Bukidnon State University COLLEGE OF NURSING Malaybalay City

A Case Presentation on PRE - ECLAMPSIA As Part of the Requirements in NCM 102 CARE OF MOTHER, CHILD, FAMILY AND POPULATION GROUP AT-RISK OR WITH PROBLEMS Submitted by: Alberto, Dani Michaela B. Antivo, Jovelyn L. Auguis, Fe B. Biao, Kathlene Joy O. Casite, Nielmark L. Gomez, Junfelm M. Jacutin, Sushmita Ann J. Jamis, Kieth G. Rellita, Jezza S. Submitted to: Hazel Paloma-Agbayani RN, MN Clinical Instuctor March 11-12, 2013

TABLE OF CONTENTS

I. Objectives II. Introduction III. Assessment a. Demographic Data b. History of Past illness c. History of Present illness d. Systems Involved IV. Anatomy and Physiology V. Pathophysiology VI. Actual Treatment a. Laboratory Exam b. Drug Study VII. Ideal Treatment a. Treatment b. Surgical Management VIII. Nursing Care Plan a. Actual Nursing Care Plan b. Ideal Nursing Care Plan IX. Discharge Plans X. Doctors Order XI. Prognosis XII. Research Update XII. References

I. OBJECTIVES General Objectives: During our 3-hour discussion, we will be able to present our case about PreEclampsia accordingly. This case presentation seeks to share and enhance our knowledge with regards to the patients general health condition and her needs. This also seeks to comprehend our skills through application of several nursing interventions and medical management. Furthermore, this case presentation intends to improve the students attitude by conveying open-mindedness and utilizing therapeutic communication all throughout the activity. Specific Objectives: During our 3-hour discussion, we aim to achieve the following objectives with regards to Pre-Eclampsia: 1. Present a thorough general health assessment of the client which includes physical assessment. 2. Correctly provide concise and complete information with regards to the patients condition. 3. Discuss an overview of Anatomy and Physiology of the Cardiovascular System, Exocrine System, Endocrine System, Integumentary System and Reproductive System. 4. Efficiently provide appropriate and proper nursing diagnosis in line with the clients medical condition. 5. Identify and discuss the ideal and actual nursing care plans for the different problems identified. 6. Skilfully formulate appropriate nursing interventions according to the standards of nursing practice. 7. Impart the outcome of the nursing interventions. 8. Convey the significance of clients response to the rendered nursing interventions. 9. Discuss the health teachings intended for the patient.

II. INTRODUCTION Pregnancy-induced hypertension (PIH) is a condition in which vasospasm occurs during pregnancy in both small and large arteries. Signs of hypertension, proteinuria, and edema develop. It is unique to pregnancy and occurs in 5% to 7% of pregnancies (Bailis & Witter, 2007). Despite years of research, the cause of the disorder is still unkonown although it is highly correlated with the antiphospholipid syndrome or the presence of antiphospholipid antibodies (Clark, Silver, & Branch, 2007). Originally it was called toxemia because researchers pictured a toxin of some kind being produced by a woman in response to the foreign protein of the growing fetus, the toxin leading to the typical symptoms. A condition separate from chronic hypertension, PIH tends to occur most frequently in women of color or with a multiple pregnancy, primiparas younger than 20 years or older than 40 years, women from low socioeconomic backgrounds, those who have had five or more pregnancies, those who have hydramnios, or those who have an underlying disease such as heart disease, diabetes, and essential hypertension PIH is classified as gestational hypertension, mild pre-eclampsia, severe preeclampsia, and eclampsia, depending on how far development of the syndrome has advanced. A woman has passed from mild to severe pre-eclampsia when her blood pressure rises to 160 mm Hg systolic and 110 mm Hg diastolic or above on at least two occasions 6 hours apart at bed rest or her diastolic pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample or more than 5g in a 24hour sample, and extensive edema are also present. With severe pre-eclampsia, the extreme edema is most readily palpated over bony surfaces, such as over the tibia on the anterior leg, the ulnar surface of the forearm, and the cheekbones, where the sponginess of fluid-filled tissue can be palpated against bone. In addition, symptoms of preeclampsia can include:

Rapid weight gain caused by a significant increase in bodily fluid Abdominal pain Severe headaches

A change in reflexes Reduced output of urine or no urine Dizziness Excessive vomiting and nausea The only real cure for preeclampsia and eclampsia is the birth of the baby. Severe

preeclampsia (blood pressure greater than 160/110) that occurs after 20 weeks of gestation in a woman who did not have hypertension before; and/or having a small amount of protein in the urine can be managed with careful hospital or in-home observation along with activity restriction. The group chose the case for the reason that they wanted to show the readers the process on how pre-eclampsia occurs and for them to fully understand and be reminded on one of the complications associated with pregnancy. III. ASSESSMENT A. Demographic Data Name: Mrs. Pre Eclampsia Sex: Female Age: 27 years old

Address: Purok-4 Kapitan Bayong, Impasug-ong Bukidnon Date of Birth: July 25, 1985 Nationality: Filipino Occupation: Housewife Dependents: John Harley Christian Lyka Charlyn and Charmaine Usual Source of Medical Care: Health Center Food Allergy: No known food allergy Drug Allergy: No known drug allergy Place of Birth: Lumbayao, Valencia City Civil Status: Married Religion: Roman Catholic 9 Year Old 7 Year Old 4 Year Old 1 Month & 11 days

Chief Complaint: Labor pains Date of Admission: January 27, 2013 Time of Admission: 4:50PM Vital signs upon admission: Temp: 36.4C BP: 120/80mmHg PR: 81 bpm RR: 21 cpm

Admitting Diagnosis: Pregnancy Uterine Full Term, Cephalic/Breech Multiple Pregnancy G4P3 (3003) Final Diagnosis: 1. G4P5 (4005) 2. Pregnancy Uterine Delivered Term Live Births Baby Girl I & II in BreechCephalic Presentation via Low Segment Transverse Caesarean Section for Multi fetal Pregnancy. Severe Pre-eclampsia. Baby girl I birth weight- 2.2 Kilogram, Baby girl II birth weight-2.4 Kilogram. Surgical Procedure: Low Segment Transverse Caesarean Section with Bilateral Tubal Ligation Date and Time of Operation: January 28, 2013 / 2:00 pm

Attending Physician: Gaye Emerald Oribello M.D

B. History of Past Illness Mrs. Pre-eclampsia completed her immunization during childhood. She experienced mumps when she was a child. She also experienced diarrhea, fever, cough, colds and she self-medicated it with over the counter medications like paracetamol and other medications before she became pregnant. When she was 16 year old she was admitted to the hospital due to accidental intake of kerosene. She stayed at the hospital for almost a week and then recovered. She had completed all her immunizations and including two shots of tetanus toxoid during her prenatal visits. She had no known food and drug allergies. C. History of Present Illness Seven hours prior to admission, the patient experienced labor pains. Four hours after, the midwife advised her to deliver the baby in the hospital because she had high blood pressure. The midwife called an ambulance to fetch her in their place. The patient arrived at Bukidnon Provincial Medical Center three hours after. She was admitted for further evaluation and tests. She manifested some problems such as headache that lasted for a minute and pain in the nape. Her Blood Pressure rose up to 180/120 mm Hg. The contractions lasted for about a minute until it became frequent. After being seen and examined by her attending physician, high blood pressure and pitting edema prior to her admission were noted. Environmental Factors

Mrs. Pre-Eclampsia resides at Purok-4 Kapitan Bayong, Impasug-ong Bukidnon. The family is composed of the parents and their three children respectively. Their house was made of bamboo walls, wooden floors and cellophane roof. The house is divided into two divisions, kitchen and room. The house is located near a slope. They were able to clean the house on a regular basis. They had a common source of water and comfort rooms which they shared with neighbors. The location of their house is not easily accessible to hospitals and also kilometers away from the health center. Socio-Economic and Cultural Factors Mrs. Pre-eclampsia is a plain housewife and her husband is a packer in a factory. She hasnt pursued her Secondary level due to financial constraints. Mrs. Pre-eclampsia was raised as a Roman Catholic where she learned her religious values but also, she still believes in superstitious beliefs. When it comes to health matters, she uses herbal medicines to treat any member of the family who has an ailment, but when serious matters arise she still refer it to health care providers for help. D. Systems Involved Cardiovascular/Circulatory System Objective Data: Temperature: Blood Pressure: 37C 160/100mmHg Radial pulse: Edema: Capillary refill: 88bpm Pitting 1 second

Nail bed color : Pink Subjective Data: Comments: The patient stated

Remarks: Patient has normal heart sounds and rhythm. Patient has high blood pressure accompanied by pitting edema. Nursing Diagnosis:

Integumentary System Objective Data: Skin: Warm and moist Turgor: Edema pinkish in color Temperature: 37C Subjective Data: Comments: The patient stated Capillary refill: 1 second

Hair: Nails:

Even distribution of hair Clean nails and

Remarks: Patient has normal skin color, temperature, hair distribution and nails. Patient is noted of pitting edema with disturbed skin integrity in abdomen. Nursing Diagnosis:

Elimination Objective Data: Mobility and Dexterity: Edema:

Ambulatory

Abdomen: Soft

Yes, Lower extremities

Urine Color: Subjective Data: Comments: The patient stated Remarks: Nursing Diagnosis:

Metabolic/Nutrition Objective Data: General Appearance: Blood Pressure: Radial pulse: Nail bed color : Capillary refill:

37C 160/100mmHg 88bpm Pink 1 second

Edema: Pitting Subjective Data: Comments: The patient stated Remarks: Patient has high blood pressure accompanied by pitting edema. Nursing Diagnosis:

Physical Assessment The Cephalocaudal assessment was done last February 25, 2013 1. Skin Brown skin in areas exposed to the sun When pinched, skin readily springs back to previous state

2. Head Absence of nodules or masses Symmetric facial features and movements Evenly distributed black hair

3. Cardiovascular Blood pressure of 130/90 mmHg Pulse rate of 90 bpm

4. Gastrointestinal/Abdomen Striae present at hypogastric and iliac regions Linea nigra present Presence of surgical incision

5. Reproductive Regular menstrual cycle Gravida 4 Para 5

IV. ANATOMY AND PHYSIOLOGY Cardiovascular System 1. Heart The heart is located within the bony thorax and is flanked on each side by the lungs approximately. The apex is directed toward the left hip and rests on the diaphragm, approximately at the level of the fifth intercostal space. Its base, from which the great vessels of the body emerge, points toward the right shoulder and lies beneath the second rib. The heart is divided into four chambers namely the two atria and two ventricles separated by the septums. There are three types of blood vessels: the arteries, the veins and the capillaries. An artery is a vessel that carries blood away from the heart and carries oxygenated blood. Small arteries are called arterioles. Veins, on the other hand are vessels that carries blood toward the heart and contains deoxygenated blood. Small veins are called venules. Lastly, capillaries are microscopic vessels that carry blood from small arteries to small veins (arterioles to venules) and back to the heart. The walls of the blood vessels, the arteries and veins have three main layers: tunica adventitia, tunica media and tunica intima. Tunica adventitia which is a fibrous

type of vessel is a connective tissue that helps hold vessels open and prevents tearing of the vessel wall during body movement. Tunica media permits changes of the blood vessel diameter. It allows the constriction and dilation of the vessels. Last but not the least is the tunica intima. Tunica intima, which in Latin means innercoat, is made up of endothelium that is continuous with the endothelium that lines the heart. In arteries, it provides a smooth lining. However in veins it maintains the one-way flow of the blood. The endothelium, which makes up the thin coat of the capillary, is important because the thinness of the capillary wall allows the exchange of materials between the blood plasma and the interstitial fluid of the surrounding tissues. There are two circulatory routes of blood as it flows through the blood vessels: the systemic and the pulmonary circulation. In systemic circulation, blood flows from the left ventricle of the heart through blood vessels to all parts of the body (except gas exchange tissues of lungs) and back to the atrium. In pulmonary circulation on the other hand, venous blood moves from the right atrium to right ventricle to pulmonary artery to lung arterioles and capillaries where gases exchange; oxygenated blood returns to the left atrium via pulmonary veins; from left atrium, blood enters the left ventricle. 2. Vasomotor Control Mechanism Blood distribution patterns, as well as BP can be influenced by factors that control changes in the diameter of arterioles. Such factor might be said to constitute the vasomotor control mechanism. Like most physiological control mechanisms, it consists of many parts. An area in the medulla called vasomotor center/ vasoconstrictor center will, when stimulated initiate an impulse outflow via sympathetic fibers that ends in smooth muscle surrounding resistance vessels, arterioles, and veins of the blood reservoir causing their constriction thus the vasomotor control mechanism plays an important role both in the maintenance of the general BP and in the distribution of blood to areas of special need. 3. Venous Return of the Blood Venous return refers to the amount of blood that is returned to the heart by the way of veins. Various factors influence venous return, including the operation of venous pumps that maintains the pressure gradients necessary to keep blood moving into the central veins and from there the atria of the heart. Changes in the total volume of blood

vessels can also alter the venous return. The return of venous blood to the heart can be influenced by the factors that change the total volume of blood in the circulatory pathway. Stated simply, the more the total volume of blood, the greater the volume of blood returned to the heart. The mechanism that change the total blood volume most quickly, making them most useful in maintaining constancy of blood flow, are those that cause water to quickly move into the plasma or out of the plasma. Most of the mechanisms that accomplish such changes in plasma volume operate by altering the bodys retention of the water. The primary mechanisms for altering the water retention in the body are the endocrine reflexes in the body. One is the ADH mechanism is released in the neurohypophysis and acts on the kidneys in a way that reduces the amount of water lost by the body. ADH does this by increasing the amount of water that kidneys reabsorb from urine before the urine is excreted from the body. The more ADH is secreted, the more water will be reabsorbed into the blood, and the greater the blood plasma volume will become. Another mechanism that changes the blood plasma volume is the renninangiotensin mechanism of aldosterone secretion. Renin is an enzyme that is released when the blood pressure in the kidney is low. Renin triggers a series of events that leads to the secretion of aldosterone. Aldosterone promotes sodium retention by the kidney, which in turn stimulates the osmotic flow of water to the kidney tubules back into the blood plasma- but only when ADH is present to permit the movement of water. Thus, low blood pressure increases the secretion of aldosterone, which in turn stimulates the retention of water and thus an increase in blood volume. Another effect of reninangiotensin is the vasoconstriction of blood vessels caused by an intermediate compound called angiotensin II. This complements the volume-increasing effects of the mechanism and thus also promotes an increase in overall blood flow. Precision of blood volume control contributes to the precision in controlling venous return, which in return yields to the precise overall control of blood circulation

Exocrine System

The exocrine systems main function is to regulate the volume and composition of body fluids and excrete unwanted materials, but it is not the only system in the body that is able to excrete unnecessary substances. 1. Kidneys The average-sized kidney measures around 12cm long, 6 cm wide, and 3cm thick. The left kidney is often larger than the right. The kidneys are highly vascular organs. Approximately, one-fifth of the blood pumped from the heart goes to the kidneys. The kidneys process blood plasma and form urine from waste to be excreted and removed from the body. These functions are vital because they maintain the homeostatic balance of the body. The kidneys maintain the fluid-electrolyte and acid-base balance. In addition, they also influence the rate of secretion of the hormones ADH and aldosterone. Microscopic functional units called nephrons make up the bulk of the kidney. The nephron is uniquely suited to its function of blood plasma processing and urine function. A nephron contains certain structures in which fluid flows through them and they are as follows: renal corpuscle, Bowmans capsule, proximal convulted tubule, Loop of Henle, distal convoluted tubule and the collecting tube. The Bowmans capsule is a cup-shaped mouth of a nephron. It is usually formed by two layers of epithelial cells. Fluids, electrolytes and waste products that pass through the porous glomerular capillaries and enter the space that constitute the glomerular filtrate, which will be processed in the nephron to form urine. The Glomerulus is the bodys well-known capillary network and is surely one of the most important ones for survival. Glomerulus and Bowmans capsule together are called renal corpuscle. The permeability of the glomerular endothelium increases sufficiently to allow plasma proteins to filter out into the capsule. Endocrine System The endocrine system performs their regulatory functions by means of chemical messenger sent to specific cells. The endocrine glands secrete their products, hormones, directly into the blood. There are two classifications of hormones: steroid hormones and non-steroid hormones. The steroid hormones which are manufactured by the endocrine cells from cholesterol, is an important lipid in the human body. Non-steroid hormones are

synthesized primarily from amino acids rather from the cholesterol. Non-steroid hormones are further subdivided into two: protein hormones and glycoprotein hormones. 1. Aldosterone Its primary function is the maintenance of the sodium homeostasis in the blood by increasing the sodium reabsorption in the kidneys. It is secreted from the adrenal cortex; it triggers the release of ADH which results to the conservation of water by the kidney. Aldosterone secretion is controlled by the rennin- angiotensin mechanism. 2. Anti-diuretic hormone (ADH) It is secreted in the neurohypophysis (posterior pituitary); it literally opposes the formation and production of a large urine volume. It helps the body to retain and conserve water from the tubules of the kidney and returned to the blood. Integumentary System Also called the integument which simply means covering, the skin is much more than an external body covering. It is absolutely essential because it keeps water and other molecules in the body. The skin has many functions; most, but not all, are protective. It insulates and cushions the deeper body organs and protects the entire body from mechanical damage, thermal damage, ultraviolet radiation, and bacteria. The uppermost layer of the skin is full of keratin and cornified in order to prevent water loss from the body surface. The skin is composed of two kinds of tissue. The outer epidermis is made up of stratified squamous epithelium that is capable of keratinizing. The underlying dermis is made up of dense connective tissue. Deep to the dermis is the subcutaneous tissue which anchors the skin to underlying organs. Subcutaneous tissue serves as a shock absorber and insulates the deeper tissues from extreme temperature changes occurring outside the body. Reproductive System The female reproductive system produces gametes may unite with a male gamete to form the first cell of the offspring. The female reproductive system also provides protection and nutrition to the developing offspring. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The next step for the fertilized

egg is to implant into the walls of the uterus, beginning the initial stages of pregnancy. If fertilization and/or implantation does not take place, the system is designed to menstruate. In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. The female reproductive anatomy includes parts inside and outside the body. The function of the external female reproductive structures (the genitals) 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 Labia minora: The labia minora lie just inside the labia majora, and surround the openings to the vagina and urethra.

Bartholin's glands: These glands are located beside 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.

Mons Pubis: A pad of adipose tissue located over the symphisis pubis, the pelvic bone joint. Its purpose is to protect the junction of the pubic bone from trauma.

Vestibule: Flattened smooth surface inside the labia.

The internal reproductive organs in the female include:

Vagina: The vagina is a canal that joins the cervix to the outside of the body. It also is known as the birth canal. Uterus : 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.

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 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 into the lining of the uterine wall. During the last few weeks of pregnancy, estrogen reaches their highest levels in

the mothers blood. This has two important consequences: it causes the myometrium to form abundant oxytocin receptors and it interferes with progesterones quieting influence on the uterine muscle. As a result, weak and irregular uterine contractions occur. These contractions, called Braxton Hicks contractions. As birth nears, two more chemical signals cooperate to convert these false labor pains into true labor. Certain cells of the fetus begin to produce oxytocin, which in turn stimulates the placenta to release prostaglandins. Both hormones stimulate more frequent and powerful contractions of the uterus. The combined effects of the rising levels of oxytocin and prostaglandins initiate the rhythmic expulsive contractions of true labor. Once the hypothalamus is involved, a positive feedback mechanism is propelled into action: stronger contraction cause the release of more oxytocin, which causes even more vigorous contractions, forcing the baby ever deeper into the mothers pelvis.

V. PATHOPHYSIOLOGY
Predisposing factors: Family history of Pre Eclampsia Socioeconomic Pre Eclampsia Precipitating factors: Multiple gestation Labor

status
Vasospasm

Reduced blood supply to organs

Vascular Effects Vasoconstricti on Poor organ perfusion Increased Blood Pressure

Kidney Effects

Interstitial Effects Diffusion of fluid from bloodstream into interstitial tissues Edema

Placenta effects Poor placental perfusion Reduced fetal nutrient and Oxygen supply

Decreased Glomeruli filtration rate & increased permeability of Glomeruli Increased serum blood urea nitrogen, uric acid and creatinine

Decreased urine output

Proteinuria

VI. ACTUAL TREATMENT OR MANAGEMENT A. Laboratory and Diagnostic Exams Date ordered 01/27/13 Laboratory and diagnostic CBC Results White cell count 17,900 Hemoglobin 11.2 Hematocrit 34.5 Platelet 364,000 Segmenters 89 Lymphocytes 11 January 23,2013 Ultrasound Normal findings 5,000-10,000/mm3 11.7-14.5 g/dl 34.1-44.3 volumes % 174,000-390,000 43.4-76.2 17.4-46.2 Significance

Twin, live, intrauterine pregnancy as described. Non-biometric parameters and suggestive of pulmonary maturity but fetus is not yet term. Single anterochondal placenta grade II. Normohydramnios. No growth discorday noted. Frank breech presentation -36 weeks and 4 days AOG -Single nuchal cord seen Cephalic presentation -36 weeks and 3 days AOG -No nuchal cord Single placenta is antherofundal in location, grade II maturity. General status: - Conscious, coherent, cooperative. Abdomen: -L1-breech L3-cephalic L4-engaged Pelvic exam: -Vagina-parallel, uterus-globular.

January 27, 2013

Physical exam

 January 27, 2013 Clinical Pelvimetry

Cervical length/dilatation/effacement: -8cm, STO, cephalic, 1st twin, 80% effaced. Cervical position: -anterior Presentation: -cephalic Membranes: -intact Adequate

B. Drug Study PO Medications

Name of drug Ranitidine

Classificatio n

Dose/ Frequency/ Route 50mg IVTT Q8 (on call)

Mechanism of action Completely inhibits action H2 at receptor site s of parietal cells, decreasing acid secretion.

Indication

Contraindication Contraindicated in patients hypersensitive to drug.

Nursing precaution Use cautiously in patients with Hepatic dysfunction. Adjust dosage in patients with impaired kidney function Use cautiously in women, patients in the perioperative period; and patients with hepatic or renal impairment, history of serious GI events of peptic ulcer disease, cardiac decompensation, Hypertension or coagulation disorders.

Ketorolac

Analgesic

30mg IVTT Q8 x 24

Unknown; may inhibit prostaglandin synthesis.

Short-term management of pain

Contraindicated in patients hypersensitive to drug and in those with a history of syndrome of nasal polyps, angioedema, bronhospastic reactivity, or allergic reaction to aspirin or other NSAIDS;in those with advance renal impairment; and in those at risk for renal failure as a result of volume depletion. Also contraindicated inpatients with a suspected or confirmed cerebrovascular bleeding, hemorrhage diathesis, and incomplete homeostasis. Not recommended for intrathecal or epidural

PO Medications

POSTOPERATIVE DRUGS

Name of drug Generic (Brand) Oxytocin

Classification

Dose/ Frequency/ Route 35 u and 20 u

Mechanism of action Synthetic form of an endogenous hormone produced in the hypothalamus and stored in posterior pituitary; stimulates the uterus, especially the gravid uterus just before the parturition, and causes myoepithelium of the lacteal glands to contract, which results in milk ejection in lactating women.

Indication

Contraindication

Nursing precaution

Hormone Oxytoxic

Lactation deficiency Antepartum; to initiate or improve uterine contraction s to achieve early vaginal delivery; stimulation or reinforcement of labor in selected cases of uterine inertia; management of inevitable or incomplete abortion; second trimester abortion. Postpartum; To pro produce uterine contraction during the third stage of labor and to control postpartum bleeding or hemorrhage.

Contraindicated Use cautiously with with significant renal impairment. cephalopelvic disproportion, unfavorable fetal positions or presentations, obstetric emergencies that favor surgical intervention, prolonged use in severe toxemia, uterine inertia, hypertonic uterine patterns, induction or augmentation of labor when vaginal delivery is contraindicated, previous cesarean section, pregnancy.

Name of drug Generic (Brand) Ketorolac

Classification

Dose/ Frequency/ Route 30mg IVTT Q8 x 24

Mechanism of action Unknown; may inhibit prostaglandin synthesis.

Indication

Contraindication

Nursing precaution

Analgesic

Short-term management of pain

Contraindicated in patients hypersensitive to drug and in those with a history of syndrome of nasal polyps, angioedema, bronhospastic reactivity, or allergic reaction to aspirin or other NSAIDS;in those with advance renal impairment; and in those at risk for renal failure as a result of volume depletion. Also contraindicated in patients with a with suspected or confirmed cerebrovascular bleeding, hemorrhage diathesis, and incomplete homeostasis. Not recommended for intrathecal or epidural administration because of its alcohol content.

Use cautiously in women, patients in the perioperative period; and patients with hepatic or renal impairment, history of serious GI events of peptic ulcer disease, cardiac decompensation, Hypertension or coagulation disorders.

Name of drug Generic (Brand) Ranitidine

Classification

Dose/ Frequency/ Route 50mg IVTT Q8

Mechanism of action Completely inhibits action H2 at receptor site s of parietal cells, decreasing acid secretion.

Indication

Contraindication

Nursing precaution

Anti ulcer agent

Duodenal and gastric ulcer (short term treatment)

Contraindicated in patients hypersensitive to drug.

Use cautiously in patients with Hepatic dysfunction. Adjust dosage in patients with impaired kidney function

Name of Classification Dose/ Mechanism of drug Frequency/ action Generic Route (Brand) Hydralazine Antihypertensive, 10mg Acts directly vasodilator(peripheral) IVTT on vascular smooth muscle to cause vasodilatation, primarily arteriolar, decreasing reticular resistance; maintenance or increases renal or cerebral blood flow.

Indication

Contraindication

Nursing precaution

Essential hypertension alone or in combination with other drugs.

Contraindicated with hypersensitivity to hydralazine, tartrazine (in 100 mg tablets marketed as Reducing apresoline); after load in CAD, mitral the treatment valvular of heart rheumatic heart failure, disease severe aortic (implicated with insufficiency, MI). and after valve replacement (doses up to 800mg tid)

Use cautiously with CVAs;increase intracranial pressure(drug-induced BP decrease increases risk of cerebral ischemia);severe hypertension with uremia; advanced renal damage; slow acytelators (higher plasma levels may be achieved)higher plasma levels may be achieved; lower dosage may be adequate);lactation,pregnancy,pulmonary hypertension

Name of drug Generic (Brand)

Classification

Dose/ Frequency/ Route

Mechanism of action

Indication

Contraindication

Nursing precaution

Name of drug Generic (Brand) Nifedipine

Classification

Dose/ Frequency/ Route

Mechanism of action Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibition of transmembrane calcium flow results in the depression of impulse formation in specialized cardiac pacemaker cells, in slowing of the velocity of conduction of the cardiac impulse, in the depression of myocardial contractility, and cardiac work, decreased cardiac energy consumption, and increased delivery of oxygen to myocardial cells.

Indication

Contraindication

Nursing precaution

Antianginal, 30 mg 1 tab, Antihypertensive, OD Calcium channel blocker.

Angina pectoris due to coronary artery spasm(Prinzmetals variant angina) Chronic stable angina (effortassociated angina) Treatment of hypertension Unlabeled uses: Anal fissures, urethral stones, topical use to improve wound healing, prevention of migraine, Reynaud phenomenon.

Contraindicated with allergy to nifedipine.

Use cautiously with lactation, pregnancy, HF, aortic stenosis. Allergy to nifedipine,pregnancy, Lactation. Skin lesions, color, Edema; orientation, reflexes;P,BP,baseline ECG,auscultation;R, Adventitious sounds.

Name of drug Generic (Brand) Tramadol

Classification

Dose/ Frequency/ Route 1 tab 3x day for 5 days,PO

Mechanism of action

Indication

Contraindication

Nursing precaution

Analgesic

Unknown; Moderate-toCertainly acting moderately severe synthetic analgesic pain. Compound not Chemically related To opioids that is thought to bind to opioids receptors and inhibit reuptake to nor epinephrine and serotonin.

Contraindicated in patients hypersensitive to drug and in those with acute intoxication from alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs.

Use cautiously in patients at risk for seizures or respiratory depression; patients with increased intracranial pressure or head injury, acute abdominal conditions, or renal hepatic impairment; and patients physically dependent on opioids.

OTHER MEDS. GIVEN:

Name of Classification Dose/ Mechanism drug Frequency/ of action Generic Route (Brand) Clindamycin Lincosamide 300mg cup Inhibits antibiotic 3x day for protein 7 days synthesis in susceptible bacteria, causing cell death.

Indication

Contraindication

Nursing precaution

Topical dermatologic solution: Treatment of acne vulgaris. Systemic administration: Serious infections caused by susceptible strains of anaerobes, streptococci, staphylococci, pneumococci; reserve use for penicillin is inappropriate; less toxic antibiotics (erythromycin) should be considered. Vaginal

Contraindicated with allergy to clindamycin, lactation.

Use caution with history of regional enteritis or ulcerative colitis; history of antibiotic associated colitis. Allergy to clindamycin, history of asthma or other allergies, hepatic or renal impairment; lactation; history of antibioticassociated colitis. Site of infection or acne; skin color,lesions;BP,R,adveventitous sounds; bowel sounds,output,liver evaluation; complete blood count,LFTs,renal function tests

preparation: Treatment of bacterial vaginosis.

VII. IDEAL TREA

VII. IDEAL TREATMENT AND SURGICAL MANAGEMENT A. Treatment 1. Normal vaginal delivery It involves the birth of the baby and the delivery of the placenta from the uterus and through the cervix and vagina. This process results from the contraction of the uterus during labor. Most women deliver 38 to 40 weeks after becoming pregnant (conception).Some vaginal deliveries incorporate additional assistance to assist vaginal delivery by using forcep or vacuum extraction applied to babies head. B. Surgical Management 1. Cesarean birth It is a form of birth accomplished through an abdominal incision into the uterus. It is one of the oldest types of surgical procedures known. It is always slightly more hazardous than vaginal birth, but compared with other surgical procedures, it is one of the safest types of surgeries and or with few complications. Cesarean birth could be scheduled cesarean birth, or emergency cesarean birth. Classic cesarean incision The incision is made vertically through both the abdominal skin and the uterus to avoid cutting the placenta. Low segment incision or low transverse incision The incision made horizontally across the abdomen just over the symphysis pubis and also across the uterus just over the cervix. Also, the most common type of cesarean incision, referred to as a, bikini incision. 2. Tubal ligation The fallopian tubes are occluded by cautery, crushing, clamping or blocking, thereby preventing passage of both sperm and ova. It is also considered a permanent method of sterilization and birth control. 3. Ultrasound Painless diagnostic procedure in which pictures of internal tissue and organs are produced by high frequency sound waves.NS

DATA

NURSING Diagnosis

OBJECTIVES

Ineffective tissue After 8 hours of perfusion nursing related to intervention vasoconstricti s, the on of blood patient will vessels be able to maintain normal blood pressure.

NURSING INTERVENTIO NS INDEPENDENT: 1. Support bed rest

RATIONALE

EVALUATION

Bed rest provide, relaxation to the patient, and it prevents from any stress that may trigger to increase the patients blood pressure To detect any increase, which is a warning that patients condition is worsening To allow accurate recording of output and comparison with intake; urinary output should be more than 600mL/24hrs (>30mL/hr). A 24hr urine sample may be collected to evaluate kidney function; mild pre-eclampsia 0.5g protein/24hrs , and severe pre-eclampsia 5g/24hrs

2. Monitor maternal well being. Take blood pressure frequently. 3. Monitor output by inserting urinary catheter; and measure urinary proteins and specific gravity

4. Support a nutritious diet

Patient needs a diet moderate to high in protein and moderate in sodium to compensate for the protein lost in the urine.

IX. DISCHARGE PLANS As the patient was about to be discharged, our group recommended the following health teachings to our client: Adequate rest

Advised patient to have adequate sleep (6-8 hours). Refrain doing strenuous activities like lifting heavy objects such as fetching water. Advised client to take her medications regularly. Implement ROM exercises Eat nutritious foods especially those low in fat and sodium s u c h a s f r u i t s , m i l k a n d vegetables.

Health Teachings MEDICATION: Continue taking medications which includes the following: Nifedifine 30mg 1 tab OD Ascorbic acid 1 tab OD Multi. Vitamins + Fe 1 tab OD (Supplement) Clindamycin 300mg 1 cap 3days (Antibiotic for pain , for 7 days) Tramadol w/ Paracetamo 1 tab 3x day for 5days

EXERCISE: Do Activities of Daily Living (ADLs) as tolerated. Instructed the client to limit the ascending stairs for at least first week after delivery at home. Instructed the client to avoid strenuous activities and practice deep breathing exercise

TREATMENT: Do daily dressing at home and follow-up after 1 week at OPD Advised client to monitor blood pressure

Instructed patient to take prescribe medications Instructed the patient to take a bath everyday Educated patient on expected lochial discharge.

OUT-PATIENT: DIET: Instructed the client to go on follow-up check-ups Recommended client to attend counseling seminars to assist her in coping with her daily life Instructed the patient to take a balance diet w/ high protein, low fat, and low sodium. Instructed the patient to increase fluid intake.

X. DOCTORS ORDER

DATE DOCTORS ORDERS January 27, 2013 5:00 PM Admit under OB

RATIONALE -To monitor patient condition and to identify some problems regarding to the mother and fetal health before and after delivery. -To prepare the GI tract -To monitor any abnormalities within the hospital admission -For the patient to be aware for any actions that may be performed while she is in the ward -To find out if there are abnormal findings regarding the patient. -To balance fluid volume in the body -To prepare the patient for delivery. -To monitor heart rate activity of the fetus. -To report any unusualities and complications during labor will happen. -Reduces BP mainly by direct effect on vascular smooth muscles or arterial resistance vessels, resulting in vasodilation. -To prevent increase of BP -To monitor the rising of blood pressure and to anticipate actions. -To deliver the baby as soon and as safe as possible -To prepare the patient for cesarean section - to prepare patient for cesarian section - Prophylaxis in cesarean section -To monitor the patient output -To prepare patient for operation. -To prepare patient for

NPO TPR q 4* hr. Secure consent

Labs CBC, UA, HBSAG, BLOOD TYPE, stat Start IV; D5LR 1L @ 30 gtts/min To Labor Room FHT q hourly Refer accordingly

8:00 PM

Hydralazine 10 mg IVTT now

10:00 PM

Start hydralazine drip D5W 250 cc + 2 days form @ 20 gtts/ min BP q 30*min, refer it > 160/100 Monitor FHT Schedule for E CS Refer for OR and Anesthesia Secure 1 u FBC for OR use Ampicillin 1g IVTT, must give once q 6* h Insert FBC attached to Urobag

10:45 PM

XI. PROGNOSIS The outlook for full recovery from preeclampsia is very good. Most women begin to improve within one to two days after delivery, and blood pressure returns to the normal pre-pregnancy range within the next 6 to 12 weeks. Prenatal care can dramatically reduce the complications and deaths of preeclampsia, because women who are diagnosed while preeclampsia is mild can receive treatment without any delay. Between 5% and 8% of pregnant women in the United States develop preeclampsia. Progress in treating eclampsia has saved the lives of both mothers and their newborns. In the United States and Britain, between 1% and 2% of women who developed eclampsia die and 3% of their babies die during or shortly after birth. The maternal death rate from eclampsia in locations where health care is not easily available can exceed 13%. Risks to the fetus from preeclampsia include intrauterine growth retardation and low birth weight, placental abruption, and stillbirth. The fetus may be delivered prematurely if the condition of the mother deteriorates. Risks to the mother include vascular organ damage; the additional risks of eclampsia include convulsions and accompanying oxygen deprivation, hemorrhage in the brain, temporary blindness, permanent neurological damage, liver or kidney damage, cerebrovascular and cardiovascular complications, and even death. The prognoses for both the fetus and mother are excellent in mild preeclampsia. If blood pressure readings are within normal limits after several weeks postpartum, the mother may still be at increased risk of hypertension later in life, and should have her blood pressure checked yearly. The long-term prognosis for children born to preeclamptic mothers is not yet known. These individuals do, however, appear to be at increased risk of chronic disease in adult life. Sign and symptoms of preeclampsia usually go away within 6 weeks after delivery. However, the high blood pressure sometimes gets worse the first few days after delivery. If you have had preeclampsia, you are more likely to develop it again in another pregnancy. However, it is not usually as severe as the first time. If you have high blood pressure during more than one pregnancy, you are more likely to have high blood pressure when you get older.

XII. RESEARCH UPDATE RESEARCH UPDATES

One in 20 Cases of Pre-Eclampsia May Be Linked to Air Pollutant Feb. 6, 2013 One in every 20 cases of the serious condition of pregnancy, preeclampsia, may be linked to increased levels of the air pollutant ozone during the first three months, suggests a large study published in the online journal BMJ Open. Mothers with asthma may be more vulnerable, the findings indicate. Thousands of women and babies die or get very sick each year from a dangerous condition called preeclampsia, a life-threatening disorder that occurs only during pregnancy and the postpartum period. Preeclampsia and related disorders such as HELLP syndrome and eclampsia are most often characterized by a rapid rise in blood pressure that can lead to seizure, stroke, multiple organ failure and death of the mother and/or baby. Pre-eclampsia is characterised by raised blood pressure and the presence of protein in the urine during pregnancy. It can cause serious complications, if left untreated. The authors base their findings on almost 121,000 singleton births in Greater Stockholm, Sweden, between 1998 and 2006; national data on the prevalence of asthma among the children's mothers; and levels of the air pollutants ozone and vehicle exhaust (nitrogen oxide) in the Stockholm area. There's a growing body of evidence pointing to a link between air pollution and premature birth, say the authors, while pregnant women with asthma are more likely to have pregnancy complications, including underweight babies and pre-eclampsia. In all, 4.4% of the pregnancies resulted in a premature birth and the prevalence of preeclampsia was 2.7%. There was no association between exposure to levels of vehicle exhaust and complications of pregnancy, nor were any associations found for any air pollutants and babies that were underweight at birth. But there did seem to be a link between exposure to ozone levels during the first three months of pregnancy and the risk of premature birth (delivery before 37 weeks) and preeclampsia, after adjusting for factors likely to influence the results and seasonal variations in air pollutants, although not spatial variations in exposure. Each rose by 4% for every 10 ug/m3 rise in ambient ozone during this period, the analysis indicated. XIII. REFEERENCES Pilliteri, Adele.

Maternal and Child Health Nursing: Care of the childbearing and childrearing family/Adele Pilliteri. 6th edition. Copyright 2010 Lippincott Williams & Wilkins. ISBN 9781451108798 Marieb, Elaine. Essentials of Human Anatomy and Physiology, 7th edition by Marieb, Elaine N., Published by Pearson Education Inc., Copyright 2003. San Francisco, CA 94111 Original ISBN 0805353860 Doenges, Marilynn Nursing care plans : guidelines for individualizing client care/ Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr.-Ed. 7. ISBN 080361294X. Copyright 2006 by F.A. Davis Company Wilson, Billie Ann Prentice Halls Nurses Drug Guide 2004, 1st Edition by Wilson, Billie Ann; Shannon, Margaret, Stang, Carolyn. Published by Pearson Education Inc. Copyright 2004 Doenges, Marilynn Nurses Pocket Guide : Diagnoses, Prioritized Interventions, and Rationales/ Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr.-Ed. 7. ISBN 9789746520423. Copyright 2008 by F.A. Davis Company