i. introduction cesarean section is a surgical

I. INTRODUCTION

Cesarean Section is a surgical procedure in which incisions are made through a woman’s abdomen and uterus to deliver her baby. The most common reason that a cesarean

section is performed (35% of all cases according to the United States Public Health Service) is that the woman has had a previous Cesarean Section. “Once a Cesarean, always a

cesarean”. 30% of all cases of Cesarean section birth are due to difficult child birth due to non progressive labor. Another 12% of Cesarean Sections are performed to deliver a

baby in a breech presentation. 9% of all cases, Cesarean Sections are performed in response to fetal distress. 14% of Cesarean Sections are indicated by other serious factors (e.g.

Cord Prolapse)

Description of the Disease

Eclampsia it is a presence of unexplained grand mal seizures in a hypertensive, proteinuric pregnant woman after 20 weeks gestation. Predisposing factors are same

with mild and sever preeclampsia. Having a primary seizure disorder does not predispose a patient to eclampsia. The presenting symptoms are those present in

preeclampsia plus unexplained tonic-clonic seizures.

In addition symptoms of eclampsia can include:

Rapid weight gain caused by a significant increase in bodily fluid

Epigastric pain

Visual disturbances, persistent headache

Pulmonary edema

Sustained blood pressure elevation greater or equal to 160/100.

Proteinuria +3 to +4 or greater or equal to 5 grams on a 24-hour urine collection.

The etiology of eclampsia is a severe diffuse cerebral vasospasm resulting to decreased cerebral perfusion and cerebral edema.

The only real cure for preeclampsia and eclampsia is the birth of the baby. The treatment that can be done is to establish airway and protect patients tongue, and magnesium

sulfate administration. The complications are intracerebral hemorrhage and or death.

The group chose the case for the reason that they wanted to show the readers the process on how eclampsia occurs and for them to fully understand and be reminded on

one of the complications associated with pregnancy.

In developing countries: preeclampsia/eclampsia impact 4.4% of all deliveries (1)and may be as high as 18% in some settings in Africa (2) If the rate of life threatening

eclamptic convulsions (0.1% of all deliveries) is applied to all deliveries from countries considered to be the least developed, 50,000 cases of women experiencing this serious

complication can be expected each year. According to Safe Motherhood.org of the 585,000 maternal annually (3), 13%, or 76,050, are due to eclampsia.

This case is a case of a 19 year old female, a resident of Norzagaray, Bulacan, who was admitted in Bulacan Medical Center on December 2, 2009 at 6:30 in the evening,

with the diagnosis of pregnancy uterine 35 5/7 weeks twin gestation cephalic in labor intrapartum eclampsia. She was transferred to the Operating Room and was given anesthesia

at 8:50pm and the operation started at 9:05PM.The procedure lasts for 40minutes and delivered at 9:45 pm. The baby boy 1 extracted at 9:17pm while baby boy 2 extracted at

9:18pm together the placenta and the operation ended at exactly 9:45PM

B. For the very reason that we are currently taking up Maternal and Child Nursing concerning Abnormal Cases. Our group had agreed upon to select this case for our Clinical Case

Study, further, we want to have deeper and comprehensive understanding of the knowledge and skills we have learned on the four corners of our classroom.

OBJECTIVES:

General Objective:

● To be able to present a comprehensive study of the cesarean section delivery in relation to eclampsia

Specific Objective:

Knowledge:

1. To be informed about cesarean delivery.

2. To acquire and import knowledge regarding the pathophysiology of eclampsia.

3. To be able to plan for needed interventions for the recovery of the patient that underwent cesarean section delivery.

4. To be able to develop Nursing Care Plan that will meet the needs of patient.

5. To be able to have a general and subsequent evaluation of the client’s conditions and well being.

Skills:

1. To be able to obtain sufficient data of the client’s history of past and present illness.

2. To be able to provide a drug study of the medication being administered after delivery and as well as the kind of diet which is allowable to a eclamptic patient.

3. To be able to do a comprehensive physical examination to a woman who underwent cs delivery.

4. To be able to analyze the different laboratory examination to the woman who underwent cs delivery.

5. To be able to implement the said plan for the eclamptic patient..

Attitude:

1. To be able to effectively establish rapport, essential for the cooperation of the client to the health care.

2. To be able to practice the use of therapeutic use of self for the complete recovery of the patient.

3. To be able to recognize and understand the client’s situation.

4. To be able to work as a team necessary for this case study.

5. To be able to practice leadership, a unique trait a nurse should have.

Nurse-Centered Objectives:

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

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

2. Formulate significant nursing diagnosis, with the significantly related nursing care plan.

3. Identify the different medications administered for this disease their indications, contraindications, side effect, and specific responsibility .

4. Identify the laboratory and diagnostic procedure done with the pre-eclamptic patient, their indication and purposes, and specific nursing responsibilities.

Client-Centered Objectives:

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

1. Understand awareness of her disease.

2. Know the possible causes of the disease.

3. Learn and understand why such laboratory examinations are being done.

A. BIOGRAPHIC DATA

I. Patients Personal Information:

Name: N.B.

Address: Old Barrio, Bigte Norzagaray, Bulacan

Birthday: September 28, 1990 Age: 19 y/o

Gender: Female

Marital Status: Single

Religion: Born Again

Race: Filipino

Occupation: Student

Birth Order: Eldest among 5 children

II. REASON FOR SEEKING HEALTH CARE

The patient’s chief complaints are abdominal pain, uterine contractions, and pain in the back that radiates around to the abdomen.

III. HISTORY OF PRESENT ILLNESS

In giving birth to her two sons, the patient undergone to caesarian section because of some complications like temporary blindness, fever, hypertension, difficulty in

hearing, and convulsion.

IV. PAST MEDICAL HISTORY

Patient NB hasn’t experienced any childhood diseases and doesn’t hospitalized during her childhood years. She had measles when she was in grade 2. According to her

mother, she doesn’t have a complete immunization and she doesn’t have any allergies during her childhood.

B. FUNCTIONAL ASSESSMENT

Functional Health Pattern Prior to hospitalization During HospitalizationI. Health Perception and Health Management

According to our patient, whenever she is sick, she only pray for her fast recovery and that she don’t take any kind of medicine, and she doesn’t even consult a physician.

When in hospital patient N.B. having her enough meal in order to regain her energy loss during labor and delivery. She eat nutritious food to supply adequate amount of nutrients needed by her body.

II. Nutritional and Metabolic Pattern According to our patient, when she got pregnant, she eats rice eight times a day excluding her snacks.

When she gave birth, she only eat half cup of rice every meal.

72 HOURS DIET RECALLDATE BREAKFAST LUNCH DINNERDecember 8, 2009

Half serving of Lugaw2 glasses of water

Half cup of rice1 serving of Pork sinigang3 glasses of water

Half cup of rice1 piece of fish and 1 serving of noodles

December 9, 2009

Half cup of Lugaw2 glasses of water

Half cup of rice1 serving of pork sinigang2 glasses of water

Half cup of rice1 serving of ginataang kalabasa2 glasses of water

December 10, 2009

Half serving of PansitHalf serving of Lugaw2 glasses of water

Half cup of rice1 serving of Pork sinigang

III. Elimination Pattern

URINE STOOL

FREQUENCY: 4 times a day 2-3 times a dayCOLOR: Clear BrownODOR: Odorless Foul OdorCONSISTENCY: Soft

URINE STOOL5 times a day Once a day

Clear Greenodorless Foul odor

soft

IV. Activity-Exercise Pattern Dancing is her only way of exercise No form of exercise. The client’s activity was spent mostly in lying down on bed.

V. Sleep-Rest PatternTIME OF SLEEP: 10:00pmWAKE-UP TIME: 5:00amSLEEPING HOURS: 7 hours

TIME OF SLEEP: 9:00pmWAKE-UP TIME: 4:00-5:00amSLEEPING HOURS: 7-8 hours of sleep

VI. Cognitive-Perceptual Pattern There are no abnormalities in her senses, particularly her vision and hearing. The patient had blurred vision when looking at far objects; on the other hand she experienced slight difficulty in hearing.

VII. Self-Perception and Self Concept Pattern

According to our client she’s not excited having a baby because she is still young and a student, she wants to pursue her studies and to have a diploma.

Patient NB told us that she’s not excited having a baby she doesn’t have any regrets at all. Now that she’s a mother, still she wants to finish her course, according to her maybe after 2 or 3 years she will continue her studies.

VIII. Role-Relationship Pattern The type of family she has according to residence is matrilocal. She is a single parent and a part of an extended family. According to her, she values her family so much and feels their love and care for her. She told us that they don’t have any family conflict/problem.

Patient NB thinks that she needs to be responsible for her sons. As a mother she will do her obligations to her sons.

IX. Sexuality-Reproductive Pattern Her first menstruation stated at the age of 13 years old. She usually used 2 pads a day. Her first sexual intercourse happened when she was 18 years old. During her pregnancy before her hospitalization she has not engage herself to sexual intercourse. She took care of her reproductive organ always and observes proper hygiene.

Patient NB verbalized that she and her parents has no plan engaging into sexual activities and she will focus to her role of being a mother and plans to continue her study in the future.

X. Coping-Stress Pattern After delivery of patient NB, she felt so much stress. She said that her two sons serve as her strength to cope with different stress that will come.

The first thing that she does whenever she has a problem is sleeping as her form of relaxation. She is very vocal I telling her problem to her mother.

XI. Value-Belief Pattern Our client’s religion is Born again. She is very active in their church. According to our patient, she is not so grateful having a baby/babies yet she’s thankful that her sons are alive.

GROWTH AND DEVELOPMENT

Theorist Theory Stages Definition Explanation

Freud Psychosexual Development Genital

12 years old—adulthood

Emerge of sexual interests and development of relationship with potential sexual patterns.

The patient already knew this stage but at the age of 19 years old, she was already pregnant and this is not the right time for having a child.

Erikson Psychosocial Development Intimacy vs. Isolation

18-25 years old

Develop commitments to others and to a life work.

As a 19 year old woman with a twin children that are responsible. She attained productivity in regards to her study which is a 3rd year college student. She already recognized her individual accomplishment as a mother and as a student.

Piaget Cognitive Development Formal Operations

11+years old

Able to see relationships and to reason in the abstract.

The client thinks more systematically and deeply. She thinks about herself and not about the future of her child because she wants to finish her study and she don’t really want to have a child.

13+ years old

Individual understands

She believes that trust is basis for relationship. In this stage the person words established

Kohlberg Moral Development

Level III: Post conventional

Stage 5: Social contract orientation

Stage 6: Universal ethics Orientation.

the morality of having democratically established laws.

It is “wrong” to violate other’s right.

The person understands the principles of human rights and personal conscience. Person believes that trust is basis for relationships.

rules from authorities and the reasons for decisions and behavior is that social and sexual rules and traditions demand the response. But sometimes she doesn’t follow rules and regulations set by government and other authorities like having a child in her early age. There’s a rule that if you are not in a right age of having a child, first you have to finish your study before doing sexual intimacy with your partner.

Fowler Stages of Faith Stage 3: Synthetic-Orientation Faith

Adolescent

Questions values and religious in an attempt to form own identity.

The client says that during her labor, it is GOD, the client herself, her family, friends and healthcare providers, provides her strength and trust.

PHYSICAL ASSESSMENT (OBSTETRIC)

a. Menarche: 14 yrs old d. LMP: Dec. 04, 2008 height:4’11’’ weight:47kgb. EDC: Sept. 11, 2009 e. Trimester: Postpartumc. AOG: 41 wks f. G: 5 P: 5

TPAL: 5-0-0-5

BP: 130/90 mmHg PR: 105 bpm RR:30rpm Temp:37.20C

Breast

1. size Equal [ ] Unequal [√ ]2. shape Symmetrical[√ ] Asymmetrical[ ]

Remarks: ____________________ Fetal presentation: cephalic presentation Attitude: vertex

Nipples Fetal lie: LOA FHR: 140 bpm

Inverted [ ] Everted [√] Lump [ ] Engagement: engaged

Discharge: ___________________

Color

Pinkish [√ ] Increased vein[√ ] First Trimester

Remarks: ____________________ 1. Presumptive signs Amenorrhea [√] Chadwick’s signs [√]

Abdomen Nausea & vomiting [√] Gonadotropic exams [√]

Linea Nigra[√ ] Striae Gravidarum[√ ] 2. Probable Signs Hegar’s sign [√] Goodell’s signs [√]

Other skin impairment [ ] Uterus within abdomen [√]

Remarks: ____________________ Changes in size, shape, & consistency of the uterus [√]

Perineum Secondary/Third Trimester

OBSTETRICAL HISTORY

INITIAL PHYSICAL ASSESSMENT


VITAL SIGNS


SIGNS OF PREGNANCY

Scars [ ] Warts [ ] Rashes [ ] Quickening [√ ] date: October 23, 2006 Uterine enlargement apparent[√ ]

Varicosities [ ] Discharge [√] Braxton Hick’s contraction [√] Chadwick’s sign [√]

Color: reddish Odor: fleshy Uterine soufflé [√] Melasma [√]

Appearance: moist Darkening of Areola of the nipples [√] Linea nigra [√]

Transparent [ ] Turbid [ ] Positive signs X-ray outline of the Fetal Skeleton [√]

Fetal movement felt by examiner [√]

Fetal heartbeat audible with stethoscope [√]

PHYSICAL ASSESSMENT

Patient: N. B. Date of Assessment:

BODY AREAS TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

A. GENERAL BODY PARTSBody built Inspection and

ObservationProportionate; Varies with lifestyle

Posture Inspection Relaxed, Erect Posture Tense, bent posture, uncoordinated movement

Deviation from normal due to uncomfortably in her incision

on her abdomen

Overall hygiene and grooming Inspection and Observation

Clean and Neat Untidy and with presence of body odor

Deviation from normal due to inability to take a bath

Body and breath odor Observation No presence of odor anywhere in the body

With presence of body odor Deviation from normal due to presence of body odor

Client’s attitude Observation Cooperative Cooperative while doing the procedure

Normal

Client’s mood/, emotional status Observation Appropriate to the situation The patient’s mood is appropriate to the situation

Normal

Quantity, quality, and organization of speech

Observation Understandable; moderate pace; exhibits thought association

Patient has understandable words and exhibits thought association

Normal

Vital Signs

1. Temperature

2. Pulse Rate

3. Respiratory Rate

Observation

Palpation

Observation

36.5-37.50 C

60-80 bpm

12-21 cpm

370 C

80 bpm

20 cpm

Normal

Normal

Normal

B. INTEGUMENTARY

Skin color Inspection Varies from light to dark brown Pallor Deviation from normal due to blood loss

Uniformity of skin color Inspection Generally uniform except for the areas exposed to the sun

Her skin is uniform except for the areas exposed to sun

She has high pigmentation in her neck, underarm, nipples and areola

Normal

Normal due to pregnancy

Presence of edema Palpation No presence of edema There is no presence of edema Normal

Skin moisture Palpation Moist in axilla and skin folds Has moisture especially in her underarm

Normal

Skin temperature Palpation Uniform varies with environment and climate

Warm to touch Normal

Skin turgor Palpation When pinched , skin springs back to previous state

Skin springs back to previous state Normal

C. NAILS

Plate shape (curvature and angle)

Inspection Convex curvature within 160˚ angle Has convex curvature Normal

Texture Inspection and Palpation Smooth Smooth texture Normal

Bed color Inspection Pink in color; vascular Pallor Deviation from normal due to poor circulation

Blanch test Inspection and Palpation Prompt return of usual color in <4 seconds

Prompt return in 3 seconds Normal

D. HEAD

SKULL

Size, shape and symmetry Inspection Rounded (Normocephalic) and symmetrical

Normocephalic and symmetrical in shape

Normal

Presence of masses, nodules and depressions

Inspection Smooth, Nodules and masses are absent. No presence of nodules Normal

SCALP

Color and Appearance Inspection White in color; no dandruff With presence of dandruff and has oily scalp

Deviation from normal due to the presence of dandruff

Areas of Tenderness Palpation Smooth, Nodules and masses are absent. Rough

No masses nor nodules

Deviation from normal due to rough texture of the scalp

Normal

HAIR

Evenness of growth;

Thickness or thinness

Inspection Evenly distributed; no infection or infestation

Evenly distributed hair, no infestation

Thick hair

Normal

E. FACE

Facial features Inspection Symmetric or slightly asymmetric facial feature

The face has symmetric features Normal

Facial Movements Inspection Symmetric Facial Movements Even facial movements Normal

F. EYES

EYEBROWS

Hair distribution. Alignment, skin quality and movement

Inspection Hair evenly distributed; symmetrically aligned; has equal movements; no

presence of lesions

Hair evenly distributed; symmetrically aligned;

Equal movement

Normal

EYELASHES

Evenness of distribution and Inspection Evenly distributed; no discharge; curl in Eyelashes are evenly distributed, Normal

direction of curl outward direction no discharge and curl in outward direction

EYELIDS

Surface characteristics, position in relation to the cornea; ability to blink; frequency of blinking

Inspection Pinkish; no visible sclera above corneas when lids open; lids closed

symmetrically; 15-20 blinks per minute

Skin intact, no charge, no discoloration

Blinks 16 times per minute

Normal

CONJUNCTIVA

Bulbar conjunctiva (color, texture, presence of lesions)

Inspection Transparent; no lesions; pinkish Conjunctiva is transparent, no lesions and pinkish

Normal

Palpebral conjunctiva (color, texture, presence of lesions)

Inspection Shiny; smooth; pink in color Shiny, smooth, pale Deviation from normal due to pale palpebral conjunctiva

SCLERA

Color and clarity Inspection Capillaries are sometime evident, sclera appear white

White in color Normal

CORNEA

Clarity and texture Inspection Transparent; smooth; shiny Transparent and shiny Normal

IRIS

Shape and color Inspection Rounded; light to dark brown in color; equal

Rounded and black in color Normal

PUPILS

1. Reaction to light

2. Visual Fields

Inspection

Inspection

Pupils equally round, react to light and accommodation

When looking straight ahead, the client can see objects in periphery

Black in color, equal in size, round, smooth border, both pupils

constrict and dilate

Normal

Extraocular Muscle Test Inspection Both eyes are coordinated in movement, Have coordinated movement Normal

moves in union with parallel alignments

G. EARS

Auricles

1. Color2. Symmetry

3. Texture and Elasticity

Inspection

Inspection

Inspection and Palpation

Color same as facial skin

Symmetrical, auricle aligned with outer canthus of the eye.

Mobile , firm and not tender. Pinna recoils after it folded.

Color of the ears are slightly darker than facial skin

Symmetrical, auricle aligned with outer canthus of the eye.

Mobile , firm and not tender. Pinna recoils after it folded.

Deviated from normal

normal

Gross Hearing Acuity

1. Voice test

Inspection

Normal sound audible

Normal voice tone audible

Normal

H. NOSE

External Inspection Symmetric, no discharge No discharge or flaring, uniform in color

Normal

Nasal Septum Inspection Intact and in midline Septum is in midline and intact Normal

Pataency of Nasal Cavities Inspection Air moves freely as the client breathes through the nares

Client breaths freely through her nares

Normal

Sinuses Inspection Not tender No tenderness Normal

I. MOUTH

Lips Inspection Uniform pink in color Smooth in texture, moist, no lesions but pale in color

Normal

Teeth Inspection 28-32 adult teeth Yellowish in color; with dental Deviation from normal due to

carries and with false teeth lack of oral hygiene

Mucosa Inspection Pink, without inflammation Pale in color, no lesions, moist and soft

Normal

Gums Inspection Pink gums; not tender; no lesions; no discharge

Light pink gums, moist and firm in texture

Normal

Uvula Inspection Positioned in the midline of soft palate Uvula is positioned in the middle if soft palate

Normal

J. PHARYNX

Mucosa Inspection No lesions Absence of lesions Normal

Tonsils Inspection Pink and Smooth; no discharge She has pink, smooth pharynx and no discharge

Normal

K. NECK

Neck Muscles Inspection Muscles equal in size, head centered; coordinated, smooth movements with no

discomfort

Equal size of muscle, head is centered; well coordinated

movements with no discomfort

Normal

Trachea Inspection Central placement in midline of neck, spaces are equal in both side

Position in the center, the spaces are equal in both side

Normal

L. BREAST

Size, symmetry Inspection symmetrical Positive enlargement, equal in size, symmetric


Areola Inspection color varies in every individual Round in shape and bilaterally the same. Positive enlargement, dark

brown in color


Nipple Inspection Round, inverted; no discharge Round, everted and equal in size, similar in color, both point in the same direction, positive discharge


is present.

N. JUGULAR VEINS

Jugular veins Inspection Not visible and no lesions Not visible Normal

O. THORAX AND LUNGS

Spine alignment Inspection Spine vertically aligned, spinal column is straight

Her spine is vertically aligned and has straight spinal column

Normal

Breathing pattern Inspection Effortless, quiet Has effortless and quiet respirations

Normal

P. MUSCULOSKELETAL MUSCLES

Size Inspection Equal in size on both sides of arm, thigh and calf

Size of both sides of arm, thigh and calf are equal

Normal

Muscle tonicity Palpation Firm Muscle is firm Normal

Bones Inspection and palpation No deformities, edema or tenderness absence of deformities, no edema nor tenderness

Normal

Joints Inspection and palpation No deformities, edema or tenderness absence of deformities, no edema nor tenderness

Normal

Q. ABDOMEN

Skin Inspection Uniform color, no lesion Refused ---

Contour Inspection flat Refused ---

Tenderness Palpation No tenderness noted Refused ---

R. UPPER EXTREMITIES

Motor strength Inspection Equal strength on each body side Equal strength on each body side Normal

Muscle Tone Palpation Normally Firm Normally Firm Normal

Presence of lesions, deformities and varicosities

Inspection No lesion, no deformities No lesion, no deformities and no tenderness

Normal

S. LOWER EXTREMITIES

Motor strength Inspection Equal strength on each body side Equal strength on each body side Normal

Muscle Tone Palpation Normally Firm Firm Normal

Presence of lesions, deformities and varicosities

Inspection No lesion, no deformities No lesion, no deformities and no tenderness

Normal

ANATOMY AND PHYSIOLOGY

Female reproductive system

Photograph of the vulva: A pictorial of the human female reproductive system. A pictorial of a non-lactating and lactating breast.

1. Pubic hair (shaved) 4. Labia majora

2. Clitoral hood 5. Labia minora

3. Clitoris 6. Perineum

http://en.wikipedia.org/wiki/File:Flushvul_numbered.jpg

FEMALE EXTERNAL REPRODUCTIVE ORGANS

Mons Pubis

The mons pubis is a softly rounded mound of subcutaneous fatty tissue beginning at the lowest portion of the anterior abdominal wall. Also known as the mons

veneris, this structure covers the front portion of the symphisis pubis after puberty. The mons pubis is covered with pubic hair, typically with the hairline forming at

transverse line across the lower abdomen. The hair is short in all women. The mons pubis protects the pelvic bones, especially during coitus.

Labia Majora

The labia majora are longitudinal, raised folds of pigmented skin, one on either side of the vulvar cleft. As the pair descends, they narrow and merge to form the

posterior junction of the perineal skin. Their chief function is to protect the structures lying between them.

Labia Minora

The labia minora are soft of skin within the labia majora that converge near the anus, forming the fourchette. Each labium minus has the appearance of shiny

mucous membrane, moist and devoid of hair follicles. The labia minora are rich in sebaceous glands, which lubricate and waterproof the vulvar skin and provide

bactericidal secretioins.

Clitoris

The clitoris, located between the labia minora, is about 5-6 mm long and 6-8 mm across. Each tissue is essentially erectile. The glands of the clitoris is partly

covered by the fold of skin called prepuce, or clitoral hood.

Urethral meatus and Paraurethral glands

The urethral meatus is located 1-2.5 cm beneath the clitoris in the midline of the vestibule: it often appears as a puckered, slitlike opening. At times the meatus is

difficult to visualize because of the presence of blind dimples or small mucosal folds. The paraurethral glands or Skene’s glands, open into the posterior wall of the

urethra close to its opening. Their secretions lubricate the vaginal opening, facilitating sexual intercourse.

Vaginal vestibule

The vaginal vestibule is a boat-shape depression and closed by the labia majora and visible when they are separated. The vestibule contains the vaginal opening, or

introitus, which is the border between the external and inter genitals

The hymen is a thin, elastic collar or semi-collar of tissue that surrounds the vaginal opening. The hymen essentially opening.

However, modern studies of female genital anatomy have revealed that the hymen surrounds rather than entirely covers the vaginal opening, and can be torn not

only through sexual intercourse but also through physical activity, masturbation, menstruation, or the use of tampons, thus dispelling old beliefs.

External to the hymen at the base of the vestibule are two small papular elevations containing the opening of the ducts of the vulvovaginal (Bartholin’s) gland. They

lie under the constrictor muscle of the vagina. This glands secrete a clear, thick, alkaline mucus that enhances the viability and motility of the sperm deposited at the

vaginal vestibule.

Perineal body

The perineal body is a wedge-shaped mass of fibromuscular tissue found between the lower part of the vagina and the anus.The superficial area between the anus

and the vagina is referred to as perineum. The muscles that meet at the perineal body are the external spinchter ani, both levator ani (the superficial and the deep

transverse perineal), and the bulvocarvernosus. These muscles mingle with elastic fibers and connective tissue in an arrangement that allows a remarkable amount of

stretching.

FEMALE INTERNAL REPRODUCTIVE ORGANS

The female internal reproductive organs are: the vagina, uterus, fallopian tube, and ovaries. These are trget organs for estrogenic hormones, and they play a unique

part in the reproductive cycle

Vagina

The vagina is a muscular and membranous tube that connects the external genital with the uterus. It extends from the vulva to the uterus to a position nearly parallel

to the pain of the pelvic brim. The vagina is often called the birth canal because it forms the lower part of the pelvis through which the fetus must pass during birth.

In the upper part of the vagina which is called the vaginal vault, there I is a recess or hallow around the cervix called the vaginal fornix. The upper 4 th of the vagina

is separated from the rectum by the pouch of douglas. This deep pouch or recess is posterior to the cervix. The walls of the vagina are covered with ridges, or rugae

crisscrossing each other. These rugae allow the vaginal tissue to stretch enough for the fetus to pass through during child birth. The vagina has 3 functions; 1st serve

as the passage for sperm and for the fetus during birth; 2nd provide passage for the menstrual products from the uterine endometrium to the outside of the body; and

lastly, it protect against trauma from sexual intercourse and infection from pathogenic organisms.

Uterus

The uterus is a hallow, muscular, thick-walled organ shaped like an upside-down pear. It lies in the center of the pelvic cavity between the base of the bladder and

the rectum and above the vagina.

The uterus is divided into two major parts, an upper triangular portion called the corpus or uterine body and a lower cylindric portion called the cervix. The upper

2/3 of the uterus (the corpus or uterine body) composed of mainly of smooth muscle layer (myometrium). The lower third is cervix or neck. The rounded upper most

(dome shaped top) portion of the corpus that extends above the points of attachment of fallopian tubes is called the fundus. The elongated portion of the uterus

where the fallopian tubes enter is called the cornua. The isthmus is the portion of the uterus between the internal cervical OS and the endometrial cavity.

The isthmus takes on importance in pregnancy because it becomes lower uterine segment.

The function of the uterus is to provide safe environment for fetal development. The uterine lining is cyclically prepared by steroid hormones for implantation of the

embryo, a process known as nidation.

Uterine Corpus

The uterine corpus is made up of 3 layers. The outer most layers is the serosal layer or perimetrium which is composed of peritoneum. The middle layer is the

muscular uterine layer or myometrium this muscle uterine layer is continuous with the muscle layer of the fallopian tubes and the vagina. This continuity helps this

organs present a unified reaction to various stimuli-ovulation, or orgasm or the deposit of sperm to the vagina. The myometrium has 3 distinct layers of uterine

involuntary muscles. The outer layer, found mainly over the fundus is made up of longitudinal muscles that cause cervical effacement and expel the fetus during

birth. The thick middle layer is made up of interlacing muscle fibers in figure-8 pattern. The inner muscle layer is composing of circular fibers that form sphincter at

the fallopian tube attachment sites and at the internal OS. The internal OS sphincter inhibits the expulsion of the uterine contents during pregnancy but stretches in

labor as cervical dilation occurs. The sphincters at the fallopian tube prevent menstrual blood from flowing backward into the fallopian tube from the uterus. The

uterine contractions of labor are responsible from the dilatation\of the cervix and provide the major force for the passage of the fetus through pelvis and vaginal

canal at birth. The mucosal layer or the endometrium of the uterine corpus is the inner most layer. This single layer is composed of columnar epithelium, glands, and

stroma. The glands of the endometrium produce a thin, watery alkaline secretion that keeps the uterine cavity moist. This endometrial milk not only help sperm

travel to the fallopian tubes but also nourishes the developing embryo before it implants in the endometrium.

Cervix

The narrow neck of the uterus is the cervix it meets the body of the uterus at the internal OS and descends about 2.5 cm. to connect with the vagina at the external

OS. Thus it provides a protective entrance for the body of the uterus. Vaginal cervix appears pink and ends at the external OS. The cervical canal appears rosy red

and is lined with columnar ciliated epithelium, which contains mucus secreting glands. The cervical mucus has three functions, first is to lubricate vaginal canal;

second is to act as a bacteriostatic agent; to provide an alkaline environment to shelter deposited sperm from the acidic vagina.

At ovulation cervical mucus is clearer, thinner more profuse and more alkaline than at other times.

Fallopian Tubes

The two fallopian tubes, also known as the oviducts or uterine tubes, arise from each side of the uterus and reach almost to the sides of the pelvis, where they turn

toward the ovaries each tube is approximately 8 to13.5 cm long. A short section of each fallopian tube is inside the uterus; its opening into the uterus is only 1mm in

diameter, this linkage increase a woman’s biologic vulnerability to disease processes.

Each fallopian tube may be divided into three parts: the isthmus, the ampulla, and the infundibulum, or fimbria. The isthmus is straight and narrow, with a thick

muscular wall and an opening (lumen) 2 to 3mm in diameter. It is the site of tubal ligation, surgical pregnancy. Curve ampulla comprises the oute r 2/3 of the tube

the ampulla ends. The ampulla ends at the fimbria which is a funnel shaped enlargement with many projection, called fimbriae reaching out to the ovary. The

longest of these, the fimbria ovarica, is attached to the ovary to increase the chances of intercepting the ovum as it is released.

The wall of the fallopian tube is made up of 4 layers: peritoneal (serous), sub serous (adventitial), muscular and mucous tissues. The peritoneum covers the tube.

The sub serous contains the blood and nerve supply and the muscular layer is responsible for the peristaltic movement of the tube. The mucosal layer, immediately

next to muscular layer is composed of ciliated and non ciliated cell. The fallopian tube has 3 functions to provide transport for the ovary the uterus (transport time

through the fallopian tube varies from 3-4 days): to provide a site for fertilization: to serve as a warm, moist, nourishing environment for the ovum or zygote

(fertilized egg).

Ovaries

The ovaries are two almond shaped structures just below the pelvic brim. One ovary is located on each side of the pelvic cavity. The ovaries are composed of three

layers: the tunica albuginea, the cortex and the medulla. The tunica albuginea is dense and dull white and serves as a productive protective layer. The cortex is the

main functional part because it contains ova, graafian follicle, corpora lutea, the generated corpora lutea (corpora albicantia) and degenerated follicles. The medulla

is completely surrounded by the cortex can contain the nerves and the blood and the lymphatic vessels. Ovaries are the primary sources of the two important

hormones: the estrogen and the progesterone.

PATHOPHSIOLOGY

A. ALGORYTHM

Pregnant woman with blood pressure higher than 140/90mmHg

Before 20 weeks of Gestation After 20 weeks of Gestation

No/stable Proteinuria New/ proteinuria, dev’t of Proteinuria No Proteinuria

blood pressure/ HELLP syndrome

Preeclampsia Gestational HPN

Preeclampsia

Eclampsia

A. EXPLANATION

The current concepts regarding the pathophysiology of eclampsia recognize that eclampsia is a multisystem disorder characterized by vasoconstriction,

metabolic changes, endothelial dysfunction, and activation of the coagulation cascade in conjunction with an inflammatory response. Women with

underlying microvascular disease, such as diabetes, hypertension, and collagen vascular disease, have a higher incidence of eclampsia.

Normal placental development involves progressive loss of the musculoelastic tissue in the spiral arteries that feed the vessels of the intervillous spaces,

which results in uterine blood flow increases of nearly 25% during the first trimester. This process of remodeling the maternal spiral arteries that

branch from the uterine artery is typically completed by 18-20 weeks' gestation.

this physiologic dilatation of the spiral arteries does not occur because the placental trophoblast cells do not invade the spiral arteries, resulting in

maintenance of narrow vessels with resultant placental hypoperfusion and ischemia. In severe cases, not only do the spiral arteries maintain their muscular

structure, but other pathologic changes also occur. Accumulation of fat-laden macrophages with fibrinoid necrosis (ie, acute atherosis), disruption of

the basement membranes, platelet deposition, mural thrombi, and proliferation of intimal and smooth muscle cells all decrease the luminal diameter.

The narrowed and damaged spiral arteries become thrombosed, resulting in placental infarction and necrosis. Uteroplacental blood flow is then reduced

by 50-75%. The anatomical reduction in blood flow may be complicated by vasospasm of the uteroplacental bed.

The primary defect in preeclampsia appears to originate at the maternal-fetal interface (the placenta). Decreased placental perfusion is thought to lead

to fetoplacental ischemia. The ischemic placenta may produce circulating antiangiogenic factors that promote generalized maternal vascular

endothelium dysfunction, leading to systemic manifestations of preeclampsia. Associated abnormalities in clotting and platelet function contribute to

vasoconstriction and platelet adhesion and aggregation, as well as to the activation of coagulation factors that increase the risk of thromboembolic

formation.

The primary feature of preeclampsia, development of hypertension, occurs when normally extreme vasodilatation does not occur. Although cardiac

output increases 30-50%, the decreased peripheral vascular resistance (PVR) results in decreased BP, even in women with chronic hypertension. Women

who develop preeclampsia experience an increase in PVR and alterations in vascular sensitivity to endogenous hormones (eg, angiotensin II,

catecholamines, vasopressin). This increase in vascular reactivity to pressor hormones may be mediated, at least in part, through damage to vascular

endothelial cells, disrupting the normal prostaglandin balance.

The normal expansion of blood volume by 50% that occurs with pregnancy is decreased by 15-20% in patients with preeclampsia. This is the

result of diminished plasma volume, leading to the relative hemoconcentration observed in preeclampsia. The plasma volume abnormality involves a

redistribution of extracellular fluid, such that interstitial fluid volume is increased while the plasma volume is decreased. The hematocrit increases as

the severity of preeclampsia increases. Circulating blood volume is maintained by the increased vascular tone. Whether the vasospasm is the cause or

effect of the vascular endothelial injury is not known. Regardless, this injury likely results in the microangiopathic hemolysis and disseminated

intravascular coagulation that accompanies severe preeclampsia.

The complication of mild preeclampsia may lead to progression of severe preeclampsia and the complication of severe preeclampsia may now lead to

eclampsia which can cause tonic-clonic seizures/ convulsions.

REVIEW OF SYSTEM

Reproductive SystemUterus Enlargement and thickening (hypertrophy) of the uterus; most marked in the fundus.

At the level of umbilicus by the 20th weeks AOG, xiphoid by the 36th week; descends slightly during the last 3 weeks due to fetal descent into the pelvis.

Cervix Pronounced softening and cyanosis (due to increased vascularity, edema, hypertrophy and hyperplasia of cervical glands) – Goodell’s sign

Cervical plug formed by clot of thick mucus.Ovaries Ovulation ceases throughout pregnancyvagina Increase vascularity, hyperemia, and softening of perineum and vulva.

Chadwick’s sign noted Vaginal mucosa increase in thickness, connective tissue loosen and small muscle cells hypertrophy Vaginal secretions increase; pH is 3.5-6 because of increased production of lactic acid (doderlein bacillus)

Breast Tender and tingle in the early week of pregnancy Increased in size, larger in nipples, more pigmented Colostrum present by 2nd trimester Elevated glanda of Montgomery (hypertophic sebaceous glands)

Integumentary SystemStriae gravidarum Reddish, slightly depressed streaks in the abdomen wall, breast, and thighs.Linea Nigra Line of dark pigment extending from the umbilicus down the midline to the symphysis pubis.Chloasma “Mask of Pregnancy” are the brownish patches of pigment on the face.Pigmentation Pigmentary changes occur because of the melanocyte-stimulating hormone elevated from the second month of pregnancy.

Metabolic Changes Weight Gain Weight gain average is 11-13 kgs. (24-28 lbs)

Fetus (3400 gm); Placenta (450 gm); Amniotic Fluid (900 gm); Uterus (1 gm); Breast Tissue (1400 gm); Blood Volume (1800 gm) maternal stores (1800-3600 gm)

Weight gain- steady, consistent is ideal; total of 24-28 lbs. First trimester = 2-4 lbs; 12-14 lbs; Third trimester = 12-24 lbs; Third trimmest 8-12 lbs.

Water Metabolism Average woman retains 6.5 liters of extra water during pregnancy.Protein Metabolism Fetus, uterus, and maternal blood re rich in protein.Carbohydrate Metabolism

Human Placental Lactogen, Estrogen, Progesterone, and Insulin produced by the placenta during pregnancy oppose the action of insulin during pregnancy.

Pregnancy, potentially, can initiate diabetes, and DM may be aggravated by pregnancy. During pregnancy, there is “sparing” of glucose used by maternal tissues and a shunting of glucose to the placenta to the placenta for

use by bthe fetus.Fat Metabolism Fats are more completely absorbed during pregnancy; plasma lipid levrels increased during the second half of pregnancy.Iron Metabolism Iron requirement increases to 20-40 mg daily.

During the last half of pregnancy, iron is transferred to the fetus and stored in the fetal liver.Endocrine ChangesPlacenta Produces ESTROGEN, PROGESTERONE, HUMAN CHORIONIC GONADOTROPIN (hCG), HUMAN PLACENTAL

LACTOGEN (hPL)Pituitary Elevated estrogen and progesterone; suppressed LH, FSH, and Oxytocin.

Cardivascular Changes Heart Heart is displaced upward by elevated diaphragm.

There may be splitting of the first heart sound, with common systolic murmurs.

Circulation Cardiac Volume increased by 40-50% causing slight cardiac hypertrophy and increased in cardiac output (cardiac output increases when the woman turns from her back to her left side.

(+) physiologic anemia Pulse rate increases 10-15 beats/minute during pregnancy Slight decrease in BP (30%) during the 2nd and 3rd trimester Hypertension – 140/90 or systolic increase of 30 mmHg or more above the baseline, diastolic rise 15 mmHg or more.

Hematologic Total circulating red blood cells increases Leukocyte count is elevated during labor Fibrinogen levels increase by 50% along with other clotting factors

Respiratory Changes Ventilation Hyperventilation occurs- increasing respiratory rate, tidal

PCO2 lowers, causing mild respiratory alkalosis (that is compensated for by lowered bicarbonate concentration)Diaphragm Enlarging uterus elevates the diaphragmUreters Ureters become dilated and elongated during pregnancy due to mechanical pressure.GFR GFR increases early in pregnancy

Glucosuria may be evident because of decreased renal threshold for glucose Protein in the urine should be reported because it may be a sign of hypertensive disorder of pregnancy or renal problem

Changes in Physiologic System of a Eclamptic Person:

Integumentary System

Edema generalized confided to face (periorbital) and fingers.

Metabolic Changes Ptoteinuria (+) 1 g/day Weight gain- greater than 1 lb/wk

Cardiovascular Changes

Hypertension 140/90 or systolic increase of 30mmHg more above the baseline, diastolic rise 15 mmHg or more.

Urinary Tract Oliguria – absent output above 500 ml in 24 hrs.Intra Uterine Growth Retardation

Absent

DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic orLaboratoryProcedure

Indication orPurpose

Date Ordered andDate Results were

released

Results NormalValues

Analysis andInterpretation

of Results

WBC Count

To determine infection orInflammation Pre-

operationAssessment of the

patient.

December 2, 2009 19.5 H 108/L 3.5-10.0 H 109/LNo infection orinflammation

is present.

RBC CountPre-operation assessment

ofThe patient.

December 2, 2009 4.23 1012/L 3.80-5.80

Decreased RBC count onpregnant is normal

because of the increase inplasma volume during

pregnancy.

HemoglobinPre-operation assessment

ofthe patient.

December 2, 2009 133 g/L 110-165 L g/L

The result indicates that a1000 ml sample of

blood contains 96 g ofhemoglobin. Decreased hemoglobin on pregnant

isnormal because of their

increase in plasma.

Hematocrit (%)Pre-operation assessment

ofthe patient.

December 2, 2009

.

366 L 1/1 .350-.500 L 1/1

The result indicates that a1000 ml sample of

blood contains .29 g ofhemoglobin. Decreased

hematocrit on pregnant isnormal because of their

increasein plasma volume.

Nursing Responsibilities during Different Laboratory Procedures

Before During After

White Blood Cell Count

Explain to the patient that the WBC test is used to detect an infection or inflammation.

Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.

Explain to the patient that he may experience slight discomfort from the needle puncture and the tourniquet.

Inform the patient that he should avoid strenuous exercise for 24 hours before the test. Also 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

Ensure subdermal bleeding has stopped before removing pressure.

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 medicationsdiscontinued before the test, as ordered.

A patient with severe leucopenia, they have little or no resistance to infection and requires protective isolation.

may need to be restricted.

Red Blood Cell Count

Explain to the patient that RBC count is used to evaluate the number of RBCs and to detect possible blood disorders.



Inform the patients that he need not restrict foods and fluids.


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

Hemoglobin

Explain to the patient that the hbg test is used to detect anemia or polycythemia or to assess his response to treatment.

Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and


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

when.


Hematocrit

Explain 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.


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

THE PATIENT AND HIS CARE

1. Medical Management

A. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy

MedicalManagement

Date Ordered GeneralDescription

Indication &Purpose

Client Responseto Treatment

IVFD5LRS 1L30gtts/min

5% dextrose in lactated ringersSolution (Osmolarity of 527-hyprtonic, pH of 4.9) -provides calories and free water, provides electrolytes.Also contains sodium lactate which is used in treating mild to moderate metabolicacidosis.

D5NM is administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirement with minimal carbohydrates calories and to correct or replace fluid losses due to change in thepatient’s diet (NPO) and during the cesarean operation.

The patient responded wellwith no signs of irritation andadverse reactions.

Nursing Responsibilities:

Check the doctor’s order

Explain the procedure to the patient

Tell the patient that she might feel a discomfort from the tourniquet and the IV insertion

Check and monitor IVF regulation and level of fluid

Check if there is a need for removal and replacement of fluid

Check if the tube is in the vein and signs of edema

Check if there is a back-flow of blood

Check if there is bubbles present in the tube

Always Monitor V/S.

B. Pharmacotherapy

DrugsGeneric name/

brand name

Date Route of administration

General action Indication with purpose

Adverse Reaction Nursing responsibilities

Cephalexin December 2009

Oral route First-generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability; usually bactericidal.

Adults: 250 mg to 1 g PO 6 hours or 500 mg q 12 hours. Maximum of 4 g daily.

CNS: dizziness, headache, fatigue, agitation, confusion, hallucination.GI: anorexia, diarrhea, nausea, pseudomembranous colitis, vomiting, gastritis, abdominal pain, oral candidiasis.Other: anaphylaxis, hypersensitivity reaction, serum sickness.

Prior to During After

-Check for doctor’s order and expired date before administration-Check for patient impaired renal function or severe infection to know if you increase dose or decrease

-Wait until patient swallow the drug properly before leaving the patient -May take 5 meals for GI upset-Give patient directed or complete prescription, obtain 5 R”s

-Instruct patient to report for any adverse effects such as; rush, diarrhea, yellow discoloration of the skin or eyes or lack of response-Evaluate for symptomatic improvement.

DrugsGeneric name/

brand name


General action Indication with purpose


Mefanamic acid

December 2009

Oral route 500mg cap q 6

Aspirin- like drug that has analgesic antipyretic.

Relief of post operative and postpartum pain.

Gastrointestinal experiences including - abdominal pain, diarrhea, dyspepsia, flatulence, gross bleeding/ perforation, heartburn, nausea, GI ulcers (gastric/duodenal), vomiting, abnormal renal function, anemia, dizziness, edema, elevated liver enzymes, headaches, increased bleeding time, pruritus, rashes, tinnitus


- Tell patient that drugs work best when taken before pain becomes severe.-Recommend abstinence from alcohol when taking medication.-Caution patient that drug can cause depen-dence.

http://www.rxlist.com/script/main/art.asp?articlekey=5799




















DrugsGeneric name/

brand name


General action Indication with Purpose


Ferrous sulfate

December 2009

PO Provides elemental iron, an essential component in formation of hemoglobin.

As a supplement during pregnancy 15-30 mg elemental iron PO daily during last two trimester.

GI: nausea, epigastric pain, vomiting, constipation, black stool, diarrhea, anorexia.Other: temporarily stained teeth from liquid forms.


- Check for the doctor’s order & drug expiration before administration-Ingestion of Calcium and iron supplements with food can decrease iron absorption by one-third. Take between meals.-take a drug history, including antacid use; or any drugs used that may interact.

-Monitor hemoglobin level, hematocrit, and reticulocyte count.

-Tell patient to take tablets with juice (preferably orange juice) or water, but not with milk or antacid.-Advise patient to report constipation and change in stool color and consistency.

DrugsGeneric name/

brand name




Captopril December 2009

PO Action: Inhibits ACE, preventing conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium and water retention and lower blood pressure.

Hypertension: Adults: Initially, 25mg PO b.i.d or t.i.d. If dosage control blood pressure satisfactorily in one or two weeks, increase it to 50 mg b.i.d or t.i.d. If dosage control blood pressure satisfactorily in another one or two weeks, expect to add diuretic. If patient needs further blood pressure reduction dosage maybe raised to 150 mg t.i.d while continuing diuretics.

CNS: Dizziness, fainting, headache, malaise, fatigue, fever. CV: Tachycardia, hypotension, angina pectoris.GI: Abdominal pain, anorexia, constipation, diarrhea, dry mouth, dysguesia, nausea and vomiting.Hematologic: leukopenia, agranulocytosis, thrombocytopenia, pancytopenia, anemia.Metabolic: hyperkalemia.Respiratory: dry, persistent non-productive cough, dyspnea.Skin: urticarial rush,


- Monitor patient’s blood pressure, and pulse rate frequently.-Assess patient’s sign for angioedema.

-Inform patient that light-headedness is possible, especially during first few days of therapy.

-Tell patient that drug causes the most frequent occurrence of cough, compared with the ACE inhibitors.

Maximum daily dose is 450 mg.

maculopapular rush, pruritus, alopecia.Other: angioedema.

DrugsGeneric name/

brand name




Nifedipine December 2009

PO Thought to inhibit calcium ion influx across cardiac and smooth muscle cells, decreasing contractility and oxygen demand. Also may dilate coronary arteries and arterioles.

Vasospastic Angina (Prinzmetal or variant angina), classic chronic stable angina pectoris.

CNS: Dizziness, light-headedness, headache, weakness, somnolence, syncope, nervousness.CV: flushing, peripheral edema, heart failure, MI, hypotension, palpitations.EENT: nasal congestion.GI: nausea, diarrhea, constipation, abdominal discomfort.Musculoskeletal: muscle cramps.Respiratory: dyspnea,


-Monitor blood pressure regularly, especially in patients who take beta blockers or antihyper-tensive.

-Watch for symptoms of heart failure.-ALERT: Don’t use capsules S.L to rapidly reduce severe high blood pressure because the result maybe fatal.

-Advice patient to avoid taking drugs with grapefruit juice.

pulmonary edema, cough.Skin: rash, pruritus.

C. Diet

Type of Diet Date Ordered,Date Performed,Date Administer

GeneralDescription

Indication &Purpose

ClientResponse toTreatment

NPOThe patient is not allowed to

takeany oral food or liquid.

This is done to preventalteration of the result of the

fasting blood sugar.bcs intakeof food can increase glucose

level.

The patient complied withthe prescribed diet.

Clear LiquidDiet

A diet of clear liquids maintains

vital body fluids, salts, andminerals; and also gives some

energy for patients when normal food intake must be interrupted. Clear liquids are easily absorbed by the body. by mouth (NPO) for a long

time. This diet is also used in preparation for medical tests

such as sigmoidoscopy, colonoscopy, or certain x-rays.

This diet reduce stimulation ofthe digestive system, and

leave no residue in the intestinal

tract. This is why a clear liquid diet is often prescribed

in preparation for surgery, andis generally the first diet givenby mouth after surgery. Clear

liquids are given when aperson has been without food

bymouth (NPO) for a long time.

The patient complied withthe prescribed diet.

D. Exercise

Activity General Description Purpose Date Order Client ResponseComplete Bed Rest Prescribed maternal

complication of pregnancyTo provide adequate rest The client adhered to the order

with out complaints.

2. Surgical management

A. Description

Low transverse caesarian section is made in the non-contractile portion of the uterus and is the one most commonly used. The bladder must be dissected off the

lower uterine segment. It has a low chance of the uterine rupture in subsequent labor. Advantage of it is that a trial of labor in a subsequent pregnancy is safe; the

risk of bleeding and adhesions is less, and the disadvantage of it is that the fetus must be in longitudinal lie; the lower segment must be developed.

B. Patients response to operation

Before During After

The patient was obviously experiencing nervousness and pain, not because of the procedure to be done but

because of the process of delivery.

She was thinking about what will be the result of the procedure. She was completely worried for the condition of her siblings.

Still, a little pain with a little discomfort was felt by the patient after the procedure.

C. Nursing care

Before During After

Explain the procedure to the client and place the client in a lithotomic position.

Assist the physician during the operation. Instruct the client and her relatives to follow the physician’s order and provide enough time to rest.

NURSING CARE PLAN

Assessment Diagnosis Inference Goals & Objectives

Interventions Rationale Evaluation

S: “Masakit padin yung tahi ko.” As verbalized by the patient.

O: Irritability Sighing Facial

Grimace V/S Taken as

follows:

BP: 120/80mmHgT: 37.1ºCPR: 88bpmRR: 18cpm

Acute pain related to surgical incision as manifested by facial grimace, irritability and sighing.

Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.

After 1-2 hours of nursing intervention, the patient will be able to tolerate the pain.

Independent: Assess client’s

attitude towards pain.

Encourage verbalization.

Encourage relaxation techniques such as breathing exercises.

Encourage use of diversional activities like socialization with others.

To evaluate client’s response to pain.

To minimize pain.

To lessen sensation of pain.

After 1-2 hours of nursing intervention, the patient was able to tolerate the pain.

Provide quiet environment.

Dependent:Independent:

Administer medication PRN.

To divert attention.

To provide additional comfort and lessen anxiety.

To relieve pain faster.

Assessment Diagnosis Inference Goals & Objectives Interventions Rationale Evaluation

S: Ø

O: Increased

environmental exposure to pathogen.

wound redness swelling

Risk for infection related to surgical incision as manifested by increased environmental exposure to pathogens, wound, redness and swelling.

Infection is an increased risk for being invaded pathogenic organisms

Short term Goal

After 2 hours of nursing intervention the patient will be will be able to identify intervention to reduce/prevention risk for infection

Short term Goal

After 2 days of nursing intervention the patient will be able to prevent infection on the incision site.

Independent:

●Assessment and document skin conditions at and around incision site.

●Health teaching about personal hygiene practices (eg. Hand washing)

●Maintain adequate hydration and nutrition. (foods rich in vitamins especially zinc and protein)

Dependent :

●Cleanse incision wound site daily as repaired. Use sterile dressing.

●To assess causative Contributing factors.

●To prevent furtherDevelopment of possible infections.

●To maintain wellness and boost Immune response

●To maintain cleanliness on the wound site and prevent transmission of microorganisms

●After 2 hours of nursing intervention the patient was be able to identify intervention to prevent risk for infection

Goal met

●After 2 days of nursing intervention the patient was be able to prevent infection on the incision site

Goal met

●Encourage to complete antibiotics as prescribed by the physician.

●To alleviate pain

DISCHARGE PLANNING

Medications

Take the following medications as prescribed:

1. Cefalexin 500mg 1 cap thrice a day (8 am, 1 pm, 6 pm)

-Cefalexin is an antibiotic.

-Cephalexin may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

upset stomach

diarrhea

vomiting

mild skin rash

http://en.wikipedia.org/wiki/Antibiotic

-It may cause an upset stomach. Take cephalexin with food or milk.

-Swallow whole and take with a full glass of water. Do not crush or chew.

- Continue to take cephalexin even if you feel well. Do not stop taking cephalexin without talking to your doctor.

2. Mefenamic Acid 500mg 1 cap thrice a day (8 am, 1 pm, 6 pm)

-Mefenamic acid is a non-steroidal anti-inflammatory drug used to treat pain.

-Its usual side effects are headache, nervousness and vomiting. Serious side effects may include diarrhea, bloody vomit, blurred vision, skin rash, itching and

swelling, sore throat and fever. It is advised to consult a doctor immediately if these symptoms appear while taking this medication

-Take with food or milk to prevent an upset stomach

-Drowsiness may occur so do not drink alcohol while taking this medicine.

-Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture

(not in the bathroom). Throw away any medication that is outdated or no longer needed.

http://en.wikipedia.org/wiki/Symptom

http://en.wikipedia.org/wiki/Fever

http://en.wikipedia.org/wiki/Diarrhoea

http://en.wikipedia.org/wiki/NSAID

3. Ferrous Sulfate 1 cap twice a day (8 am, 8 pm)

-Ferrous sulfate may cause side effects. Your stools will turn dark; this effect is harmless.

- Fish, meat (especially liver), and fortified cereals and breads are good dietary sources of iron; emphasize them in a well-balanced diet.

-Tell the doctor if either of these symptoms is severe or does not go away:

constipation

stomach upset

- Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture

(not in the bathroom). Throw away any medication that is outdated or no longer needed

4. Methylergometrine 1 cap thrice a day

- Oxytoxic drug, acts directly on the uterine smooth muscle to stimulate the rate, and amplitude of uterine contraction, induce in a rapid sustained tetanic, uterotonic

effect that shorten the third stage of labor and reduces blood loss, the uterine become more sensitive to the drug towards the end of pregnancy.

- used for management and prevention of postpartum and postbortal hemorrhage by producing firm uterine contraction and decreasing uterine bleeding

Environment / Exercise

- Increase physical activity and be independent as possible. This includes Personal Hygiene, getting in and out of bed, without assistance and walking.

- Spend time out of the bed each day. Get out of bed at least 2-3 times each day and walk for short distances or sit in a chair at the bedside to promote

circulation which prevents formation of blood clots and enhances healing.

- Avoid strenuous activity

- Riding in a car is allowed. Ride in an upright position with seatbelt fastened.

- Avoid bending from the waist. Bend with knees, keeping the back straight.

- Get enough sleep

- Stay in a calm free from noise environment.

Treatment

- Take the medications as prescribed and complete the course of anti biotics.

Health Teaching

- Encourage the client to practice a breastfeeding to her infant because of the advantages for both of them.

MOTHER:

* it is economical in terms of time, money, and effort.

* more rapid involution

* there are less incidence of breast cancer

BABY:

* to have a close relationship between mother and infant

* the milk of mother contains antibodies specially Immunoglobulin A that protect against common illness

* less incidence of gastrointestinal disorder

* also available at a light temperature

- Eat nutritious foods.

Outpatient

-See B. Bautista at Bulacan Maternity and Children’s Hospital for follow up check up two weeks after discharge.

Diet

-Eat a regular diet

-Consume foods rich in iron content such as meat (especially liver), and fortified cereals and breads which are good dietary sources of iron.

-Eat foods low in fiber content to reduce fecal mass and avoid intestinal

-Sample menu for one day:

Breakfast

1/2 cup orange juice 1 egg (poached or egg substitute

1/2 cup skim milk or milk (2% fat) 1 two-inch slice of corn bread

1 teaspoon margarine or butter Hot, non-caloric beverage

Lunch

1 cup tomato juice 2 ounces broiled chicken

1/2 cup mashed potatoes 1/2 cup steamed kangkong

1 slice bread 1 banana

1 teaspoon margarine or butter 1 cup yogurt made from skim milk or milk (2% fat)

Dinner

1/2 cup apple juice 1/2 cup steamed kangkong

1/2 cup white rice 1/2 cup steamed spinach

1 cup lettuce and peeled, seeded tomatoes 2 teaspoons oil and vinegar dressing

1 slice bread 1 teaspoon margarine or butter

1/2 cup skim milk or milk (2% fat) Hot, non-caloric beverage

- Include 6 to 8 cups of fluids, such as water, per day.

Spiritual

-Pray for a healthy life

-Attend mass every Sunday

CONCLUSION

Nurses can help the nation achieve National Health Goals. These goals speak directly to both fetus and the mother because pregnancy is a high risk

factor for them. Close monitoring in pregnant women and health teaching as much as possible about pregnancy could definitely reduce life threatening

complications.

Studies show that there is no certain facts that will give us the idea where pre-eclampsia arise. But there so many factors that could prevent this

complication such as diet modifications, proper compliance with the health care providers, proper exercise.And if the complication is already present, proper

monitoring, proper diet and drug compliance should be ruled in.

RECOMMENDATIONS

With this study, the student nurses were able to gain more knowledge and wider view and perspective of the complication of pregnancy which is pre-

eclampsia. Thus, the student nurses would like recommend and share some pointers on how to deal with different diseases with pregnancy specifically pre-

eclampsia.

To the government, primarily they should allocate sufficient budget to sustain and provide better facilities. They must be responsible enough to create

awareness program for care and management for all the Filipino people.

To the health care team, they should righteously implementing basic and ideal procedures regardless of the health care facilities where they belong.

They must observe and always remember to keep in line with their duties towards both the mother and the child during the pregnancy.

To 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.

BIBLIOGRPHY

Simply MCN Maternity Nursing, Jerome Balisnomo, RN, MAN, pages 179,181,189,

Fundamentals of Nusing, Delaune and Lander Book, pages 320-327

i. introduction cesarean section is a surgical

Documents

cesarean delivery

cesarean section delivery

cesarean sections

introduction cesarean

previous cesarean section

disease eclampsia

etiology of eclampsia

pathophysiology of eclampsia