BULACAN STATE UNIVERSITY City of Malolos, Bulacan COLLEGE OF NURSING

A CASE STUDY ABOUT PREGNANCY-INDUCED HYPRETENSION

(PREECLAMPSIA)
. Submitted by: BSN 2-A Group 3

REYES, Angelo REYES, Clarizza REYES, Rudy Mark ROBLES, Charmaine Dale RONQUILLO, Ma. Elaine ROSAL, Miracle ROXAS, Paulo Raphael SALVADOR, Ann Laurice SANICOLAS, Janet

Submitted to: Level II Clinical Instructors

TABLE OF CONTENTS:

I. INTRODUCTION .................................................................................................................................................................................................................................... Statistics ..................................................................................................................................................................................................................................................... Objective ................................................................................................................................................................................................................................................... Significance of the Study ..........................................................................................................................................................................................................................

II.NURSING ASSESSMENT A. Demographic Data ............................................................................................................................................................................................................................... B. Reason for Visit/Chief Complain ........................................................................................................................................................................................................ C. History of Past Illness.......................................................................................................................................................................................................................... D. History of Present Illness .................................................................................................................................................................................................................... E. Family Nursing History....................................................................................................................................................................................................................... Genogram .................................................................................................................................................................................................................................................. F. Functional Health Pattern ................................................................................................................................................................................................................... G. Growth and Development................................................................................................................................................................................................................... III.ANATOMY AND PHYSIOLOGY ....................................................................................................................................................................................................... Review of Systems .................................................................................................................................................................................................................................... IV.PATIENT AND HER ILLNESS..

Patho-physiology(Schematic Diagram)....................................................... Physical Assessment.. Laboratory / Diagnostic Procedures

V.PATIENT AND HER CARE A. Medical Management .............................................................................................................................................................................................................................

a. Intravenous Fluid

b. Drugs ...................................................................................................................................................................................................................................................... c. Diet .......................................................................................................................................................................................................................................................... d. Exercise/Activity ................................................................................................................................................................................................................................... B. Surgical Management. C. Nursing Problem Prioritization ............................................................................................................................................................................................................. D. Nursing Care Plan ................................................................................................................................................................................................................................... VI.DISCHARGE PLANNING.................................................................................................................................................................................................................... A. General Condition of the Client upon Discharge. B. METHODS. VII. CONCLUSION .................................................................................................................................................................................................................................... VIII. BIBLIOGRAPHY ..............................................................................................................................................................................................................................

I.

INTRODUCTION

This is a case of Mrs. RS, a 22 year-old woman living with her partner in San Roque, Hagonoy, Bulacan. She was admitted at the Bulacan Medical Center last January 8, 2011 at exactly 11:20 AM. It is due to possibility of giving birth with chief complaint of labor pain accompanied by severe headache and seizure episodes. Pregnancy Induced Hypertension is hypertension which occurs after 20 weeks and solved 6 weeks postpartum. It is formerly known as Toxemia but later not proven as authorities failed to find any toxins. It may further be classified into two Gestational Hypertension and Preeclampsia. Gestational Hypertension is sustained blood pressure elevation of greater than or equal to 140/90 mmHg after 20 weeks of pregnancy. Preeclampsia, on the other hand, is sustained blood pressure elevation after 20 weeks of gestation in the absence of preexisting hypertension. The risk factors for Preeclampsia are as follows: Primipara due to 1st exposure to chorionic villi; Multiple pregnancy due to increased exposure to chorionic villi; Decreased mothers socio-economic status; Low intake of CHON predisposed to PIH; Hyadatidiform mole; Diabetes mellitus; Age extremes; Chronic hypertension; and Chronic renal disease. Pregnancy Induced Hypertension may be assessed using the Triad signs and Symptoms, namely, Hypertension, Edema and Proteinuria or Albuminuria. The Medical Management for PIH are using antihypertensive drug Hydralazine (Apresoline) and convulsion prevention by Magnesium Sulfate. Magnesium Sulfate is a CNS depressant or anti-convulsant. Its antidote is Calcium Glutonate. Prior to administration, we must first evaluate physical parameters for Magnesium Sulfate toxicity. There is no surgical management for Pregnancy Induced Hypertension. Promoting bedrest and preventing convulsion by Nursing Measures are the Nursing Responsibilities for PIH. For Home Care, we simply ensure adequate protein intake (1g / 1kg / day). Preeclampsia develops in about 7% of pregnancies. Incidence is significantly higher in low socioeconomic groups. About 5% of females with preeclampsia develop eclampsia; of these, about 15% die from PIH itself or its complications. Fetal mortality is high due to the increased incidence of premature delivery and uteroplacental insufficiency. In the Philippines, there are 46,392 incidents of PIH with an estimated population of 86,241,697 used. The rank for Maternal Mortality: By Main Cause in the Philippines (1995) is as follows: 1. Complications related to pregnancy occuring in the course of labour, delivery and puerperium 524; 2. Hypertension complicating pregnancy, childbirth and puerperium 348; 3. Postpartum Hemorrhage 333; 4. Pregnancy with abortive outcome 164; and 5. Hemorrhages related to pregnancy 119.

GENERAL OBJECTIVES

KNOWLEDGE: Acquire and / or develop knowledge of the Student Nurses in the causes, risk factors and management of Preeclampsia Obtain and / or develop knowledge of the client about the basic definition, possible causes, risk factors, complications, medical and home management for Preeclampsia Impart sufficient knowledge about managing Preeclampsia from Student Nurses to the client

SKILLS: Develop skills of Student Nurses in assessing for Preeclampsia using the Triad Signs and Symptoms Enhance skills of Student Nurses in rendering medical care and observing nursing responsibilities for Preeclampsia Acquire and / or improve skills of the client on applying home management imparted by the Student Nurses and the medical staff

ATTITUDE: Establish and develop a harmonious relationship between the client and Student Nurses through participation and cooperation of both Develop cooperation and teamwork between the members of Group 3 as we work on our Case Study Impart on the client an open and accommodating impression on medical practitioners, including Student Nurses

II.

NURSING ASSESSMENT

A. PERSONAL HISTORY BIOGRAPHIC DATA NAME: Mrs. RS ADDRESS: San Roque, Hagonoy, Bulacan AGE: 22 y/o BIRTHDATE: July 16, 1988 BIRTH PLACE: Cha-ong, Quezon SEX: Female RACE: Asian CIVIL STATUS: Married OCCUPATION: Plain housewife NATIONALITY: Filipino RELIGIOUS ORIENTATION: Roman Catholic EDUCATIONAL ATTAINMENT: High School Undergraduate HEALTHCARE FINANCING & USUAL SOURCE OF MEDICAL CARE: None DATE OF ADMISSION: January 8, 2011 TIME: 11:20 AM

DATE OF INTERVIEW: January 11, 2011 DATE OF PHYSICAL ASSESSMENT: January 11, 2011

TIME: 1:00 PM TIME: 2:50 PM

ADMISSION DIAGNOSIS: G2P0 (0010) Pregnancy Uterine 38 4/7 weeks AOG, CIL, Intrapartum Eclampsia FINAL DIAGNOSIS: Pregnancy Uterine 38 4/7 weeks AOG delivered via NSD to an alive baby girl 2300 g, 47 cm with an APGAR Score of 9 DATE OF DISCHARGE: January 15, 2011 TIME: 5:00 PM

B. CHIEF COMPLAINT / REASON FOR VISIT Sobrang sakit ng ulo ko tapos nagconvulsion na ako. Pagkatapos ay nawalan na raw ako ng malay kaya dinala na ako dito sa ospital. as verbalized by the client.

C. HISTORY OF PESENT ILLNESS The client was admitted in the hospital at 11:42 AM of January 8, 2011. Two days prior admission, the client experienced mild headache. She just ignored it, and thought that it was just normal just an ordinary headache. She did not seek any medical consultation. Four hours prior admission, the client experienced epigastric pain, so the family thought that she will be giving birth and already and has started to labor. But then the pain she was experiencing continued. When asked to rate the pain, she said it was 7/10. Three hours prior to admission, she experienced dizziness and blurring of vision accompanied by severe headache. She rated it as 9/10. After that, she had two seizure episodes, described as upward rolling of eyeballs and stiffing of extremities. OB History The patients experienced her menarche when she was 14 y/o. Her menses duration is about 5 days and she consumes 2 pads (soaked with blood) a day. She experiences dysmenorrhea and takes analgesics like Tylenol whenever there is pain. Her Last Menstrual Period (LMP) was on April 14, 2010 and her Expected Date of Confinement (EDC) was on January 21, 2011. She was admitted to the hospital two weeks before her EDC.

The patient is Gravida 2, Para 1, Abortion 1 and 1 Living children. (G2P1T1P0A1L1). D. HISTORY OF PAST ILLNESS The client told us that this was her 2nd time of hospitalization. The first one was when she had an abortion. It was last December 2009. The fetus on her womb was 3 months old. Her abortion was due to chromosomal imbalance. She stated that she completed her immunizations when she was still a child. These immunizations include: BCG, DPT, MMR and Hepa B vaccines. In addition, she already had 2 shots of Tetanus Toxoid (TT). When having minor influenzas in the past, she mostly depends on Over-The-Counter Drugs (OTC). When she has a fever, she usually just buys Biogesic from a drugstore and does not seek any medical advice / consultation. The client also stated that she does not have any allergies; denies having blood transfusion in the past and does not experience injuries except for having an abortion, in which she underwent Dilatation and Curettage (D&C). She also said that her family practices self-medication, having and taking OTC Drugs. She believes in Albularyo and Hilot especially when she was still in their province.

E. FAMILY HEALTH HISTORY The client has a familial history of Heart Disease in her paternal side. Her grandfather died because of heart attack. Our clients father drinks alcohol occasionally and so does the rest of the family. Two of her uncles are Hypertensive. Her uncle had stroke, but has recovered now. In her maternal side, her grandfather died due to Lung Disease. One of the family members drinks alcohol. Likewise, her sister (eldest among her siblings) died because of heart disease when she was still 19 y/o. Hindi raw siya pwedeng mag asawa, sabi ng doctor. as verbalized by the client. However, she said that she is considerably living in a good environment with the fact that she is now with her husband and away from her family in Quezon. She added that only few members of her husbands family have vices (smoking and drinking alcohol). Except those with the above mentioned family health problem, all the other members are healthy.

F. FUNCTIONAL HEALTH PATTERN

Functional Health Pattern

Prior to Hospitalization

During Hospitalization

1. Health Perception / Heath Management Pattern

The client viewed health as the absence of any disease and is being physically fit to accomplish activities of daily living. She also said that in order to stay healthy, she must eat balance and healthy foods. Upon asking her, her rate for her health on a scale of 1-10 (1 being the lowest and 10 being the highest) is 7. When asked if she is drinking alcohol beverages, she replied Pag may okasyon lang sa amin,pinagbawalan na kasi ako e. She had an abortion last Dec. 2009 and was able to follow prescribed management for her condition. She is not smoking. She had cough, colds, and fever before and she usually takes over-the-counter drugs like Biogesic and Paracetamol and takes rest to manage it.

Upon asking the client about her health, she replied Medyo mabuti na ngayon.Hmm diba mataas ang BP ko e bakit ba kailangan akong salinan ng dugo? as verbalized by the client. When she gave birth to her baby, she had a complication that make her rate her health as 5 from a 1 -10 scale. She had series of seizure during the delivery. She said that the present illness slightly affected her normal daily activities. When asked why she said so, she replied that for she cant be home yet; feels dizzy when shes about to ambulate; and experiences headache during the hospital stay. Her episiotomy and episioraphy also gave her pain and discomfort. She manages those conditions by taking a rest and moving in a minimal range. She is following the medication prescribed by her OB-Gyne as follows: Cefalexin, Mefenamic Acid when there is pain,and Ferrous sulfate at the right time and right dose. Meds like Amlodipine, Hydralazine, and Diazepam are also given once with active seizure as prescribed. January 8 Breakfast Skipped January 9 Breakfast 1 glass of milk 1 pack of sky flakes January 10 Breakfast 2 cup of milk 2pcs.of tinapay

2. Nutritional and Metabolic Pattern

January 5 Breakfast 1 cup of coffee 1 cup of rice 8pcs. of steamed

January 6 Breakfast 1 cup of coffee 3pcs.of pandesal 2 glasses of

January 7 Breakfast 1 cup of coffee 1 pack of beef mami

shrimp 2glassesof water Lunch 1 cup of rice 8pcs. of steamed shrimp 2 glasses of water Snack 2 pcs. of bread 1 glass of orange juice

water

Lunch 1 cup of rice 1 medium size leg of chicken 2 glasses of water Snack 2 pcs of pandesal with cheese 2 glasses of water Dinner 1 cup of rice 1 medium size tilapia 2 glasses of water

Lunch 1 cup of rice 1 small size bangus 2 glasses of water 1 slice papaya Snack none

Lunch Lunch NPO as ordered by the physician Dinner skipped Snack Dinner

Lunch 1 cup of rice 1saucer of pakbet 1 small pc of bangus 2 glasses of water Dinner 1 cup of rice 1 saucer of tokwa with sitaw 2 glasses of water

Dinner 1 cup of rice 1bowl of sinigang na hipon 3 glasses of water

Dinner 1 cup of rice 1 small size bangus 1 bowl of pinakbet 2 glasses of water

She only eats what the hospital gave her. She is maintaining a diet of low salt low fat diet (LSLF) as ordered by the physician. Doesnt experience difficulty in eating. The client was not able to properly breast feed her baby so shes using a breast pump. Wala kasing lumalabas eh,as verbalized by the client.

The client said that she frequently included seafood like fish like bangus, shrimp, and crabs in her diet. She seldom eats meat and vegetables. Mrs. R.S. considers her diet high in iodine. She usually consumes 6-8 glasses of

3. Elimination Pattern

water in a day and drinks a cup of coffee every morning. She doesnt experience any difficulty in swallowing but sometimes she experience difficulty in chewing because of her teeth aches. Her wound heals faster and no skin dryness. Output Frequency Amount Characteristics Urine 10 times 1500ml Light yellow color; Stool 3x a day --aromatic Brown, slightly formed, odor

Output Urine Stool

Frequency 2 ---

Amount 300ml ---

Characteristics Dark yellow ---

Client has not yet defecates since being hospitalized. She urinates twice a day during the hospitalization. foul

She gains weight during pregnancy. She usually defecate 3x a day with a slightly formed stool, brown in color and has a foul odor. The client said that she urinates 10x a day when she is pregnant, but if not, she only voids 3-4x a day with yellowish color. Last Jan. 7, the client vomited twice after dinner. Nagsuka ko dalawang beses pagkakain, parang tubig lang sya, as verbalized by the client. She perspires moderately due to her activities of daily living.

4.Activity / Exercise Pattern

_0_ Feeding _0_ Dressing

_0_Grooming _0_General Mobility

_0_ Feeding _II_ Dressing

_0_Grooming _II_General Mobility

_0_Bathing _0_Toileting _0_Bed Mobility

_0_ Cooking _0_Home Maintenance _0_ Shopping

_II_ Bathing _II_ Toileting _0_Bed Mobility

_II_ Cooking _II_Home Maintenance _II_ Shopping

Level 0 - Full self-care Level I - Requires use of equipment/device Level II Requires assistance or supervision from another person Level III Requires use or supervision from another person, device, or equipment Level IV Is dependent and does not participate

Level 0 - Full self-care Level I - Requires use of equipment/device Level II Requires assistance or supervision from another person Level III Requires use or supervision from another person, device, or equipment Level IV Is dependent and does not participate

She has enough strength to do everyday work. During During the first day in the hospital, patient was not able to morning she exercises by walking in their street. When walk. She had episodes of seizure so she was so weak and she has nothing to do, she usually sits down and rest. was monitored for seizure precaution. Her episiotomy also gave her pain and discomfort. She walks uneasily and need assistance from others. When she needs anything, she asks her husband to do it for her because she can feel the pain. On the day of interview, Medyo masakit ulo ko..hindi ako naglalakad-lakad kasi baka mahilo ako, as verbalized by the client. She take a rest and about to sleep to manage it. January 5 9 pm 5am 6 hours January 6 9pm 4:30am 5hours January 7 9pm 5am 6hours
Time of Sleep Time of Awakening

5.Sleep- Rest Pattern

January 8 9 pm 5am

January 9 9pm 4:30am 8hours

Time of Sleep Time of Awakening Total No. of sleep

January 10 9pm 5am 7hours

Total No. 7 hours of sleep

Nap January 5 Total No. 1 hour of sleep

January 6 1hour

January 7 2hours

Nap

January 8

January 9 2hours

Total No. 2 hours of sleep

January 10 2hours

The client usually sleeps for 8 hours, from 9pm to 5 am. However, three days prior to admission, she wakes up every midnight. Nagigising ako sa hating-gabi tapos nahihirapan na akong ibalik antok ko, as verbalized by the client. Two days prior to hospitalization, client frequently experiencing mild headache especially during late evening.

During her stay in the hospital, she was able to have enough rest and sleep. She sleeps for 7-8 hrs in a day. She said that after giving birth she was very tired and so she was just sleeping the whole day. Mga dalawang araw pagkapanganak ko e tulog lang ako ng tulog, as verbalized by the client. However, she was pale during the day of interview and so she was for Blood transfusion as ordered.

6.Cognitive Perceptual Pattern

Mrs. R.S. was able to understand, communicate, remember and make decisions by herself. She doesnt have any alterations in her senses except for this past week that she experience blurring of vision and dizziness. She doesnt try any consultation for eye or ears.

During hospitalization, our client is pale, experiencing dizziness and sometimes blurring of vision. When we ask something to the client, she frequently asks her husband to recall what happened. Nakakalimutan ko nga minsan e..parang nagging ulyanin na?

7.Self Perception/ Self-Concept Pattern

She is cheerful and friendly person. Minsan depende kasi..sabi nga ng iba apakamatampuhin lalo ngayong nagbuntis ako as verbalized client.The client stated that she dont want to anything on herself.

moody, When the patient was asked what she feels about herself, ko daw she said Ok lang. Medyo di na sexy,nanganak na kasi,. by the When the patient was asked what she feels about the delivery, change Nalungkot lang kami dahil nandito pako ngayon sa hospital tapos ganito pa pero masaya ko dahil may anak na ako, as verbalized by the client.

8.Role Relationship Pattern

9.Sexuality Reproductive Pattern

She was living in there own house which is far away from their parents place. Her husband provides the financial support in their family which is enough for them in their everyday living. When it comes in decision making both of them has the right to decide. If theres problem encountered, they solve it together and sometimes with the help of her husbands family, just like what they did during her dilemma about losing her first baby. Our clients menarche is when she was 14 y/o. Her menses duration is about 5 days and she consumes 2 pads (soaked with blood) a day. She experiences painful feeling in the abdomen during her menstruation. For these, she takes analgesics like Tylenol and Paracetamol.

The birth of their new baby brought happiness for both of them as well as to their relatives.She stated, Masaya talaga kami kasi gusto talaga naming magkaanak na para mapalitan yong nawala. She said that they had moved on for the personal loss of their first baby. They have strong family tie on her in-laws and the husbands family treats her as their own child.

After this first baby, she doesnt want to get pregnant again because of fear that shell be having complication again. Di muna namin iisipin yan..nung una e abortion, ngayon naman ganto so tama na muna yong isa, as verbalized by the client.

Her Last Menstrual Period (LMP) was on April 14, As for a woman in early postpartum or puerperrial period, 2010 and her Expected Date of Confinement (EDC) was she has vaginal discharges after delivery of her baby. Her on January 21, 2011. She was admitted to the hospital two discharges are characterized as lochia rubra. weeks before her EDC. The patient is Gravida 2, Para 1, Abortion 1 and 1 Living children. (G2P1T1P0A1L1). Pregnancy was planned for they wanted to have a baby after she had spontaneous abortion. She watches television, sleeps or takes a nap to relax or to relieve stress. She doesnt use drugs or alcohol to relieve stress. When she had an abortion, it affects her and her family. When dealing with problems, she often seeks her mother-in-laws advice and responds well to this

10.Coping Stress Tolerance

The client sees that giving birth is a blessing and not a problem.Her family always help her to cope up with the problem. Praying also helps her to deal with stressful situation. Their only concern for now is financial matters. Clients husband said, Hirap nga eh hindi namin alam kung

situation with the help of her partner.

11.Values/Belief Pattern

saan kukuha ng pera. Dapat kasi eh sa bahay lang manganganak. Kaya lang nagkakomplikasyon, kaya yun..andyan na yan eh. Our client is a Roman Catholic. She attends mass The client always believes that God is always there to every Sunday. She believes that God will help them in help them. times of crisis and difficulties. She also believes in Albularyo and Hilot especially when she was still in their province.

G. GROWTH AND DEVELOPMENT PSYCHOSOCIAL (Erikson) STAGE Intimacy V.S. Isolation PSYCHOSEXUAL (Freud) Genital COGNITIVE (Piaget) Formal Operations phase MORAL (Kohlberg) Law and Order Orientation SPIRITUAL (Fowler) Individuating reflexive

DEFINITION

Creativity, productivity, concern for others

Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment

Uses rational thinking. Reasoning is deductive and futuristic

The person wants established rules from authorities, and the reason for decisions and behaviour is not social and sexual rules and traditions demand the response

Awareness of truth from a variety of viewpoints.

ANALYSIS

The client has more concerned about their

The client does not fully .The client is appropriate possess the characteristic in this stage. She solve

The client is already in this stage because at

Client R.S is a Roman Catholic,

future especially on her child. She has aptitude to care and guide her child. She is also well committed to her husband.

of this stage. Even though she has a deep intimacy to her husband and separated from her family she still relies on them. Her family and her husband affect the way she made a decision and she still depends on them.

problem with scientific the moment the client reasoning and able to became competent in finds the bright side in making decisions about every situation. She herself as well as in her understands causality family, she do this by and can deal with the past, present and future, collaborating problems together with her just the way she deal or cope with the lost of her husband and sometimes previous baby. She is with her significant also futuristic; she others. She knows how shows this by to respect authorized verbalizing her worries rules and regulation, in providing the needs of and follows law and her family after she promote those gives birth. universal values.

and believes in God. Even though she has a different religion from others she still possesses a feeling of acceptance and respect on the religion that others have. She achieved it because she has an awareness of truth from different viewpoints.

III. ANATOMY AND PHYSIOLOGY A. Organ System Involved FEMALE REPRODUCTIVE SYSTEM The female reproductive system (or female genital system) contains two main parts: the uterus, which hosts the developing fetus, produces vaginal and uterine secretions, and passes the male's sperm through to the fallopian tubes; and the ovaries, which produce the female's egg cells. These parts are internal; the vagina meets the external organs at the vulva, which includes the labia, clitoris and urethra. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the Fallopian tube into the uterus. If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina. The ova are larger than sperm and have formed by the time a female is born. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system through menstruation. Internal A female's internal reproductive organs are the vagina, uterus, fallopian tubes, cervix and ovary.

Vagina
The vagina is a fibro muscular tubular tract leading from the uterus to the exterior of the body in female mammals, or to the cloaca in female birds and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the oviduct. The vagina is the place where semen from the male is deposited into the female's body at the climax of sexual intercourse, commonly known as ejaculation. Around the vagina, pubic hair protects the

vagina from infection and is a sign of puberty. The vagina is mainly used for sexual intercourse.

Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible, the remainder lies above the vagina beyond view. The vagina has a thick layer outside and it is the opening where baby comes out during delivery. The cervix is also called the neck of the uterus.

Uterus
The uterus or womb is the major female reproductive organ of humans. The uterus provides mechanical protection, nutritional support, and waste removal for the developing embryo (weeks 1 to 8) and fetus (from week 9 until the delivery). In addition, contractions in the muscular wall of the uterus are important in ejecting the fetus at the time of birth. The uterus contains three suspensory ligaments that help stabilize the position of the uterus and limits its range of movement. The uterosacral ligaments, keep the body from moving inferiorly and anteriorly. The round ligaments restrict posterior movement of the uterus. The cardinal ligaments also prevent the inferior movement of the uterus. The uterus is a pear-shaped muscular organ. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. If the egg does not embed in the wall of the uterus, a woman begins menstruation and the egg is flushed away.

Oviducts
The Fallopian tubes or oviducts are two tubes leading from the ovaries of female mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy.

Ovaries
The ovaries are small, paired organs that are located near the lateral walls of the pelvic cavity. These organs are responsible for the production of the ova and the secretion of hormones. Ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, after travelling down the oviduct to the uterus, occasionally being fertilized on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel.

External
The external components include the mons pubis, pudendal cleft, labia majora, labia minora, Bartholin's glands, and clitoris.

CARDIOVASCULAR SYSTEM The heart is a muscular organ found in all vertebrates that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions. The heart is enclosed in a double-walled sac called the pericardium. The superficial part of this sac is called the fibrous pericardium. This sac protects the heart, anchors its surrounding structures, and prevents overfilling of the heart with blood. It is located anterior to the vertebral column and posterior to the sternum. The size of the heart is about the size of a fist and has a mass of between 250 grams and 350 grams. The heart is composed of three layers, all of which are rich with blood vessels. The superficial layer, called the visceral layer, the middle layer, called the myocardium, and the third layer which is called the endocardium. The heart has four chambers, two superior atria and two inferior ventricles. The atria are

the receiving chambers and the ventricles are the discharging chambers. The pathway of blood through the heart consists of a pulmonary circuit and a systemic circuit. Blood flows through the heart in one direction, from the atrias to the ventricles, and out of the great arteries, or the aorta for example. This is done by four valves which are the tricuspid atrioventicular valve, the mitral atrioventicular valve, the aortic semi lunar valve, and the pulmonary semi lunar valve. Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation. Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation. A separate system known as the bronchial circulation supplies blood to the tissue of the larger airways of the lung. Arteries are blood vessels that carry blood away from the heart. All arteries, with the exception of the pulmonary and umbilical arteries, carry oxygenated blood. Pulmonary arteries The pulmonary arteries carry deoxygenated blood that has just returned from the body to the heart towards the lungs, where carbon dioxide is exchanged for oxygen. Systemic arteries Systemic arteries can be subdivided into two types muscular and elastic according to the relative compositions of elastic and muscle tissue in their tunica media as well as their size and the makeup of the internal and external elastic lamina. The larger arteries (>10mm diameter) are generally elastic and the smaller ones (0.110mm) tend to be muscular. Systemic arteries deliver blood to the arterioles, and then to the capillaries, where nutrients and gasses are exchanged. The Aorta The aorta is the root systemic artery. It receives blood directly from the left ventricle of the heart via the aortic valve. As the aorta branches, and these arteries branch in turn, they become successively smaller in diameter, down to the arteriole. The arterioles supply capillaries which in turn empty into venules. The very first branches off of the aorta are the coronary arteries, which supply blood to the heart muscle itself. These are followed by the branches off the aortic arch, namely the brachiocephalic artery, the left common carotid and the left subclavian arteries.

Aorta the largest artery in the body, originating from the left ventricle of the heart and extends down to the abdomen, where it branches off into two smaller arteries (the common iliac). The aorta brings oxygenated blood to all parts of the body in the systemic circulation. The aorta is usually divided into five segments/sections: Ascending aortathe section between the heart and the arch of aorta Arch of aortathe peak part that looks somewhat like an inverted "U" Descending aortathe section from the arch of aorta to the point where it divides into the common iliac arteries -Thoracic aortathe half of the descending aorta above the diaphragm -Abdominal aortathe half of the descending aorta below the diaphragm Arterioles Arterioles, the smallest of the true arteries, help regulate blood pressure by the variable contraction of the smooth muscle of their walls, and deliver blood to the capillaries. Veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the lungs; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood. Veins differ from arteries in structure and function; for example, arteries are more muscular than veins and they carry blood away from the heart. Veins are classified in a number of ways, including superficial vs. deep, pulmonary vs. systemic, and large vs. small. Superficial veins Superficial veins are those whose course is close to the surface of the body, and have no corresponding arteries. Deep veins Deep veins are deeper in the body and have corresponding arteries. Pulmonary veins The pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the heart.

Systemic veins Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart. Atrium sometimes called auricle, refers to a chamber or space. It may be the atrium of the lateral ventricle in the brain or the blood collection chamber of a heart. It has a thin-walled structure that allows blood to return to the heart. There is at least one atrium in animals with a closed circulatory system. Right atrium is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the superior and inferior vena cava and the coronary sinus, and pumps it into the right ventricle through the tricuspid valve. Attached to the right atrium is the right auricular appendix. Left atrium is one of the four chambers in the human heart. It receives oxygenated blood from the pulmonary veins, and pumps it into the left ventricle, via the atrioventricular valve. Ventricle is a chamber which collects blood from an atrium (another heart chamber that is smaller than a ventricle) and pumps it out of the heart. Right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk. Left ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aortic valve. NERVOUS SYSTEM The nervous system is an organ system containing a network of specialized cells calledneurons that coordinate the actions of an animal and transmit signals between different parts of its body. In most animals the nervous system consists of two parts, central and peripheral. The central nervous system of vertebrates (such as humans) contains the brain, spinal cord, and retina. The peripheral nervous system consists of sensory neurons, clusters of neurons called ganglia, and nerves connecting them to each other and to the central nervous system. These regions are all interconnected by means of complex neural pathways. The enteric nervous system, a subsystem of the peripheral nervous system, has the capacity, even when severed from the rest of the nervous system through its primary connection by the vagus nerve, to

function independently in controlling the gastrointestinal system. Neurons send signals to other cells as electrochemical waves travelling along thin fibers called axons, which cause chemicals called neurotransmitters to be released at junctions called synapses. A cell that receives a synaptic signal may be excited, inhibited, or otherwise modulated. Sensory neurons are activated by physical stimuli impinging on them, and send signals that inform the central nervous system of the state of the body and the external environment. Motor neurons situated either in the central nervous system or in peripheral ganglia, connect the nervous system to muscles or other effector organs. Central neurons, which in vertebrates greatly outnumber the other types, make all of their input and output connections with other neurons. The interactions of all these types of neurons form neural circuits that generate an organism's perception of the world and determine its behavior. Along with neurons, the nervous system contains other specialized cells called glial cells (or simply glia), which provide structural and metabolic support. Nervous systems are found in most multicellular animals, but vary greatly in complexity.[1] Sponges have no nervous system, although they have homologs of many genes that play crucial roles in nervous system function, and are capable of several whole-body responses, including a primitive form of locomotion. Placozoans and mesozoansother simple animals that are not classified as part of the subkingdomEumetazoaalso have no nervous system. In Radiata (radially symmetric animals such as jellyfish) the nervous system consists of a simple nerve net. Bilateria, which include the great majority of vertebrates and invertebrates, all have a nervous system containing a brain, one central cord (or two running in parallel), and peripheral nerves. The size of the bilaterian nervous system ranges from a few hundred cells in the simplest worms, to on the order of 100 billion cells in humans. Neuroscience is the study of the nervous system. URINARY SYSTEM The urinary system (also called the excretory system) is the organ system that produces, stores, and eliminates urine. In humans it includes two kidneys, two ureters, the bladder, the urethra, and two sphincter muscles. Kidney The kidneys are bean-shaped organs that lie in the abdomen, retroperitoneal to the organs of digestion, around or just below the ribcage and close to the lumbar spine. The organ is about the size of a human fist and is surrounded by what is called Peri-nephric fat, and situated on the superior pole

of each kidney is an adrenal gland. The kidneys receive their blood supply of 1.25 L/min (25% of the cardiac output) from the renal arteries which are fed by the abdominal aorta. This is important because thekidneys' main role is to filter water soluble waste products from the blood. The other attachment of the kidneys is at their functional endpoints the ureters, which lies more medial and runs down to the trigone of urinary bladder. The kidneys perform a number of tasks, such as: concentrating urine, regulatingelectrolytes, and maintaining acid-base homeostasis. The kidney excretes and re-absorbs electrolytes (e.g. sodium, potassium and calcium) under the influence of local and systemic hormones. pH balance is regulated by the excretion of bound acids and ammonium ions. In addition, they remove urea, a nitrogenous waste product from the metabolism of amino acids. The end point is a hyperosmolarsolution carrying waste for storage in the bladder prior to urination. Humans produce about 2.9 litres of urine over 24 hours, although this amount may vary according to circumstances. Because the rate of filtration at the kidney is proportional to the glomerular filtration rate, which is in turn related to the blood flow through the kidney, changes in body fluid status can affect kidney function. Hormones exogenous and endogenous to the kidney alter the amount of blood flowing through the glomerulus. Some medications interfere directly or indirectly with urine production. Diuretics achieve this by altering the amount of absorbed or excreted electrolytes or osmalites, which causes a diuresis.

IV.

PATIENT AND HER ILLNESS

PATHOPHYSIOLOGY (Schematic Diagram)

Modifiable Factor: Low Socio Economic Status Primipara (younger than 20 or older than 40 Multiple Pregnancies With underlying disease -heart disease -diabetes with vessel or renal involvement Cardiac Output Non-Modifiable: Gender Age Pregnancy

Production of Prostaglandin (Vasodilator)

Sensitivity to Angiotension II

Responsiveness to blood pressure changes

Vasospasm

Kidney

Liver

Brain

Eyes

Pancreas

Blood Flow resistance

Tissue Ischemia

Cerebral Edema

Retinal Vasoconstriction

Tissue Ischemia

Glomerular Degeneration

Liver Edema

Cerebral Congestion

Blurred Vision

Vomiting

Glomerular Permeability

Epigastric Pain

Cerebral Irritability

Scotoma

Serum proteins Albumin and Globulin escapes into the urine

SEIZURE

Rolling of Eyeballs

PROTEINURIA

HEADACHE

Glomerular Filtration

Lowered Urine Output

Tubular reabsorption of Na

HO retention

EDEMA

PHYSICAL ASSESSMENT NAME: Mrs. RS AGE: 22 years old Vital Signs: PR: 86 bpm RR: 21 cpm DATE: January 11, 2011 TIME: 2:50 PM

TEMPERATURE: 36.5 C BP: 140/100 mmHg

AREAS TO BE ASSESS GENERAL APPEARANCE 1. Body built, height, and weight in relaxation to clients age, lifestyle and health. 2. Clients posture and gait, standing, sitting and walking, 3. Clients overall hygiene and grooming. 4. Body and breath odor.

TECHNIQUE Inspection

NORMAL FINDINGS Proportionate, varies with lifestyle Relaxed, erect posture Clean, neat No body odor or minor body odor relative to work; no breath odor No distress noted Healthy appearance

ACTUAL FINDINGS Proportionate, appropriate with her lifestyle; mezomorph Relaxed, erect posture Clean, neat No body odor or minor body odor relative to work; no breath odor No distress found Healthy appearance

REMARKS Normal

Inspection Inspection Inspection

Normal Normal Normal

5. Signs of distress in posture or facial expression. 6. Obvious signs of health or illness.

Inspection Inspection

Normal Normal

7. Clients attitude 8. Clients affect/ mood; appropriates of the clients response 9. Quantity of speech, quality and organization 10. Relevance and organization of thoughts. SKIN 1. Skin color and uniformity

Inspection Inspection

Cooperative Appropriate to situation

Cooperative Answering the questions properly

Normal Normal

Inspection

Inspection

Understandable, moderate pace; exhibit thought association Logical sequence; make sense; has sense of reality

Understandable, moderate pace; exhibit thought association Has sense of reality and logical sequence

Normal

Normal

Inspection

Uniform

Uniform in color, Pale Has presence of edema Presence of flat nevi on her face Moist Uniform; within normal range When pinched, skin springs back to previous state but not immediately especially on palms Convex curvature Highly vascular and pink in color

2. Presence of edema. 3. Skin lesions 4. Skin moisture 5. Skin temperature 6. Skin turgor

Palpation Inspection Palpation Inspection, Palpation Inspection Inspection, Palpation

No edema Freckles, some birthmarks, some flat and raised nevi Moisture in skin folds and the axillae Uniform; within normal range When pinched, skin springs back to previous state

Deviation from normal due to ineffective tissue perfusion Deviation from normal due to water retention Normal Normal Normal Deviation from normal due to ineffective tissue perfusion Normal Normal

NAILS 1. Fingernails plate shape to Inspection determine its curvature and angle 2. Fingernails and toenail bed color. Inspection Palpation Convex curvature; angle of nail plate about 160 Highly vascular and pink in light skinned clients

3. Tissues surroundings nails 4. Fingernail and toenail texture 5. Blanch test of capillary refill

Inspection Inspection Inspection, Palpation

Intact epidermis Smooth texture Prompt return of pink capillaries

Skin was intact Smooth in texture Within 4 seconds; the capillaries are visible

Normal Normal Deviation from normal due to ineffective tissue perfusion Normal normal Normal Normal

HAIR & SCALP 1. Evenness of growth over the scalp 2. Hair thickness or thinnest. 3. Presence of infections or infestations. 4. Texture and oiliness over the scalp SKULL 1. Size, shape and symmetry. 2. Nodules or masses

Inspection Inspection, Palpation Inspection Inspection

Evenly distributed hair, Thick hair, thin hair No presence of infections or infestations Silky, resilient hair

Hair was equally distributed Thin hair No presence of infections or infestations Silky, resilient hair

Inspection

Rounded; smooth skull contour Smooth,

Rounded, smooth skull contour, no nodules found

Normal

Palpation FACE 1. Facial FEATURES 2. Symmetry of the facial movements EYEBROWS & EYELASHES 1. Evenness of distributions and direction of curl Inspection Inspection Symmetry or slightly asymmetric facial features Symmetrical facial movements Symmetry facial features Symmetry in facial movements Normal Normal

Inspection, Palpation

Hair evenly distributed; curled Hair evenly distributed, equal movement slightly outward

Normal

EYELIDS 2. Surface characteristics and ability to blink

Inspection

Skin intact no discharge no discoloration, Approximately 15 to 20 involuntary blinks per minute Transparent; capillaries sometimes evident Shiny, smooth and pink or red

Skin intact, no presence of discharge, 16 involuntary blinks per minute

Normal

CONJUNCTIVA 1. Bulbar conjuctivas color, texture and presence of lesions 2. Palpebral conjunctivas color, texture and presence of lesions. SCLERA 1. Color and clarity CORNEA 1. Clarity and color

Inspection, Palpation Inspection, Palpation

Lesions absent but pale in appearance

No lesions, pale in appearance

Deviation from normal due to ineffective tissue perfusion Deviation from normal due to ineffective tissue perfusion Normal

Inspection

Sclera appears white

Clear, presence of capillary, white in color Iris slightly visible, Clear

Inspection

Transparent, shiny and smooth; details of the iris are visible Flat and rounded

Normal

IRIS 1. Shape and color PUPILS 1. Color, shape and symmetry of size Inspection Flat and round Normal

Inspection

Black in color, equal in size; normally 3 to 7 mm in diameter

Rounded, black in color

Normal

2. Pupil light reaction and accommodation

Inspection

Illuminate pupil constricts Non-illuminated pupil constricts Pupils constrict when looking at near object; pupils dilate when looking at far objects

Pupils constrict when looking at near object; pupils dilate when looking at far objects

Normal

VISUAL ACUITY 1. Test near vision 2. Test distance vision LACRIMAL GLAND, LACRIMAL SAC AND NASOLACRIMAL DUCT 1. Presence of edema EXTRAOCULAR MUSCLES 1. Test each eye for alignment and coordination VISUAL FIELDS 1. Test for peripheral visual fields EARS AURICLES Inspection Both eyes coordinated, move in unison, with parallel alignment When looking straight ahead, client can see objects in the periphery Both eyes coordinated Normal Inspection Inspection Able to read newsprint 20/20 vision on Snellen chart Able to read newsprint *Was not able to perform because we dont have Snellen chart. Normal

Inspection, Palpation

No edema or tenderness over lacrimal gland

No edema or tenderness

Normal

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

Normal

1. Color and symmetry of size and position.

Inspection

Color same as facial skin Symmetrical Auricle is aligned with the outer canthus of the eye Mobile firm and not tender; pinna recoils after it is folded

Symmetrical, auricles aligned with the outer canthus of the eye

Normal

2. Texture, elasticity and areas of Palpation tenderness.

Firm and not tender, pinna recoils after it is folded

Normal

EXTERNAL EAR CANAL 1. Cerumen, skin lesions, pus and blood HEARING ACUITY TEST 1. Clients response to normal voice tones. 2. Perform watch tick test. NOSE 1. Shape, size or color and flaring or discharge from the nares 2. Presence of redness, swelling, growths and discharge of nares, using the flashlight 3. Position of nasal septum 4. Test patency of both nasal septum

Inspection

Distal third contains hair follicles and glands , dry cerumen, grayish tan color

Dry, no discharge

Normal

Normal voice tones audible Able to hear ticking in both ears

Normal voice tones audible Able to hear ticking in both ears

Normal Normal

Inspection

Symmetry and straight, no discharge or flaring, uniform in color Mucosa pink, clear watery discharge, no lesion Intact and in the midline Air moves freely as the client breathes through the nares

Symmetry and straight, no discharge or flaring, uniform in color Mucosa pink, no lesion

Normal

Inspection

Normal

Inspection Inspection

Intact and in the midline Air moves freely as the client breathes through the nares

Normal Normal

5. Tenderness, masses and displacement of bone and SINUSES 1. Presence of tenderness LIPS 1. Symmetry of contour, color and texture BUCCAL MUCOSA 1. Inspect for color, moisture, texture, and presence of lesions

Palpation

Not tender, no lesions

Not tender, no lesions

Normal

Palpation

Not tender

No tenderness

Normal

Inspection

Uniform in pink color, symmetry, moist

Pale in color; smooth, symmetry of contour. And lips are pale.

Deviation from normal due to ineffective tissue perfusion

Inspection

Uniform in color, moist, smooth, soft, glistening and elastic texture

Pinkish but slightly pale; moist

Deviation from normal due to ineffective tissue perfusion

TEETH 1. Inspect for color, number and condition and presence of dentures. GUMS 1. Color and condition Inspection Pink gums, Moist, firm texture of gums Slightly pale Deviation from normal due to ineffective tissue perfusion Inspection 32 adult teeth Smooth,white shiny enamel 29 adult teeth 2 decayed tooth; yellowish Deviation from normal due to improper oral hygiene

TONGUE/FLOOR OF THE MOUTH

1. Color and texture of the mouth floor and frenelum.

Inspection

Smooth tongue base with prominent veins

Rough texture due to the presence of taste buds and prominent veins are observed

Normal

2. Position, color and texture, movement and base of the tongue PALATES AND UVULA 1. Color, shape, texture and the presence of bony prominences. 2. Position of the uvula and mobility ORPHARYNX AND TONSILS 1. Color and texture 2. Size of the tonsils, color and discharge. 3. Gag reflex NECK AND LYMPH NODES 1. Symmetry and visible mass in the thyroid gland 2. Placement of the trachea

Inspection

Central in position, pink in color

Central in position, pink in color

Normal

Inspection Inspection

Light pink, smooth, soft palate Pinkish hard palate; lighter color in soft palate Positioned in midline of soft midline palate

Normal Normal

Inspection Inspection Palpation

Pink and smooth Pink and smooth; No discharge; normal size Should elicit gag reflex

pink Pink and no discharge

Normal Normal

gag reflex present

Normal

Inspection Palpation Inspection Palpation

Not palpable Central placement in midline of neck

No masses found, Not palpable Midline of the neck

Normal Normal

3. Smoothness and the areas of enlargement, masses or nodules in the thyroid gland BREASTS 1. Inspect the breast for size , symmetry, contour 2. Skin characteristics

Palpation

No masses or nodules

No masses or nodules

Normal

Inspection Palpation Inspection Palpation Inspection Palpation

Rounded, slightly unequal in size Skin uniform in color; skin smooth and intact Bilaterally round and dark brown in color; no presence of discharge

slightly unequel in size, no tenderness, masses and lesions Visible veins (due breast engorgement and presence of milk), uniform skin color: light brown, skin is smooth Round, dark brown in color, lactating

Normal Normal

3. Nipple condition and presence of discharges ABDOMEN 1. Skin integrity 2. Contour and Symmetry UPPER AND LOWER EXTREMES 1. Motor strength

Normal

Inspection Inspection Palpation

Uniform color Symmetric contour

Presence of linea nigra and strecth marks Symmetric contour

Normal due to pregnancy Normal

INSPECTION

Equal strength on each body side No lesions; no deformities; no tenderness

2. Presence of lesions, deformities and varicosities

INSPECTION

Upper extremities are equal in strength Normal while lower extremities (we were unable to perform due to the clients condition) No lesions; no deformities; no tenderness Normal

Laboratory/Diagnostic Procedures

V.

THE PATIENT AND HER CARE A. MEDICAL MANAGEMENT

a. INTRAVENOUS FLUID MEDICAL MANAGEMENT DATE ORDERED, TAKEN/GIVEN, CHANGED, DISCONTINUED GENERAL DESCRIPTION INDICATION/ PURPOSE CLIENTS RESPONSE NURSING RESPONSIBILITIES

Dextrose 5% in Lactated Ringers Solution (D5LR) 1 liter, regulated at 30-31 gtts/min.

Date ordered: January 8, 2011 11:20 am Date given: Jan. 8,2011 11:25 am Date changed: January 8, 2011 6:00 pm

Dextrose 5% in Lactated Ringers Solution is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration. It is indicated for intravascular dehydration with interstitial or cellular overhydrationare. Used to treat post operative dehydration from blood loss and given for caloric replacement.

Indicated for parenteral replacement of extracellular losses of fluid and electrolytes, as required by the clinical condition of the patient.

Client responded to treatment without any allergic/anaphylactic reaction. No discomfort during the insertion of cannula, administration of fluid, and removal of cannula.

-Verify Doctors order. -Take a thorough past/ current medical history. -Check the site. -Know what other medications the patient is on especially things like diuretics and heart meds. -Monitor vital signs -Monitor labs/electrolytes like sodium, potassium, calcium, and chloride.

MEDICAL MANAGEMENT

DATE ORDERED, TAKEN/GIVEN, CHANGED, DISCONTINUED Date ordered: January 8,2011 8:10 pm Date discontinued: January 10, 2011 10:48 am

GENERAL DESCRIPTION

INDICATION/ PURPOSE

CLIENTS RESPONSE

NURSING RESPONSIBILITIES

Dextrose 5% in water (D5W) + 20 u of Oxytocin regulated @ 20gtts/min

This medication is a solution given by vein (through an IV). It is used to supply water and calories to the body. It is also used as a mixing solution (diluents) for other IV medications. Dextrose is a natural sugar found in the body and serves as a major energy source. When used as an energy source, dextrose allows the body to preserve its muscle mass.

Patient is at risk for having low blood sugar

Client uterus is contracted

Patient is at risk for having high sodium.

Oxytocin promotes contraction of the uterus

1.Monitor pt. frequently for: Signs of infiltration / sluggish flow b. Signs of phlebitis / infection c. Dwell time of catheter and need to be replaced d. Condition of catheter dressing 2. Check the level of the IVF. 3. Correct solution, medication and volume. 4. Check and regulate the drop rate.

b. Drugs GENERIC/ BRAND NAME DATE ORDERED, TAKEN/GIVEN, CHANGED AND DISCONTINUED ROUTE OF GENERAL ADMINISTRATION, ACTION, DOSAGE CLASSIFICATION, FREQUENCY MECHANISM OF ACTION 1 gram;twice a day Tranexamic acid is an antifibrinolytic agent that competitively inhibits breakdown of fibrin clots. It blocks binding of plasminogen and plasmin to fibrin, thereby preventing haemostatic plug dissolution. Absorption: Absorbed from the GI tract; peak plasma concentrations after 3 hr (oral). Bioavailability: 3050%, unaffected by food intake. Distribution: Widely throughout the body. INDICATION/ PURPOSE CLIENTS RESPONSE NURSING CONSIDERATIONS

TRANEXAMIC ACID

Ordered and discontinued: January 8, 2011

>Tranexamic acid (Lysteda, Cyklokapron, Transamin) is a synthetic derivative of the amino acid lysine. It exerts its antifibrinolytic effect through the reversible blockade of lysine-binding sites on plasminogen molecules. It inhibits endometrial plasminogen activator and thus prevents fibrinolysis and the breakdown of blood clots. >Tranexamic acid is used as firstline

Tranexamic acid helps to breakdown the blood clots in her right eye.

Prior: This drug should not be prescribed to patients that have allergic reactions to Tranexamic Acid and its components. >Tranexamic Acid should also not be used by people with pre-existing blood clots or those patients that have bleeding into the brain. >Colorblind patients and those that have eye problems should not use Tranexamic Acid. >Patients may take Tranexamic Acid with or without meals. During: >If patients

Protein-binding: Very low. Crosses the placenta and distributed into breast milk. Excretion: Urine (as unchanged drug); 2 hr (elimination halflife)..

nonhormonal treatment of dysfunctional uterine bleeding, and heavy bleeding associated with uterine fibroids.

experience stomach upsets, the drug should be taken with meals and with a full glass of water. >Individuals taking Tranexamic Acid should take the drug according to the dose prescribed by their physician. After: >Patients should not stop taking Tranexamic Acid because they start to feel better in the middle of the treatment. > Missed doses of Tranexamic Acid should be taken as soon as recalled.

GENERIC/ BRAND NAME

DATE ORDERED, TAKEN/GIVEN, CHANGED AND DISCONTINUED

ROUTE OF GENERAL ADMINISTRATION, ACTION, DOSAGE CLASSIFICATION, FREQUENCY MECHANISM OF ACTION Hydralazine is a direct-acting vasodilator which acts predominantly on the arterioles. It reduces BP and peripheral resistance but produces fluid retention. Hydralazine tends to improve renal and cerebral blood flow and its effect on diastolic pressure is more marked than on systolic pressure. Onset: Oral: 45 min. IV: 10-20 min. Duration: Oral and IV: 3-8 hr. Absorption: Rapidly absorbed from the GI

INDICATION/ PURPOSE

CLIENTS RESPONSE

NURSING CONSIDERATIONS

HYDRALAZINE

Ordered: January 8, 2011 Discontinue: January 8, 2011

TID

Hydralazine (Apresoline) is a direct-acting smooth muscle relaxant used to treat hypertension by acting as a vasodilator primarily in arteries and arterioles. By relaxing vascular smooth muscle, vasodilators act to decrease peripheral resistance, thereby lowering blood pressure and decreasing after load.

Hydralazine helps in decreasing the blood pressure of the client after few hours of taking the medication.

Prior: >Tell the doctor if the

client have kidney disease, lupus, angina pectoris (chest pain), or if ever had a stroke. >Take with meals >Should not use this medication if allergic to hydralazine, or if the client have coronary artery disease, or rheumatic heart disease affecting the mitral valve. During: >While taking hydralazine, avoid getting up too fast from a sitting or lying position, or you may feel dizzy. Get up slowly and steady yourself to prevent a fall.

tract after oral admin. Distribution: About 90% bound to plasma proteins. Metabolism: Undergoes considerable firstpass metabolism by acetylation in the GI mucosa and liver. Excretion: Mainly excreted in urine as metabolites.

After: >report flu-like symptoms >Patients should be informed of possible side effects and advised to take the medication regularly and continuously as directed. >To be sure this medication is helping the condition and is not causing harmful effects to the client; blood pressure will need to be checked often. She may also need occasional blood tests. Health teaching: >The client should call doctor at once if the client have a serious side effect such as fast or pounding heartbeats, swelling, numbness or tingling, dark-colored urine, joint pain or swelling with fever,

chest pain, weakness or tired feeling, and urinating less than usual or not at all.
>Encourage the client to use hydralazine as directed, even if the client feels well. High blood pressure often has no symptoms, so the client may not know when her blood pressure is high. She may need to use blood pressure medication for the rest of her life.

c. DIET

TYPE OF DIET

DATE ORDERED,DATE CHANGED,DATE DISCONTINUED

GENERAL DESCRIPTION

INDICATION/PURPOSES

CLIENT RESPONSE

NURSING RESPONSIBILITIES

Nothing by Mouth

Date ordered/ January 8, 2011 11:20 am Date changed: January 8, 2011 04:05 pm

NPO may be ordered in some cases, such as before surgery to present aspiration related to anesthesia, and after surgery until bowel sounds return.NPO is necessary for women during labor and delivery.

It is usually posted above the bed of a patient, or on the clients chart who is about to undergo surgery or special diagnostic procedures requiring that the digestive tract be empty or who is unable to tolerate food and fluids by mouth for some reason.

Our client easily withstands the stress of NPO for a short period and doesnt pose any nutritional challenge.

PRIOR Encourage or provide a good oral hygiene Provide the patient with ice chips o sips of h2o as allowed DURING urge the patient to avoid watching others eat suggest alternate activities at mealtimes AFTER Encourage the clients beneficial eating patterns /habits. Choose nutritious food

Date ordered: Low-Salt Low-Fat Diet January 8, 2011 9:30 pm After discharge Cont. LSLF diet as ordered

A diet that limits the intake of salt (sodium chloride); often used in treating hypertension or edema or certain other disorders

It is usually instructed to patients to Control and / or decrease levels of cholesterol in your blood and control and / or decrease blood pressure and / or fluid retention.

Clients blood pressure cholesterol level and edema on extremities will return to normal conditions.

that are within financial budget to gain the strength again PRIOR Encourage patient to eat foods that has low fat and low salt contents DURING Explain to the client the benefits of the diet she is into. AFTER Assess client for any change in cholesterol level

Diet-as-Tolerated Date ordered/ January 8, 2011 8:30 pm Only given when client can tolerate any food she desires that is nutritious, if this will not lead to any complications and if it would interfere with any lab test results. Provides immediate replenishment of loss nutrients due to diet restrictions or medical/surgical interventions through oral intake Client eagerly eats after she regained her strength The client hesitated to eat food from the hospital so she ate the food that was brought by her sister-in-law. In general: PRIOR Promote the importance of balanced diet to the client. DURING Instruct client to eat green leafy vegetables.

AFTER Teach client to eat foods rich in protein.

d. EXERCISE

Type of Exercise

Date Ordered/ Date Started/ Date Discontinued

General Description

Indications/Purposes

Clients Response

Nursing Responsibilities

- Ambulation

- A rhythmic, ordered movement of the legs, knee and feet that lets the body shift its weight to each leg alternately to initiate movement and travel.

- Aids in restoring circulation in the lower extremities - Prevents pooling of blood and creation of blood clots

- Client responded to regimen in a positive manner - No cramping, leg pain noted before, during and after the regimen.

Prior: -educate the client about the importance of taking exercise after medical/surgical procedures -establish rapport and gain cooperation with the client During: -ensure that the client will reestablish her normal health status without overdoing the exercise After:

- Helps in readying the leg muscles to reaccomodate body weight after bed rest.

-the client will be able to continue the exercise to regain health and maintain wellness

B. Surgical Management

Medio-Lateral Episiotomy
A right medio-lateral episiotomy begins at the vaginal opening in the midline with the incision directed toward the right buttocks at a 45-degree angle. The main advantage of the medio-lateral episiotomy is that it is less likely to extend into or involve the anal sphincter and the rectum. Disadvantages of the medio-lateral episiotomy are significant and include increased blood loss, increased pain, difficult repair, and an increased risk of long-term discomfort, especially during intercourse.

How Is an Episiotomy Performed?

Both midline and medio-lateral episiotomies are easy to perform-they involve the simple incision of the opening of the vagina. The episiotomy should be performed when 3 or 4 centimeters (cms) of the baby's head is visible at the vaginal opening. If the mother has not received anesthesia in the form of an epidural block, local anesthesia may be given at the site of the episiotomy. The area is cleaned with soap. The provider then inserts two fingers into the vaginal opening to protect the baby's head (the fingers should be inserted between the baby's head and the tissue of the vaginal opening). One blade of the scissors is then inserted between the two fingers and a small incision, approximately 2 to 3 cms in length, is made. The incision may be made in the midline or medio-laterally. After the incision has been made, the physician gently supports the episiotomy site to prevent further tearing by pinching the tissue just below the incision. Gentle pressure is also placed against the top of the baby's head to prevent the head from rapidly or abruptly delivering. A controlled delivery is preferred because it is easier to prevent tearing during a slow and steady delivery of the baby's head.

After delivery of the baby and the placenta, the vagina and perineum are cleaned and carefully examined. The physician must be sure that there has been no tearing of the vaginal walls or cervix. The doctor or midwife may use a special instrument (a metal retractor) to adequately visualize the vagina and cervix. Once the provider is certain there has been no further tearing, the episiotomy itself will be visualized. The physician may wash the area with sterile water or an antibacterial soap solution. If the incision has involved the lining of the rectum or the anal sphincter (a doughnut shaped muscle that controls the anus and prevents the leakage of stool), sterile fluids may be used to wash out the wound. In most cases, the episiotomy will involve only the vaginal lining and the tissue directly below the vagina. However, if the episiotomy does extend into the anal sphincter or the rectal lining, these portions should be repaired first. All repairs are performed with suture (surgical thread) that absorbs into the body and does not require removal. A very thin suture is used to bring together and close the rectal mucosa and larger and stronger sutures are used to repair the anal sphincter. After the rectal mucosa and the anal sphincter have been repaired, a simple repair of the remaining episiotomy is required. Several stitches may be required to bring together the deeper tissues below the vaginal lining; a continuous suturing of the vaginal mucosa and the skin outside the vagina is required to completely close the incision.

EPISIORRHAPHY
Repair of a lacerated vulva or an episiotomy. Episiotomy is indicated if: There is a serious risk to the mother of second or third degree tearing When Perineal muscles are excessively rigid In cases where a natural delivery is adversely affected, but a caesarean section is not indicated 'Natural' tearing will cause an increased risk of maternal disease being vertically transmitted The baby is very large When instrumental delivery is indicated Prolonged late decelerations or fetal bradycardia during active pushing When a woman has undergone FGM (female genital mutilation), indicating the need for an anterior and or mediolateral episiotomy The baby's shoulders are stuck (shoulder dystocia), or a bony association (Note that the episiotomy does not directly resolve this problem, but it is indicated to allow the operator more room to perform maneuvers to free shoulders from the pelvis) Risks in Episiotomy: Many studies have found that the procedure offers no benefit in routine deliveries, and there is no evidence to suggest that it improves a woman's sexual function. It has also been found that women who have an episiotomy have more intercourse-related pain after pregnancy and take longer to resume having

sex after childbirth. If an episiotomy cut is made, there is more of a chance that it will become a larger tear or even extend into the muscles around the rectum. This can lead to later problems with controlling gas and sometimes stool. When no episiotomy is made and a woman is just allowed to tear, these problems are less likely to happen.

Additional risks include: Bleeding Bruising Incontinence Infection Swelling

Patients response to operation Mahapdi ang tahi ko tuwing umiihi ako. As verbalize by the client. The client said that shes scared every time she voids because she feels like her suture are rupturing. She said that its hard to eliminate, and its hard to clean her suture because its painful.

Nursing Responsibilities

Prior Before the client under go to the operation we should make sure that she explains well the procedure about the operation so that the client know what we will do to her and how she can cooperate all through out the procedure. We should also explain what is the operation, how does the operation done, what is the purpose of the operation so the client can also ask question about the procedure that can help her lessen her anxiety. We can also advice some health teaching that can help our client in the operation.

During During the operation we can now provide comfort to our client to lower her tension. We can now apply some health teaching that we teach prior the operation like we can advice to take a deep breath that can help her lessen her tension.

After After the operation we can now assess the genital of the client if there are some abnormalities that she gets from the operation. We also assess if shes doing well and if shes applying our health teaching like, cleaning well her suture and advise her to follow the doctors medication andto take the medication on time because it can help her to recover fast.

C. Nursing Problem Prioritization As giving importance to ABCs of life, the situations that have been affected our client are: 1. Circulation 2. Elimination 3. Pain

Date identified

Cues

Problem or Nursing diagnosis

Justification

January 11, 2011

Subjective: Medyo masakit ang ulo ko, hindi nga ko naglalakad lakad baka kasi mahilo ako. as verbalized by the client

Ineffective tissue perfusion related to decreased hemoglobin concentration of blood with 55g/dl as manifested by paleness and weakness in appearance.

Objectives: Pale Paleness of palpebral and bulbar conjunctiva Decreased hemoglobin concentration in blood with 55 g/dl Capillary refill for about 4 seconds Extremity weakness Altered skin characteristics Weak pulse edema

This is our first priority because it is important in order to function well. It is our circulatory system which has the ability to transport oxygen and nutrients necessary to meet cellular needs. Once become severe our circulation will greatly affected.

January 11, 2011

Subjective: Hindi pa ko natatae simula ng pinasok ako ditto sa hospital as verbalized by the client

Constipation related to irregular defecation habits secondary to not defecating for 1 week as manifested by percussed abdominal dullness

This is our second priority because it is a vital way of how our body excretes waste products. Once being stocked, toxicity level of waste products will increased and so, it will affect our body system.

Objective: headache use of anticonvulsants (MgSO4) percussed abdominal dullness abdominal tenderness

Subjective: May kirot pa din yung tahi ko as verbalized by the client. January 11, 2011 Objective: Pallor Weak Bent posture Grimace Pain scale of 7/10 With observable pain

Acute pain related to disturbance of skin and tissue integrity secondary to episiotomy as manifested by pain scale of 7/10.

This is our last priority for pain/ discomfort because it is the ability to control internal/external environment to maintain comfort.

D. Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS Ineffective tissue perfusion related to decreased hemoglobin concentration of blood (55g/dl) as manifested by paleness and weakness in appearance. PLANNING Long Term Goal: After 8 hours of Nursing Intervention, the client will be able to demonstrate increased perfusion and will decrease BP from 140/100 mmHg to normal ranges. Short Term Goal: > Within 1 hour, verbalize understanding of condition, therapy regimen and side effects of medication. INTERVENTION Independent: > Monitor blood pressure every 4hours. > Instruct to have enough rest on semi fowlers position. > Instruct to eat low fat and low salt diet. >Instruct in BP monitoring at home, advise purchase of home monitoring equipt. >Emphasize importance of avoiding use of aspirin, some OTC drugs, vit. containing potassium and alcohol when taking anti coagulants. >Encourage quiet, restful atmosphere. >Encourage early ambulation,when possible. RATIONALE EVALUATION After 8 hours of Nursing Intervention, the client was able to demonstrate increased perfusion and decreased BP from 140/100 mmHg to 120/80mmHg.

Subjective: Medyo masakit ang ulo ko, hindi nga ko naglalakad lakad baka kasi mahilo ako. as verbalized by the client. Objectives: Pale Paleness of palpebral and bulbar conjunctiva Decreased hemoglobin concentration in blood with 55 g/dl Capillary refill for about 4 seconds Extremity weakness Altered skin characteristics Weak pulse edema

> To know the base line of BP > Sodium tends to be excreted at a faster rate.

> To reduce edema that may activate renin angiotensin-aldosterone system. >Facilitates management of hypertension. >To promote wellness of the client.

Goal met > Within 1 hour, verbalized understanding of condition, therapy regimen and side effects of medication.

>Within 1hour, demonstrate behaviors/

lifestyle changes to improve circulation.

>Conserves energy/ lowers tissue oxygen demands. >Enhances venous return.

Goal met Within 1hour, demonstrated behaviors/lifestyle changes to improve circulation.

 Vital signs: BP: 140/100mmHg PR: 86bpm RR: 21cpm

>Within 30 mins, promote wellness.

>Discuss and encourage use of relaxation activities. Dependent: > Administer anti- hypertensive drug as ordered.

>to decrease tension level

Goal met >Within 30 mins, promoted wellness.

> To control the BP and to avoid other complications.

ASSESSMENT Subjective: Hindi pa ko natatae simula ng pinasok ako ditto sa hospital as verbalized by the client

NURSING DIAGNOSIS Constipation related to irregular defecation habits secondary to not defecating for 1 week as manifested by percussed abdominal dullness.

PLANNING Long Term Goal After 8 hours of nursing interventions, the patient will establish or return to normal patterns of bowel functioning.

INTERVENTION Independent: >Instruct in/encourage a diet of balanced fiber and bulk(e.g. fruits and vegetables) and fiber supplements. >Determine stool color, consistency, frequency, and amount. > Encourage fluid intake of 2500-3000 ml/day within cardiac tolerance. > Encourage to eat high-fiber rich foods.

RATIONALE

EVALUATION

>To facilitate return of usual pattern of elimination; to improve consistency of stool >Assists in identifying causative or contributing factors and appropriate intervention. >Assists in improving stool consistency > To enhance easy defecation.

After 8 hours of Nursing Interventions, the patient wasnt able to established or return to normal patterns of bowel functioning.

Objective: headache use of anticonvulsants (MgSO4) percussed abdominal dullness abdominal tenderness Short Term Goal >Within 1 hour, verbalize understanding of etiology and appropriate interventions/solutions for individual situations. >Within 1hour,demonstrate behaviors/lifestyle changes to prevent recurrence of problem.

>Encourage client to identify/determine elements that usually stimulate bowie activity and any interfering factors. >Recommend avoiding gas forming foods.

>To determine usual pattern of elimination.

Goal met> Within 1 hour, verbalized understanding of etiology and appropriate interventions/solutions for individual situations. Goal met >Within 1hour, demonstrated behaviors/lifestyle changes to prevent recurrence of problem.

>To decrease gastric distress and abdominal distension. >Facilitates defecation when constipation is present.

>Discuss use of stool softeners, mild stimulants, bulk-forming laxatives, or enemas as indicated. Monitor effectiveness.

>Within 4hours,participate in bowel program as indicated.

Collaborative: >Establish bowel program to include suppositories as appropriate. >Consult with dietitian to provide well-balanced diet high in fiber and bulk.

>To know when long term or permanent bowel dysfunction is present. >Fiber resists enzymatic digestion and absorbs liquids in its passage along the intestinal tract and thereby produces bulk, which acts as a stimulant to defecation. >To facilitate monitoring of long-term problems.

Goal unmet >Within 4hours, client has not participated in bowel program as indicated.

>Within 30 mins, promote wellness.

>Encourage client to maintain elimination diary if appropriate.

Goal met >Within 30 mins, promoted wellness.

ASSESSMENT Subjective: May kirot pa din yung tahi ko as verbalized by the client. Objective: - Pallor - Weak - Bent posture - Grimace - Pain scale of 7/10 - With observable pain

NURSING DIAGNOSIS Acute pain related to disturbance of skin and tissue integrity secondary to episiotomy as manifested by pain scale of 7/10.

PLANNING Long Term Goal: After 6 of nursing intervention the client may alleviate pain scale from of 8/10 to 3/10. Short Term Goal: 2 Report pain is relieved/control. 1 Follow prescribed pharmacological regimen. 1 Verbalize nonpharmacologic methods that provide relief. 2 Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation. -

INTERVENTION Assess for referred pain, as appropriate. -

RATIONALE To help determine possibility of underlying condition or organ dysfunction regarding treatment. To rule out the worsening of underlying condition/developmen t of complications.

EVALUATION After 6 of nursing intervention the client was able to alleviate pain scale from 8/10 to 3/10. Short Term Goal:

Obtain clients assessment of pain, reassess each time pain is reported, note and investigate changes from previous reports.

Met Report pain is relieved/control.

Observe nonverbal cues/pain behaviors and other objective Defining Characteristics, as noted.

Observations may/ may not be congruent with verbal reports or may be only indicator present when client is able to verbalize.

Met Follow prescribed pharmacological regimen.

Monitor skin color/temperature and vital signs. Provide comfort measures, quiet environment and calm

Which are usually altered in acute pan.

Met Verbalize nonpharmacologic methods that provide relief. Met Demonstrate use of relaxation skills and

To promote nonpharmacological pain management.

activities. Instruct in/ encourage use of relaxation techniques. To reduce concern of the unknown and associated muscle tension. To prevent fatigue.

diversional activities, as indicated, for individual situation.

Encourage adequate rest periods.

VI. DISCHARGE PLANNING A. General Condition of Client upon Discharge: Upon discharge the client has stable vital signs and without IVF connected. The physicians also notify her to take her oral medication and continue low salt low fat diet. She was also instructed to maintain perineal hygiene and breast hygiene. B. METHODS M-edication Continue oral medications as follows: Cefalexin: 500 mg TID Nursing Consideration: Note for severity of infection. FeSO4: 300 mg BID Nursing Consideration: Ingestion of calcium consumed with a meal or 1 hour after may inhibit dietary supplement. Amlodipine: 5mg OD Nursing Management: may take as directed, once a day with/without meals but foods help decrease stomach upset. Avoid grapefruit juice because it increases drug concentration. Mefenamic Acid: 150 mg every 8 hours Nursing Consideration: Take immediately after meals. Take medication as prescribed; be sure to take it on timewith exact dose. E-xercises Kegels Exercise contracting and relaxing muscles of the perineum 5 10 times in succession as if trying to stop voiding. This perineal exercise can be helpful in postpartum period to reduce pain and promote perineal healing. Ambulation is the most effective way to stimulate lower extremities circulation.

T-reatment

Advice client not to engage in any household chores that might jeopardize her health. Advice client to follow doctors order regarding the medication they have been given. Advice client to comply with her post operative medication refer to the physician in the nearest hospital if abscess formation is present.

H-ygiene Perineal Hygiene Instruct client to cleanse perineum from front to back to avoid infection. Instruct her how to remove soiled perinea pad and where to dispose it. She should not us vaginal douches until she returns for her post partial check-up Breast Hygiene Instruct client to wash her breast daily with clean water at the time of her bath or shower and then dry them with soft towel. Avoid using soaps, because it my tend to dry and crack nipples. O-ut-Patient D-iet Maintained low salt low fat diet. Encourage to eat green leafy vegetables and food rich in iron. Encourage Fluid in take. Return to JICA Bldg. after ne week: Tuesday, January 22,2011

S-ex/Spiritual Sex: Coitus is safe as soon as womans lochia has turned to alba and if episiotomy was completely heal. Spiritual: Encourage to continue trusting in the Lord, ask for his guidance and always pray. Focus on things that will focus on values in life.

VII. CONCLUSION After working on our Case Study, we, the Student Nurses from Group 3 of BSN 2-A, were able to develop knowledge in the causes, risk factors and management of Preeclampsia. We were also able to impart sufficient knowledge to our client about the management for the said condition. Consequently, our client also acquired and developed knowledge on basic definition, possible causes, risk factors, complications, medical and home management for Preeclampsia. Our group was also able to develop skills in assessing for Preeclampsia using the Triad Signs and Symptoms, rendering medical care and performing nursing responsibilities. As a result, our client was also able to exhibit and improve her skills in managing her condition through the knowledge we imparted. As we finished our Case Study, our group was able to establish and develop a harmonious relationship between us and the client through participation. We also developed cooperation and teamwork between the members of our group. Lastly, we were able to impart to our client an open and accommodating impression on medical practitioners, including Student Nurses like us.

VIII. BIBLIOGRAPHY Statistics for Preeclampsia http://www.wrongdiagnosis.com/p/eclampsia/stats-country.htm Growth and Development Kozier & Erbs Fundamentals of Nursing 8th Edition Volume 2 Anatomy and Physiology Reproductive - http://en.wikipedia.org/wiki/Female_reproductive_system_(human) http://www.google.com.ph/imglanding?q=female+reproductive+system&um=1&hl=tl&sa=N&tbs=isch:1&tbnid=RQfphKO5xG7KVM:&imgrefurl=http://www.am a-assn.org - picture http://www.google.com.ph/imglanding?q=female+reproductive+system&um=1&hl=tl&sa=N&tbs=isch:1&tbnid=ebGu1iKHwto2OM:&imgrefurl=http://med.saisay an.com/2010/01 Nervous - http://en.wikipedia.org/wiki/Nervous_system Urinary - http://en.wikipedia.org/wiki/Urinary_system http://www.google.com.ph/imglanding?q=urinary+system&um=1&hl=tl&tbs=isch:1&tbnid=BWuCLPiB_hmM:&imgrefurl=http://academic.kellogg.cc.mi.us/herbrandsonc/bio201_mckinl - picture Nursing Care Plan Nurses Pocket Guide Edition 11