pre eclamsia case study
TRANSCRIPT
I INTRODUCTION
Pre- eclampsia, also referred to as toxemia, is a medical condition where
hypertension arises in pregnancy in association with significant amounts of protein in
the urine. Pre- eclampsia refers to a set of symptoms rather than any causative factor,
and there are many causes for the condition.
A woman has passed from mild to Severe Pre- eclampsia when her blood
pressure has risen to 160mmHg systolic and 110mmHg diastolic or above on at least
two occasions 6 hours apart at bed rest or her diastolic pressure is 30mmHg above the
pre- pregnancy level.
Complications of hypertension are third leading cause of pregnancy- related
deaths, superseded only by hemorrhage and embolism. Pre- eclampsia is associated
within increased risk of placental abruption, acute renal failure, cerebrovascular and
cardiovascular complications, disseminated intravascular coagulation, and maternal
death. Magnesium Sulfate is the first- line treatment of prevention of primary and
recurrent eclamptic seizures. The mother and her family deserve careful teaching
regarding the problem, its observation, and its treatment. Regular, adequate prenatal
care is the best insurance for control of the complication.
In the case of Mrs. EQ, 29 years old from Purok 3 Brgy. 16 GingoogCity. She
was admitted to MOPH- Gingoog (OB Ward) last January 19, 2015 at 11:35 AM with
diagnosis of labor pain and mild pre-eclampsia.
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II OBJECTIVES
General Objectives:
At the end of this Abnormal OB case study, knowledge and ideas will be gained
about abnormal pregnancy, the diagnoses, causes, effects, planning and implementing
interventions for the health benefit of the client and also practice skills and deal
appropriate attitudes towards the client. And also we did this case study for us to have a
deeper understanding of what is preeclampsia is thus to give us an idea of how we
could give proper nursing care for our client with this condition.
Specific Objectives:
The students will be able to:
A. Present a complete assessment regarding (mild preeclampsia), through
nursing health history, physical assessment and the interpretation of the
laboratory examinations done on the patient.
B. Discuss the anatomy and physiology of the reproductive, Pathophysiology
of the patient’s condition, usual clinical manifestation and possible
complication of the condition.
C. Enumerate the necessary medications needed and be familiar to its mode
of action.
D. Formulate a workable nursing care plan on the subjective and objective
cues gathered through nurse-patient’s interaction to be able to help the
patient towards wellness.
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III DEMOGRAPHIC DATA
Name : Ms. EQ
Address : P-3, Brgy. 16, Gingoog City
Age : 29 years old
Gender : Female
Occupation : House Wife
Religion : Roman Catholic
Civil Status : Single
Nationality : Filipino
Educational Attainment : High School Graduate
Date of Admission : January 19, 2015, 11:35 AM
Room Number : OB ward
Physician : Dr. Marlene Coronado
Chief Complain : Labor pain
Diagnosis : PUFT – in labor with Mild Pre Eclampsia. G5 P5
LMP : April 09, 2014
EDD : January 16, 2015
AOG : 40 weeks
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IV Developmental Theories
Erick Erickson’s Psychosocial Theory
(Ego Development Outcome: Generativity vs. Self absorption or Stagnation)
The significant task is to perpetuate culture and transmit values of the
culture through the family (taming the kids) and working to establish a stable
environment. Strength comes through care of others and production of
something that contributes to the betterment of society, which Erickson calls
Generativity, so when we’re in this stage we often fear inactivity and
meaninglessness.
Mrs. G, do not want to stay longer in the hospital because she felt useless
that she cannot do things she wants and felt stuck in the room frequently to
protect herself from infection. She felt hopeless with her condition.
Sigmund Freud’s Psychosexual Theory (Genital Stage)
Ms. EQ is now on the genital stage, wherein Freud said that on this stage
a person will develop a heterosexual relationship. Our client has indeed
developed it, lived together with her partner and is now a mother to her kids.
Jean Piaget’s Cognitive Theory (Formal Operational Stage)
Our client is on the last stage of cognitive theory, which is the formal
operational theory. In this stage, client will show understanding in abstract
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concepts and Ms. Je has shown that by means of communicating to us when she
verbalized that everything that has happened to her during the course of her
pregnancy has a reason. She viewed her life positively, and is very welcoming of
what future will await her.
Lawrence Kohlberg’s Moral Development Theory
In Stage five (social contract driven), the world is viewed as holding different
opinions, rights, and values. Such perspectives should be mutually respected as
unique to each person or community.
We observed that she respect and listen to the opinion of others and view
herself as different to others having unique attitudes and personality. She’s very
cooperative.
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V ASSESSMENT
FAMILY HISTORY
Ms. EQ is the youngest of 3 children. She originally lives in Villanueva, Misamis
Oriental. 13 years ago, she met Mr. EQ. Mr. EQ was working on a construction site in
Villanueva. He was a middle child of 9 children. He originally was from P-3, Brgy. 16,
Gingoog City, their current residence.
The love story of Mr. and Ms. EQ can be considered as something out of track.
Ms. EQ got pregnant with her first daughter with the hopes that they will get married
soon. However, until now with five children, they were still not able to have their
relationship blessed with the sacred sacrament of marriage.
Mr. and Ms. EQ together with their five children live in P-3, Brgy. 16, Gingoog
City.They moved from Villanueva to Gingoog City upon Ms. EQ’s first pregnancy. Mr.
EQ is a pedicab driver and Ms. EQ is a plain housewife. Mr. EQ sets off at 7 o’clock and
return home for lunch at 11 o’clock. At 5 in the afternoon, Mr. EQ would return home
with P150.00 for the family.
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OB HISTORY
Ms. EQ has had five normal spontaneous vaginal deliveries. Her first child was a
baby girl born last January 23, 2002. She gave birth at a public hospital in Villanueva,
Misamis Oriental. Her second child was a baby boy born last November 15, 2004 at
home with the help of a midwife. Her third child was also delivered at home, a baby boy
born last November 13, 2007. The first three children were born in Villanueva, Misamis
Oriental, even when they already moved to Gingoog. She stated that whenever she’s
pregnant, her mother would always want her to go back to Villanueva and have her
baby delivered there because her mother wants to take care of her.
The fourth son was delivered at home last March 31, 2011 in Gingoog City with
the help of a midwife. Her fifth child, a baby boy was born last January 19, 2015 in
Misamis Oriental Provincial Hospital Gingoog in which she experienced high blood
pressure during the onset of the third trimester. According to her, during the prenatal
check-up her blood pressures are normal ranging from 110/ 80 to 120/90. But as we
checked her records, we found out that there was a significant increase of the blood
pressure on her third visit. She usually has her prenatal check-up at the Barangay
Health Center of Brgy. 16. Moreover, she stated that this is the first pregnancy that she
experienced high blood pressure.
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DISEASE HISTORY
During the interview, Ms. EQ admitted that in her family, hypertension is
common, especially to her mother’s side. However, with her previous pregnancies
according to her, she did not experience hypertension. She has no history of
hospitalization aside from when she delivered her first baby.
HISTORY OF PRESENT ILLNESS
Ms. EQ was admitted to the hospital’s emergency room at 11:35 AM last January
19, 2015, with chief complaint of labor pain. Patient’s blood pressure is 140/90 mmHg,
fundal height of 29 cm, weighed 49 kilos, G5 P4 with doctor’s initial diagnosis of pre-
eclampsia.
Her last menstrual period was April 9, 2014, with an expected date of
confinement on January 16, 2015. She is on her 40th week gestation.
Her laboratory results show a +1 protienuria. However, we were not able to have
a copy of her lab results. A mild edema was noted by the barangay midwife during her
prenatal visits.
PRENATAL CHECK-UP
FIRST VISIT
Ms. EQ’s prenatal record reveals that her first prenatal check up was on
September 17, 2014. Blood pressure of 120/80, AOG is 23 weeks, weighed 43 kg. The
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midwife gave her 30 tablets of ferrous sulfate and multivitamins with iron. She was
advised to drink plenty of water, have enough rest, eat vegetables, and avoid salty
foods and spicy foods. She was advised to get a urinalysis and CBC laboratory but was
unable to comply.
The ferrous sulfate is necessary to supplement or help in the production of blood
cells and avoid anemia, as physiologically, a pregnant woman will have 30 – 50%
increase in blood volume. Multivitamins is necessary to supplement and prevent
micronutrient deficiency that may happen during pregnancy, especially that Ms. EQ has
a very low weight. It is important to avoid salty food because it may cause UTI during
pregnancy which is very dangerous to the fetus inside. The fetus might get the illness.
Another important reason is that, too much salt will attract water that may lead to water
retention causing edema. Spicy foods are not good because it will cause hemorrhoids.
SECOND VISIT
Ms. EQ’s second prenatal check-up was on Nov. 26, 2014 at 33 weeks gestation
with a blood pressure of 120/80 and weighs 45 kg. We see no significant change in her
vital signs. She was given the same recommendations; however, she admitted that it is
very hard for her to comply in terms of the diet because she is so fund of eating “bulad”,
“ginamos” and instant noodles.
THIRD VISIT
On the third visit on Dec. 19, 2014 at 36 weeks AOG, Ms. EQ had a significant
increase in her blood pressure. Her BP was 140/90 which alarmed the midwife. She
weighed 47 kg with the FH of 28 cm.
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PHYSICAL AND VITAL SIGNS ASSESSMENT
HOME VISITATION ASSESSMENT
MOTHER
TIME T P R BPFirst Visit
Feb. 5, 302536.6C 84bpm 24cpm 140/90mmHg
Second VisitMarch 1, 2015
37.0C 84bpm 23cpm 160/120mmHg
Third VisitMarch 3, 2015
36.4C 86bpm 23cpm 160/120mmHg
BABY
TIME T P RFirst Visit
Feb. 5, 302536.4C 157bpm 45RR
Second VisitMacrh 1, 2015
36.4C 156bpm 46RR
Third VisitMarch 3, 2015
36.5C 158bpm 44RR
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GORDON’S FUNCTIONAL ASSESSMENT
PATTERNS
1.Health Pattern and Health Management -Client completed her prenatal check-up in
the Barangay 16 Health Center. According
to her, the vital signs are normal but when
we checked her records, we noticed her
vital signs during her prenatal are not
normal. The patient had completed her
immunization, and she was given Ferrous
Sulfate at their barangay.
2.Nutritional/Metabolic -The client eats 3 times daily and her food
preferences are instant noodles,
vegetables and fish.
3.Elimination -During her pregnancy, she has a good
elimination pattern. She voids according
approximately 5-6 times daily. She
defecates daily also.
4.Activity-Exercise -Prior to hospitalization, she does not have
any special activities. Her exercise was
only when she’s moving around the house
doing household chores. During
hospitalization she was instructed to
complete bed rest due to her condition.
5.Sleep-Rest -She experienced disturbance in her sleep
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because of discomfort during her
pregnancy, like difficulty breathing.
6.Cognitive-Perceptual -Client answers questions according to
what was asked to her. She was oriented
to place, time and person. However, we
can say that her willingness to learn on
what to do still needs further motivations.
7.Self-Perception—Self-Concept -Although she’s willing to listen to what we
have to say, she seemed to be passive
concerning her condition.
8.Role-Relationship -As a mother, she seemed to be struggling
with the nutritional intake of her children
because she has 2 malnourished kids.
However,she is able to do all the
household chores,
9.Sexuality-Reproductive -According to Ms. EQ, now that there is a
new baby, they find it hard to engage in
sexual activities because the baby is
sleeping in the bed with them. She also
said that her partner usually comes home
tired and there is no more interest in doing
sexual activities.
-However, she said that normally they
would engage in such activities at least
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twice a week.
10.Coping-Stress Tolerance -Knowing her condition during her
hospitalization stresses her because she
was shocked. But she told us that, she
can no longer prevent it because it’s there
already.
11.Value-Belief -Ms. EQ is a devout Roman Catholic. She
is a member of the BEC and believes that
having faith in God will help us to get
through challenges.
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DOCTOR’S ORDER AND INTERPRETATION
1. TPR q4
- To monitor the patients vital signs as the baseline of her health status.
- To monitor her blood pressure if there’s abnormalities and can be given easily the prescribed medicines ordered by the doctor.
2. Stat IVF D5LR 1L @ 20gtt
- forsequential administration since her BP is high, it has to be monitored so that medications will infused through IVTT.
- It’s a maintenance fluid.
3. NPO in active labor
- To avoid altering the descent of the baby.
- To avoid defecation during delivery.
- To avoid full stomach.
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VI ANATOMY AND PHYSIOLOGY
CARDIOVASCULAR SYSTEM
The Heart
The heart lies in the mediastinum, behind the body of the sternum. The shape of
the heart tends to resemble the chest. The heart has chambers divided into four cavities
with the right and left chambers (atria and the ventricles) separated by the septum.
The Blood Vessels
There are 3 types of blood vessels: the
arteries, the veins and the capillaries. An artery
is a vessel that carries blood away from the
heart. It carries oxygenated blood.
Small arteries are called arterioles.
Veins, on the other hand are vessels that carries blood toward the heart. It contains the
deoxygenated blood. Small veins are called venules. Often, very large venous spaces
are called sinuses. Lastly, capillaries are microscopic vessels that carry blood from
small arteries to small veins (arterioles to venules) andback to the heart. The walls of
the blood vessels, the arteries and veins have three main layers: tunica adventitia,
tunica media and tunica intima. Tunica adventitia which is a fibrous type of vessel is a
connective tissue that helps hold vessels open and prevents tearing of the vessel wall
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during body movement. Tunica media is a smooth muscle, sandwiched together with a
layer of elastic connective tissue. It permits changes of the blood vessel diameter. It
allows the constriction and dilation of the vessels. Last but not the least is the tunica
intima. Tunica intima, which inLatin means inner coat, is made up of endothelium that is
continuous with the endothelium that lines the heart. In arteries, it provides a smooth
lining. However in veins it maintains the one-way flow of the blood. The endothelium,
which makes up the thin coat of the capillary, is important because the thinness of the
capillary wall allows the exchange of materials between the blood plasma and the
interstitial fluid of the surrounding tissues.
Circulation of the blood in blood vessels
There are two circulatory routes of blood as it flows through the blood vessels:
the systemic and the pulmonary circulation. In systemic circulation, blood flows from the
left ventricle of the heart through blood vessels to all parts of the body (except gas
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exchange tissues of lungs) and back to the atrium. In pulmonary circulation on the other
hand, venous blood moves from the right atrium to right ventricle to pulmonary artery to
lung arterioles and capillaries where gases exchanged; oxygenated blood returns to the
left atrium via pulmonary veins; from left atrium, blood enters the left ventricle.
Vasomotor Control Mechanism
Blood distribution patterns, as well as BP can be influenced by factors that
control changes in the diameter of arterioles. Such factor might be said to constitute the
vasomotor control mechanism. Like most physiological control mechanisms, it consists
of many parts. An area in the medulla called vasomotor center/ vasoconstrictor center
will, when stimulated initiate an impulse outflow via sympathetic fibers that ends in
smooth muscle surrounding resistance vessels, arterioles, and veins of “the blood
reservoir” causing their constriction thus the vasomotor control mechanism plays an
important role both in the maintenance of the general BP and in the distribution of blood
to areas of special need.
Venous return of the Blood
Venous return refers to the amount of blood that is returned to the heart by the
way of veins. Various factors influence venous return, including the operation of venous
pumps that maintains the pressure gradients necessary to keep blood moving into the
central veins and from there the atria of the heart. Changes in the total volume of blood
vessels can also alter the venous return.
The return of venous blood to the heart can be influenced by the factors that
change the total volume of blood in the circulatory pathway. Stated simply, the more the
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total volume of blood, the greater the volume of blood returned to the heart. The
mechanism that change the total blood volume most quickly, making them most useful
in maintaining constancy of blood flow, are those that cause water to quickly move into
the plasma or out of the plasma. Most of the mechanisms that accomplish such
changes in plasma volume operate by altering the body’s retention of the water.
The primary mechanisms for altering the water retention in the body- they are the
endocrine reflexes in the body. One is the ADH mechanism is released in the
neurohypophysis and acts on the kidneys in a way that reduces the amount of water
lost by the body. ADH does this by increasing the amount of water that kidneys
reabsorb from urine before the urine is excreted from the body. The more ADH is
secreted, the more water will be reabsorbed into the blood, and the greater the blood
plasma volume will become.
Another mechanism that changes the blood plasma volume is the
renninangiotensin mechanism of aldosterone secretion. Renin is an enzyme that is
released when the blood pressure in the kidney is low. Renin triggers a series of events
that leads to the secretion of aldosterone. Aldosterone promotes sodium retention by
the kidney, which in turn stimulates the osmotic flow of water to the kidney tubules back
into the blood plasma- but only when ADH is present to permit the movement of water.
Thus, low blood pressure increases the secretion of aldosterone, which in turn
stimulates the retention of water and thus an increase in blood volume. Another effect of
reninangiotensin is the vasoconstriction of blood vessels caused by an intermediate
compound called angiotensin II. This complements the volume increasing effects of the
mechanism and thus also promotes an increase in overall blood flow. Precision of blood
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volume control contributes to the precision in controlling venous return, which in return
yields to the precise overall control of blood circulation.
EXOCRINE SYSTEM
The exocrine system’s main function is to regulate the volume and composition
of body fluids and excrete unwanted materials, but it is not the only system in the body
that is able to excrete unnecessary substances.
Kidneys
The kidneys resemble the lima beans in shape.
The average-sized kidney measures around
11cm by 7cm by 3cm. The left kidney
is often larger than the right. The kidneys are highly
vascular organs. Approximately, one-fifth of the blood
pumped from the heart goes to the kidneys. The kidneys process blood plasma and
form urine from waste to be excreted and removed from the body. These functions are
vital because they maintain the homeostatic balance of the body. The kidneys maintain
the fluid-electrolyte and acid-base balance. In addition, they also influence the rate of
secretion of the hormones ADH and aldosterone.
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Microscopic functional units called nephrons make up the bulk of the kidney. The
nephron is uniquely suited to its function of blood plasma processing and urine function.
A nephron contains certain structures in which fluid flows through them and they are as
follows: renal corpuscle, Bowman’s capsule, proximal convulted tubule, Loop of Henle,
distal convoluted tubule and the collecting tube. The Bowman’s capsule is a cup-shaped
mouth of a nephron. It is usually formed by two layers of epithelial cells. Fluids,
electrolytes and waste products that pass through the porous glomerular capillaries and
enter the space that constitute the glomerular filtrate, which will beprocessed in the
nephron to form urine.
The Glomerulus is the body’s well-known capillary network and is surely one of
the most important ones for survival. Glomerulus and Bowman’s capsule together are
called renal corpuscle. The permeability of the glomerular endothelium increases
sufficiently to allow plasma proteins to filter out into the capsule.
ENDOCRINE SYSTEM
The endocrine system performs their regulatory functions by means of chemical
messenger sent to specific cells. The endocrine system, secreting cells send hormones
by way of the bloodstream to signal specific target cells throughout the body. Hormones
diffuse into the blood to be carried to nearly every point in the body. The endocrine
glands secrete their products, hormones, directly into the blood. There are two
classifications of hormones: steroid hormones and non-steroid hormones. The steroid
hormones which are manufactured by the endocrine cells from cholesterol, is an
important lipid in the human body. Non-steroid hormones are synthesized primarily from
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amino acids rather from the cholesterol. Non-steroid hormones are further subdivided
into two: protein hormones and glycoprotein hormones.
Aldosterone
Its primary function is the maintenance of the sodium homeostasis in the blood
by increasing the sodium reabsorption in the kidneys. It is secreted from the adrenal
cortex; it triggers the release of ADH which results to the conservation of water by the
kidney. Aldosterone secretion is controlled by the rennin- angiotensin mechanism.
Estrogen
It is secreted by the cells of the ovarian cells that promote and maintain the
female sexual characteristics.
Progesterone
It is secreted by the corpus luteum. It is also known as a pregnancy- promoting
steroid and it prevents the expulsion of the fetus in the uterus.
Anti-diuretic hormone (ADH)
It is secreted in the neurohypophysis (posterior pituitary); it literally opposes the
formation and production of a large urine volume. It helps the body to retain and
conserve water from the tubules of the kidney and returned to the blood.
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REPRODUCTIVE SYSTEM
The female reproductive system produces gametes may unite with a male
gamete to form the first cell of the offspring. The female reproductive system also
provides protection and nutrition to the developing offspring. The most essential organ
is the ovary which carries the ova. The uterus, the fallopian tubes and the vulva are
accessory organs.
Ovaries
It is an almond-shape organ. It contains the ova and is responsible in expelling
the ova. It also produces estrogen and progesterone.
Fallopian Tubes
It usually measures approximately 10- 12 cm. It has two parts: the ampullae and
the fimbriae. The ampullae which is the largest part is where the fertilization takes place.
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The fimbriae on the other hand, are responsible for the transportation of the ovum from
ovary to uterus. It holds the ovary.
Uterus
The uterus is a pear-shaped organ and has three parts: the fundus (upper),
corpus (body), and the isthmus (lower). It is known as the organ for menstruation. When
pregnant, it gives nourishment to the growing fetus.
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VII PATHOPHYSIOLOGY
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DISCUSSION OF THE PATHOPHYSIOLOGY
Whereas all hypertensive disorder in pregnancy (pre-eclampsia. Essential
hypertension, secondary hypertension) share high blood pressure as a common theme
(probably mediated inappropriate vasoconstriction) pre- eclampsia is the only disorder
with multisystem abnormalities.
The triad of physiological derangement in pre-eclampsia is:
1. Intensive vasospasm
2. Local or disseminated intravascular coagulation
3. Plasma volume contraction.
With the case of Ms. EQ, history of hypertension in the family plays a very big
factor. Another factor was that, she is now in her fifth pregnancy at the age of 29 which
may cause disruptions in placental formation. Her diet is also of great influence. As
stated by her, she enjoys eating “bulad”, “ginamos” and instant noodles. This diet could
influence the kidney infiltration causing the protein specifically albumin to be excreted.
Although the cause of pre- eclampsia is unknown the placenta appears to be the
culprit- delivery of the placenta is the only known cure and the disorder is more frequent
with large placenta mass,ex. Twins, or abnormal placenta. Current hypotheses propose
release of a toxic factor from the placenta which alters maternal endothetial cell
functions, though this is unproven.
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Vasospasm follows due to excess production or sensitivity to vasoconstrictions
(antigiotensis II. Serotonin and endothelin are the most popular candidates) and
decreased production sensitivity to vasodilators.(prostacyclin and nitric oxide are the
current candidates here). This issue is by no means resolved.
Intravascular coagulation is associated with platelet activation, thrombocytopenia
and, often reduced production of anti- thrombin III.
Plasma volume contraction follows vasospasm, capillary leakage and, in more
severe cases, reduction in plasma osmotic pressure. There is redistribution of fluid from
the intravascular to interstitial fluid spaces so that total extra cellular volume remains
unaltered. These are important consideration as intravascular volume correction may
result in pulmonary edema when capillary permeability is high and plasma osmotic
pressure low.
The net result of this triad of abnormal physiology is organ hypoperfusion system
most commonly affected are the kidney (manifested by reduced GFR,
proteinuria ,hyperuriceamia and occasionally oliguria), the liver (manifested by elevated
aspartate transaminase with or without epigastric and upper quadrant pain), the brain
(manifested by intrauterine fetal growth retardation and less commonly placenta
abruption or fetal death in utero). Peripheral edema is common but is not a useful
clinical sign. Pulmonary edema is rare and when it occurs is usually teratogenic.
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VIII NURSING CARE PLAN
ANTE-PARTUM
FEAR
Cues and evidences
Nursing Diagno
sisDefinition Nursing Goals Intervention Rationale
Subjective data:“Nahadloklagekona ma cesarean kokaydakodawakongtiyan.; verbalized by the patient.”
Objective Data:>Increase alertness>Sad facial expression
Fear related to past history as evidenced by increases alertness.
Responses to perceived threat isconsciously recognized as a danger.
At the end of 30 minutes the mother will be able to:
Acknowledge and discuss fears with others.
Display emotion of confidence throughout the course of her pregnancy.
Therapeutic:1. Support the
mother emotionally to have a positive outlook throughout her pregnancy by staying with the client.
Educative:2. Discuss client’s
perceptions/fearful feeling and listen client’s concern.
Collaborative:3. Refer to the
physical therapist to develop exercise program.
>Providing client with usual or desired support person can diminish feeling of fear.
>Promotes atmosphere of caring and permits explanation/correction of misperception.>Provides a healthy outlet for energy generated by fearful and promotes relaxzation.
Evaluation: After our series of intervention the patient acknowledged and discuss fear
with others and display emotion of confidence throughout the coarse of her pregnancy.
Goals met.
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ANTE-PARTUM
INEFFECTIVE BREATHING PATTERN
CUESNURSING
DIAGNOSISDEFINATI
ONNURSING
GOALINTERVENTION
RATIONALE
SUBJECTIVE:“maglisodlagekoogginhawalabinainighigdanaku,” as verbalized by the patient.
Objective: Alteration
in depth breathing
Dyspnea
Ineffective breathing pattern related to pain as manifested by alteration in depth of breathing.
Inspiration and/or expiration that does not provide adequate ventilation.
At the end of 30mins. The mother will be able to:
Establish a normal effective respiratory pattern
Verbalizes relief for shortness of breath.
Therapeutic:
Encourage mother to use pillows behind the head and shoulders at night.
Educative:
Educate the mother to assume proper and positioning every time she sits and sleep.
Collaborative:
Refer to general exercise program as indicated.
For her to breathe properly at night.
To have effective breathing pattern.
To maximize client’s level functioning.
Evaluation: After our series of intervention the patient established normal effective
respiratory pattern, and verbalized relieved for shortness of breath.
> Goal met
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POST PARTUM
SLEEP DEPRIVATION
Assessment Nursing Diagnosis
Analysis GoalsIntervention
Rationale
SUBJECTIVE:“Dilikomakatulogkaypuronalangsakitsalawasakogibati.” As client verbalized.
OBJECTIVE:>1 hr. at sleep per day PTA> 30 mins at sleep per day upon admission
Sleep deprivation R/T discomfort on perineum secondary to labor and delivery.
Prolonged periods at time w/out sleep
SHORT TERM:
After 3 hrs. at nursing intervention, the client will >report decreased feeling at discomfort as manifested by verbalizing feeling at comfort.> achieved at least 5-6 hrs. at continuous sleep per day>show signs decreased yawning at daytime.> report decreased body malaise
LONG TERM:After 3 days of nursing Intervention the client will> be able to reestablish and maintain normal sleep pattern> achieve 7-8 hrs. at continuous sleep per day.> report absence of body malaise
INDEPENDENT identify
presence of related factors that can continue to sleep deprivation
position client in a comfortable position
provide comfort measures
assess sleep pattern
>to identify Causatives contributing factors
to alleviance discomfort
-to distract attention on pain,reduce tension and promote nonpharmacological pain management
to help in providing better
Evaluation: After series of interventions the client knew the importance of sleep in her
condition and adjusted lifestyle to accommodate genuine changes.
> Goal partially met
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IX DRUG STUDY
Ante Partum
Name of Drug
Indication
Mechanism of Action
Adverse effects
Side EffectsSpecial NursingResponsibility
Generic Name:Tetanus Toxoid
Provide passive immunity to tetanus
Promotes immunity to tetanus by inducing production of antitoxin
SYST:
Anaphylaxis
GI: Nausea,
vomiting, anorexia, Integumentary skin abscess, urticaria, itching, swelling
CV: Tachycardia Hypotension
SYST:
Lymphadenitis
CNS:
Crying, fretfulness, fever drowsiness
Determine date of last tetanus immunization
Don’t use hot or cold compresses may increase severity of local reaction
Obtain history of allergies and reaction to immunization
Contraindication in immunosuppresion and immunoglobulin abnormalities
Assess for skin reaction: swelling, rash, urticaria
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Intra Partum
Name of Drug
IndicationMechanism
of ActionAdverse Effects
Side EffectsSpecial Nursing
Responsibility
Generic Name:Oxytocin
Brand Name:Syntocinon
Classification:Oxytocin
Dosage10 ‘u’ oxytocin infusedat D5LR 1L
Induction or Stimulation of labor
Chemical effect:Causes potent and selective stimulation of uterine and mammary gland smooth muscle.
Maternal
CNS:Subarachnoid, hemorrhage, seizures, coma
CV:Hypertension, arrhythmias
Other:
Hypersensitivity abruption placenta, impaired uterine blood flow, increased uterine motility, anaphylaxis
Maternal
GI:Nausea, vomiting, constipation
CV:Increased heart rate, systematic venous return, and cardiac output.
Integumentary:
Rash
Other:Titanic contractions,Pelvic hematoma
Fetal Blood hyperbilirubin
Assess intake output
Should never be given simultaneously by more than one route.
Do the ff. every 15 mins. Monitor and record uterine contractions, heart rate, blood pressure, fetal heart rate, and character of blood loss.
Not recommended for routine IM use. However 10 minutes may be given IM after delivery of placenta to control postpartum uterine bleeding.
Don’t give IV bolus injection.
Should have magnesium sulphate
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Post-Partum
Name of drug
IndicationMechanism of
ActionAdverse Effects
Side Effect
Special NursingResponsibility
Generic Name:Ferrous Sulfate
Brand Name:
Classification:Hematinics
Dosage:1 cap PO, OD
Iron deficiency
Prophylaxis for iron deficiency anemia
Provide elemental iron, an essential component in the formation of hemoglobin
CNS: Seizure
MSC: Anaphylaxis
GI: Nausea, constipation black and red tools, epigastric pain, diarrhea
CNS: dizziness, headache
Other: temporary staining teeth
Check for constipation record color and amount of stool. Teach dietary measures for preventing constipation.
To avoid staining teeth, give elixir iron preparations with straw
Administer between meals for best absorption may give juice, do not give with antacids.
Administer at least 1 hour since corrosion may occur in the stomach.
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Post-Partum
Name of drug
IndicationMechanism
of ActionAdverse Effects
Side EffectsSpecial NursingResponsibility
Generic Name:Mefenamic Acid
Brand Name:Postan, Pontel
Relief of moderate pain when therapy will not exceed one week.
Treatment of primary dysmenorrhea
Anti- inflammatory analgesic, and antipyretic activities related to inhibition of prostaglandin synthesis; exact mechanism of action are not known
GI: cholestatic, hepatitis, peptic ulceration
GU: Nephrotoxicity
HEMA: Blood dyscrasis
Hepatic:hepatotoxicity
GI: Nausea, anorexia, vomiting, diarrhea, jaundice, constipation, flatulence, cramps, dry mouth
CNS: Dizziness, drowsiness, anxiety, insomnia
CV: Tachycardia,Palpitations
Integumentary:Rash, sweating
Give milk or food to decrease GI upset.
Arrange for periodic ophthalmologic examination during long- term therapy
Contraindicated in GI ulceration or inflammation
Stop drug if rash, visual disturbances or diarrhea develops
Should not administer for more than 1 week at a time, because of risk of toxicity increases
Warm patient against hazardous activities that require alertness until CNS effects of the known drug
Evaluate therapeutic response:
Decreased pain, stiffness, swelling in joint, ability to move more easily.
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Post- Partum
Name of drug
Indication MechanismAdverse Effects
Side Effects
Special NursingResponsibility
Generic Name:Amoxicillin trihydrate
Brand Name:Amoxil
Classification: Anti- infective
Dosage500mg T.I.P.O
Infection due to susceptible strains of Haemophilis influenza, Escherichia coli, protues mirabilis, Neisseria gonorhoeae, streptococcus pneumonia, non- penicillinase- produang staphylococcus
Helicobacter pylori infection in combination with other agents.
Post- exposure prophylaxis against bacillus antraris.
Bacterial: inhibits synthesis of cell wall of sensitive organism, causing cell death.
CNS: Seizure
GI: Pseudo membranes
MISC: Anaphylaxis,Serum sickness
HEMA: Bone marrow depression, granulocytopenia
GI: Diarrhea, nausea, vomiting
Derm: Rashes
Culture infected area prior to treatment; reculture area response is not expected.
Give in oral preparations only, amoxicillin is not affected by food.
Continue therapy for at least 2 days after signs of infection have disappeared; is recommended.
Use corticosteroids or antihistamines for skin reaction
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Post- Partum
Name of Drug
IndicationMechanism of
ActionAdverse Effects
Side EffectsSpecial NursingResponsibility
Brand Name:Terramycin
Generic Name:
Classification:Ophthalmic anti- invectives
Dosage:Neonates- 1 drop of 1% solution
Prevention of gonorrheal ophthalmic neoraturom
Causes of protein denaturation, which prevents gonorrheal ophalmianeonatorum,.Bacteriostatic, germicidal and astringent.
Eye:
Periorbita, edema, temporary staining of lids and surrounding the tissue, conjunctions (with concentration of 1% or greater)
Integumentary:Irritation, discoloration of tissue
Don’t use repeatedly
Always wash hands before instilling solution
Don’t irritate eye after installation
Store wax ampule from lightand heat
Solution may stral the skin and utensils
Handle carefully
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X DISCHARGE PLAN
Exercise
1. Encourage patients on deep breathing exercises.
2. Move extremities when lying.
3. Elevate the head part when sleeping, to promote increase peripheral circulation
4. Encourage overall passive and active exercises program during pregnancy to
prevent need for cesarean birth.
5. Exercises like tailor sitting, squatting, Kegel exercise, pelvic rocking, and
abdominal muscle contraction will promote easy delivery.
Treatment:
1. Use of drugs
2. Catheterization
3. Obtaining labs. (CBC, platelets count, liver function, BUN and creatinine,
Health Teaching:
1. Encourage patient foe sodium restriction.
2. Encourage to avoid foods rich in oil and fats.
3. Encourage patient to limit her daily activities and exercises.
Ongoing Assessment:
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1. Observe carefully for symptoms at prenatal visit.
2. Give instruction about what symptoms to watch for so she can alert her clinician
if additional symptoms occur between visits.
Diet:
1. Low fats and sodium diet, restriction if possible.
2. High in protein, calcium and iron.
3. Adequate fluid intake
Sex:
1. limit sexual activity
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