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Holy Angel University

Angeles City
College of Nursing

Pre-Eclampsia

December 05, 2008


I. INTRODUCTION

Description of the Disease

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

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

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

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

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

earlier.

In addition symptoms of preeclampsia can include:

• Rapid weight gain caused by a significant increase in bodily fluid

• Abdominal pain

• Severe headaches

• A change in reflexes

• Reduced output of urine or no urine

• Dizziness

• Excessive vomiting and nausea

The exact causes of preeclampsia are not known, although some researchers

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

causes.

The only real cure for preeclampsia and eclampsia is the birth of the baby. Mild

preeclampsia (blood pressure greater than 140/90) that occurs after 20 weeks of gestation

in a woman who did not have hypertension before; and/or having a small amount of

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

with activity restriction.


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

process on how pre-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.

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.
II. NURSING HISTORY

a.) Demographic Data

Mrs. Ob, a 39 years old housewife and first time mother, who currently

resides at Guagua Pampanga with her husband Mr. Gyne. She was born a Filipina

on November 9, 1969 in Sta. Rita Guagua Pampanga. The patient was admitted at

a Regional Hospital with a chief complaint of abdominal pain, last November 15,

2008 at around 3:00 p.m.

b.) Socio-Economic and Cultural Factors

Mrs. Ob is plain housewife and her husband is an extra laborer on a

construction site. She graduated at a Public High School. And she didn’t continue

her college level due to financial problem.

Mrs. Ob was raised as a Roman Catholic, were she learned about religious

values but she still believes in super natural forces and superstitious beliefs. When

it comes in health matters, she seeks the help of a albularyo and uses herbal

medicines to treat any member of the family who has an ailment. But when

serious matters arise she still refers to medical professionals for help.

c.) Environmental factors

Ms. Ob resides at Guagua Pampanga and occupies the ancestry house of

her family. The location of their house is not easily accessible to hospitals, health

centers and other government institutions. Mrs. Ob did not report any problems

regarding her environment which interfered to her pregnancy.


Maternal-child Health History

a.) Maternal – Obstetric record (for OB cases)

Mrs. Ob was married to Mrs. Gyne at the age of 33 years old. She has a

record of T1P0A0L1M0 at her 39th week of gestation. She underwent low

transverse ceasarian section under a certain obstetrician at the regional hospital

last November 18, 2008 at around 10:00 in the evening, she delivered her 1st child

who is term baby with hyperbilirubinemia.

b.) Antepartal/ Prenatal Preparation

When Mrs. Ob was still pregnant, she only consulted once in a district

hospital all throughout.

c.) Significant Trimestral Changes (1st to 3rd trimester)

Mrs. Ob rxperienced some changes in her pregnancy, such as striae

gravidarum, linea nigra, and melasma. She also experienced nausea and vomiting,

dizziness, and headache.


Family Health Illness History

Grandmother Grandmother Grandfather


Grandfather
     
 

Father
Mother


Patient

Legend:
 hypertension
 died of old age
 pneumonia
 asthma
 deceased
π pre eclampsia

*pink border – mother side


*blue border – father side
*violet border - patient
Both the grandparents from the mother’s side died from old age. From the father’s

side, the grandmother died from Hypertension and the father was died from Pneumonia.

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

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

aggravating factors like anxiety, nervousness and fear.


PHYSICAL ASSESSMENT

November 27, 2008

SKIN

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

• skin temperature uniform and within the normal range (37°C)

• when pinched, skin readily springs back to previous state

• moist skin folds

• nails with smooth texture

• nail beds pink

• prompt capillary refill time (2 seconds)

• bipedal non-pitting edema

HEAD

• absence of nodules or masses

• symmetric facial features and movements

• symmetric nasolabial folds

• evenly distributed black hair

• no infestations

EYES

• eyebrows symmetrically aligned with equal movement

• eyelashes equally distributed and curled slightly outward

• skin of eyelids intact with no discoloration

• lids close symmetrically

• bilateral blinking exhibited


• no discharge, edema or tearing

• white sclera

• pink palpebral conjunctiva

• iris black in color

• pupils equal in size with smooth borders

• illuminated pupils constricts

• pupils converge when near object is moved toward the nose

• when looking straight ahead, the client can see objects in the periphery

• both eyes coordinated, move in unison with parallel alignment

EARS

• color same as facial skin

• symmetrically aligned

• pinna immediately recoils after it is folded

• pinna is not tender

• no lesions or discoloration

• dry cerumen, grayish-tan color

• normal voice tones audible

• able to hear ticking of a watch in both ears

NOSE

• symmetric and straight

• no discharge or flaring

• absence of lesions and tenderness

• nasal septum intact and in the midline


MOUTH AND THROAT

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

• buccal mucosa is of uniform pink color

• gums are pink

• tongue pink, moist, at central position

NECK

• head centered

• lymph nodes not palpable

BREAST

• firm

• generally symmetric in size

CARDIOVASCULAR

• BP 180/100 mmHg

• PR 114

• reported palpitations

• symmetric pulse strength

RESPIRATORY/CHEST

• chest symmetric

• chest wall intact, no tenderness, no masses

• symmetric chest expansion and excursion


• RR: 29 breaths per minute

GASTROINTESTINAL/ABDOMEN

• striae present at hypogastric and iliac regions

• linea nigra present

• no tenderness

• presence of surgical incision

URINARY

• absence of nocturia, dysuria, urgency, hesitancy,

• light yellow urine

REPRODUCTIVE

• regular menstrual cycle

• G1P1

MUSCULOSKELETAL/EXTREMITIES

• muscle equal size on both sides of the body

• no bone deformities

• no tenderness
NEUROLOGIC

• can respond to verbal commands

• oriented

• conscious

• displayed anxiety
PHYSICAL ASSESSMENT

November 28, 2008

SKIN

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

• skin temperature uniform and within the normal range (37°C)

• good skin turgor

• moist skin folds

• nails with smooth texture

• nail beds pink

• prompt capillary refill time

• bipedal non-pitting edema

HEAD

• rounded

• smooth skull contour

• symmetric facial features

• symmetric nasolabial folds

• symmetric facial movements

HAIR

• thick black hair

• evenly distributed

• no infestations
EYES

• eyebrows symmetrically aligned

• eyelashes curled slightly outward

• exhibited bilateral blinking

• both eyes coordinated, move in unison and with parallel alignment

• white sclera

• pink palpebral conjunctiva

• pupils equally round and reactive to light and accommodation

• iris black in color

• pupils equal in size with smooth borders

• illuminated pupils constricts

• no discharge

EARS

• color same as facial skin

• symmetrically aligned

• pinna immediately recoils after it is folded

• pinna is not tender

• no lesions or discoloration

• dry cerumen, grayish-tan color

• normal voice tones audible

NOSE AND SINUSES

• symmetric and straight

• no discharge

• absence of lesions and tenderness


• nasal septum intact and in the midline

• sinuses not tender

MOUTH AND THROAT

• outer lips uniform pink color

• symmetric contour

• buccal mucosa is of uniform pink color

• no abrasions and ulcerations

• gums are pink

• tongue pink, moist, at central position

• tongue moves freely with no tenderness

• palate surface intact

• uvula positioned in midline

• palatine tonsils pink and smooth and not swollen

NECK

• head centered

• head movement coordinated and smooth with no discomfort

• lymph nodes not palpable

BREAST AND AXILLAE

• rounded, generally symmetric

• areola rounded and the same shape

• nipples round, everted and equal in size

• milk letdown
CARDIOVASCULAR

• BP 160/100 mmHg

• PR 106

• prompt capillary refill time (less than 1 second)

• symmetric pulse strength

RESPIRATORY/CHEST

• chest symmetric

• chest wall intact, no tenderness, no masses

• full symmetric chest expansion and excursion

• respiratory rate of 22 breaths per minute

GASTROINTESTINAL/ABDOMEN

• striae present at hypogastric and iliac regions

• symmetric movement caused by respiration

• tender because of suture from cesarean operation

URINARY

• yellowish urine

REPRODUCTIVE

• regular menstrual cycle

• G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES

• muscle equal size on both sides of the body

• equal strength

• no bone deformities

• no tenderness

• no tenderness on calf muscle when dorsiflexed

NEUROLOGIC

• can respond to verbal commands

• oriented

• conscious
PHYSICAL ASSESSMENT

November 29, 2008

SKIN

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

• skin temperature uniform and within the normal range (37.2°C)

• when pinched, skin readily springs back to previous state

• moist skin folds

• nails with smooth texture

• nail beds pink

• nail plate angle about 160°

• prompt capillary refill time

• bipedal non-pitting edema

HEAD

• rounded

• smooth skull contour

• no masses, tenderness in the scalp

• symmetric facial features

• symmetric nasolabial folds

• symmetric facial movements

HAIR

• thick, evenly districbuted black hair

• no infestations
EYES

• eyebrows symmetrically aligned

• exhibited bilateral blinking

• anicteric sclera

• pink palpebral conjunctiva

• pupils equally round and reactive to light and accommodation

• no discharge

EARS

• symmetrically aligned

• pinna not tender and immediately recoils after folded

• no lesions or discoloration

• dry cerumen, grayish-tan color

• normal voice tones audible

• able to hear ticking of a watch in both ears

NOSE AND SINUSES

• symmetric and straight

• no discharge or flaring

• absence of lesions and tenderness

• nasal septum intact and in the midline

• both nares patent

MOUTH AND THROAT

• outer lips uniform pink color


• symmetric contour

• buccal mucosa is of uniform pink color

• gums are pink

• tongue pink, moist, at central position

• palate surface intact

• uvula positioned in midline

• palatine tonsils pink and smooth and not swollen

• gag reflex present

• 30 adult teeth, 2 molars missing, 1 with black discoloration of the enamel

NECK

• neck muscles equal in size, head centered

• head movement coordinated and smooth with no discomfort

• lymph nodes not palpable

BREAST AND AXILLAE

• areola rounded and the same shape

• nipples round, everted and equal in size

• milk letdown

CARDIOVASCULAR

• BP 150/100 mmHg

• PR 96

• strong, regular rhythm

• prompt capillary refill time (less than 1 second)


RESPIRATORY/CHEST

• chest symmetric

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

• chest wall intact, no tenderness, no masses

• full symmetric chest expansion and excursion

• respiratory rate is 28 breaths per minute

GASTROINTESTINAL/ABDOMEN

• striae present at hypogastric and iliac regions

• rounded contour

• symmetric movement caused by respiration

• tender because of suture form cesarean operation

URINARY

• yellowish urine

REPRODUCTIVE

• regular menstrual cycle

• G1P1 (1-0-0-1-0)

MUSCULOSKELETAL/EXTREMITIES

• muscle equal size on both sides of the body

• smooth coordinated movements

• equal strength
• no tenderness

• walks aided to maintains balance

• no tenderness on calf muscle when dorsiflexed

NEUROLOGIC

• can respond to verbal commands

• oriented

• conscious
DIAGNOSTIC AND LABORATORY PROCEDURES

Date
Ordered and
Diagnostic or Analysis and
Indication or Date Normal
Laboratory Results Interpretation
Purpose Results Values
Procedure of Results
were
released
WBC Count To determine November 8.0 5-10 x No infection or

infection or 16, 2008 109/L inflammation

inflammation is present.

Pre-operation

assessment of

the patient.

RBC Count Pre-operation November 3.3 4.2-5.4 x Decreased

assessment of 16, 2008 1012 /L RBC count on

the patient. pregnant is

normal

because of the

increase in

plasma volume

during

pregnancy.
Hemoglobin Pre-operation November 96 120- The result

assessment of 16, 2008 160g/L indicates that a

the patient. 1000 ml

sample of

blood contains

96 g of

hemoglobin.

Decreased
hemoglobin on

pregnant is

normal

because of

their increase

in plasma

volume.
Hematocrit Pre-operation November 0.29 0.37-0.47 The result

(%) assessment of 16, 2008 g/L indicates that a

the patient. 1000 ml

sample of

blood

contains .29 g

of hemoglobin.

Decreased

hematocrit on

pregnant is

normal

because of

their increase

in plasma

volume.

Nursing Responsibilities During Different Laboratory Procedures

White Blood Cell Count


Before

• 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 may need to be restricted.

During

• Ensure subdermal bleeding has stopped before removing pressure.

After

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

hematoma is large, monitor pulses distal the venipuncture site.

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

discontinued before the test, as ordered.

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

requires protective isolation.

Red Blood Cell Count

Before
• Explain to the patient that RBC count is used to evaluate the number of RBCs and

to detect possible blood disorders.

• 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 patients that he need not restrict foods and fluids

During

• Ensure subdermal bleeding has stopped before removing pressure.

After

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

Hemoglobin

Before

• 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 when.

• Explain to the patient that he may experience slight discomfort from the needle

puncture and the tourniquet.


During

• Ensure subdermal bleeding has stopped before removing pressure.

After

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

Hematocrit

Before

• Explain to the patient that hct is tested to detect anemia and other abnormal

conditions

• 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 patients that he need not restrict foods and fluids

During

• Ensure subdermal bleeding has stopped before removing pressure.

After

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


III. THE PATIENT AND HIS ILLNESS

Efforts to unravel the pathogenesis of pre-eclampsia have been hampered by the

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

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

adverse pregnancy outcome.


Abnormal placentation (stage 1), particularly lack of dilatation of the uterine

spiral arterioles, is the common starting point in the genesis of pre-eclampsia, which

compromises blood flow to the maternal–fetal interface. Reduced placental perfusion

activates placental factors and induces systemic hemodynamic changes. The maternal

syndrome (stage 2) is a function of the circulatory disturbance caused by systemic

maternal endothelial cell dysfunction resulting in vascular reactivity, activation of

coagulation cascade and loss of vascular integrity. Pre-eclampsia has effects on most

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

brain.
V. THE PATIENT AND HIS CARE

1. Medical Management

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

Medical Date Ordered General Indication & Client Response

Management Description Purpose to Treatment


IVF Date Ordered 5% dextrose in D5NM is The patient

November 15, lactated ringers administered by responded well


D5LRS 1L
2008 solution intravenous with no signs of
30gtts/min
(Osmolarity of infusion for irritation and
Date d/c
527-hyprtonic, parenteral adverse reactions.
November 20,
pH of 4.9) maintenance of
2008
-provides routine daily fluid

calories and free and electrolyte

water, provides requirement with

electrolytes. minimal

Also contains carbohydrates

sodium lactate calories and to

which is used in correct or replace

treating mild to fluid losses due to

moderate change in the

metabolic patient’s diet

acidosis. (NPO) and during

the cesarean

operation.

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

Brand name and Date ordered/ Route of General action Client response

Generic name Date started/ Administration,

Date changed/ Dosage and

Frequency of

Administration
Mefenamic 11-19-08 P.O., 500mg, Inhibits Patient was

Acid TID for pain prostaglandin relieved from

synthesis by pain.

decreasing the

activity of the

enzyme,

cyclooxygenase,

which results in

decreased

formation of

prostaglandin

precursors
Cephalosporin 11-19-08 I.V., 750mg, q8 Inhibits bacterial The patient did
Cefuroxime cell wall not acquire

sodium synthesis by infection and

binding to one or did not

more of the experience any

penicillin- adverse

binding proteins reaction.

(PBPs) which in

turn inhibits the

final

transpeptidation

step of

peptidoglycan

synthesis in

bacterial cell

walls, thus

inhibiting cell

wall

biosynthesis.

Bacteria

eventually lyse

due to ongoing

activity of cell

wall autolytic

enzymes

(autolysins and

murein

hydrolases)

while cell wall

assembly is
arrested.

Ferrous Sulfate 11-19-08 P.O., O.D. Replaces iron, The patient

found in responded well

hemoglobin, to treatment

myoglobin, and and did not

other enzymes; experience any

allows the adverse

transportation of reaction.

oxygen via

hemoglobin.
Nifedipine 11-19-08 P.O., 10mg, BID Inhibits calcium The patient

ion from responded well

entering the to treatment

"slow channels" and did not

or select experience any

voltage-sensitive adverse

areas of vascular reaction.

smooth muscle

and myocardium

during

depolarization,

producing a

relaxation of

coronary

vascular smooth

muscle and

coronary

vasodilation;

increases
myocardial

oxygen delivery

in patients with

vasospastic

angina

c. Diet

Type of Diet Date Ordered, General Indication & Client

Date Performed, Description Purpose Response to

Date Administer Treatment


NPO 11-17-08 The patient is not This is done to The patient

11-19-08 allowed to take prevent complied with

any oral food or alteration of the the prescribed

liquid result of the diet.

fasting blood

sugar.bcs intake

of food can

increase

glucose level
Clear Liquid 11-19-08 A diet of clear This diet reduce The patient

Diet 11-20-08 liquids maintains stimulation of complied with

vital body fluids, the digestive the prescribed

salts, and system, and diet.

minerals; and also leave no residue

gives some energy in the intestinal

for patients when tract. This is

normal food intake why a clear

must be liquid diet is


interrupted. Clear often prescribed

liquids are easily in preparation

absorbed by the for surgery, and

body. by mouth is generally the

(NPO) for a long first diet given

time. This diet is by mouth after

also used in surgery. Clear

preparation for liquids are

medical tests such given when a

as sigmoidoscopy, person has been

colonoscopy, or without food by

certain x-rays. mouth (NPO)

for a long time.

d. Exercise

Activity General Purpose Date Order Client

Description Response

Complete Bed Prescribed To provide 11-18-08 The client

Rest maternal adequate rest adhered to the

complication of order without

pregnancy complaints.
VI. NURSING CARE PLAN

Cues Nursing Scientific Objective Nursing Rationale Expected


diagnoses Explanation intervention outcomes
S-“sumasakit Acute pain Unpleasant After 2-4 hr of - Provide quite -to promote pain Goal Partially

nga daw ung related to sensory nursing environment management. met AEB pt

tahi niya at postparum experience intervention, the rated the pain

sumusigaw siya” arising from post pt rate the pain -Encouraged to -to reduce tension from 8 to 5 in a

as the SO surgical incision from 8 to 3 in a do deep pain scale of 1-

verbalized from cesarean pain scale of 1- breathing 10

section. 10 exercise

O- facial -to prevent

grimaces - Encouraged fatigue

Rated pain as 8 adequate rest

in a pain scale of period

1-10, 10 being -to reduce

the highest - Encouraged to pressure on the


Guarding support the affected area

behavior affected area

upon movement

Cues Nursing Scientific Objective Nursing Rationale Expected


diagnoses Explanation intervention outcomes
S-“ayoko na Disturbed body Severity of the After 2-4 hrs of -Encouraged -to begin to Goal met the

muna dapat image related to abdominal nursing client to looked/ incorporate patient

mabuntis kc pregnancy AEB wound due to intervention, the touch the changes into recognized and

papangit ung changes in surgery, a new patient will able affected body body image. verbalized

katawan ko appearance type of tissues to understand the area understanding of

tsaka bat ang develops that change of body -to bring back body changes.

itim ng pek-pek eventually will image. -Encourage the the usual

ko” as pt causes scar client to have a physical images.

verbalized formation daily exercise.

-to feel that the


O-presence of -Advised the SO patient still

melasma to give support worthy.

-presence of to the pt

bipedal edema (especially

emotional

feelings) -to aid in

recovery.

-Assist pt to

identify positive

behavior
Cues Nursing Scientific Objective Nursing Rationale Expected
diagnoses Explanation intervention outcomes
S: “bumibilis Decreased Pregnancy After 4 hrs of -Keep client on - decreases Goal Met AEB

nga tibok ng cardiac output Induced nursing bed and in oxygen within 4 hrs. of

puso ko” related to altered Hypertension is a intervention, the position of consumption nursing

verbalized by heart rate (111 condition in patient will comfort intervention the

the patient bpm) AEB which display pt. HR

tachycardia, pt’s vasospasms hemodynamic -decrease -to promote decreased from

report of occur. It is caused stability (heart stimuli; provide adequate rest 111 bpm to 100
O: -with the
palpations; by altered cardiac rate will decrease quiet env’t bpm, BP from
tenderness of
(r/t) decreased output that injures from 111 bpm to -to reduce 140/100 to
abdominal are
venous return endothelial cells 100 bpm, BP -Encouraged anxiety 120/80 (Normal

-facial grimaces AEB edema of the arteries. from 140/100 to deep breathing BP)

(ankle), SOB Blood vessels 120/80) exercise


-BP= 160/100
(28) become less -to reduce risk for
mmhg
resistant to -Encouraged orthostatic
pressor changing hypotension
RR= 28 cycles
substances. This positions slowly
per min.
results to -to provide

PR= 111 bpm vasoconstriction -give encouragement

and increases BP information

dramatically about positive

signs of -to prevent in

improvement changes in

cardiac pressures

-Instruct client to or impede blow

avoid or limit flow

activities that

may stimulate

valsalva

response (rectal

stimulation,
bearing down

B.M)

Cues Nursing Scientific Objective Nursing Rationale Expected


diagnoses Explanation intervention outcomes
S- Risk for Constipation After 4 hrs of - Educate - Information Goal Met AEB
constipation may happen due nursing patient/ SO can help client to the patient

O- decreased related to post to disturbance of intervention, the about safe and make beneficial verbalized

ambulation of CS delivery. normal bowel patient will risky practices choices when understanding

the patient bcs movements verbalize for managing need arises. about

of pain and the because understanding constipation. constipation and

complete bed intestines were the etiology and gained

rest ordered of displaced during appropriate - Instruct balance - To improve knowledge of

the physician. surgical intervention if fiber and bulk in consistency of appropriate

procedure. constipation may diet and fiber stool and intervention.

occur. supplements. facilitate passage

through colon.

- Promote

adequate fluid - To promote

intake, also soft stool and

suggest drinking stimulate bowel

warm fluids. activity.


- Encourage

activity within -To stimulate

limits of constrictions of

individual the intestines

ability.

Cues Nursing Scientific Objective Nursing Rationale Expected


diagnoses Explanation intervention outcomes
O- postpartum Impaired Skin The incision After 2-4 hrs of -stress proper - to control the Goal Met AEB

surgery Integrity related from the nursing hand hygiene. spread of the patient was
to surgery cesarean section intervention, the infection. able to knew

altered the skin patient will able -Encouraged to the preventive

integrity making to know the increase foods - to aid in tissue measures of

it more preventive that are rich in repair wound healing

susceptible to measures of protein

pathogens and wound healing

even the pt’s -Encouraged -to maintained the

normal flora proper clothing proper skin

moisture.

-Apply

appropriate -to help in wound

dressing healing
VIII. Discharge Plan

General Condition of client upon discharge

During nurse-patient interaction upon discharge, the patient was wearing a

comfortable pair of white shirt and white pajama and a pair of flat slip-ons while being

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

visible infestations. She was oriented enough to follow instructions and answers

questions asked by the student nurse.

Methods

M- Instructed the patient to take the following home medication as ordered by the

physician:

Mefenamic Acid 500mg PRN

Ferrous Sulfate OD

Nifedipine 10mg BID

E- Instructed patient to avoid strenuous activities. And practice deep breathing

exercise.

T- n/a
H- Instructed patient to take a bath everyday. Emphasize the importance of breast

feeding.

O- Advice to visit or have a follow up check-up with her attending physician.

D- Low fat, Low salt diet.


IX. 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 shows 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.


X. 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.


XI. BIBLIOGRAPHY

http:// www.nursingcrib.com

http:// www.medicinenet.com

http:// www.wrongdiagnosis.com

http:// www.umm.edu.com

http:// www.doh.gov.ph