new case of pre-eclampsia

8/8/2019 New Case of Pre-eclampsia

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UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUSMINANTE UNO, CAUAYAN CITY, ISABELA

Case StudyOf

PRE-ECLAMPSIA(In partial fulfillment in NCM-104 Related Learning Experience)

Submitted by:

DELA CRUZ,Angela

DELA PE A,Vanessa

EDER,Charmaine

FLAVIANO,Jinky

GUIUO,Jayke

JUAN,Claire

LAZO,Bryan

MACARILAY,Gary

MAGWELANG,Daisy Faith

MALUBAY,Krissa Lea

MANUEL,Kristine Nelly

MARQUEZ,Clarisol

GROUP 7 of BSN 4 A,C,D

Submitted to:

MS. PRIMA ELVIE CONDAT, RN, MAN

Clinical Instructor


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I. IntroductionPre-eclampsiais an abnormal condition of pregnancy characterized by the onset of acute

hypertension after the 24th

week of gestation. The classic triad of pre-eclampsia is hypertension , proteinuria , and edema . It is classified as mild or severe. It commonly causes abnormalmetabolic function, increase of central nervous system, irritability, hyperactive reflexes,compromised renal function, hemo-concentration, and alteration of fluid and electrolyteimbalance. Complication includes the premature separation of placenta hemolysis, cerebralhemorrhage, ophthalmologic damage, pulmonary edema, hepatocellular changes, fetalmalnutrition, and lowered birth weight. The most serious complication is eclampsia, which is canresult in maternal and fetal death.

S tatistical Data>Approximately 5-7 % of all pregnancies are complicated by pre-eclampsia.

>Pre-eclampsia usually occurs in womans pregnancy but may occur for the first time insubsequent pregnancy.

II. NURSING HISTORY

A. Demographic DataPatients Name : Mrs. Pre eclampsiaAge : 35 years oldSex : FemaleAddress : Purok 1, Alingay, San Guillermo Isabela

Civil status : MarriedOccupation : HousewifeDate and Time of Admission : July 19, 2010/8:35 amReligion : Roman CatholicDate Chief complain : Dizziness, Nape PainAdmitting diagnosis : Pre-eclampsiaAttending Physician : Dr. X

B. Patients health history1. Past healt h hi story

Mrs. Pre-eclampsia always takes OTC drugs whenever she feels ill. Three days prior to admission, Mrs. Pre-eclampsia already feels dizziness and nape pain, so shecannot perform her responsibilities at home.

2 . Pr e sent hi story July 29, 2010, Mrs. Pre-eclampsia admitted to EDH at exactly 8:35 am because

she can no longer tolerate the pain and dizziness that she feels. Her initial vital signswas; BP-180/110mmHg, T-36.7 , PR-93bpm, RR-18cpm. She was diagnosed with

pre-eclampsia.3 . Fam ily hi story

One of the patient relative from her mother side has also history of pre-eclampsia and hypertension.

4 .

edic al Hi story Mrs. Pre-eclampsia was not yet undergone in any form of surgical procedureand she delivered their four children at home without any complication.

5 . Ob st etr ical Hi story a. Past Pregnancy

The patient doesnt have any complication of her previous pregnancy. Shedelivered her four children in normal way in their house and she was assisted bythe midwife. However she never experienced having vaccine.


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b . Present PregnancyThe patient experienced dizziness, she mentioned that she is using pills. She

has undergone ultrasound last July 20, 2010. The result was in the single intrauterine

fetus exhibiting active cardiac pulsation bodily movement, with fetal heart rate128bpm. She really doesnt know her LMP, but as she said that her 4 th child is at 10months old. And her AOG was 26 weeks.

C. GORDONS FUNCTIONAL PATTERN1. Health Perception-Health Management

Before hospitalization, she considers herself healthy because shes able to perform her daily activities without any difficulties but according to her she got easily tired. She rarelyhas illness and if she does, she manages it by having enough rest and takes an OTCmedicine that cures common illness like colds, cough and flu. Her perceptions towardsherself began to change, she verbalizes that if the illness worsen she doesnt consult the

doctor. She doesnt drink any alcoholic beverages or smoke cigarettes.During Hospitalization, the patient no longer consider herself as healthy, she cant

stand or sit alone because every time she does, it only worsen her headache. She takes a bathonce a day but with the aid of others through tepid sponge bath. She still doesnt drink alcohol and smoke cigarette.

2 . Nutritional- Metabolic PatternBefore hospitalization, the patient usually eats food 3 times a day which she considers

to be nutritious like meat and rice and sometimes vegetables and fish for at least twice aweek. She usually drinks 8-10 glasses of water a day. She doesnt have any eating problemsexcept for the times that her tooth aches.

During Hospitalization the patients appetite changed because she bites her tongue the

morning prior to consultation. She still eats three (3) times a day but in small amount, and itis composed of low salt and low fat diet.3 . Elimination Pattern

Before hospitalization, the patient usually void for at least 5-7 times a day; 2-4 timesin the morning and 2-3 times in the evening and defecate once day.

During Hospitalization, the patient had noticed that her elimination pattern changes,she voids 3 times a day and doesnt feel any urge to defecate unlike before.

4. Activity- Rest PatternBefore, the patient doesnt have any exercise, she was not able to perform her daily

activities like performing basic necessities, cleaning their house and surroundings, preparingfood for her family, gardening and washing their clothes because she prefer to take care of

her 10 months old baby. She really enjoy sitting and sleeping with her baby most of thetime.During hospitalization, the patient usually lies on her bed; she had a limited movement

and cant sit or stand because of her severe headache and dizziness.5 . Sleep- Rest Pattern

Before, she usually sleeps from 8 pm to 5 am, and usually takes a nap in the morningfrom 9am-11am and in the afternoon from 1:30pm-4:00pm. But when she started to suffer headache, it became hard for her to fall asleep and when she does, it was already 11pm or 12midnight, it will be interrupted whenever her head began to aches again. She usually wakesup at 5 am in the morning.

During hospitalization, the patient sleeps for 5-6 hours in the evening, and has been

easily disturbed by patients SO and nurses. She also doesnt take an afternoon nap/sleep.6 . Cognitive- Perceptual ResponseBefore hospitalization, the patient doesnt have any problem in reading, writing,

hearing and speaking. She doesnt have any visual problems, she make things easier to learn by asking others to help her and by discovering it by her.

During Hospitalization, the patient cannot read clearly, she does have blurred visionand difficulty in speaking. She can still make things easier to learn by asking help or information to other people who knows more about a certain topic/ issue.


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7. Self Perception- Self Concept PatternBefore, the patient feels good about herself, she feels healthy and strong. Her

relationship with her friends, family and relatives were considered to be fine and she canexpress herself to them easily. She said that shes always on a good mood. The things thatannoyed her is when other people makes a story about her or about her loved ones, but shemanages it by not listening to their stories and not being affected.

During hospitalization, the patient feels very bad about herself, she feels sad becauseof her condition. She also feel afraid and depressed but not hopeless, shes hoping thateverything will be fine.

8 . Role- Relationship PatternBefore and during hospitalization the patient has a good family relationship. They are

happy though they admit that they are living in poverty. She has lots of friends and sheshappy with them. She can also express herself to them by showing what she feels. Every

time that shes having a problem, the first person who always helps her to resolve it was her husband.

9 . Sexuality- Reproductive PatternBefore hospitalization, the patient completely expresses herself as a woman wearing

by womans clothes, acting like a woman and doing her responsibilities as a mother andwife. She shows her love and affection onto her family by serving them and helping them.She doesnt have any menstrual difficulties.

During hospitalization, the patient was still able to show affection onto her familythough shes in the hospital by asking them several things about their lives like, how theyare, what is their problem and how shell be able to help them despite of her condition.

10. Coping- Stress Tolerance PatternBefore hospitalization, the patient stressors were; her neighbors who love gossiping,and financial related problems. She manages these stresses by praying to GOD and asking

her husbands help.During hospitalization, the patients main stressor was her health problems and their

hospital bills. Her way of coping with it was asking her family and God help.11. Value- Belief

The patient is a Roman Catholic; she goes to church every Sunday to ask guidancefrom God. According to her, in times of problems, God is the only one who can help us to

be strong, and when you need help, just pray and God will help you find ways to be fine.

III. Physical Assessment General Appearance:

The patient was lying on bed, conscious and weak complaining headache and difficulty inspeaking.Vital Signs:T emperatur e: 36.7

C Puls e rat e: 93 bpm Re spiratory rat e: 18 cpm Blood Pr e ssur e: 180/110 mmHg F etal heart tone: 140 bpm Dat e of A sse ssment : July 19, 2010 Weigh t : 76 kg T ime of A sse ssment : 8:00 PM till 8:50 PM

BODY PARTS TECHNIQUE USED FINDINGS ANALYSIS

HEADy Hair

SKULL AND FACE

y Eyes and Vision

>INSPECTION

>INSPECTION

>INSPECTION

>Evenly distributed, thick,silky>Rounded (normocephalicand symmetrical, withfrontal, parietal andoccipital prominences).

y Eyebrowssymmetrically

>Normal

>Normal

>Normal


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y EARS ANDHEARING

y NOSE ANDSINUSES

y M OUTH ANDOROPHARYNX

y NECK

>INSPECTION

>INSPE CTION

>PALPATION

>INSPECTION

INSPECTION

aligned, equal inmovement.

y Eyelashes equally

distributed,y Pupils color is black,

equal in size andround.

y B lurred vision

y Color is same asfacial skin,symmetrical,auricle aligned with

outer canthus of eyey Dry cerumen,

sticky, wet invarious shades of brown

y Normal voice tonesaudible

y Able to hear in bothears

y Symmetrical, nodischarge andflaring, uniform incolor

y (-) lesionsy Nasal septum is

intact and inmidline

y (-) Tenderness,

y Lips is pallor withlocalized swellingand dryness

y Tongue is pink incolor, moist, slightlyrough with thinwhitish coating

y (+) lesions,tenderness,restricted mobility,and swelling of tongue.

y Light pink, smooth,soft palate

y Lighter pink hardpalate

y Uvula is positionedin midline of softpalate

y Presence of hyperpigmentation

>Normal

>Normal

>Increase B P possiblycompresses bloodvessels in the retina>Normal

>Normal

>Normal

>Normal

>Normal

>Normal

>Normal

>Normal

>Poor hygiene

>Normal

>Probably due tofalling andaccidentally biting of tongue

>Normal

>Normal

>Normal

>Due to increaseestrogen


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UPPER EXTREM ETIESy Skin

y Nails

Chest and backy Skiny B reast

y Thorax andLungs

(anterior and posterior)

y Heart

y Abdomen

PALPATION

INSPECTIONPALPATION

INSPECTION

B LANCH TEST

INSPECTION

INSPECTIONPALPATION

AUSCULTATION

AUSCULTATION

INSPECTIONPALPATIONLEOPOLD SM ANUEVER

of skiny Head is centeredy Lymph nodes are

not palpabley Thyroid gland

ascends duringswallowing

y Shiny and dryy +1 Edema on left

and right forearmto the phallanges

y (+) Early clubbing at180, thick, pallor,intact epidermis.

y capillary refillreturn to usualcolor in 3 sec.

y (-) Lesions, (-)nodules

y (+)Enlargement,(+)tenderness, andhyperpigmentationof areola

y Vibrations areprominent over theareas near thebronchi.Vibrationsare strongestbetween the firstand second ribsalong the sternumanteriorly andbetween thescapulaeposteriorly

y heart sounds areaudible in all areasbut loudest atapical area

y no masses andtenderness.

y (-) scars, color isuniform, roundedor scaphoid,symmetricalmovements causedby respiration,umbilicus is

concave, positionedmidway betweenthe xiphoid processand the symphysispubis, color is thesame as thesurrounding skin.

>Normal>Normal

>Normal

>Poor hydration>Due to fluidretention

>Poor arterialcirculation

>Poor circulation

>Normal

>Possibly due toincreased estrogenproduction

>Normal

>Normal

>Normal


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LOWER EXTREM ETIESy Skin

y Toenails

INSPECTION

INSPECTION

y FHT=140

y Shiny, dry,

(+)bipedal edema+1

(+)early clubbing 180

>due to fluid and

water retention.Large uterus slowsvenous return causingthe blood to pull.>Indicates lack of oxygen and poorcirculation.

IV. LABORATORY RESULTCBC

PARAMETERS NORMALVALUE RESULT ANALYSISHemoglobin Male: 130-180

g/lFemale: 110-

160g/l

133g/L Normal.

RBC 5.0-10.0 2 .0 Decreased due tofluid retention

Lymphocytes 20-40 17 % Indicates problemcontrollinginfection

Eosinophils 1-3 1 % Normal Neutrophils 55-65 82 Increased due to

sudden onset of increase BP with

edemaURINALY S I S

ANALYSISCOLOR SMOOKY BROWN (+) PUS, (+) RBCs/ bacteria

TRANSPARENCY TURBIDREACTION PH 6.0 Normal

SPECIFICGRAVITY

1.020 Normal

M I C RO SC O P I C F IN D ING S ANALYSIS

HYALINE 0-1 Conglomerations of proteinand indicate proteinuria

GRANULAR 0-3 Indicates kidney failure

PUS CELLS Many Indicates infectionRBCs Many Due to fluid retention and

reabsorption of waste material

AMORPHOUS FEW NormalCHE M I C AL T ES T ALBUMIN +++ Due to increased BP that may

decline kidney function.


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U TZ R E P OR T

Pregnancy Evaluation>There is a single intrauterine fetus exhibiting active cardiac pulsation and bodilymovement. (FHR 128/min).>Based on BPDFL and AC measurements. The age of gestation is 26 weeks.>Placental implantation is fundal draping posteriorly, no previa.>Amniotic fluid volume is low (AFl=7.8cm)>Estimated fetal weight is 0882 grams with sign of cord coil.>it is a girl.

REMARKS:>single intrauterine pregnancy 26wks AOG alive

>Oligohydramnios

V. REVIEW OF THE SYSTEM

A. ANATOMY AND PHYSIOLOGY

The HeartThe heart is a large muscular organ which constantly pushes oxygen-rich blood to the

brain and extremities and transports oxygen-poor blood from the brain and extremities to thelungs to gain oxygen. Blood comes into the right atrium from the body, moves into the rightventricle and is pushed into the pulmonary arteries in the lungs. After picking up oxygen, the

blood travels back to the heart through the pulmonary veins into the left atrium, to the leftventricle and out to the body's tissues through the aorta.

Systemic CirculationSystemic circulation supplies nourishment to all of the other tissues located throughout

your body. It plays an integral role in the overall circulatory system. The arteries carryoxygenated blood away from the heart leaving through the aortic arch. It branches out to formsmaller arteries that run throughout the body. The internal layer of an artery is smooth allowing

blood to flow quickly while the outer layer is strong to withstand the great pressure of the bloodflow from the heart.These smaller arteries will branch out again into capillaries where the exchange of

substances occur and oxygen and nutrients from the blood are released. The endothelium, aselectively permeable membrane of single layer cells is found in the capillaries allowing for faster diffusion and transfer. The great number of branches is to increase the cross-sectionalsurface area of the tissues. This also helps to lower the blood pressure in the capillaries where theflow of blood is slowed out to give more time for the exchange of substances.


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During the systemic circulation blood is passed through the kidneys. This phrase isknown as renal circulation where the kidneys filter much of the waste from the blood. Blood also

passes through the small intestines through the portal circulation where it is passed through the

liver and the sugars filtered stored for use later. The remaining blood will be returned to theheart by the veins.

The Cardiovascular SystemYour heart and circulatory system make up your cardiovascular system. Your heart works

as a pump that pushes blood to the organs, tissues, and cells of your body. Blood delivers oxygenand nutrients to every cell and removes the carbon dioxide and waste products made by thosecells. Blood is carried from your heart to the rest of your body through a complex network of arteries, arterioles, and capillaries. Blood is returned to your heart through venules and veins. If all the vessels of this network in your body were laid end-to-end, they would extend for about60,000 miles (more than 96,500 kilometers), which is far enough to circle the earth more thantwice!

The one-way circulatory system carries blood to all parts of your body. This process of blood flow within your body is called circulation. Arteries carry oxygen-rich blood away fromyour heart, and veinscarry oxygen-poor blood back to your heart.

In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into your lungs and the pulmonary vein that brings oxygen-rich blood back to your heart.

In the diagram, the vessels that carry oxygen-rich blood are colored red, and the vesselsthat carry oxygen-poor blood are colored blue.

Twenty major arteries make a path through your tissues, where they branch into smaller vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygenand nutrients to your cells. Most capillaries are thinner than a hair. In fact, many are so tiny, onlyone blood cell can move through them at a time. Once the capillaries deliver oxygen andnutrients and pick up carbon dioxide and other waste, they move the blood back through wider

vessels called venules. Venules eventually join to form veins, which deliver the blood back toyour heart to pick up oxygen.

The KidneyThe kidneys are a pair of vital organs that perform many functions to keep the blood

clean and chemically balanced. Understanding how the kidneys work can help a person keepthem healthy.

The kidneys are bean-shaped organs, each about the size of a fist. They are located near the middle of the back, just below the rib cage, one on each side of the spine. The kidneys aresophisticated reprocessing machines. Every day, a persons kidneys process about 200 quarts of


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blood to sift out about 2 quarts of waste products and extra water. The wastes and extra water become urine, which flows to the bladder through tubes called ureters. The bladder stores urineuntil releasing it through urination.

The kidneys remove wastes and water from the blood to form urine. Urine flows from thekidneys to the bladder through the ureters.

Wastes in the blood come from the normal breakdown of active tissues, such as muscles,and from food. The body uses food for energy and self-repairs. After the body has taken what itneeds from food, wastes are sent to the blood. If the kidneys did not remove them, these wasteswould build up in the blood and damage the body.

The actual removal of wastes occurs in tiny units inside the kidneys called nephrons. Eachkidney has about a million nephrons. In the nephron, a glomeruluswhich is a tiny blood vessel,or capillaryintertwines with a tiny urine-collecting tube called a tubule. The glomerulus acts asa filtering unit, or sieve, and keeps normal proteins and cells in the bloodstream, allowing extrafluid and wastes to pass through. A complicated chemical exchange takes place, as waste

materials and water leave the blood and enter the urinary system.In the nephron (left), tiny blood vessels intertwine with urine-collecting tubes. Each

kidney contains about 1 million nephrons.At first, the tubules receive a combination of waste materials and chemicals the body can

still use. The kidneys measure out chemicals like sodium, phosphorus, and potassium and releasethem back to the blood to return to the body. In this way, the kidneys regulate the bodys level of these substances. The right balance is necessary for life.

In addition to removing wastes, the kidneys release three important hormones:y erythropoietin, or EPO, which stimulates the bone marrow to make red blood cellsy renin, which regulates blood pressurey calcitriol, the active form of vitamin D, which helps maintain calcium for bones and for

normal chemical balance in the body

Functions of the Kidney1. Excretion of waste 2. Acid-base homeostasis 3. Osmolality regulation 4. Blood pressure regulation 5. Hormone secretion


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VI. Course in the Ward

DOCTOR S ORDER ANALYSIS NURSING RESPONSIB ILITIES

7/19/108:35

Admitted patient

Low salt, low fat diet

Urinalysis

CB C

8:40am B P-190/100Hydralazine 5mg q 8 TIVT

8:50amM agnesium sulfate 5mg deep I M stat8:55amM ethyldopa 250mg 1 tab B ID

IVF:D5LRS IL X 12

M onitor VS q shift; B Pmonitoring q 1

Refer

9:25 B P-200/120

M ay give another 5mgHydralazine IV nowStart Ampicillin 500mg q 6 TIVTANST (-)For pelvic UTZ once possible

7/19/10IVF to follow:D5NM 1L

4:55pmNifedipine 5mg SC state

B P-200/130Hydralazine 5mg IV at q 6

8:00pm B P-180/100Hydralazine 5mg IV stat

>initiates initial care

>to know the right diet to betaken

>To check if there areabnormalities in her urine output

>To check for anyabnormalities/changes in herblood counts

>Help lower blood pressure

>muscle relaxant>to prevent seizures

>help lower blood pressure

>to provide route for giving IVmedication>to determine baseline data>determine if there are anychanges/abnormalities

>Allow health team to plan andinitiate appropriate action

>Help lower latest B P

>it helps to eradicate bacteria.

>to determine accurate AOG

>Hypotonic solution that providewater and treat fluid imbalance

>it help lower blood pressure



>facilitated transfer from ER toOB ward.>promote & encourage to eatfood low salt, low fat.>explain consequences of saltyfood>facilitate in the collection of urine>submitted request to the

laboratory>follow-up result>submitted request to thelaboratory

>explain the benefits/ actions of the drugs

>Explain the purpose of medication

>emphasize the importance of this medication>monitored & regulated asordered>for close monitoring of her vitalsign especially blood pressure>to prevent furthercomplications>Review patient chart

> explain the benefits/ actions of the drugs>explain the benefits/ actions of the drugs>To explain the procedure>to help the client understandthe procedure

>regulated as ordered

> explain the benefits/ actions of the drugs

> explain the benefits/ actions of the drugs> explain the benefits/ actions of the drugs


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11:45pm B P-200/110M ethyldopa 250mg to 1 tab

TID

Change IVF to D5W 500cc +amps hydralazine to titrate B P to160/90Hold IV Hydralazine q 6

7/20/107:45 AM M gSO4 5mg each buttocks deepIM 8:14 AM Hook back D5W to run x KVOHydralazine 5mg slow IV now,may give another dose after 30mins. If repeat, diastolic B P is100mmHg and above may giveup to 4 doses (max.20 mg).07/20/10Refer to O B


>same osmotic solution thathelp to lower the latest B P

>hydralazine is alreadyincorporated to IVF

>for replacement in deficiencystate.

>passageway of the medication.>it is a vasodilator that lowersthe B P and decreased heart rate.

>for further observation &studies


>Regulated as ordered

>Regulated as ordered


>regulated as ordered.>check B P first before giving themeds and be sure to give it inslow IV.>administer slowly to avoidsudden fall in blood pressure

>Explain to the client why it isnecessary


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IX. DISCHARGE CARE PLAN

The patient was referred to OB last July 20, 2010.

R eferences:

1. Maternal And Child Health Nursing: Care Of The Child Bearing And Child Rearing FamilyBy Adele Pillitteri Volume 1 Page 427,431 5 th Edition

2. http://www.nlm.nih.gov/medlineplus/anatomy.html

3. Nurses Pocket Guide Diagnoses, Prioritized Interventions, And Rationales By Marilyn E.Doenges, Mary Frances Moorhouse, Alice C. Murr 11 th Edition Page 145-151, 324-327, 605-610, 721-726, 414-418 , 433-438

4. Davis/s Drug Guide for Nurses 11 th Edition

5. http://www.docstoc.com/docs/13189236/NursingCribcom---Nursing-Care-Plan-Pregnancy-Induced-Hypertension-PIH-Preeclampsia-and-Eclampsia

new case of pre-eclampsia

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