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UNIVERSITY OF MAKATI

COLLEGE OF ALLIED HEALTH STUDIES

J.P. Rizal ext.,West Rembo, Makati City

A Mini Case Presentation in

Maternal and Child Nursing 1

As partial fulfillment in requirement

For OB Ward.

2AN1A

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I. INTRODUCTION

Eclampsia, which is considered a complication of severe preeclampsia, is commonly

defined as new onset of grand mal seizure activity and/or unexplained coma during

pregnancy or postpartum in a woman with signs or symptoms of preeclampsia.

Ten percent of all pregnancies are complicated by hypertension. Eclampsia and

preeclampsia account for about half of these cases worldwide and have been recognized

and described for years despite the general lack of understanding of the disease.

We chose this case to present because it is the only available case in the ward, and this

is what our seniors suggested we present.

II. OBJECTIVESGeneral Objective

The group has chosen to do further study in this case that impacted the interest of each

member. More importantly, the focus of this case study shall address questions pertaining to,

yet one of the most significant cases in the ward.

Lastly the subject matter to be presented will enforce the students ability to apply

theoretical knowledge and skills in sensitive procedure done with in the operating room(OR),

specially the insertion of the intrajugular catheter.

Specific Objectives:

1. To identify the factors that lead to the development of the problem,

2. To analyze the relationship between factors leading to the development of the problem,

3. To discuss the relevant procedures that were utilized for effective nursing intervention,

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4. And to evaluate the patient and familys responsibilities to enface the interventions

applied by the student nurse.

III. NURSING HISTORYBIOGRAPHICAL DATA

Name : Patient X

Age : 18

Gender : Female

Address :

Nationality : Filipino

Religion : Catholic

Birthdate : September 30, 1993

Hospital : Ospital ng Makati

Date of Admission : September 22, 2012

Date of Interview : September 25, 2012

Informant : Patient X and significant others

Reliability : 95%

Source of information : Patient

Criteria for reliability :

A. extent of data gathered demographics, history habits = 30%

B. Level of consciousness od interviewee condition, willingness to disclose info = 40%

C. Completeness of correlating facts Fluidity of transpiring events = 25%

CHIEF COMPLAIN

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- Pain in Labor

HISTORY OF PRESENT ILLNESS

- 6hrs. prior patient was admitted at lying-in due to regular uterine contraction. I.E

upon admission was cervix 7cm with Bow. 2 hrs; cervix was fully dilated kindly referred

with episodes of exhaustion and loss of consciousness and continue to --- referred to

OB

PAST MEDICAL HISTORY

Hypertension, Diabetes, Asthma, Cancer, Heart Disease

FAMILY HISTORY

PATIENT X

MOTHER

FATHER

GRANDMOTHER TITA

GRAND

MOTHER

TITA

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Legend:

= eclampsia hypertensive

= Diabetic

IV. GORDONS FUNCTIONAL HEALTH PATTERNFUNCTION HEALTH

PATTERN

BEFORE

HOSPITALIZATION

DURING

HOSPITALIZATIONINTERPRETATION

I. Healthperception andhealth

management

pattern

According to the patient,

her condition was good

with normal daily activity

performed every day,

before she gothospitalized. She

maintaining good health

and exercising every

morning. When she is

sick, she is the one taking

care of herself. None of

her family smoke, And

she drinks alcohol

occasionally.


she is not well. Shes

experiencing pain on her

right hand, back and in

her vagina due to

episioraphy.

Patient didnt have any

cough, colds, or fever.

II. Nutrition andmetabolic

pattern

The patient consumes

1cup of rice every meal

with vegetable and fruit.

Before she got

hospitalized, she had a

good appetite and had no

problem swallowing food.

She also regularly

consumes 8 glasses (or

more) of water a day.

According to her, she

easily gets well whenever

she gets minor illness. She

doesnt buy cooked foodsoutside.

During her

hospitalization, she only

consumed what kind of

diet the physician orders.

III. Eliminationpattern

Before being hospitalized,

she regularly defecates

once everymorning

. -Feces: usually soft.

-Color of the feces: brown.

She regularly defecates

once a day. During

hospitalization she is not

having hard time

urinating and defecating

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She doesnt have any

difficulty in defecating and

urinating.

-Urine color: clear or

yellowish

-Odor: usual unnoticed by

the patient.

-sweat: not too much

Urine color: yellow or

amberOdor: usual

unnoticed by the patient.

-sweat: not too much

. -Feces: usually soft.

-Color of the feces:

brown.

IV. Activity andexercise

pattern


she regularly finishes her

daily routine. She

exercises every morning,

by doing basic stretching

and walking. Before

hospitalization, she can

perform her daily

activities; getting up from

bed, sitting, taking a bath,urination, defecation,

change of clothes, and

any other movement on

her own.

During hospitalization,

she can only perform

minimal movements and

needs assistance for

getting up and walking.

V. Cognitive-perceptual

pattern

The patient can hear

clearly. Her vision is

normal.


there is no change on her

hearing, still normal

vision.

-Experiencing back pain,

pain in the right arm dueto IV lines, and swelling of

her left arm.

VI. Sleep- restpattern

According to the patient

she sleeps for 6hrs in the

evening and 2hrs for

siesta.

According to her, she

watches TV for her to

relax.


she can only sleep with

less than 6 hours. She also

states that the only way

she can relax in the

hospital is when she is in

bed.

VII. Self-

perception,

Self-concept

pattern.

ccording to the patient,

efore hospitalization she

as cheerful and her body

as strong.

According to her and

elative, she doesnt easily

ets angry or worried on

imple thing. She easily

ets sad but she doesnt

ry.

According to her husband,

he noticed that her wife is

perplex because she cant

still accept what just

happened to her baby.

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Bruise in right arm

Due to IV lines

Gastrointestinal System

Pain in the abdomen Due to surgery(CS)

Respiratory System

There are no significant finding

Musculoskeletal System

(-) muscle pain

(-) shoulder pain

(-) standing alone

(-) ambulatory

(-) joint pain

(-) fracture

(+) back pain

(+) cramps

(-) claudication

Genito-urinary System

Masakit yung tahi (Episioraphy) amenorrhea

Nervous System

(+) numbness and burning sensations

(-) Syncope

(-) numbness

(-) disturbance in balance and coordination

(-) dizziness

(+) poor memory

(+) drowsiness

(+) headache

(-) Memory loss

(-) tingling sensation

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V. Physical Assessment

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CEPHALOCAUDAL

EXAMINATION

TECHNIQUES FINDINGS REFERANCE FINDINGS

HEAD

HAIR

EYES

Inspection

Palpation

Inspection

Palpation

Inspection

(-) lesions

(+)dry and grayish

facial skin

(-) areas of

deformity

Symmetric facial

features

(-) palpable masses

or lesions

Evenly distributed

black hair

(-) infestations

Brittle and dry hair

in texture

Eyebrows

symmetrically

aligned

Eyelashes equally

distributed

(+) Sunken eyes

(+) periorbital

edema

Whitish red sclera

Pale Conjunctivae

brown iris

(+) PERRLA (2-3 mm

diameter of iris)

(-) discharge

Symmetrically

aligned

Intact tymphanic

membrane

(-) masses

(-) discharge

(-) lesions

(-) lesions

(-)dry and grayish

facial skin

(-) areas of deformity

Symmetric facial

features

(-) palpable masses or

lesions

Evenly distributed

black hair

(-) infestations

normal texture

Eyebrows

symmetrically aligned Eyelashes equally

distributed

(-) Sunken eyes

(+) periorbital edema

White sclera

Pale Conjunctivae

Black iris

(+) PERRLA (2-3 mm

diameter of iris)

(-) discharge

Symmetrically aligned

Intact tymphanic

membrane

(-) masses

(-) discharge

(-) lesions

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EARS

NOSE

MOUTH AND THROAT

Inspection

Palpation

Inspection

Inspection

Pinna immediately

recoil after it is

folded

pale nasal mucosa

Teeth (+)

incomplete

dentition

Gums and Mucosa

(-) swelling

(-) bleeding

(-) infection

Gums are slightly

pale

normal Pharynx

and Tonsillar Fossa

grayish and dry

oral mucosa (-) swelling and

lesions

(-) lips are greyish

and pale

Tongue is

yellowish brown,

dry and at midline

position

(-) uremic breath

(-) lesions

Not supple

(+) jugular vein

engorgement

(+) Right

Intrajugular

catheter

Pinna immediately

recoil after it is folded

Pink nasal mucosa

Teeth (+) complete

dentition

Gums and Mucosa

(-) swelling

(-) bleeding

(-) infection

Gums are pink

normal Pharynx and

Tonsillar Fossa

Pink and moist oral

mucosa

(-) swelling and

lesions

(+) lips are pinkish and

moist

Tongue is pink, moist

and at midline

position

(-) uremic breath

(-) lesions

Supple

(-) vein engorgement

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NECK

Inspection

Palpation

Thyroid: non-

palpable

Carotid pulses are

(-) lymph nodes

palpable or

lymphadenophaty (-) masses or

lesions present

Suprasternal Notch:

(-) pulsation

Intact

Thyroid: non-palpable

(-) lymph nodespalapable or

lymphadenophaty

(-) masses or lesions

present

Suprasternal Notch:

(-) pulsation

THORAX AND LUNGS Inspection

Palpation

Percussion

Auscultation

(+) symmetrical

expansion with

respiration

(+) altered Tactile

fremitus on the

bases of the thorax

(+) tympanic sound

(-) crackles

(-) added or

adventitious sound

(+) symmetrical

expansion with

respiration

(+) Tactile fremitus

bilateral

(+) resonant sound

(+) normal vesicularbreathing sounds

(-) added or

adventitious sound

HEART Inspection

Palpation

(+) not visible PMI

(+) regular rhythm

Precordium:

(-) parasternal

impulse

(-) thrills

PMI- palpable in 5th

ICS, apical area

S1- heard best at

apex, normal

intensity

S2- heard best at

(+) not visible PMI

(+) regular rhythm

Precordium:

(-) parasternal

impulse

(-) thrills

PMI- palpable in

5thICS, apical area

S1- heard best at

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Auscultation base,

Extra Sounds- (-)

(-)murmurs

apex, normal intensity

S2- heard best at

base,

Extra Sounds- (-) S3,

S4

(-)murmurs

ABDOMEN Inspection

Palpation

(+) globular

(+) pallor,

yellowish gray skin

(-) scars, striae

(+) skin pinch goes

back

slowly

(+) dry skin

(+) Fluid wave

technique

(determining

ascites)

Liver: (-) palpable

Spleen: (-) palpable

Right & left Kidney:

(-) palpable

(-) globular

(-) pallor, yellowish gray

skin

(-) scars, striae

(+) skin pinch goes back

rapidly

(-) dry skin

(-) Fluid wavetechnique

Liver: (-) palpable

Spleen: (-) palpable

Right & left Kidney: (-)

palpable

EXTREMITIES Inspection

Palpation

Upper extremities:

(+) pallor, yellowish

gray skin

(-) cyanosis

(-) rashes

(+) bruises

Palms dry in texture

and pale.

(-) nails cyanosis and

clubbing

(+) thick and brittle

nails

(-) cold to touch

(+) dry skin

(+) skin pinch goes

back

Upper extremities:

(-) pallor

(-) cyanosis

(-) rashes

Palms normal in color

and texture


clubbing

(+) thick and brittle nails

(-) warm to touch

(-) slightly moist

(+) skin pinch goes back

rapidly

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VII. Course in the Ward

Auscultation

Inspection

Palpation

slowly

Left brachial pulse is

bouncing

Left AVF has thrill

Radial pulses are

symmetric but

bouncing.

(-) delayed capillary

refill

Left AVF has bruits

during auscutation

Lower Extremities:

(+) pallor, yellowish

gray skin

(-) cyanosis

(-) rashes

(+) edema

(+) dry skin


Clubbing

(+) thick and brittle

nails

Pulse of Dorsalis

pedis and Posterior

tibia was

symmetric but

bounding

Pitting edema: +2

(4mm)

(-) delayed capillary

refill

(-)cold & clammy

extremities

Left brachial pulse

should be normal

Radial pulse normal and

symmetric

(+) capillary refill within

1-2 secs.

left AVF has bruits during

auscutation

(-) pallor

(-) cyanosis

(-) rashes

(-) edema

(-) dry skin


clubbing

(-) thick and brittle nails

Pulse of Dorsalis pedis

and Posterior tibia was

normal and symmetric

(-) edema

(+) capillary refill within

1-2 secs.

(-) cold and clammy

extremities

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VIII. Diagnostics

HEMATOLOGY

9/24/12 7:35amRESULT NORMAL

Hemoglobin 7.5 12-16g/L

Hematocrit 0.23 0.37-0.47

9/25/12 4:00am

RESULT NORMAL

Hemoglobin 8.6 12 16 g/L

Hematocrit 0.26 0.37 0.47

CLINICAL CHEMISTRY

9/24/12 6:39pm

24 hrs urine

protein

SI Units Conventional Units

Total Volume 200.00ml

24 hrs urineprotein

143.40 143.40 mg/24 hrs.

9/24/12

Examination Result Normal

BUN 6.67 2.49 - 6.4 mmo/L

BUA 515.8 148.70 458.0

umol/LLDH 301.6 225 450 u/L

SGPT 15.1 0 49 u/L

SGOT 21.94 0 37 u/L

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