Ateneo de Davao University

College of Nursing

A Case Presentation on
Preeclampsia

In Partial Fulfillment of the Requirements in Nursing Care Management 102 RLE

Submitted by:

Rubia, Arnikka B.
Santillan, Ma. Princess Gccae H.
Segura, Riel R.
Sinoy, Beverly R.
Suasin, Ann Michelle C.
Tandog, Jesse Nigel A.
Zamora, Harisson Ford S.
Zarra, Von Lovel D.
BSN- 3H Group 5

Submitted to:
Ms. Christine Joy H. Barlis, RN

January 17, 2009

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 Table of Contents

I. Acknowledgment……………………………………………………………… 1

II. Introduction…………………………………………………………………… 2

III. Objectives……………………………………………………………………... 4

IV. Patient’s Data…………………………………………………………………. 5

V. Genogram…………………………………………………………………….. 6

VI. Family Background…………………………………………………………… 8

VII. Developmental Data………………………………………………………….. 11

VIII. Nursing Theories……………………………………………………………… 16

IX. Definition of Complete Diagnosis……………………………………………. 21

X. Physical Assessment………………………………………………………….. 23

XI. Anatomy and Physiology…………………………………………………….. 28

XII. Etiology and Symptomatology……………………………………………….. 33

XIII. Pathophysiology……………………………………………………………… 42

XIV. Doctor’s Order……………………………………………………………….. 45

XV. Diagnostic Exam……………………………………………………………… 51

XVI. Drug Study…………………………………………………………………… 64

XVII. Nursing Care Plan…………………………………………………………….. 79

XVIII. Recommendations/Health Teachings…………………………………………. 101

XIX. Discharge Plan………………………………………………………………… 103

XX. Prognosis……………………………………………………………………… 105

XXI. References…………………………………………………………………….. 107

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 Acknowledgement

This case study has provided the researchers new knowledge’s and ideas to
understand the condition women undergo that made human species survived until now.

With the following people, this case study has been successfully completed and was
made possible:

First, the researchers would like to thank the Lord for his continuous guidance and
support and from protecting us from any harm and danger. We also would like to thank Him
for his everlasting love for us that made us strong to face all the trials and difficult situations.

Second, they would like to thank their parents for guiding them to what is right and
for supporting them all the way in all aspects in their lives. They also would like to recognize
their presence that also made them strong and helped them to become better persons.

Third, they would like to extend their deepest gratitude to Ms. Joy Barlis, R.N., Mr.
Roy Cresencio Linao, R.N., Ms. Melba Gabuya, R.N., Mrs. Mary Jean Silvino, R.N., and
Mrs. Ludy D. Senoc, R.N. for guiding them throughout the whole rotation. They thank them
for sharing their expertise in the field of Maternal and Child Nursing.

Fourth, they are also grateful to Mrs. Roselle Baniel, R.N. for sharing to them her
knowledge and experience through her lecture class for the MCN concept.

Lasty, they also appreciate the help of the DMSF staff for guiding them inside the
delivery room and for letting them copy the chart of the patient.

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 Introduction

“To be pregnant is to be vitally alive, thoroughly woman, and undoubtedly inhabited.”

-Anne Buchanan & Debra Klingsporn

Lass, girl, lady, miss, woman- these are the words that we often associate with the
females. However, what is greatly remarkable in describing a woman is when the time you
call her mother. Aside from imbibing feminine characteristics, what differentiate mothers are
their experiences of being pregnant. Pregnancy may be considered as one of the most
fulfilling and momentous events in a woman’s life. But amidst the joy that it gives, it also
brings inevitable hardships on the part of the woman. Indeed, a pregnant woman has her one
foot on the grave.

In pregnancy, an expectant mother may undergo physical and physiologic changes, and a
lot of difficulties. Discomforts like morning sickness, fatigue, urinary frequency, heartburn,
constipation, varicosities, low back pain, stretch marks and many more are common to them.
They can also suffer from complications like bleeding, incompetent cervical os, Hydatidiform
Mole, Placenta previa and even Pregnancy- induced hypertension.

For this case study, the researchers have chosen to dwell more on one of the types of
pregnancy- induced hypertension which is Preeclampsia.

Pre-eclampsia is a medical condition where hypertension arises in pregnancy

(pregnancy-induced hypertension) in association with significant amounts of protein in the
urine. Because pre-eclampsia refers to a set of symptoms rather than any causative factor, it is
established that there are many different causes for the syndrome. It also appears likely that
there is a substance or substances from the placenta that may cause endothelial dysfunction in
the maternal blood vessels of susceptible women. While blood pressure elevation is the most
visible sign of the disease, it involves generalized damage to the maternal endothelium and
kidneys and liver, with the release of vasopressive factors only secondary to the original
damage.

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 Pre-eclampsia may develop from 20 weeks gestation (it is considered early onset before
32 weeks, which is associated with increased morbidity) and its progress differs among
patients; most cases are diagnosed pre-term. Apart from abortion, Caesarian section, or
induction of labor, and therefore delivery of the placenta, there is no known cure.

Pre-eclampsia occurs in as many as 10% of pregnancies, usually in the second or third

trimester, and after the 32nd week when it comes to international statistics. But nationally,
Pre-eclampsia occurs in 46,392 women from a population of 86,241,697 in the Philippines.

This study features Ms. S, 30 years of age and a resident of Tagum City, Davao del Norte.
She was admitted at the Davao Medical School Foundation (DMSF) Hospital last January 13,
2009 and was diagnosed with Preeclampsia.

The researchers have chosen this case primarily because it is one of the most common
and predominant complication among pregnant women. And as a fact, Preeclampsia is just
one of the many complications that would end fatally if left untreated. Moreover, as part the
researchers’ lecture concept, they find the case interesting because it is where they can apply
their learning and understanding of the said disease.

As student nurses and hopefully, as registered nurses in the near future, the
researchers would want to dig deeper on what is happening to a patient with Preeclampsia
and what will be the treatment modalities that will be given. By that, they are hoping that
they will be able to find the right plan of care and sound interventions that will help them to
become efficient nurses later on.

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 Objectives

General

The researchers formulate a general objective to guide them throughout the case
study:

To gather data that is comprehensive and significant to the patient’s condition

that will help the researchers to garner knowledge and experience about the MCN
concept, to help the researchers understand the women’s situation and feelings during
pregnancies and labor, to apply what the researchers learned from their lecture class.
And also, for the researchers to explore, investigate, analyze and present a
comprehensive case study regarding the case of Ms. S.

Specific

1.) To establish a good rapport and therapeutic relationship with the patient to gather
much information about her personal data and her present condition through interview
2.) To gather pertinent data found in the medical chart
3.) To conduct a thorough physical assessment as a part of the baseline data gathering
4.) To study the anatomy and physiology of the affected system of the patients current
condition
5.) To trace the pathophysiology of the disease process
6.) To determine and interpret the medical management employed including laboratory
and diagnostic procedures
7.) To identify and study the drugs prescribed to the patient which affects the patient’s
current situation.
8.) To formulate nursing care plans and health teachings that is appropriate for the
patient’s problem
9.) To formulate prognosis based on the gathered information

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 Patient’s Data

Personal Data

Code Name: Ms. S

Age: 30 years old

Sex: Female

Nationality: Filipino

Place of birth: Tagum

Date of birth: March 30, 1978

Civil Status: Single

Address: PPGO Sampao, Tagum City, Davao Del Norte

Occupation: STANFILCO employee

Religion: Roman Catholic

Educational Attainment: College Graduate, BSMA

Source of Information: The Patient and her chart

Clinical Data

Room: Recovery room, Bed 5

Date of Admission: January 13, 2009 - 2pm

Vital Signs on Admission: None

Chief Complaints: 4MP with Cervical Uterine Contraction Preeclampsia

Attending Physician: Dr. Valle Santos Soviva

Admitting Physician: Dr. Elma R. Sanchez

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 Genogram

** Teofila Cerilo Perporonia

♥X ♥ ♥∆ X ΘX

1. Angelina 9. *Rodel

1. Anyana
2. Linda 10. *Sherlina
♥

2. Oscar
3. ** 11. *Boy
♥

3. *Tatoy
4. Carolina 12. *Dodong

4. *Milagros
5. *Delia 13. *Gina
7. *Didi
8. ** 16. Josephine
5. *Zenny
6. *Cerilo Jr. 14. *Bobong

8
6. *Jose
7. *Henry 15. *Randy
8. ** 16. Josephine
 1. Ms. S 2. Kathy 3. Karlo

Legend:
* not in particular order
** names are unknown to the
patient

♥ hypertention

∆ asthma

Θ diabetic

X deceased
Note: The patient is not familiar
with all of the diseases and the
order of her parent’s family
members.

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 Family Background / Health History

Family Health History

Ms. S, 30 years old, is the eldest among the three children in the family. She was on
February 30, 1978 at Tagum, Davao del Norte. She studied at Odella Elementary School
(Kinder to Grade 6), St. Mary’s College (high school) and finished Bachelor of Science in
Management Accountancy at Ateneo de Davao University in March 2000. She works at
STANFILCO’s administration office from 8:00 am to 5:00 pm, Mondays thru Saturdays.
Oftentimes, she extends her working hours beyond 5:00 pm. During weekends, she visits her
family at Asuncion, Davao del Norte. Both of her siblings are still studying.

At present, she lives with her officemate, Rosalie, at a company compound where she
works.

She has only a little knowledge of her parent’s health history. She reported that her
paternal grandparents have hypertension. Anyana, and her father, Oscar had hypertension.
Her maternal grandfather, Cerilo also has hypertension and asthma, while her grandmother
has diabetes. On the other hand, the diseases of her other relatives were unknown to her, and
she’s not even sure in the order of her parent’s family members.

The baby she’s conceiving is the offspring of her fourth sexual partner. However, she
opts to conceal his identity.

Effects/ Expectations of Illness to self/family

Ms. S had an unplanned pregnancy, although she and her partner were planning to
have a baby this year. However, she got worried about her pregnancy and feared of
undergoing a Cesarean operation to deliver the baby. She was very anxious because her
uncle’s (Randy) wife died after the Cesarean operation.

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 She and her partner shoulder the hospital expenses since the latter was a PhilHealth
member. However, she verbalized that the company does not cover the expenses for
hospitalization.

She expects to have a safe pregnancy and hopes to recover faster. She also hopes that
God will protect her if she will undergo a Cesarean operation. In addition, her family looks
forward to the new member as well.

Client’s Health History

Past illness/es

The patient stated that she had measles and mumps during childhood. She was then
hospitalized at a clinic in Hijo, Tagum. She had no chickenpox. She also underwent surgery
to remove a lump on her neck when she was a child. Additionally, she was admitted at
Ricardo Limso Hospital due to persistent headache. It was found out that she had intestinal
parasites but failed to recall the diagnosis and other significant proceedings. She also
verbalized having allergies to foods such as dried fish, chicken and shrimp during high school
which resulted to itchiness and rashes on both arms. She was given Verlix when she visited a
clinic in Hijo.

She also takes mefenamic acid for headache. During her college days, she
experienced headache with vomiting once a month. She immediately sought medical care at
CHDC and was diagnosed with astigmatism.

Currently, she reported no allergies.

Present illness/es

She underwent a Pap smear prior to her pregnancy. She has no contraceptive history.
She experienced back pains and amenorrhea for a month. Then, she decided to visit a doctor,
and it was found out that she was pregnant. She has regular prenatal check-ups for the first 3
months at Tagum Doctors hospital under Dr. Pedido, twice at CHDC under Dr. Freira and
currently at DMSF Hospital with Dra. Santos. She reported that she experienced spotting on
early weeks of pregnancy. During her few months of prenatal visits, it was said that her
spotting was due to stress. An IE (internal examination) at DMSF was done and revealed that

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there were polyps inside her cervix. She experienced frequent urination and breast tenderness
on her first trimester. She also felt that her womb was getting bigger. She heard the fetal
heart tone for the first time on her 2nd prenatal visit, using a Doppler, at Tagum Doctors
Hospital. It was on her fifth month of pregnancy that she felt the movements of the baby
inside the uterus. It became stronger during the 6th and 7th months. Linea gravida and stretch
marks were observed by the patient on the 6th month. Edema was also present on her face,
hands and feet during the 7th month of pregnancy.

She had her tetanus toxoid injection during her prenatal visit with Dra. Santos last
Tuesday, January 6, 2009, and an increase in blood pressure was noted, 140/90. It was
repeated with a blood pressure of 120/90. Thereafter, she was advised to monitor her BP.
After taking her BP by a company nurse which has 160/100, she returned to Dra. Santos and
was diagnosed of pre-eclampsia last Friday January 9, 2009. Last Saturday, January 10, 2009,
she revisited and was given methyldopa as her medication. She stopped working on January
13, 2009. Ms. S verbalized that she can handle her work but feels exhausted at times.
Moreover, she reported blurring of vision prior to her admission on January 13, 2009

Client’s lifestyle, diet, and activities of daily living (ADL)

The client verbalized that she has no control on her eating prior to her pregnancy. Her
meals would include fish, rice and fruits vegetables. She also eats in between meals such as
biscuits and bread, and often eats at the office. She drinks calamansi juice everyday and
minimal amount of soft drinks at least twice every week. Although, she admitted that she
frequently drink during Christmas season. At present, she’s eating on a low salt, low fat, and
low sugar diet upon the doctor’s prescription.

On her 7th month of pregnancy, she hired a helper to do the laundry.

Developmental Data

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 Theories Assess- Stages Justification
ment

Formal Operational
Piaget's Cognitive The patient finished her degree
The formal operational
Theory in Accountancy. She shows
stage is characterized by
signs that indicate
the ability to formulate
understanding of her present
hypotheses and
conditions such as a keen look,
systematically test them to
nodding, and verbalizations
Formal Operational arrive at an answer to a
A that include “Lagi day...” and
problem. The individual in
(11 years old “Mao bitaw...” She
C the formal stage is also
onwards) comprehends instructions well,
able to think abstractly and
H whether spoken in bisaya,
to understand the form or
tagalog, and english. When
I structure of a mathematical
asked about how she manages
problem. Another
E problems in her life, she
characteristic of the
answers in a rational way,
V individual is their ability to
evidently thinking over the
reason contrary to fact.
E situations and the best ways to
handle each of them.
D

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 O
N
Erikson’s Stage 6: Intimacy versus The patient is able to relate
Psychosocial T Isolation well to other people, creating a
Theory H harmonious relationship with
The tasks for young
E her neighbors and persons
adult are to unite self-
around her. However, she still
identity with identities of
P has no lifetime commitment.
friends and to make
R Although she has her sexual
Stage 6: commitments to others.
O partner, she was not able to
Fear in such
Intimacy C mention a husband and
commitments results in
E marriage in the equation,
versus isolation and loneliness.
S which are very vital in this
Isolation S stage.

(Young Adilthood)
O
F

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 ON

Havighurst’s THE Young Adulthood The patient is not yet married.

Developmental She may have a partner whom
P Developmental tasks for
Theory she plans to have a child with
young adults include:
R but she was not able to
• Selecting a mate mention about a wedding in the
O
• Learning to live days to come. If there will be
C with a marriage no complications, she will be
Young Adulthood
partner having her own baby soon
E
• Starting a family whom she will take care and
S
and rearing children rear as the infant grows.
S • Managing a home
• Getting started in
an occupation
O • Taking on civic

F responsibility
• Finding a congenial
social group
A

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Fowler’s Spiritual Stage 4: Individuative- The patient goes to church
Development Reflective Faith frequently and is active in their
GKK. She is responsible to her
Individuative-reflective
beliefs and attitudes and is
faith is crucial for older
mature enough to handle her
adolescents and young
life well. She doesn’t depend
Stage 4: adults because they
A on others in making her
become responsible for
Individuative- decisions but is willing to
C their own commitments,
Reflective faith listen to suggestions and
beliefs, and attitudes. Many
H comments. She has a firm will
adults do not develop to
and strong determination when
I this stage, and for some
it comes to her self and is not
people, it does not emerge
E easily swayed by others to
until they are in their 30s
change just because others
V or 40s. Searching for self-
want her to be that way.
identity no longer defined
E
by the composition for
D significant others is a
primary concern.

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 ON

“Transformation” THE Ages 29 to 34 The patient has manifested

Theory of signs that she accepts herself
Self-acceptance increases
for who she is and is not
Roger Gould as the need to prove
P insecure to anybody. On the
oneself disappear. Marriage
other hand, she still has so
R and careers are well
many plans for her future. She
O established, and young
wants to secure the future of
C parents want to accept their
Ages 29 to 34 her upcoming baby by making
E own children for what they
sure that she will not have
S are becoming without
some difficulty in financial
S imposing rules. Questions
aspects. She wants to rear her
about life in general life are
O child properly and take care of
still present.
him/her has he/she grows.
F

Nursing Theories
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Sister Callista Roy- Roy Adaptation Model

Roy defines a person as an adaptive system, a whole comprised of parts that functions
as a unity for some purpose. The person is a biopsychosocial being in constant interaction
with a changing internal and external environment. Nursing attempts to alter the environment
when the person is not adapting well or has an effective coping responses. Basically the nurse
attempts to manipulate stimuli in such a way as to allow the client to cope effectively.

In Roy’s view, the nurse must first assess how the client behaves in each adaptive
mode then determine what can be altered in that mode to produce more efficient and effective
responses.

The self-concept mode, the physical self is affected or threatened during procedures
causing anxiety, guilt and distress. Those are responses within the personal self to physical or
emotional stressors.

In conjunction with the client’s condition, the client verbalized feelings of anxiety as
to what will happen to her and the baby and asked if she will be okay. Nurses should use
counseling techniques on how to adapt to the present situation and learn how to cope with it.
It is necessary for the nurse to establish a therapeutic relationship conveying empathy by
being available to client for listening and talking. Then assist client to learn precipitating
factors then learn methods of coping with anxiety.

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Dorothea Orem

Dorothea Orem explains Universal Self-Care Requisites as all the things that are need
by individuals, at all stages of life, to be able to care for ones self. Orem uses the self-care
requisites as a basis for assessment the nursing process. To state it in an easy way to
understand, she takes all the elements that need to be right for an individual to function
wholly and independently and then works backward, identifying self-care deficits. Each
component of the assessment is broken up into two parts, the health habits and the review of
systems

Activity and rest requisites are the next requisites that Orem examines. Physical
assessment would include mentation and activities of daily living. Does the patient have a
steady gaite? Does the patient live alone? Neurological assessment should be done at this
time. Review sleep patterns, muscle tone, and peripheral vascular disease.

During the course of our care with the client, we have been tasked to get an hourly
BP to determine if there are any deviations for referral. As a result, the patient was not able
to have a good rest and sleep during the course of our duty and as evidence, she talks in a
manner where the tone seems tired and dark circles around here eyes as apparent. According
to Orem, sleep patterns should be taking into consideration. It is but our responsibility to
monitor the patient. Explaining the necessity of disturbances for monitoring vital signs when
hospitalized is essential for the client to understand the purpose of the procedure but care
must be done as possible without waking the client. The use of shades to black out light such
as the curtain situated near the bed must be kept wide open to cover the patient so as to alter
the environment conducive for sleeping. Noise should be kept minimal so avoid waking up
the client.

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Kolcaba

According to Kolcaba in Comfort Teory, her assumption is that human beings have
holistic responses to multiple, complex stimuli, comfort is a desirable outcome and germane
to nursing, human beings strive to meet comfort needs, it is a process that is continuous,
having comfort needs met strengthens patients to engage in health-seeking behaviors of their
own, patients who are given the power to engage in health-seeking behaviors of their own
have a better perceptions of and about their health care and lastly, when an institution’s care
is based on a system of values that is focused on the patient or those who receive care, that
institution is said to have integrity.

There are 3 types of comfort:

a. Relief: how a recipient is when they have had their specific need met; free of discomfort
b. Ease: state of relaxation or happiness; “at ease”
c. Transcendence: the recipient rising above their level of discomfort, trouble or pain;
strengthened, motivated, determined
By having these comforts met, the patient is made stronger immediately or holistically.

During our duty, the patient complained that the room is warm for her and that she
feels discomfort and needs to set the air conditioner to a higher level. When she slept she
removed her blanket but she still sweats, although not that obvious. Her skin is warm to
touch and face is oily. The nurses set the aircon to her according to her request but reported
that she there was only a little improvement. The room is big and there is another patient at
the other side who complains again of having the room too cold for her and she experienced
chills. There was no attempt to remodify the environment so the patient appears and reported
discomfort. In this case it is necessary to address her need since it may contribute to the
sleeping pattern of the patient as well.

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Myra Levine

The nursing process of Levine's conceptual model is conservation, which is defined as

"keeping together" and emphasizes the wholeness and integrity of every individual.
Assessment of the individual's nursing requirements leads to development of a
trophicognosis, defined as a nursing care judgment arrived at by the scientific method.
Nursing intervention is structured according to four conservation principles: conservation of
energy, structural integrity, personal integrity, and social integrity.

Conservation of social integrity focuses attention on the individual's place in his or

her family, community, and society. Nursing intervention is based on helping the individual to
preserve his or her place in a family, community, and society.

It is very apparent that watchers are not allowed to enter in the delivery room to
watch the client and give support, morally or emotionally. In the theory, nursing should
involve human interaction aside from the nurse, as a social being, the patient is inclined to
interact with other people and because of this interaction, she will maintain and promote her
relationship with other people. In addition, we all know that the family is a source of the
strength of an individual, aside from giving counselling. The human interaction relies on
communication, rooted in the organic dependency of the individual human being in his
relationships with other human beings. This again may also contribute to decrease any
stressors that might cause a chain of reactions that psychologically and emotionally
threatening which then may lead to a possibility of developing a physiologic reaction such as
anxiety.

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 Faye Abdellah

According to her, nursing is based on an art and science that mould the attitudes,

intellectual competencies, and technical skills of the individual nurse into the desire and

ability to help people , sick or well, cope with their health needs.

To view Abdellah’s 21 nursing problems according to Maslow’s hierarchy of needs,

in the physiologic needs, the nurse must facilitate the maintenance of a supply of oxygen to

all body cells, nutrition of all body cells, fluid and electrolyte balance, elimination, maintain

good body mechanics and prevent and correct deformities, good hygiene and physical

comfort, promote optimal activity: exercise, rest and sleep and to facilitate the maintenance

of regulatory mechanisms and functions.

Although we have met the some needs mentioned above, there are some needs that

needs intervention such as maintaining good mechanics, good hygiene and rest and sleep

pattern were left unattended. Client seemed to slouch even in a semi-fowlers position. This

could affect the airway which then may contribute to a difficulty in breathing. The patient’s

hair and oral care was not given even when the next shift arrived and she stated during the

physical assessment around 8 am that she had not yet brushed her teeth when instructed to

open her mouth for inspection. Her hair was not combed and neglected to take attention

unto it. Rest and sleep was also affected because of the BP monitoring, and appeared tired

during the interview. Endorsing to the next shift must be made so the staff will be aware for

further modification to help the patient restore her energy.

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 Definition of Complete Diagnosis

Preeclampsia is an abnormal condition of pregnancy characterized by the onset of

acute hypertension after the twenty-fourth week of gestation. The classic triad of
preeclampsia is hypertension, proteinuria, and edema… preeclampsia commonly causes
abnormal metabolic function, including negative nitrogen balance, increased central nervous
system irritability, hyperactive reflexes, compromised renal function, hemoconcentration, and
alterations of fluid and electrolyte balance…

 page 953. Mosby’s Medical, Nursing, & Allied Health Dictionary. 3rd edition. The
C.V. Mosby Company. St. Louis Missouri. 1990.

A woman is said to be mildly preeclampsia when her blood pressure rises to 140/90 mm
Hg, taken on two occasions at least 6 hours apart. The diastolic value of blood pressure is
extremely important to note because it is this pressure that best indicates the degree of
peripheral arterial spasm present.

A second criterion is systolic blood pressure greater than 30 mm Hg and diastolic pressure
than 15 mm Hg above pregnancy values.

 pages 406-406. Pillitteri, Adele, PhD, RN, PNP. Maternal & Child Health Nursing:
Care of the Childbearing & Childrearing Family. 4th edition. Lippincott Williams &
Wilkins. 2003.

Preeclampsia is a pregnancy-specific syndrome in which hypertension develops after 20

weeks of gestation in a previous normotensive woman. It is a multisystem, vasospastic
disease process of reduced organ perfusion characterized by the presence of hypertension and
proteinuria. Preeclampsia is usually categorized as mild or severe in terms of management.

 page 372. Wong, D.L. PhD, RN, PNP, CPN, FAAN. Maternal & Child Nursing Care
3rd edition. Mosby Inc. USA. 2006

23
 Preeclampsia refers specifically to hypertension after 20 weeks’ gestation with
proteinuria. It is more common in multiparas, women carrying multiple fetuses, women with
hypertension for 4 years or more, clients with a family history of pre-eclampsia or
hypertension in a previous pregnancy, and clients with renal disease.

 page 524. Orshan, Susan A. PhD, RN, BC. Maternity, Newborn, & Women’s Health
Nursing Comprehensive Care Across the Lifespan. Lippincott Williams & Wilkins.
Philadelphia, PA. 2008.

24
 Physical Assessment

GENERAL SURVEY

Ms. S is a 4’11’’ 30 year old Filipino female weighing 55 kg. She is lying on the bed
conscious, coherent, awake and afebrile upon assessment with D5LR 1L at 100 cc/hr infusing
well at right cephalic vein at 330 cc level with a side drip of D5W 500cc at 58 cc/hr hooked
at y-port at 120cc level with 02 at 4 LPM. She appears edematous. She is not in good
grooming with a light blue gown on. Ms. S is not in respiratory distress. She has difficulty
upon ambulation.

VITAL SIGNS

BP= 130/90 mm Hg PR= 74 bpm RR= 22 cpm T= 36.1 °C

SKIN

Ms. S’ skin is warm, slightly dry, rough and returns quickly to its normal shape when
picked up between two fingers and released. The color of the skin is brown, with papules on
the face, nevi and scars. No bruising and bleeding present. Edema is present although out her
body.

HEAD

Skull size is normocephalic. Skull and face are symmetrical with an equal distribution
of hair. Hair is long, curly, oily, not brittle, and generally black. No white hair present. There
are no dandruff and infestations present. No lesions, lacerations, tenderness noted.

25
FACE

Face portrays emotion, intelligence and understanding. It is symmetrical with no

masses and involuntary movements. The face is round and brown in color. It is edematous
and appears moonfaced. The forehead is not furrowed with wrinkles.

EYES

Ms. S does not use any corrective aids. Eyebrows are free of flakes, scars and lesions
with a slightly thick equal distribution of hair on both sides. Lashes are directed outwards
with no lid eversion or inversion. Lid margins are clear, lacrimal duct opening are evident at
the nasal side of the upper and lower lids. Palpebral fissures are equal in size when eyes are
open. Blinking reflex is present. Eyelids are brown in color and consistent with the color of
the face surrounding them and are not edematous. Bulbar and palpebral conjunctiva is pink
with no growths or lesions present. She has an anicteric sclera with no pigmentations and an
isocoric pupil with a pupillary size of 2mm. Pupil equally round reactive to light and
accommodation. Iris is dark brown. Eyeballs are symmetrical with no sunkening or bulging
observed. Eyeballs move in a conjugate fashion with convergence. There is no evidence of
nystagmus or strabismus. Peripheral vision is present. No discharges or excessive watering of
the eyes noted. Patient reported that she has astigmatism but does not have any visual
difficulty at the time of inspection.

EARS

Ears are symmetrical and are of equal size bilaterally and a color consistent with her
facial color. Pinnas are free of lesions, masses, swelling, redness, tenderness, and discharges.
It is in line with the eyes. External canals are clear with minimal cerumen. No inflammation,
masses, discharges and foreign bodies noted. Patient has no difficulty hearing at a distance of
6 feet. No pain upon pressing the mastoid process.

NOSE
26
 The nose is symmetrical, with a color consistent with the face. It is in the midline with
no deformities, or skin lesions, and no bleeding and foreign body present. Nasal cannula is
attached at a rate of 4 LPM. She has no difficulty breathing on both nostrils at a time for
inspection. No nasal flaring observed. No discharges present upon assessment. The nasal
mucosa is pinkish in color. Maxillary and frontal sinuses are not tender upon palpation.

MOUTH

Mouth is proportional and symmetrical to the other parts of the face. Lips are dark red
with no masses and congenital defect but appear edematous and slightly dry but shiny. No
chaps and fissures observed on the lips. No upper first and second molars present. No
overlapping of teeth present and are generally in its arrangement. Dental caries present at the
left upper incisor. No abnormal dental shape noted. Patient has no dentures or any artificial
teeth. Gums are pink in color with no discharges, swelling, retraction, bleeding or lesions
observed. Buccal mucosa is pink in color and is smooth and fine. Tongue is in midline with a
white coating in the center without lesions. It is symmetrical, moist and no deviations from
the midline. Hard palate and soft palate are free of lesions. Uvula rises when the patient says
“ah”. It is pink in color with no ulcerations noted. Tonsils are not inflamed. No ulcerations
and exudates present. Patient has no difficulty of masticating and swallowing. Halitosis is
present. No voice change or hoarseness noted. Disorder of speech is absent.

NECK

Neck is symmetrical with no masses. Swelling was noted. Pulsations on the jugular
vein were noted upon observation No jugular vein distention noted. Range of motion is
normal and moves easily without discomfort upon rotation, flexion, extension and
hyperextension. Lymph nodes and salivary glands are not palpable. No torticollis present.

BREAST

27
 Nipples are everted at the time of inspection. No masses, crusting and discharges of
the nipples reported. No tenderness and swelling of breast tissue reported. Axilla is free of
lesions rashes, and infections. Lymph nodes are not palpable.

CHEST and LUNGS

Thorax is moves easily without impairment upon registration. No spinal deformities

noted. No tenderness and swelling reported. Respiratory rate is 22 cycles per minute with
regular, and deep respirations without noise. No adventitious sound noted upon auscultation.
No dyspnea, cough, hemoptysis, hiccups noted. No crepitation and pleural friction rub
present.

HEART

No pericardial bulge present. Apical heart beat is present upon auscultation with a
point of maximal impulse in the 5th intercostal space left midclavicular line. Ms. S has a
cardiac rate of 74 beats per minute and is regular. No abnormal beats, palpitations, thrills or
murmurs present upon auscultation.

ABDOMEN

Abdomen is round and symmetrical when patient is in supine position. No rashes

present. Striae present at lower quadrant of the abdomen. The abdomen has normal bowel
sounds of 4 bowel sounds per minute.

GENITO –URINARY

Ms. S does not have any difficulty or pain upon urination. Her last menstrual period
was on May 30, 2008 which lasted for 4 days. She had a regular menstrual cycle and
complains pain. Patient reports with a whitish to yellowish discharge.

28
UPPER EXTREMITIES

The shoulders, arms, elbows and forearms are free of nodules, deformities and
atrophy. Range of motion is normal. No redness or pallor, bone enlargements, nodules and
atrophy noted upon inspection of the hands and wrists. Arms, forearms and hands are
edematous but with no pitting. The palms are slightly callused and slightly rough. Fingernails
are clean and trimmed well with no nail polish on. It has a smooth texture. Nail beds are pink
in color and intact. Capillary refill time is 2 seconds. Fingers are complete with no
deformations and contractures noted. Radial, ulnar and brachial pulses are present.

LOWER EXTREMITIES

Hip joint and thighs are symmetrical with no pain, tenderness, or deformities present.
Edema noted at both feet with a score of +1 at positive pitting. No scars are present in the feet
and legs. No inflammation noted in the lower limb with an active range of motion and
absence of limitation. Toenails are with a dark green nail polish and long Lower extremities
pulses are present on both sides. Patient has difficulty with ambulation and complains pain
upon standing with a score of 6 from a pain scale of 1 to 10 but gradually disappears after
some time.

29
 ANATOMY AND PHYSIOLOGY

The Female Reproductive System

The female reproductive system is designed to carry out several functions. It produces the
female egg cells necessary for reproduction, called the ova or oocytes. The system is
designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg
by a sperm, normally occurs in the fallopian tubes. After conception, the uterus offers a safe
and favorable environment for a baby to develop before it is time for it to make its way into
the outside world. If fertilization does not take place, the system is designed to menstruate
(the monthly shedding of the uterine lining). In addition, the female reproductive system
produces female sex hormones that maintain the reproductive cycle.

What parts make-up the female anatomy?

The female reproductive anatomy includes internal and external structures.

The function of the external female reproductive structures (the genital) is twofold: To enable
sperm to enter the body and to protect the internal genital organs from infectious organisms.
The main external structures of the female reproductive system include:

• Labia majora: The labia majora enclose and protect the other external reproductive
organs. Literally translated as "large lips," the labia majora are relatively large and
fleshy, and are comparable to the scrotum in males. The labia majora contain sweat
and oil-secreting glands. After puberty, the labia majora are covered with hair.

30
 • Labia minora: Literally translated as "small lips," the labia minora can be very small
or up to 2 inches wide. They lie just inside the labia majora, and surround the
openings to the vagina (the canal that joins the lower part of the uterus to the outside
of the body) and urethra (the tube that carries urine from the bladder to the outside of
the body).

• Bartholin’s glands: These glands are located next to the vaginal opening and produce
a fluid (mucus) secretion.
• Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is
comparable to the penis in males. The clitoris is covered by a fold of skin, called the
prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the
clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs include:

• Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the
outside of the body. It also is known as the birth canal.
• Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a
developing fetus. The uterus is divided into two parts: the cervix, which is the lower
part that opens into the vagina, and the main body of the uterus, called the corpus. The
corpus can easily expand to hold a developing baby. A channel through the cervix
allows sperm to enter and menstrual blood to exit.

31
 • Ovaries: The ovaries are small, oval-shaped glands that are located on either side of
the uterus. The ovaries produce eggs and hormones.
• Fallopian tubes: These are narrow tubes that are attached to the upper part of the
uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the
uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the
fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the
uterine wall.

What happens during the menstrual cycle?

Females of reproductive age (anywhere from 11-16 years) experience cycles of hormonal
activity that repeat at about one-month intervals. (Menstru means "monthly"; hence the term
menstrual cycle.) With every cycle, a woman’s body prepares for a potential pregnancy,
whether or not that is the woman’s intention. The term menstruation refers to the periodic
shedding of the uterine lining.

The average menstrual cycle takes about 28 days and occurs in phases: the follicular phase,
the ovulatory phase (ovulation), and the luteal phase.

There are four major hormones (chemicals that stimulate or regulate the activity of cells or
organs) involved in the menstrual cycle: follicle-stimulating hormone, luteinizing hormone,
estrogen, and progesterone.

32
OVARIAN CYCLE:

Phases:

• Follicular Phase = encompasses day 1 to 14 of a 28-day cycle. A follicle begins to

develop in response to rising level of FSH. The follicle produces estrogen, which
causes the ovum contained in the follicle to mature. As the follicle grows, it fills with
estrogen-rich fluid and begins to resemble a tiny blister on the surface of the ovary.

When the pituitary gland detects high levels of estrogen from the mature
follicle, it releases a surge of LH. This sudden increase in LH causes the follicle to
burst open, releasing the mature ovum into the abdominal cavity, a process called
ovulation. It occurs on the day 14 of a 28-day cycle.

• Luteal Phase = After ovulation, LH levels remain elevated and cause the remnants of
the follicle to develop into a yellow body called the corpus luteum. In addition to
producing estrogen, the corpus luteum secretes a hormone called progesterone.

If fertilization does not take place, the corpus luteum begins to degenerate, and
estrogen and progesterone levels fall. This process leads back to day 1 of the cycle,
and the follicular phase begins anew.

UTERINE CYLE:

Phases:

• Menstrual Phase

- day 1 to 5; the uterine lining is shed because of low levels of progesterone

and estrogen. At the same time, a follicle is beginning to develop and starts producing
estrogen.

• Proliferative Phase

- day 6 to 14; When estrogen levels are high enough, the endometrium begins
to regenerate. Estrogen stimulates blood vessels to develop. The blood vessels in

33
 turn bring nutrients and oxygen to the uterine lining, and it begins to grow and
become thicker. It ends with ovulation on day 14.

• Secretory Phase

-The corpus luteum begins to produce progesterone, which causes the uterine
lining to become rich in nutrients in preparation for pregnancy. Estrogen lining levels
also remain high so that the lining is maintained. If pregnancy does not occur, the
corpus luteum gradually degenerates, and the woman enters the ischemic phase.

• Ischemic Phase

- day 27 to 28, estrogen and progesterone level fall because the corpus luteum
no longer produce them. Without these hormones to maintain the blood vessel
network, the uterine lining becomes ischemic. When the lining starts to slough, the
woman has come full cycle and is once again at day of the menstrual cycle.

34
 Etiology

BASIC ACTUAL RATIONALE

ETIOLOGY

PRECIPITATING FACTORS

Pregnancy √ Preeclampsia is a pregnancy-related hypertensive

disorder that occurs in approximately 6% of
pregnant women.
http://www.cdc.gov/genomics/hugenet/ejournal/A
GT.htm

Long X Recently, however, there have been reports that a

Interval of long interpregnancy interval is an independent
Pregnancy predictor of preeclampsia in women with no
preeclampsia in the previous pregnancy. This
finding suggests that the protective effect of past
pregnancies may decline over time or that another
factor correlating with time may also contribute to
the increased risk with long interpregnancy
intervals.
http://aje.oxfordjournals.org/cgi/content/full/157/3
/195

Obesity X Of these, obesity (where the risk of preeclampsia

increases three-fold), is the most common. As
over 30% of women of reproductive age are
obese, increased BMI may be responsible for 30-
40% of all cases of preeclampsia.
http://www.preeclampsia.org/PositionStmt_lateEff
ects_Oct06.pdf

Urinary X When evaluating interactions between variables,

Tract we found that primiparas who had UTI during
Infection pregnancy were five times more likely (OR 5.3,
95% CI 2.9 9.7) to have preeclampsia than were

35
 primiparas who did not have UTI during
pregnancy.
http://www.reproductivemedicine.com/toc/auto_a
bstract.php?id=1823

BASIC ACTUAL RATIONALE

ETIOLOGY

PREDISPOSING FACTORS
36
 Sex √ By definition, preeclampsia is a disease of pregnant
women.

http://emedicine.medscape.com/article/953579-
overview

Primiparas √ If the first pregnancy modifies the maternal spiral

arteries so that trophoblastic invasion occurs more
smoothly thereafter, this factor might explain the lower
incidence of preeclampsia among multiparas. Compared
with primiparas without hypertension, multiparas
without hypertension conceived faster, had a lower
incidence of preeclampsia, and recurred less frequently
to infertility treatment. In primiparas, we found an
increase of approximately 50 percent in the risk of
preeclampsia for women reporting a TTP longer than 2
months.
http://aje.oxfordjournals.org/cgi/content/full/157/3/195

Genetics X Several factors suggest that susceptibility to

preeclampsia is partly inherited. For example, a study
of Swedish twins reported an estimated heritability of
54%. Several candidate genes have been suggested in
previously published studies.
http://www.cdc.gov/genomics/hugenet/ejournal/AGT.ht
m

Support for the theory that pregnancy-induced

hypertension unmasks a genetic predisposition for
essential hypertension comes from similarities in
angiotensinogen gene allele distribution in these two
conditions. Ward et al.(24) have reported a higher
incidence of a variant allele of the angiotensinogen
gene in women with a history of preeclamptic
37
 pregnancy compared with normotensive pregnancy.
http://jcem.endojournals.org/cgi/reprint/84/6/1858.pdf

Age (less X Teenagers, who account for 13% of all pregnancies,

than 20 yo & tend to neglect prenatal care. The result is an increased
greater than incidence of preeclampsia, preterm labor, and anemia,
35 yo) which often leads to fetal growth restriction.
http://www.merck.com/mmpe/sec18/ch262/ch262b.htm
l

Overall, older mothers (over age 35) were more likely

than were younger women to experience complications
during pregnancy and delivery.

The study authors found that the risk of delivery

complications increased with the mother's age, as did
the risk of premature birth and infant death. n addition,
older pregnant women were more likely to have
diabetes and hypertension during pregnancy.
http://www.sciencedaily.com/releases/2007/03/0703082
20614.htm

It is known that older women are more likely to have

pre-existing medical disorders such as diabetes mellitus
or hypertension (Hansen, 1986). Because risk of fetal
chromosomal abnormalities increases as maternal age
increases.
http://www.merck.com/mmpe/sec18/ch262/ch262b.htm
l

Low X Studies have linked maternal low birth weight (<5%)

Socioecono with an increased risk of preeclampsia during their own
mic status pregnancies.28, 29, 30 The effect of the mother’s own
(Malnutritio low birth weight was noted during both the first and
n) second pregnancy. Earlier onset preeclampsia before 34
weeks’ gestation is also 2-3 times more common among
women who were born with weight less than the 5th
38
 percentile.
http://emedicine.medscape.com/article/953579-
overview

Race X Relating the frequency of preeclampsia to race is

difficult. However, the spectrum of preeclampsia-
eclampsia is observed more commonly in black women
and is thought to be related to a higher prevalence of
hypertensive disorders found in the black population.
This is exaggerated by cases of preeclampsia in
nulliparous women. Some studies note up to a 3-fold
higher risk among black women, while other studies
have not found an increased risk in black women.
http://emedicine.medscape.com/article/953579-
overview

Multiple X Twin pregnancies are twice as likely to be complicated

Pregnancy by preeclampsia as single pregnancies. Half of triplet
pregnancies develop preeclampsia.
http://www.americanpregnancy.org/multiples/complicat
ions.htm

Chronic X Pregnant women are considered to have chronic

Hpn hypertension (CHTN) if hypertension was present
before the pregnancy or if it develops before 20 wk of
pregnancy. Hypertension increases risk of fetal growth
restriction by decreasing uteroplacental blood flow.
CHTN increases risk of preeclampsia to up to 50%.
http://www.merck.com/mmpe/sec18/ch262/ch262b.htm
l

Heart X In the first study, Norwegian researchers found that

Disease cardiovascular risk factors that show up before
pregnancy increase the risk of preeclampsia sevenfold.

"This study is the first that confirms the hypothesis that

lipid and blood pressure abnormalities before

39
 pregnancy are strong predictors of preeclampsia," said
lead author Elisabeth Balstad Magnussen, a research
fellow in the Department of Public Health Faculty of
Medicine, Norwegian University of Science and
Technology, Trondheim.

http://health.usnews.com/usnews/health/healthday/0711
02/preeclampsia-linked-to-heart-disease-risk.htm

With X Magnussen's team then found that those women who

underlying had high blood pressure, high cholesterol and high
conditions blood sugar levels before pregnancy were seven times
(essential more likely to develop preeclampsia compare with the
hpn, others.
diabetes)
In addition, women who had a family history of high
blood pressure, heart disease, or diabetes had double the
risk of developing preeclampsia.
http://health.usnews.com/usnews/health/healthday/0711
02/preeclampsia-linked-to-heart-disease-risk.htm

Symptomatology

Symptoms Present/ Absent Rationale

1. Hypertension √ The vascular spasm may be caused by

increased cardiac output that injures
the endothelial cells of the arteries and
the action of prostaglandins (notably
decreased prostacylcin and increased
thromboxane). Vasoconstriction then
40
 occurs and blood pressure increases.
(Pillitteri, 2003)

2. Proteinuria X Vasospasm in the kidney increases

blood flow resistance. Degenerative
changes develop in kidney glomeruli
because of the back-pressure. This
leads to increased permeability of the
glomerular membrane, allowing the
serum proteins and globulin to escape
into the urine (proteinuria). (Pillitteri,
2003)

3. Edema √ Increased tubular reabsorption of

sodium occurs. Because sodium
retains fluid, edema results. Edema is
further increased because as more
protein is lost, the osmotic pressure of
the circulating blood falls and fluid
diffuses from the circulatory system
into the denser interstitial space to
equalize the pressure. (Pillitteri, 2003)

4. ↓ urine output Vasospasm in the kidney increases

blood flow resistance. Degenerative
changes develop in kidney glomeruli
because of the back-pressure.
Degenerative changes also result in
decreased glomerular filtration, so
there is lowered urine output and
clearance of creatinine. (Pillitteri,
2003)

5. seizure X Seizures precipitated by systemic or

metabolic disturbances and by
primary CNS insults also fall into the
category of provoked seizures.
41
 Toxemia of pregnancy (former name
of pregnancy induced hypertension),
water intoxication, uremia, and CNS
infection also may precipitate a
seizure. (Porth, 2002)

6. Epigastric pain RUQ X Right upper quadrant or epigastric

pain is due to stretching of the hepatic
capsule by edema or hemorrhage, and
hepatic ischemia.
http://www.geocities.com/jenloulorico
/research.htm

7. Blurring of vision √ Spasm of the arteries in the retina

leads to vision changes. (Pillitteri,
2003)

8. Fetal distress Vasospasm results to poor placental

perfusion that may reduce the fetal
nutrient and oxygen supply, resulting
to fetal distress. (Pillitteri, 2003)

9. Thrombocytopenia X Thrombocytopenia or a lowered

platelet count occurs as platelet
cluster at the sites of endothelial
damage. (Pillitteri, 2003)

10. Headache √ In hypertensive encephalopathy and

crises related to pheochromocytoma
and preeclampsia, a sudden rise in
blood pressure leads to headache.
http://www.wiserwiki.com/Headache

11. ↑ ALT (SGPT), AST X Patients with mild preeclampsia show

(SAGOT), & LDH little or no alteration in hepatic
enzyme levels, but in severe
preeclampsia marked increases in
42
 serum glutamic-oxaloacetic
transaminase (SGOT), serum
glutamic-pyruvic transaminase
(SGPT), and lactic dehydrogenase
(LDH) are commonly found.
http://www.tabebak.com/Thesis/Gyna
e-Nursing/PREECL.htm

12. Weight gain √ A weight gain of more than 2 lb/wk in

the normal trimester or 1 lb/wk in the
third trimester usually indicates
abnormal tissue fluid retention.
(Pillitteri, 2003)

43
Predisposing Factor Precipitating Factor
Age (<20 y.o / >40 y.o) Pathophysiology Pregnancy
Asian women
Primiparas
Low socioeconomic status
Multiple pregnancies
Hydramnios
Underlying disease ( diabetes,
hpn, renal impairment)

Unknown etiology

↑Cardiac output

Injury of the endothelial cells of the arteries

Abnormal release of prostaglandins

↓Prostaglandin ↑Thromboxane

↑Platelet aggregation

↑Platelet deposition at the site of

endothelial injury

Elevation of Vasospasms ↓Platelet count

BP

Vasoconstriction √Thrombocytopenia

44
↓Tissue perfusion in Poor liver ↓Uteroplacental perfusion Poor renal perfusion
the brain perfusion

√Altered LOC
√Headache Mild liver ↓Fetal nutrient & 02 Placental
reaction supply production
↓Retinal perfusion alterations of toxins

√Fetal distress
√Visual changes Release of liver
enzymes Release of uterine ↑Glomerular ↓GFR
renin membrane
permeability
√Epigastric pain RLQ Angiotensin II
√↑ALT & AST √Albuminuria
formation
√Edema
Fluid shifting
ECF-interstitial ↑Serum Creatinine
√Edema tissues
Further ↑Aldosterone
√Oliguria
vasoconstriction
√Weight gain

Na+ reabsorption

H2O retention √Oliguria

45 √Weight
gain
 Hypertesion Hypervolemia

Further ↓tisue perfusion on organs √Further edema

Worsening of s/s

If treated (medication; CS) If not treated

Fair prognosis
Mother Fetus

Eclampsia
Abruption Prematurity Uterine Fetal
placentae growth acidosis
Cerebral edema Seizures Atelectasis CH Renal Cardiac failure Hemorrhage retardation
F failure

Maternal death Fetal death

46
 Doctor’s Order

DATE ORDER RATIONALE REMARKS

01 – 13 – 2009 Pls. admit For proper evaluation Done

and management and
care for the client
Wt: 52kg Low fat, low salt Recommended for Done

T: 35.7 patients with

hypertension because
P: 91 salt draws water and

R: 17 fats may further

occlude the arteries
BP: 160/110 causing an increase

↓ in the pressure.

Monitor vital signs Monitoring, at a Done

160/100 @ 1pm
q4 regular interval, the
changes in condition
& note progress can
be evaluated through
vital signs

Labs:

Complete Blood Complete blood Done

Count (CBC), count is the
Platelet determination of the
quantity of each
quantity of each type
of each blood cell in
a given specimen of
blood, often
including the amount

47
 of hemoglobin,
hematocrit, and the
proportion of various
white cells.

Platelet count and

other blood
components that will
help determine the
underlying diagnosis.

Serum Glutamic- Measuring SGPT is Done

Pyruvic used to determine
Transaminase whether the liver or
(SGPT) heart is damaged.
The blood SGPT
levels are thus
elevated with liver
damage (for
example, from viral
hepatitis) or with an
insult to the heart
(for example, from a
heart attack).

Serum creatinine Measuring serum Done

creatinine is used to
indicate renal
function.

Lactate Measurement of Done

Dehydrogenase LDH has been used
(LDH) for differential
diagnosis of bacteria
versus viral
meningitis

48
Urinalysis An indicator of Done
health and disease, it
is helpful in the
detection of renal or
metabolic disorders.
It is an aid in
diagnosing and
following the course
of treatment in
diseases of the
kidney and urinary
system and in
detecting disorders in
other parts of the
body such as
metabolic or
endocrinic
abnormalities in
which the kidneys
function normally.

Biophysical Scoring A noninvasive test Done

(BPS) care of OB – that predicts the
sinologist presence or absence
of fetal asphyxia and,
ultimately, the risk of
fetal death in the
antenatal period.

Start venoclysis with Patient has fluid loss Done

D5LR 1L at 100cc/hr that she can not
compensate for.
D5LR an isotonic
solution was ordered
to replenish the loss

49
 fluid and to give
nutrition to both the
patient and the baby.

MgSO4 4gm slow Upon admission the Done

IVTT now BP was high so
MgSO4 STAT was
ordered to lower the
BP.

MgSO4 drip with To prevent Done

D5W 500cc + 20gm preeclampsia into
MgSO4 at 2gm/hr developing to
eclampsia.

Baseline Electronic Establish a baseline Done

Fetal Monitoring so as when
(EFM) examining the
condition of the baby
in the uterus unusual
changes in its heart
rate could easily be
noted.

Meds:

Methyldopa 250mg To treat patient’s Done

1tab q 6 hypertension.

Hydralazine 5mg Lowers blood Done

IVTT PRN for DBP pressure and allows
≥ 110 blood to flow more
easily through the
veins and arteries.
Pls. notify once Inform client’s Done
admitted physician once she is
admitted.

3:45am Dexamethasone 6mg Given to the client Done

50
 IM q 12 X 4 doses because of her risk of
delivering
prematurely in order
to promote
maturation of the
fetus' lungs.

EFM q shift To continuously Done

monitor the condition
of the baby in utero.

4:00am Increase Given to the client Done

Dexamethasone to because of her risk of
12mg IM q 12 X 2 delivering
doses prematurely in order
to promote
maturation of the
fetus' lungs.

6:50pm Caltrate Plus 1tab Helps maintain the Done

BID functional integrity
of the nervous and
muscular system. It
also aids in the
maintenance of
cardiac function.

51
1 – 14 – 2009 IVF to follow: D5LR Above IVF Done
1L at 100cc/hr consumed and needs
12:45am
to be replaced with
same IVF to

Side drip to follow: Side dripped was Done

D5W 500cc + 20gm almost consumed and
MgSO4 at 2gm/hr was ordered to be
followed up to
prevent preeclampsia
into developing to
eclampsia.

52
 Diagnostic Exam

Reference Nsg
Exam Result Clinical Indication Interpretation
Range Responsibility

Hematology (January 13, 2009)

53
Hemoglobin 119 g/L M: 140-170 Hemoglobin is an Below normal
important range, a
F: 120 - 150 component of red decreased level
blood cells that of hemoglobin
carries oxygen and may indicate a
carbon dioxide to decrease in the
and from tissues. circulating
The hemoglobin number of
determination test erythrocytes or Prepare the
is used to screen for anemia. client:
diseases associated Explain that this
with anemia and in test measures
determining acid- the number of
base balance. The blood
oxygen carrying components
capacity of the comprising the
blood is also blood.
determined by the
Hemoglobin
concentration.
Care after test:
Hematocrit 0.36 M: 0.40 - Measures the Below normal
0.60 percentage of RBC range, a low Observe the
in a blood volume. hematocrit level client for signs
F: 0.38 – The test is indicates low of anemia
0.40 performed to help percentage including pallor,
diagnose blood volume of red dyspnea, chest
disorders, such as blood cells or pain, and
polycythemia, anemia. fatigue.
anemia or abnormal
dehydration, blood
transfusion Encourage rest
decisions for severe periods for
symptomatic client
anemias, and the experiencing
effectiveness of fatigue related
those transfusions. to anemia.

Erythrocytes 3.68 4.0 – 6.0 Below normal

This test is used to
X10^12/L range, low
X10^12/L evaluate any type Evaluate client’s
erythrocyte count
of decrease or ability to
which may
increase in red perform
indicate a
blood cells. These activities of
decreased red
changes must be daily living.
blood cell
interpreted
54 in
Monocytes 4% 2 – 6% They are the second Within normal
line of defense range
against bacterial
infections and
foreign substances.
The test is used to
determine the
number of
monocytes and
their response to
inflammatory and
cellular immune
stimuli.

Eosinophil 2% 2 – 4% WBCs that increase Within normal

in allergic and range
parasitic
conditions. They
occur at antigen-
antibody reaction
sutes. The test is
used to determine
certain parasitic
infections.

Platelet 280 150 – 450 The smallest Within normal

Count formed elements in range
X10^9/L X10^9/L blood that promote
blood clotting after
an injury. The test
is performed to
determine if blood
clots normally,
evaluate platelet
production, and to
diagnose and
monitor a severe
increase or
decrease in platelet
count

55
 Reference Nsg
Exam Result Clinical Indication Interpretation
Range Responsibility

Urinalysis (January 13, 2009)

56
Physical Exam

Color Light Yellow Urine specimens Normal Color

Yellow may vary in color
from pale yellow to
dark amber. Due to
the presence of
abnormal pigments,
the color of urine
changes in many
disease states

Transparency Clear Clear to Urine specimen may Normal

Prepare client:
slightly hazy appear clear to Transparency
cloudy. This helps to
indicate presence of
-Explain that this
WBC, RBC,
test is to look for
bacteria, pus,
problems with the
phosphates, urates
urine and the
and uric acid in the
organs that help
urine composition.
form it.
REACTION 6.0 4.6 - 8 It expresses the Within normal
exact strength of the range
urine as a dilute acid
-Advise the client
or base solution and
to wash the peri-
measures the free
anal area prior to
hydrogen ion
collecting the
concentration in the
specimen to avoid
urine.
contamination
Specific 1.010 1.010-1.035 Specific gravity is a Within normal with vaginal
Gravity means by which the range secretions or
kidney’s ability to stool.
concentrate urine is
measured.

Chemical Exam -Inform the client

57 that a specimen
58
 Reference Nsg
Exam Result Clinical Indication Interpretation
Range Responsibility

Blood Chemistry (January 13, 2009)

Creatinine 66.2 44.00 - 88.00 Creatinine is a Within normal Prepare the

umol/L umol/L nitrogenous waste range. client:
product produced
Explain that this
during protein
test is important
metabolism in
to help
muscle tissue. The
understand how
test is used to
well the kidneys
determine kidney
are working.
function and/or
damage.

Care after the

test:

Assess fluid and

nutritional status
of client for clues
or renal
impairment and
other disease
causing changes
in creatinine
levels.

Continuously
monitor fluid
balance through
daily weights and
intake and output
59
 recordings.

Evaluate for
increased fluid
volume
manifested by
edema, decreased
urine out put,
neck vein
distention,
dyspnea and
hepatomegaly.

60
 Serum 19.4 0.0 – 34.0 SGPT is done to Within normal Prior to taking
Glutamic – diagnose liver range. the blood
U/L U/L
Pyruvic disease. In addition, sample, the
Transaminase such enzyme is nurse should
elevated in inform the
myocardial patient about the
infarction. test(s) to be

LDH 396.4 225.0 – 450.0 LDH is most often Within normal performed and

measured to check range. the preparation

U/L U/L
for tissue damage. for the test.

The enzyme LDH

1. define and
is in many body
explain the
tissues, especially
test
the heart, liver,
2. state the
kidney, skeletal
specific
muscle, brain,
purpose of
blood cells, and
the test
lungs.
3. explain the

LDH affects the procedure

chemical reaction
4. discuss test
for the conversion
preparation,
of pyruvate and
procedure,
lactate.
and posttest
care

61
Exam Clinical Indication Nsg Responsibility

Ultrasound Report Ultrasound is a test using sound waves Prepare client:

at the very high frequency. It is
(January 13, 2009)
valuable in: (1) determining fetal age;
(2) facilitating amniocentesis by - Explain that the test is
locating a suitable pool of amniotic non-invasive and will not
fluid; (3) ascertaining if fetal be uncomfortable except
development is normal; (4) for a full bladder.
determining fetal viability; (5)
localizing the placenta; and (6)
Have the client drink
confirming masses associated with
800-1000 mL of water
pregnancy.
another liquid 1 hour
prior to the exam to fill
the bladder.

Instruct the client not to

void until the test is
completed so that
visualization is optimal.

Care after the test:

Allow the client to void.

General Presentatio Amniotic Fluid Placental Location Previa

Vetex  Normal  Anterior  No previa

 Bleech Low normal Posterior Low lying free of os

62
 Transverse Oligohydramnios  Fundal Low lying edge of os

Oblique Polyhydramnios Right Partial previa

Variable Left Total previa

Measurements

CRL: mm ga: No of fetus: single Biophysical

OPD: mm ga: Profile Score

FHR: 150bpm
BPD: 74.7 mm ga: 30 W Tone: 2
AFI: 10.6cm
HC: 267.6 mm ga: 29 1/7 W Mov’t: 2

AC: 244.3 mm ga: 28 5/7 W EFWL: 1322 gms Breathing: 2

FL: 55.6 mm ga: 29 2/7 W Best Estimated U/S Gestational Age: 29 2/7 W AFI: 2

Total: 8
EDC:

63
Final Impression:

Single Intrauterine pregnancy in breech position with good cardiac and somatic activities

30 weeks by BPD; 29 wks 2 days by femur length

Placenta Anterofundal, Grade III consider premature placental aging

No previa

Normohydramnios; BPS = 8/8

Sonographic estimated fetal weight is appropriate for gestational age

 no cord coil noted at the time of scan

 suggest close fetal monitoring

64
 DRUG STUDY

Calcium Carbonate
GENERIC NAME
BRAND NAME Kalcinate, Alka-Mints, Amitone, Cal-Sup, Chooz,
Equilet,Titralac, Apo-Cal, Tums
CLASSIFICATION Antacid, Mineral and Electrolyte
replacements/supplements
DOSAGE 1 tab BID
MECHANISM OF ACTION Replacement of Calcium in deficiency states. Control
of hyperphosphatemia in End Stage Renal Disease
without promoting aluminum absorption (Calcium
Acetate)
INDICATION • Gastric hyperacidity

• Treatment & prevention of hypocalcemia

• Emergency treatment for hyperkalemia,

hypermagnesemia, and as an adjunct in cardiac
arrest.

• For the control of hyperphosphatemia in End

Stage Renal Disease

CONTRAINDICATION • Hypercalcemia

• Digitalized clients

• Ventricular fibrillation.

65
 • Cancer clients with bone metastases

• Renal calculi

• Hypophosphatemia

• Hypercalcemia

DRUG INTERACTION • Magnesium: may compete for GI absorption

• Tetracyclines, quinolones:decreases absorption
• Thiazide diuretics or vitamin D: Co-
administration wich may lead to milk-alkali
syndrome and hypercalcemia.
• Decreased absorption with corticosteroids.
• Decreases absorption of tetracyclines, iron,
quinolones, sodium fluoride, zinc and calcium-
channel blockers
• Enhances cardiac effects of digitalis glycosides
and may precipitate digitalis intoxication.
SIDE EFFECTS • GI: N and V, constipation, GI irritation,
abdominal pain, flatulence,
• CV: bradycardia, arrhythmias,
• GU: calculi, hypercalcuria, polyuria, azotemia
• CNS: tingling, , confusion, delirium
• Others: fatigue, dry mouth, thirst, weakness
ADVERSE REACTIONS • Cardiac arrhythmias
• Hypercalcemia
NURSING RESPONSIBILITIES 1. Assess patient’s underlying condition before
therapy and regularly thereafter.

2. Monitor calcium level, especially in pt w/ renal

impairment or dehydration. Assess for symptoms
of hypocalcemia (muscle twitching, colic, cardiac
arrhythmias, Chvostek’s or Trousseau’s sign).
Then notify physician or other health care

66
provider.

3. Look for adverse reactions and interactions.

4. Give 1 hour after meals, prn and at bedtime.

5. Divide daily oral calcium supplements into 3-4

doses.

6. Advise pt not to take drug indiscriminately and

not to switch antacids w/o consulting prescriber.

7. Chewable tablets should be chewed well before

swallowing.

8. Follow oral doses w/ a full glass of water,

except when using calcium carbonate as a
phosphate binder in renal dialysis.

9. Do not administer with foods containing large

amounts of phosphorus(milk, dairy products), and
phytic acid ( cereals). Administration w/ milk
products may lead to milk-alkali syndrome (N and
V, confusion, headache).

10. If possible, do not take w/in 1-2 hours w/ other

medications.

11. Advise patient that calcium carbonate may

cause constipation. Encourage to increase bulk in
diet. Patient may need to use laxatives w/ the
order of the prescriber.

12. Take note that severe constipation may

indicate toxicity.

67
 Dexamethasone
GENERIC NAME
BRAND NAME Aeroseb- Dex, Decadron, Dexasone (CAN),
Hexadrol, Maxidex Ophthalmic
CLASSIFICATION Antiasthmatics, corticosteroids
DOSAGE 12mg IM q 12 x 2 doses
MECHANISM OF ACTION In pharmacologic doses, all agents suppress
inflammation and the normal immune response.
Therapeutic effects: suppression of inflammation and
modification of the normal immune response.
INDICATION • Management of cerebral edema: Diagnostic agent
in adrenal disorders

CONTRAINDICATION • Active untreated infections (may be used in

patients being treated for some forms of
meningitis). Known alcohol, bisulfite, or
tartrazine hypersensitivity or intolerance (some
products contain theseand should be avoided in
susceptible patients). Administration of live virus
vaccines.

DRUG INTERACTION • Increase risk of hypokalemia with thiazide and

loop diuretics, amphotericin B, piperacillin, or
ticarcillin. Decreased effects of
anticholinesterases with corticotropin, profound
muscular depression is possible. Decreased
steroid blood levels with phenytoin,
Phenobarbital, rifampin. Decreased levels of
salicylate with dexamthasone.

SIDE EFFECTS

• Adverse reactions/ side effects are much

more common with high-dose/ long-term
therapy.
• Stomach upset
• Increased appetite
• A latent diabetes mellitus
• Immunsuppressant action
68
• Psychiatric disturbances, including
personality changes, irritability, euphoria,
mania
69
 Hydralazine
GENERIC NAME
BRAND NAME Apresoline
CLASSIFICATION Antihypertensives, vasodilators
DOSAGE 5mg IVTT PRN for DBP greater than or equal to 110
MECHANISM OF ACTION Direct-acting peripheral arteriolar vasodilator.
Maintains or increases renal and cerebral blood flow.
INDICATION • Moderate to severe HPN (with a diuretic).

CONTRAINDICATION • Hypersensitivity. Some products contain

tartrazine and should be avoided in patients with
known intolerance.

DRUG INTERACTION • Increase hypotension with acute ingestion of

alcohol, other antihypertensives, or nitrates.
MAO inhibitors may exaggerate hypotension.
May decrease pressor response to epinephrine.
NSAIDs may decrease antihypertensive
response. Betablockers decrease tachycardia
from hydralazine.
• Diarrhea
• Compensatory tachycardia due to baroreceptor
SIDE EFFECTS
reflex
• Headache
• Loss of appetite
• Nausea or vomiting
• Pounding heartbeat
• Drug-Induced Lupus Erythematosus

• dizziness
ADVERSE REACTIONS
• drowsiness
• angina
• arrhythmias
• rashes

NURSING RESPONSIBILITIES 1. Monitor BP and pulse frequently during initial

dose adjustment and periodically during therapy.
70
2. Monitor frequency of prescription refills to
determine adherence.

3. Don’t confuse hydralazine with hydroxyzine.

71
 Magnesium Sulfate
GENERIC NAME
BRAND NAME Epsom salt
CLASSIFICATION Mineral and electrolyte replacements/ supplements
DOSAGE Drip with D5W 500cc + 2g/hr
MECHANISM OF ACTION An important cofactor for enzymatic reactions and
plays an important role in neurochemical transmission
and muscular excitability. Resolution of eclampsia.
INDICATION • Convulsions (treatment) - Intravenous
magnesium sulfate is indicated for immediate
control of life-threatening convulsions in the
treatment of severe toxemias (pre-eclampsia
and eclampsia) of pregnancy and in the
treatment of acute nephritis in children.
• Hypomagnesemia (prophylaxis and treatment)
- Magnesium sulfate is indicated for
replacement therapy in magnesium deficiency,
especially in acute hypomagnesemia
accompanied by signs of tetany similar to
those of hypocalcemia.
• Magnesium sulfate is also used to prevent or
treat magnesium deficiency in patients
receiving total parenteral nutrition.

• Tetany, uterine (treatment) - Magnesium

sulfate is indicated in uterine tetany as a
myometrial relaxant.
CONTRAINDICATION • Magnesium sulfate should not be administered
parenterally in patients with heart block or
myocardial damage.

DRUG INTERACTION CNS Depressants— When barbiturates, narcotics or

other hypnotics (or systemic anesthetics), or other
CNS depressants are to be given in conjunction with
magnesium, their dosage should be adjusted with
caution because of additive CNS depressant effects of
magnesium. CNS depression and peripheral
transmission defects produced by magnesium may be
antagonized by calcium.
72

Neuromuscular Blocking Agents— Excessive

neuromuscular block has occurred in patients
73
 Methyldopa
GENERIC NAME
BRAND NAME Aldomet
CLASSIFICATION Antihypertensives, centrally acting antiadrenergics
DOSAGE 250mg 1tab q 6 hr
MECHANISM OF ACTION Methyldopa lowers blood pressure by decreasing the
levels of certain chemicals in your blood. This allows
your blood vessels (veins and arteries) to relax
(widen) and your heart to beat more slowly and easily.

Methyldopa is used to treat hypertension (high blood

pressure).
INDICATION • Hypertension

CONTRAINDICATION • With active hepatic disease, such as acute

hepatitis and active cirrhosis
• With liver disorders previously associated with
methyldopa therapy with hypersensitivity to
any component of these products.

• On therapy with monoamine oxidase (MAO)

inhibitors.
DRUG INTERACTION • When methyldopa is used with other
antihypertensive drugs, potentiation of
antihypertensive effect may occur. Patients
should be followed carefully to detect side
reactions or unusual manifestations of drug
idiosyncrasy.
• Patients may require reduced doses of
anesthetics when on methyldopa. If
hypotension does occur during anesthesia, it
usually can be controlled by vasopressors. The
adrenergic receptors remain sensitive during
treatment with methyldopa.
• When methyldopa and lithium are given
concomitantly the patient should be carefully
monitored for symptoms of lithium toxicity.
Read the circular for lithium preparations.

• Several studies demonstrate a decrease in the

74
bioavailability of methyldopa when it is
ingested with ferrous sulfate or ferrous
gluconate. This may adversely affect blood
75
 Nursing Care Plan
Date Cues Need Nursing Diagnosis
J S/O A Ineffective
A > Fetal heart rate C uteroplacental tissue
N of 164 bpm T perfusion related to
U > Maternal blood I vasospasm of spiral
A pressure of 140/90 V arteries secondary to
R mmHg I preeclampsia
Y T
15, Y ® Preeclampsia is
2009 - characterized by an
@ E increased in blood
12:00 X pressure resulting
am E from vasospasm of
R arteries (for this
C case, we are
I pertaining to the
S spiral artery) that
E causes
vasoconstriction.
P This then leads to a
Objectives Interventions Evaluation
Within 2 hours of 1. Assist the patient in January 15, 2009
nursing care, the identifying lifestyle @
patient will adjustment (e.g., avoiding 2:00 am
manifest an prolonged sitting, sitting
increase in with crossed legs, or GOAL MET
uroplacental standing; developing
tissue perfusion exercise plan for Within 2 hours of
as evidenced by: cardiovascular fitness during nursing care, the
1. fetal heart rate pregnancy; avoiding wearing patient manifested
regulated to constrictive clothing; an increase in
normal range maintaining a balance diet uroplacental tissue
(120-160 bpm) with adequate hydration) perfusion as
2. a decrease in that may be needed because evidenced by:
maternal blood of changes in physiologic 1. fetal heart rate of
pressure function during pregnancy. 145 bpm
® Decreases factors that 2. maternal blood
could lead to decreased pressure of 130/90
perfusion of oxygen to mmHg
uterus, placenta, and fetus.
76
A decrease in oxygen 2. Check and monitor vital
T supply to the signs hourly.
T placenta which is ® Permits monitoring of
E otherwise known as cardiovascular response to
R ineffective illness state and provides
N uroplacental early warning of perfusion
perfusion. problems.
(p. 371, Carol 3. Monitor fetal heart rate
Mattson Porth, and well being.
Essentials of ® Provides early warning of
Pathophysiology, perfusion problems, and
Lippincott Williams promotes early intervention.
and Wilkins, 2007) 4. Institute O2, with an
initial volume of at least
2L/min.
® It enhances
uteroplacental perfusion
thereby decreasing fetal
heart workload.
5. Monitor intake and output
every hour.

77
 ® To check for renal
perfusion and to determine
fluid loss and need for
replacement or fluid excess
which further increases BP
6. Instruct the patient to
assume the left side lying
position when lying down.
® To promote placental
perfusion and prevent the
compression of vena cava.
7. Provide quiet, non-
stimulating environment for
the patient.
® It reduces anxiety and
promotes rest. Both
measures will assist in
maintaining peripheral
circulation by avoiding
vasoconstriction.
8. Provide the patient and

78
 family factual information
and support as needed.
® It reduces anxiety and
provides teaching
opportunity.
9. Provide low-sodium diet
(not more than 6g daily or
less than 2.5 g daily).
Restrict intake of protein.
® It assists in controlling
blood pressure. Restriction
of protein helps limit BUN.
10. Refer to other health care
professionals as necessary
® Provides support and
fosters cost-effective
collaboration through use of
readily available resources

79
Date Cues Need Nursing Diagnosis Objectives Interventions Evaluation

J Subjective: C Acute pain related to Within one hour 1. Assist patient during January 15, 2009
A > “Sakit inig O abrupt change in of nursing care, ambulation. @
N tindog,” as G pressure to the pelvic the patient will ® Patient complains of pain 1:00 am
U verbalized by the N area while report a decrease especially during
A patient. I ambulation secondary in pain sensation ambulation. Assistance GOAL MET
R T to pregnancy as evidenced by a decreases the pain felt by the
Y Objective: I pain scale of 2-4. patient. Within one hour of
15, > pain scale of 6 V ® Increased pressure ® 2. Encourage the patient nursing care and
2009 > grimaced face E on the pelvic area to talk about the pain interventions, the
@ > guarded - leading to tissue experience in as much detail patient was able to
12:00 behavior P injury which causes as desired. verbalize a decrease
am > respiratory rate E to release of ® Pain is subjective in in pain sensation
of 26 cpm R inflammatory nature, and only the patient with a pain scale of
C mediators with can fully describe it 2.
E subsequent 3. Monitor vital signs at least
P nociceptor every 30 minutes.
T stimulation. Pain ® Detects early changes
U impulses are then that might indicate increase

80
A transmitted to the or decrease in pain.
L dorsal horn of the 4. Administer pain
spinal cord, where medication as ordered.
P they make contact Monitor and record amount
A with second order of pain 30 minutes after and
T neurons that cross to have the patient re-rank pain
T the opposite side of (0-10). If pain not relieved,
E the cord and ascend collaborate with physician
R through the regarding change of
N spinothalamic tract medication
to the reticular ® Response to pain and pain
activating system medication is unique to each
(RAS) and thalamus. patient.
The location and the 5. Give massage
meaning of pain immediately following
occur at the level of administration of each pain
the somatosensory medication and after each
cortex. turning.
(p. 767, Carol ® Assists in muscle
Mattson Porth, relaxation and improves
Essentials of action of pain medication by

81
Pathophysiology, stimulating the nerve fibers
Lippincott Williams to close the transmission
and Wilkins, 2007) gate.
6. Turn patient and maintain
anatomic alignment with
pillows or other padded
support.
® Helps stimulate
circulation. Alignment helps
prevent pain from
malposition and enhances
comfort.
7. Provide calm, quiet
environment. Limit activity
following pain medication
administration.
® Promotes action and
effect of medication by
providing decreased stimuli.
8. Apply heat compress on
the affected region according

82
 to what the patient states
provides the best pain relief.
® Causes vasodilation that
will assist in relieving the
pain.
9. Use noninvasive pain
relief techniques as
appropriate:
-progressive relaxation
-rhythmic breathing
-distraction
-guided imagery
® Provides diversion from
pain. Decreases anxiety and
muscle tension. Also it
increases comfort and
empowers the patient.
10. Teach the patient and
significant others:
-the cause of pain
-common and expected side

83
 effects of analgesics
-avoiding and minimizing
pain
® Knowledge assists the
patient in feeling like an
active participant on the
health team. Decreases
sense of powerlessness.
Promotes effective pain
management.

84
Date Cues Need Nursing Diagnosis Objectives Interventions Evaluation

J Subjective: S Mild anxiety related Within 2 hours of 1. Alleviate anxieties. January 15, 2009
A “Day, nag-guol ko, E to upcoming surgery care, the patient Validate observations with @
N dili ba na hadlok L secondary to will: patient. Encourage free 4:00 am
U magpa-opera?” as F Caesarian Section 1. verbalize expression of emotions/
A verbalized by the - awareness of verbalization. GOAL MET
R patient. P ® Anxiety is an feelings of ® Feelings are real, and it is
Y E emotional state anxiety, helpful to bring them out in Within 2 hours of
15, R characterized by 2. identify healthy the open so they can be nursing interventions
2 Objective: C feelings of ways to deal with discussed and dealt with. and health teachings,
009 > asks questions E apprehension, and express 2. Validate source of fear. the patient was able
@ frequently P discomfort, anxiety, and Provide accurate, factual to:
2:00 > poor eye contact T restlessness, or 3. use resources/ information. Active-listen 1. verbalize
am > increased I worry. A mild level of support systems concerns. awareness of
wariness O anxiety can mobilize effectively. ® Identification of specific feelings of anxiety,
> facial tension N a patient to take a fear helps patient to deal 2. identify healthy
> difficulty - position, act on the realistically with it. Patient ways to deal with
concentrating S task that needs to be may have misinterpreted and express anxiety,
E done, or learn to preoperative information or and

85
L alter lifestyle habits.
F When patients
- receive unwelcome
C news about results of
O diagnostic studies,
N they are sure to
C experience anxiety.
E (pp. 100,103,
P Smeltzer, Suzanne C.,
T and Bare, Brenda G.
Brunner &
P Suddarth’s Textbook
A of Medical-Surgical
T Nursing Volume 1.
T Lippincott Williams
E & Wilkins.
R Lippincott-Raven
N Publisher. 2004)
86
have misinformation 3. use resources/
regarding surgery. support systems
3. Provide preoperative effectively.
education, including visit
with OR personnel before
surgery when possible.
Discuss anticipated things
that may concern patient.
® Can provide reassurance
and alleviate patient’s
anxiety, as well as provide
information for formulating
intraoperative care.
Acknowledges that foreign
environment may be
frightening, alleviates
associated fears.
4. Compare surgery
schedule, chart, patient
identification band, and
signed operative consent.
 ® Provides for positive
identification, reducing fear
that wrong procedure may be
done.
5. Inform patient/ SO of
nurse’s intraoperative
advocate role.
® Develop trust/ rapport,
decreasing fear of loss of
control in a foreign
environment.
6. Introduce staff at time of
transfer to operating suite.
® Establishes rapport and
psychologic comfort.
7. Inform patient anticipating
spinal anesthesia that
drowsiness occurs, that more
sedation may be requested
and will be given if needed,
and that surgical drapes will

87
 block view of the operative
field.
® Reduces concerns that
patient may “see” the
procedure.
8. Give simple, concise
directions/ explanations to
sedated patient. Review
environmental concerns such
as personnel, machines and
instruments, as needed.
® Impairment of thought
processes makes it difficult
for patient to understand
lengthy instructions.
9. Encourage/ instruct in
mental imagery/ relaxation
methods; e.g., imaging a
pleasant place, use of music/
tapes, slow breathing, and
meditation.

88
 ® Promotes release of
endorphins and aids in
developing internal locus of
control, reducing anxiety.
May enhance coping skills,
allowing body to go about its
work of healing.
10. Prevent unnecessary
body exposure during
transfer and in OR suite.
® Patients are concerned
about loss of dignity and
inability to exercise control.

89
Date Cues Need Nursing Diagnosis Objectives Interventions Evaluation

J Subjective: A Activity intolerance Within the 8-hour 1. Monitor current potential January 15, 2009
A > “Dali lang ko C related to bed rest shift, the patient for desired activities @
N kapuyon,” as T secondary to will be able to: ® Provides baseline for 7:00 am
U verbalized by the I preeclampsia 1. perform at least planning activities and
A patient. V one activity of increased in activities. GOAL MET
R I ® Most activity daily living 2. Assist the patient with
Y T intolerance is related 2. learn and self-care activities as Within the 8-hour
14, Objective: Y to generalized demonstrate how needed. Let the patient shift, the patient was
2009 > observed - weakness and to do range of determine how much able to:
@ difficulty in E debilitation motion exercises assistance is needed. 1. comb her hair, eat
11:00 ambulation X secondary to acute or ® Allows the patient to have her food on her own
pm > grimaced face E chronic illness and some control and choice in 2. learn and
during ambulation R disease. This is plan; helps the patient to demonstrate how to
> respiratory rate C especially apparent gradually decrease the do range of motion
of 26 cpm I in older patients with amount of activity exercises.
> patient in supine S a history of intolerance.
position most of E orthopedic, 3. Monitor vital signs before
the time cardiopulmonary, and after activity.

90
P diabetic, or
A pulmonary-related
T problems. (p.7
T Gulanick, M. &
E Myers, J. L., Nursing
R Care Plans Nursing
N Diagnosis and
Intervention 6th
Edition. Mosby ,
2007)
91
® Vital signs increase with
activity and should return to
base line within 5-7 minutes
after activity. This allows
immediate action when
abnormalities take place in
the vital signs.
4. Encourage rest as needed
in between activities.
® Planned rest assists in
maintaining and increasing
activity tolerance.
5. Provide for a quiet, non-
stimulating environment.
® Allows proper resting
period for the patient’s body
to recuperate.
6. Encourage adequate
dietary intake.
® Provides adequate
nutrition to meet metabolic
 demands.
7. Collaborate with
physician regarding oxygen
therapy.
®Oxygen may be needed for
shortness of breath
associated with increased
activity.
8. Collaborate with a
physical therapist in
establishing a appropriate
exercise plan.
® Provides most
appropriate activities for the
patient.
9. Teach the client
appropriate exercise
methods to prevent injury.
® Basic safety measures to
avoid complicating
conditions.

92
 10. Encourage client to do
Range of Motion exercises.
® To promote proper blood
circulation, maintain muscle
tone and joint flexibility.

93
Date Cues Need Nursing Diagnosis
J S/O: A Self-care deficit
A C related to pain upon
N > observed T ambulation
U difficulty in I secondary to
A ambulation V pregnancy
R > grimaced face I within level of
Y during ambulation T ® Pregnancy
14, > oily hair Y involves anatomical
2009 > halitosis present - changes in a
@ > patient stays in E woman’s body,
11:00 bed most of the X particularly he
pm time E enlargement of the
R abdominal area to
C accommodate the
I growing fetus. This
S change leads to an
E increase in pressure
to the pelvic area of
Objectives Interventions Evaluation
Within the 8-hour 1. Assist the patient with January 15, 2009
shift, the patient self-care activities as needed. @
will be able to: Let the patient determine 7:00 am
1. perform self- how much assistance is
care activities needed. GOAL MET
® Allows the patient to have
own ability some control and choice in Within the 8-hour
2. learn verbalize plan; helps the patient to duty, the lient was
the importance of gradually decrease the able to:
proper hygiene. amount of activity 1. comb her hair
intolerance. 2. learn and
2. Provide extra time for verbalize the
giving daily care. importance of proper
® Instills trust, avoids hygiene.
overwhelming the patient,
facilitates self-motivation,
and allows immediate
feedback on self-care.
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P a woman’s body. Due
A to this, she
T experiences pain and
T discomfort whenever
E she move about, thus
R interfering with her
N activities of daily
living, including her
proper hygiene,
which then results to
inability to take care
of herself, otherwise
known as self care
deficit.
(Gulanick and
Myers, Nursing Care
Plans 6th ed.,
Pennsylvania, USA)
95
3. Provide privacy and safety
for the patient to practice
self-care.
® Avoids embarrassment for
the patient, provides basic
safety, and allows practice
under closely supervised
situation.
4. Collaborate with the
health care team for proper
management of pain.
® Pain plays a major role in
inhibiting the patient from
doing self-care activities.
Proper management of pain
helps in maximizing the
activities that the patient can
perform.
5. Provide positive
reinforcement for each self-
care accomplishments.
 ® Increases self-esteem and
motivation.
6. Perform ROM exercises.
® Increases circulation and
maintains muscle tone and
joint mobility.
7. Assist the patient in
planning measures to
overcome or adapt to self-
care deficits.
® Promotes care planning
and encourages
participation in care.
8. Monitor vital signs at least
every 4 hours.
® Baseline data needed to
validate progress.
9. Monitor bowel
elimination at least once
daily.
® Baseline data that assist

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 in determining bowel
functioning pattern.
10. Emphasize to the patient
the importance of proper
hygiene and how it affects
her health and the health of
the baby inside her.
® Increases awareness and
motivates the client to
perform self-care activities.

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 Recommendation

To the Patient:

In order for Ms. S to achieve full recovery, the researchers highly encouraged the
patient to maintain good nutrition by eating foods with roughage such as whole
grains, raw fruits, and vegetables and try to eat less food high in salt and fats.
Resumption of activities should also pace gradually to avoid any problems, strenuous
activities must be avoided and exercises or ADL’s should be done as tolerated.
Advised the importance of follow-up examinations and treatments for these will
promote faster recovery for the patient and possible complications that may arise will
be treated immediately.

To the Significant Others:

Ms. S’s family must understand the importance of early detection of illnesses; the
researchers would like to encourage them to have routine prenatal and postpartum check-
ups to avoid any further complications that may occur if not treated early. Consult a
doctor if unusualities occur to the patient so that proper medications may be prescribed to
treat the underlying condition. They must extend their support, for assistance and
guidance is a good way of helping the patient, and collaborate in plans to promote faster
recovery. Lastly, is to always have a healthy way of living, by doing such, the body is
more ensured that it is protected from any diseases

To our fellow Student Nurses:

In line with this case study, the researchers would like to emphasize to practice
teamwork and unity among the group so that better output will be formulated. Be
sensitive and respond to the needs of other group members and if you’re done with your
task, try to help the others and contribute something that would make the work better.
Being calm is always a good move. Fix the problems in a peaceful manner. Follow the set
schedule for this will promote organization within the group. Be open-minded to
suggestions and prevent intensive discussions so that healthy relationship within the
group will be maintained. Lastly be a role model to the patients we take care of.
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 Discharge Planning

Medicine:

a.) Encouraged client to take medications as prescribed by her physician.

b.) Teach patient of the different side and adverse effects of the drugs she is
taking such as drying of mouth, nausea and present of rashes.
c.) Report any unusualities when taking the prescribed drug such as nausea and
vomiting or skin allergies.
d.) Instruct her not to take other medications without consulting with her
physician to prevent any harmful drug-drug interactions.

Exercise:

a.) Encouraged the patient to do simple exercises as tolerated such as range of

motion exercises.

b.) Informed patient to refrain strenuous activities for up to 6 months.

c.) Encouraged patient to have adequate rest periods and sleep to promote faster
recovery.

Treatment:

1. Encouraged to increase in fluid intake to avoid drug side effects such as dry
mouth or constipation.
2. Encouraged the patient to comply with the medication as ordered by her
physician.
3. Explain the importance of adhering to her treatment regimen.

Hygiene:

a.) Encouraged patient to bathe if not contraindicated by her physician’s orders.

b.) Encouraged the patient to do ADL’s within the limits of her safety.
c.) Tell the patient to notify the physician immediately if there are unusualities.

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d.) Encourage him to follow all the instructions including medications, diet
regimen and do and don'ts that was instructed to him by the physician.
e.) Teach the patient to ensure rest for himself as much as possible

Out- patient referral:

a.) Inform the patient to have follow up check- ups to prevent further
complications and to update the medical team concerning the progress
of the patient’s condition and to promote continuity of care
b.) Advised patient to report any signs and symptoms or any unusualities
that may occur.
c.) Encourage him to comply with all the modifications and instructions
given to him.

Diet:

a.) Increase Oral fluid intake to 6-8 oz glasses of water per day.
b.) Eat less salty and fatty foods as this may increase her blood pressure.
c.) Eat foods with roughage such as whole grains, fruits, and vegetables to have
adequate nutrition.

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 Prognosis

Criteria Poor Fair Good Justification

Onset of / She had regular prenatal check-ups, which
Disorder helped in the early detection of her present
condition, at Tagum Doctors Hospital and
twice on CHDC, it was during her last
prenatal visit on January 6, 2009 that Dra.
Santos noted an increase in her blood
pressure. She was advised to monitor her
BP. After taking her BP with a company
nurse which was 160/100, she returned and
was diagnosed with pre-eclampsia on
January 9, 2006. She was given
methyldopa as her medication.
Duration of / It was only last Tuesday, January 6, 2009
Disorder that Ms. S was diagnosed with pre-
eclampsia and it was only on our last day
of duty, January 13, 2009 that she was
admitted at DMSF Hospital
Environmental / Ms. S is presently living with her
factors officemate Rosalie at a company
compound where she works. Although she
has no other people to take care of her,
aside from her officemate, she was able to
manage well.
Family Support / Although Ms. S is not yet married to her
partner, her parent looks forward to the
additional member in their family; they
fully support her in having her first baby.
Aside from her family, her partner also
looks forward as well.
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 Willingness to / Ms. S is well oriented to her medications
take medication and knows how essential they are for the
and treatment maintenance and supplement for her health
and for her unborn baby as well. She is
willing to be treated and had good
compliance to her doctor’s prescription.
Predisposing / Sex and being a primipara is the only
Factors predisposing factors present. Although
there is history of hypertension in her
family however hers is only pregnancy
induced.
Precipitating / The only precipitating factor present is
factors pregnancy and by definition pre-eclampsia
is a disease of a pregnant woman
CALCULATION:
LEGEND: RANGE:

Good- 3x5= 15 Poor=1

1.0-1.6
Fair- 2x2= 4
Fair=2 1.7- 2.3
Poor- 1x0= 0 Good=3

Total = 19/7 = 2.7 – Good

Prognosis is defined as how a patient is expected to do after the disease is

diagnosed. By computing several factors we can arrive at a certain conclusion on how
well she will cope. Based on the computations above, the researchers believe that the
client’s prognosis is good. The client may have been pre-eclamptic since she was
pregnant but with regular prenatal check-ups it was detected at an early stage and proper
medical interventions was given immediately.

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102
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13. http://en.wikipedia.org/wiki/Pre-eclampsia

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