck and monitor IF9 regulation and level of fluid

?heck if there is a need for removal and replacement of fluid

?heck if the tube is in the vein and signs of edema

?heck if there is a back1flow of blood

?heck if there is bubbles present in the tube

!lways 'onitor F".

b. &har%acotherap#

Arand name and

=eneric name

#ate ordered

#ate started

#ate changed

oute of

!dministration,

#osage and

9reDuency of

!dministration

=eneral action ?lient response

'efenamic

!cid

))1)-1+3 P.


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?efuroxime

sodium

cell wall

synthesis by

binding to one or

more of the

penicillin1

binding proteins

(PAPs which in

turn inhibits the

final

transpeptidation

step of

peptidoglycan

synthesis in

bacterial cell

walls, thus

inhibiting cell

wall

biosynthesis.

Aacteria

eventually lyse

due to ongoing

activity of cell

wall autolytic

en$ymes

(autolysins and

murein

not acDuire

infection and

did not

experience any

adverse

reaction.


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arrested.

9errous "ulfate ))1)-1+3 P.


36/50

myocardial

oxygen delivery

in patients with

vasospastic

angina

c. Diet

&ype of #iet #ate


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interrupted. ?lear

liDuids are easily

absorbed by the

body. by mouth

(NP


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1I. NURSING C'R) &('N

?ues Nursing

diagnoses

"cientific

%xplanation


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=uarding

behavior

support the

affected area

upon movement

affected area

?ues Nursing

diagnoses

"cientific

%xplanation


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?ues Nursing

diagnoses

"cientific

%xplanation


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K /3 cycles

per min.

PK ))) bpm

pressor

substances. &his

results to

vasoconstriction

and increases AP

dramatically

changing

positions slowly

1give

information

about positive

signs of

improvement

1Instruct client to

avoid or limit

activities that

may stimulate

valsalva

response (rectal

stimulation,

hypotension

1to provide

encouragement

1to prevent in

changes in

cardiac pressures

or impede blow

flow


43/50

bearing down

A.'

?ues Nursingdiagnoses

"cientific%xplanation


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1 %ncourage

activity within

limits of

individual

ability.

1&o stimulate

constrictions of

the intestines

?ues Nursing

diagnoses

"cientific

%xplanation


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to surgery cesarean section

altered the skin

integrity making

it more

susceptible to

pathogens and

even the pt@s

normal flora

intervention, the

patient will able

to know the

preventive

measures of

wound healing

1%ncouraged to

increase foods

that are rich in

protein

1%ncouraged

proper clothing

1!pply

appropriate

dressing

infection.

1 to aid in tissue

repair

1to maintained the

proper skin

moisture.

1to help in wound

healing

able to knew

the preventive

measures of

wound healing


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1III. Dischar5e &lan

=eneral ?ondition of client upon discharge

#uring nurse1patient interaction upon discharge, the patient was wearing a

comfortable pair of white shirt and white paEama and a pair of flat slip1ons while being

sealed on a chair cuddling her baby boy. >er hair was untidy and up in a ponytail with

visible infestations. "he was oriented enough to follow instructions and answers

Duestions asked by the student nurse.

"ethods

"1 Instructed the patient to take the following home medication as ordered by the

physician:

'efenamic !cid 4++mg PN

9errous "ulfate


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1 Instructed patient to take a bath everyday. %mphasi$e the importance of breast

feeding.

O1 !dvice to visit or have a follow up check1up with her attending physician.

D1 ;ow fat, ;ow salt diet.


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I3. Conclusion

Nurses can help the nation achieve National >ealth =oals. &hese goals speak

directly to both fetus and the mother because pregnancy is a high risk factor for them.

?lose monitoring in pregnant women and health teaching as much as possible about

pregnancy could definitely reduce life threatening complications.

"tudies shows that there is no certain facts that will give us the idea where pre1

eclampsia arise. Aut there so many factors that could prevent this complication such as

diet modifications, proper compliance with the health care providers, proper exercise.

!nd if the complication is already present, proper monitoring, proper diet and drug

compliance should be ruled in.


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3. Reco%%endations

With this study, the student nurses were able to gain more knowledge and wider

view and perspective of the complication of pregnancy which is pre1eclampsia. &hus, the

student nurses would like recommend and share some pointers on how to deal with

different diseases with pregnancy specifically pre1eclampsia.

&o the government, primarily they should allocate sufficient budget to sustain and

provide better facilities. &hey must be responsible enough to create awareness program

for care and management for all the 9ilipino people.

&o the health care team, they should righteously implementing basic and ideal

procedures regardless of the health care facilities where they belong. &hey must observe

and always remember to keep in line with their duties towards both the mother and the

child during the pregnancy.

&o the community and the family, that they must be insufficient coordination with

the government and the health care team regarding promotion of health before, during,

and after the delivery of the baby.

case-study-preeclampsia 3.doc

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