Sie sind auf Seite 1von 40

CONTENTS

TABLE OF CONTENTS

I. INTRODUCTION 3
II. DATABASE AND HISTORY 6
III. NURSING SYSTEMS REVIEW CHART 7
IV. DEVELOPMENTAL DATA 18
V. MEDICAL MANAGEMENT 20
VI. PATHOPHYSIOLOGY 22
VII. DRUG STUDY 24
VIII. NURSING MANAGEMENT 27
IX. REFERRALS AND FOLLOW UP 38
X. EVALUATION AND IMPLICATIONS 38
XI. BIBLIOGRAPHY 39

Page | 1
I. INTRODUCTION
Overview of the Case

In the case of Mrs. Irene O. Cabasag, 39 years old from Tambaling 11, Bolobolo,
El Salvador, Misamis Oriental, she was admitted to Northern Mindanao Medical Center
(A2F1-OB-WARD 7 Service Ward - Bed 5) last December 6, 2013 at 7:00pm with a
chief complaint: 3 days prior to admission, patient had onset of headache associated
with dizziness and epigastric pain condition tolerated, no consult done. Her
admissiondiagnosis is: Pregnancy uterine, 31 5/7 weeks age of gestation, chronic
hypertension with superimposed preeclampsia severe, G2P1(1001). Her principal
diagnosis is: Pregnancy Uterine Pre Term, cephalic presentation delivered to a live
premature baby girl APGAR 9, BW 2.4kg, via Normal Spontaneous Vaginal Delivery.

What Is Chronic Hypertension?

There are 2 types of chronic hypertension: essential hypertension and secondary


hypertension. We do not know the cause of essential hypertension, but because
hypertension commonly runs in families, we know that genes are involved. A minority of
individuals has secondary hypertension, which means that the hypertension is
explained by another condition such as kidney disease, narrowing of the artery to the
kidney, and adrenal tumors. In many such cases, the hypertension will resolve after
treatment for the underlying problem. If you are undergoing evaluation for a secondary
form of hypertension, it is advisable to be treated for the underlying condition before
becoming pregnant. A third type of hypertension is called pregnancy-induced
hypertension. Some women develop new-onset hypertension in pregnancy, which can
present in the second half of pregnancy, usually in the third trimester.

What Are Some of the Complications of Chronic Hypertension During


Pregnancy?

Most women with chronic hypertension do well in pregnancy. In normal


pregnancy, blood pressure falls at the end of the first trimester and then increases to
pre-pregnancy values in the third trimester. For the majority of women with chronic

Page | 2
hypertension, blood pressure follows the same pattern. Some women, however,
experience a rise in blood pressure during pregnancy, which can increase their risk for
stroke and other complications and may therefore require more aggressive
antihypertensive treatment. A healthcare professional should monitor you to ensure that
a hypertension-related complication does not develop.

A more worrisome complication of chronic hypertension is the development of


superimposed preeclampsia. Preeclampsia is a serious condition that can affect many
organ systems and cause liver dysfunction, kidney failure, and an increase in bleeding
tendency, and at times it can progress to eclampsia seizures. Superimposed
preeclampsia is more likely to occur in women who have poorly controlled hypertension,
underlying renal disease, and diabetes mellitus. At present, there is no treatment for
preeclampsia except for delivery of the baby; therefore, babies of women who have this
condition are frequently born prematurely. Another complication of chronic hypertension
that may cause premature birth is placental abruption. An abruption is an early
separation of the placenta from the wall of the uterus, usually leading to strong
contractions, bleeding, and early delivery.

Objective

The objective of making this case study is to identify the problem of our patient and to
determine the factors that contribute to this kind of disease so that specific actions
should be done and rendered to our patient. The group has selected the patient having
this kind of disease because the primary concept that should fit our study is all about
abnormalities pertaining obstetric and gynecologic nursing. Having this kind of case
study is a privilege for us because it would be a good learning process by adding new
knowledge and concept about different kinds of diseases that may be present in some
patients. By making this case study we can identify the disease step by step, its nature
on how this disease occur, and nursing actions that would be appropriate for the patient.

Page | 3
SCOPE and LIMITATIONS of the STUDY

The study was conducted at Northern Mindanao Medical Center Delivery Room and OB
Ward, Cagayan de Oro City in which observation, analyzing and understanding the
patients condition was done. We were only given 24hours on understanding patients
problem. The study is also limited to the condition of the patient, which are chronic
hypertension with super imposed pre-eclampsia and its effect during pregnancy. The
study focuses only on obtaining the patients profile, health history and present health
condition; assessing, recording, and gathering of pertinent data about the patient.
Estimating the nursing needs and coping capacity of the patient. Finding the primary
health problems of the patient and the appropriate nursing interventions to solve the
condition of the patient. The objectives, nursing care plans, doctors order, and drug
study evaluation for the patient also done in this study.

Page | 4
II.DATA BASE AND HISTORY

Our Patient is Irene O. Cabasag, 39 years old married femaleform Tambaling 11,
Bolobolo, El Salvador, Misamis Oriental. G2P1with an LMP of May 28, 2013 and an
EDC of February 4, 2014. Her AOG is 315/7weeks and was admitted due to onset of
headache associated with dizziness and epigastric pain.

While at the Delivery Room her BP was fluctuating from 180/110 to 200/120
mmHg.Patient Cabasag had herfirst child in 1997 with NSVD, few years after she
developed hypertension.

During her assessment in the labor room, her fundal height was 27cm. FHB was
taken and recorded at 160 BPM RUQ. Internal examination was done. The patient was
in active labor. In her ultrasound report, her diagnosis is:

Pregnancy Uterine, 29 weeks and 5 days by fetal biometry, singleton, live,


cephalic in presentation.
Postero-fundal placenta, grade II.
Adequate Amniotic Fluid
Estimated Fetal weight of 1651.22 grams

Her admitting diagnosis was Pregnancy uterine, 31 5/7 weeks age of gestation,
chronic hypertension with superimposed preeclampsia severe, G2P1 (1001)

She had previous NSVD deliveryin 1997. Coughs and colds with few bouts were
also experienced with the date not specifically recalled. She takes OTC medications for
common ailments like biogesic for fever and alaxan for pain reliever.

Upon interview her hypertension started with her second pregnancy and upon
further investigation she had a heredo-familial history of hypertension on her mothers
side.

The physician in charge of Mrs. Cabasag is Dr. Brobo.

Page | 5
III. NURSING SYSTEM REVIEW CHART

Name ofPatient: Irene O. Cabasag Date of Assessment: December 10, 2013


Body Measurements:
Weight: 67 Kg Height: 52

Vital Signs upon Assessment:


Temp: 37C PR: 106bpm RR: 24cpm BP: 160/100 mmHg

Blurred Vision
EENT
Facial Edema
[ ] Impaired Vision [ ] Blind [ ] Pain
BP 160/100
[ ] Reddened [ ] Drainage [ ] Gums
Tachypnea
[ ] Impaired Hearing[ ] Deaf [ ] Burning Epigastric Pain
[X] Edema [ ] Lesions [ ] Teeth Tachycardia
Assess Eyes, Ears, Nose, Proteinuria
and throat for any abnormalities Vaginal Bleeding
[ ] No Problem Episiotomy

Hyperreflexia
RESPIRATORY
[ ] Asymmetrical [X] Tachypnea[ ] Apnea Significant lower
extremities edema
[ ] Rales [ ] Cough [ ] Barrel Chest
[ ] Bradypnea [ ] Shallow [ ] Rhonchi
[ ] Sputum [ ] Diminished[ ] Dyspnea
[ ] Orthopnea [ ] Labored [ ] Wheezing
[ ] Pain [ ] Cyanotic
Assess respiration, rate, rhythm, depth, pattern,
breath sounds, comfort
[X] No Problem

Page | 6
CARDIOVASCULAR
[ ] Arrhythmia [X] Tachycardia [ ] Numbness
[ ] Diminished Pulse[ ] Edema [ ] Fatigue
[ ] Irregular [ ] Bradycardia [ ] Mur-mur
[ ] Tingling [ ] Absent Pulse [ ] Pain
Assess heart sounds, rate, rhythm, pulse, blood pressure,
circulation, fluid retention, comfort
[ ] No Problem

GASTROINTESTINAL
[ ] Obese [ ] Distension[ ] Mass Confused

[ ] Dysphagia[ ] Rigidity [X] Pain


Assess abdomen, bowel habits, swallowing,
bowel sounds, Comfort.
[ ] No Problem

GENITO URINARY and GYNE


[X] Pain [X] Urine Color [X] Vaginal Bleeding
[ ] Hematuria [ ] Discharges [ ] Nocturia
Assess Urine frequency, control, color, odor, comfort, Gyne Bleeding,
Discharges
[ ] No Problem

NEUROLOGIC
[ ] Paralysis [ ] Stuporous [ ] Unsteady
[ ] Seizure [ ] Lethargic [ ] Comatose
[ ] Vertigo [ ] Tremors [X] Confused
[X] Vision [ ] Grip
Assess motor function, sensation, LOC, Strength, Grip, gait, coordination,
Speech
[] No Problem

Page | 7
MUSCULOSKELETAL and SKIN
[ ] Appliance [ ] Stiffness [ ] Itching
[ ] Petechiae [ ] Hot [ ] Drainage
[ ] Prosthesis[ ] Swelling [ ] Lesions
[ ] Poor Turgor[ ] Cool [ ] Deformity
[ ] Wound [ ] Rash [ ] Skin Color
[ ] Flushed [ ] Atrophy [ ] Pain
[ ] Echymosis [ ] Diaphoretic[ ] Moist
Assess mobility, motion gait, alignment, joint function, Skin color, texture, turgor,
integrity
[X] No Problem
Place an (X) in the area of abnormality. Comment at the space provided. Indicate the
location of the problem in the figure if appropriate, using (X).

Page | 8
NURSING ASSESSMENT II

SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] Hearing Loss Comments: [ ] Glasses [ ] Languages
[X] Visual Changes Ambot di ko ka [ ] Contact [ ] Hearing Aide
[ ] Denied klaro. As Lens [ ] Speech Difficulties
verbalized by the
client. Pupil Size: R_3mm _ L _3mm__

Reaction: _PERRLA (Pupil Equally Round


& Reactive to Light Accommodation
OXYGENATION:
[ ] Dyspnea Comments: Respiration: [ ] Regular [X] Irregular
[ ] Smoking History Dili man pud ko Pt. has a condition of rapid
__ gapaninigarilyou Describe: breathing (Tachypnea)
_______________ g di pudko ga-
[ ] Cough lisudbahinsapag R: Symmetric to left; full chest
[ ] Sputum -ginhawa. As expansion
[X] Denied verbalized by L: Symmetric to right; full
the client. chestexpansion
CIRCULATION: Heart Rhythm: [ ] Regular [X] Irregular
[ ] Chest Pain Comments: Ankle Edema:Patient has 1+ mild pitting,
[X] Leg Pain Gasakitdapit sa slight indentation, no perceptible swelling of
[X] Numbness of akong tiyan og the leg
__ extremities akong tiil oi As
[ ] Denied verbalized by Pulse Car Rad DP Fem*
the client. Right + 106bpm + +
Left + 106bpm + +

Comments Pulses on both left and right

Page | 9
: are present and palpable
NUTRITION:
Diet: Low salt, Low fat [ ] Dentures [X] None
[ ]N [ ]V Comments:
Character dili man
_________________ pudkokabatiugka With
Full Incomplete
[ ] Recent change in sukaonlabinanuo Patient
weight, appetite nsapagsuka. As X
[ ] Swallowing verbalized by the Upper
difficulty client. X
[X] Denied Lower
ELIMINATION:
Usual bowel pattern: [ ] UrinaryComments: Bowel sounds:
Thrice a day Frequency No _normoactive 10 bowel sounds
[ ] Constipation 15 times/day abdominal per minute__
__ Remedy [ ] Urgency tenderness Abdominal Distention:
Papaya [ ] Dysuria upon Present: [X]Yes [ ]No
__ Date of last BM [ ] Hematuria palpation.
Dec. 6, 2013 [ ] Incontinence Urine:
[ ] Diarrhea [X] Polyuria Color: Yellowish
__ Character [ ] Foly in place Odor: Foully
[] Denied Consistency:

MGT. OF HEALTH & ILLNESS:


[ ] Alcohol [X] Denied Briefly describe the patients ability to follow
__ Amount & Frequency treatments (diet, meds, etc.) for chronic
Dili sad koga-inom.as problems (if present).
verbalized by the client The patient is following the instructions that
SBE Last Pap is given to her and takes her medications
Smear: religiously.

Page | 10
LMP: May 28, 2013

SKIN INTEGRITY:
[ ] Dry Comments: [ ] Dry [X] Cold [ ] Pale
[ ] Itching okra man, dili man [ ] Flushed [ ] Warm
[ ] Other kogapangatol . As [ ] Moist [ ] Cyanotic
[X] Denied verbalized by the *Rashes, ulcers, decubitus (describe size,
client. *location, drainage):
No rashes, ulcers, or decubitus noted;
striaegravidarum&linea negra were
observed.
ACTIVITY/SAFETY
: Comments: [ ] Level of Consciousness and Orientation
[ ] Convulsion Kalipongon ko The client is awake and coherent
[X] Dizziness molakaw. As __ Gait: __ Walker __ Cane __ Other
[X] Limited motion verbalized by the __ Gait: __ Steady
of joints client. __ Gait: _X_ Unsteady: _______________
[ ] Sensory and motor losses in face or
Limitation in ability extremities:
to: No sensory and motor loses on face and
[X] Ambulate extremities noted.
[ ] Bathe Self
[ ] Other
[ ] Denied [X] Range of Motion Limitations:
Client cannot move her legs well

[X] Facial Grimaces


[ ] Guarding

Page | 11
[X] Other Signs of Pain:
Patient is complaining of epigastric
pain

[ ] Siderail release form signed (60+ years)


COMFORT/SLEEP/AWAKE: None (N/a)
[X] Pain Comments:
Location: Dili kayo ko
Pelvic region katulog tarong
Frequency: sakit ako pus-on.
8/10 as verbalized by
Remedies: the client.
Alaxan/Biogesic
[ ] Nocturia
[X] Sleep Difficulties
[ ] Denied
COPING:
Occupation: Housewife Observe non-verbal behavior:
Members No eye contact during the assessment.
of Patient was grouchy at the time of interview.
household: Husband and
children The person and his phone number that can
Be reached anytime:
Most Not on record
supportive
person: Husband

Page | 12
SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)
Not OrderedDaily Weight Not OrderedPT/OT__________
Not OrderedBP q Shift Not OrderedIrradiation
Not OrderedNeuro VS 12/06/2013 Urine Test: Protein Trace
Not OrderedCVP/SG. Reading Not Ordered24 hour Urine Collection
Date Diagnostic/ Date Done Date I.V. Fluids/ Blood Date Disc.
ordered Laboratory Ordered
Exams
11/06/2013 Ultrasound 11/06/2013 12/06/2013 D5LR 1L 12/07/2013
@30gtts/min
12/06/2013 Blood Chem 12/06/2013 12/07/2013 PNSS 1L + 40 12/07/13
mEq s KCl
@30gtts/min
12/06/2013 Urinalysis 12/06/2013 12/09/2013 D5LR 1L Ongoing
@20gtts/min
12/08/2013 CBC 12/08/2013

LABORATORY TEST RESULT AND INTERPRETATION:

BLOOD COUNT RESULT:

Test Result Unit Expected Values

White Blood Cells 11.68 x10^3/uL 5.0 10.0

Red Blood Cells 3.67 x10^6/uL 4.2 5.4

Hemoglobin 11.2 g/dL 12.0 16.0

Hematocrit 32.5 % 37.0 47.0

Platelet 8.9 fL 9.0 16.0


Distribution Width

Monocyte 11.0 % 4.5 10.5

Page | 13
WHITE BLOOD CELL COUNT: is a blood test to measure the number of white blood
cells (WBCs).

- The white blood cell count of patient Cabasag was greater than the expected value
of or the normal value of white blood cell we have to our body.

- The white cell count (the number of cells in a given amount of blood) in someone
with an infection often is higher than usual because more WBCs are being produced or
are entering the bloodstream to battle the infection.

After the body has been challenged by some infections, lymphocytes "remember" how
to make the specific antibodies that will quickly attack the same germ if it enters the
body again.

RED BLOOD CELL COUNT: is a blood test that tells how many red blood cells (RBCs)
you have.

- The red blood cell count of patient Cabasag was less than the expected value of or the
normal value of red blood cell we have to our body.

- Red blood cells carry oxygen to all parts of your body. When your red blood cell (or
hemoglobin) count is low, parts of your body do not get enough oxygen to do their work.
This condition is called anemia and can make you feel very tired.

HEMOGLOBIN: is a protein in red blood cells that carries oxygen. A blood test can tell
how much hemoglobin you have in your blood.

-The hemoglobin of patient Cabasag was less than to the expected value or normal
result.

HEMATOCRIT: is a blood test that measures the percentage of the volume of whole
blood that is made up of red blood cells. This measurement depends on the number of
red blood cells and the size of red blood cells.

-The hematocrit of patient Cabasag was lesser than the expected value of a normal
result.

PDWCOUNT: Platelet Distribution Width is an indication of variation in platelet size,


which can be a sign of active platelet release.

-The PDW of patient Cabasag was lesser than the expected value of a normal result.

Page | 14
MONOCYTE COUNT:This test measures the amount of monocytes in blood.
Monocytes are a type of white blood cell (WBC). This test is used to evaluate and
manage blood disorders, certain problems with the immune system, and cancers,
including monocytic leukemia. This test may also be used to evaluate for the risk of
complications after a heart attack.

-The monocyte of patient Cabasag was higher than the expected value of a normal
result.

URINALYSIS

Urine Test

A urine test checks different components of urine, a waste product made by


the kidneys. A regular urine test may be done to help find the cause of symptoms. The
test can give information about your health and problems you may have.

-The color of the urine of patient Cabasag was straw and the clarity was turbid,the
color of urine is affected to what she taking. The pH result was 6.0 it is an indication that
the body's fluids elsewhere are too acid, and it is working overtime to rid itself of an acid
medium.They have few epithelial cells, few bacteria and the calcium oxalate was rare in
her urine. If theirs bacteria, epithelial cells seen in the urine there was an infection.

The ALT(GPT) was in normal result, ASAT(SGOT) was in normal result,


Creatinine was in normal result, Blood in uric acid was in normal result. Patient
Cabasag has few bacteria in her urine it means she has an infection in her urine that will
lead to urinary tract infection.

Bacteria are common in urine specimens because of the abundant normal microbial
flora of the vagina or external urethral meatus and because of their ability to rapidly
multiply in urine standing at room temperature. Therefore, microbial organisms found in
all but the most scrupulously collected urines should be interpreted in view of clinical
symptoms.

Diagnosis of bacteriuria in a case of suspected urinary tract infection requires culture. A


colony count may also be done to see if significant numbers of bacteria are present.
Generally, more than 100,000/ml of one organism reflects significant bacteriuria.
Multiple organisms reflect contamination. However, the presence of any organism in
catheterized or suprapubic tap specimens should be considered significant.

Page | 15
ULTRA SOUND:

LMP: May 28, 2013 AOG: 23 weeks & 1 day EDC: February 4, 2014

No. of Fetuses: One PLACENTA


Presentation: Cephalic Location: Postero-fundal
FHB: 60 bpm Grade: II
Amniotic Fluid Index: 13.5cm Distance from internal os
Remarks:

Pregnancy Uterine, 29 weeks and 5 days by fetal biometry, singleton, live,


cephalic in presentation.
Postero-fundal placenta, grade II.
Adequate Amniotic Fluid
Estimated Fetal weight of 1651.22 grams

Page | 16
IV. DEVELOPMENTAL DATA

The term growth and development both refers to dynamic process. Often used
interchangeably, these terms have different meanings. Growth and development are
interdependent, interrelated process. Growth generally takes place during the first 20
years of life; development continues after that.

Growth:

1. Physical change and increase in size.


2. It can be measured quantitatively.
3. Indicators of growth include height, weight, bone size, and dentition.
4. Growth rates vary during different stages of growth and development.
5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent
stages and slows during childhood.
6. Physical growth is minimal during adulthood.

Development:

1. It is an increase in the complexity of function and skill progression.


2. It is the capacity and skill of a person to adapt to the environment.
3. Development is the behavioral aspect of growth.

Page | 17
Eriksons Stages of Psychosocial Development Theory

STAGE AGE CENTRAL (+) RESOLUTION (-) RESOLUTION


TASK

Young 18-40 Intimacy Intimate Impersonal


Adulthood y/o vs. relationship with relationships.
isolation another person.
Avoidance of
Commitment to relationship,
work and
Career or lifestyle
relationships.
commitments.

Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves


more intimately with others. We explore relationships leading toward longer-term
commitments with someone other than a family member. Successful completion can
lead to comfortable relationships and a sense of commitment, safety, and care within a
relationship. Avoiding intimacy, fearing commitment and relationships can lead to
isolation, loneliness, and sometimes depression.

Havighursts Developmental Stage and Tasks

Adulthood - Selecting a mate

- Achieving a masculine or feminine social role

- Learning to live with a marriage partner

- Starting a family

- Rearing children

Page | 18
- Managing a home

- Getting started in an occupation

- Taking on civic responsibility

- Finding a congenial social group

It is the period of life to which they have looked forward during their adolescence and
early adulthood. And the time passes so quickly during these full and active middle
years that most people arrive at the end of middle age and the beginning of later
maturity with surprise and a sense of having finished the journey while they were still
preparing to commence it.

V. MEDICAL MANAGEMENT

December
06, 2013
7:00 PM Admit to OB
TPR every 4 hours For further monitoring
Low salt and Low fat Diet To prevent hypertension

Laboratory Exams
Blood Chem, Urinalysis

Start IVF with D5LR 1 L @ To replace lost fluids and


30gtts/min electrolytes
BP>200/120 mmHg
Magnesium Sulfate 5gms deep
IM on alternate buttocks q6H x Anticonvulsant drug
4doses as maintenance dose
RR 23cpm

FBC F14 attach, I and O q4


Hydralazine 5mg IVTT now Antihypertensive drug for high blood
Methyldopa 250mg 1tab q8H Treatment of sustained moderate to
severe hypertension

Page | 19
CBR with TP
Refer the BP if >160/100
Refer accordingly
December
07, 2013
7:10am Continue medication To maintain blood pressure
Monitor BP Served as baseline data
10:45am Follow-up other labs and refer For the doctor to see the result
Check vital signs every 4 hours To monitor the vital signs
FHB every 4 hours To monitor FHB
Change PNSS 1L + 40 mEq s KCl
@30gtts/min Source of water and electrolytes
Transport to OB-OPD clinic for To check for any abnormalities
3:00pm fetal heart assessment
Given hydralazine as prescribed Antihypertensive drug for high blood
May transport patient to OB-
To check for any abnormalities
8:00pm OPD clinic for fetal heart rate
8:40pm FHT 152bpm Normal FHB
Hydralazine 5mg q15min
Antihypertensive drug for highblood
provide for DBP 110mmHg
December
08, 2013 Continue BP Measure for baseline information.
Continue Medication To improve patients condition.
Continue CBR with TP
December
09, 2013 Continue BP
8:00 am Continue Medication To improve patients condition.
Change IVF with D5LR 1 L @ To replace lost fluids and
20gtts/min electrolytes
10:00 am For trans abdominal Ultrasound To diagnose pregnancy condition
especially the fetus condition

Continue monitoring V/S & FHB Monitor the V/S & FHB whether
every 4hrs. a good base line rate is present.
May transport patient to Delivery
7:00 pm Room To prepare for delivery.

Page | 20
V. Pathophysiology
Chronic Hypertension is characterized by either a BP 140/90
mmHg or greater before pregnancy or diagnosed before 20
weeks' gestation; Preeclampsia is characterized by a BP of
140/90 mm Hg or greater after 20 weeks' gestation

Precipitating Factors:
Predisposing
Factors: Chronic Hypertension with
Stress
superimposed Preeclampsia
Sedentary
Gender
Lifestyle
Pregnant
Increase Systemic
Age
Vascular Resistance
Heredity

Increase Afterload

Decrease blood flow


to Organs

Blood Pressure

Juxtaglomerular
Cells

Angiotensinogen Renin
Angiotensin I

Angiotensin II

Arteriolar Vasoconstriction
Adrenal Cortex
stimulation II
Increase Peripheral Resistance
Increase
Aldosterone

Page | 21
Increase Blood
Pressure

After 20 weeks of

gestation

Increasing Blood

Pressure

Effects on Fetus

I. Premature Placental Aging


II. Decreased Placental Flow
and FGR
III. Fetal Hypotension and Low
Amniotic Fluid
IV. Increase Risk of Diseases
V. Placental Abruption

Page | 22
VI. DRUG STUDY

GENERIC BRAN DATE CLASSIF DOSE/FR MECHANISM OF ACTION SPECIFIC CONTRAI SIDE NURSING
NAME OF D ORDERE ICATION EQUENC INDICATI NDICATIO EFFECTS/TOXI PRECAUTION
ORDERE NAME D: Y ROUTE ON N C EFFECTS
D DRUG
Hydralaz Aprso Decem antihyp 5mg It works by relaxing the Treat- Patients -flushing -the nurse should
blood vessels so that ment of with (feeling of inform the patient
ine line ber 6, ertensiv IVTT
blood can flow more severe Coronar warmth) of possible side
2013 e essentia y artery
easily through the effects and
l hyper- disease; -headache
body.Hydralazine tension. mitral advised to take
apparently lowers valvular -upset the medication
blood pressure by rheumati stomach regularly and
exerting a peripheral c heart continuously as
vasodilating effect disease. -vomiting prescribed by the
through a direct doctor
-loss of
relaxation of vascular appetite -advised the
smooth muscle. patient to avoid
Hydralazine, by altering -diarrhea alcohol because it
cellular calcium can make the
metabolism, interferes -constipation side effects from
with the calcium -eye tearing hydralazine worse
movements within the -the nurse should
vascular smooth -stuffy nose administer this
muscle that are drug cautiously to
responsible for -rash postpartum
initiating or maintaining patients with
-in
the contractile state. pregnancy advance renal
(teratogenic) damage,
suspected
coronary artery
disease.

Page | 23
GENERIC BRAN DATE CLASSIF DOSE/FR MECHANISM OF ACTION SPECIFIC CONTRAI SIDE NURSING
NAME OF D ORDERE ICATION EQUENC INDICATI NDICATIO EFFECTS/TOXI PRECAUTION
ORDERE NAME D: Y ROUTE ON N C EFFECTS
D DRUG
Magnesi Epso Decem Anti- 5gms Magnesium is
the Indicate - CNS: -Reserve IV use
d to Patients in eclampsia for
um m ber 6, convuls deep IM second most plentiful
prevent with -Weakness, immediate life
Sulfate Salt 2013 ant on caution of the seizures allergy dizziness, threatening
associat to fainting, situations
alternate intracellular fluids. It is
ed with magnesi sweating -Give IM route for
buttocks essential for the pre- um deep IM injection
eclamps products CV: of undiluted
q6 activity of many ia, and ;heart (50%) solution
4doses -Palpations
enzyme systems and for block, -Monitor serum
control myocard magnesium levels
as plays an important of GI:
ial during parenteral
mainten role with regard to seizures damage; therapy
with hepatitis -Excessive -Monitor knee-jerk
ance neurochemical bowel
eclamps - reflex
dose activity, -Do not give
transmission and ia. perianal magnesium
muscular excitability. irritations sulfate to patient
Magnesium sulfate with abdominal
Metabolic: pain, nausea and
reduces striated vomiting
-
muscle contractions Hypomagnes
and blocks peripheral aemia and
toxicity in
neuromuscular patients with
transmission by renal failure
reducing acetylcholine
release at the
myoneural junction.
Additionally,

Page | 24
Magnesium inhibits
Ca2+ influx through
dihydropyridine-
sensitive, voltage-
dependent channels.
This accounts for
much of its relaxant
action on vascular
smooth muscle.

GENERIC BRAN DATE CLASSI DOSE/F MECHANISM OF ACTION SPECIFI CONTRAIN SIDE NURSING
NAME OF D ORDER FICATI REQUEN C DICATION EFFECTS/TOXI PRECAUTION
ORDERE NAME ED: ON CY INDICATI C EFFECTS
D DRUG ROUTE ON

Page | 25
Methyld Aldo Dece Anti- 250mg This - - -
Although the medica Patients Drowsiness Tolerance may
opa met mber Hyper 1tab mechanism of action tion is with occur, Monitor
6, tensiv q8 has yet to be used active -Headache hepatic
conclusively alone hepatic function,
2013 e demonstrated, the -Muscle
or with disease - Discontinue
antihypertensive effect other -History weakness drug if fever,
of Methyldopa probably medica of abnormalities in
is due to its metabolism tions to methyld -Swollen liver function
to alpha- treat opa- ankles or tests, or
methylnorepinephrine, high associat feet jaundice occur.
which then lowers blood ed liver
arterial pressure by -Upset
pressu dysfuncti - Discontinue if
stimulation of central stomach
re on edema
inhibitory alpha-
-Vomiting progresses or
adrenergic receptors,
signs of CHF
false
-Diarrhea occur.
neurotransmission,
and/or reduction of -Dry mouth
plasma renin activity.
Methyldopa has been
shown to cause a net
reduction in the tissue
concentration of
serotonin, dopamine,
norepinephrine, and
epinephrine.

Page | 26
VII. NURSING MANAGEMENT

Ideal Nursing Interventions for Hypertension:

Nursing Diagnosis Nursing Interventions Rationale

Risk for decreased 1. Monitor blood Comparison of pressures


cardiac pressure, measure in provides a more
output related to both arms/thighs three complete picture of
increased afterload, times, use correct cuff vascular
vasoconstriction, size and accurate involvement/scope of
myocardial technique. problem. Systolic
ischemia, and hypertension also is an
ventricular established risk factor for
hypertrophy. cerebrovascular disease
and ischemic heart
disease, when diastolic
pressure is elevated.

2. Note May indicate heart


dependent/general failure, renal or vascular
edema. impairment.

3. Note presence, quality Pulses in the legs/feet


of central and may be diminished,
peripheral pulses. reflecting effects of
vasoconstriction
(increased systemic
vascular resistance
[SVR]) and venous
congestion.

4. Observe skin color, Presence of pallor; cool,


moisture, temperature, moist skin; and delayed
and capillary refill time. capillary refill time may
be due to peripheral
vasoconstriction or reflect
cardiac
decompensation/decreas
ed output.

Page | 27
Nursing Diagnosis Nursing Interventions Rationale

Page | 28
Acute Pain 1. Assess pain scale. Helpful in evaluating
related to Determine specifics of pain, effectiveness of
increased e.g., therapy.
cerebral vascular location, characteristics.
pressure.
2. Encourage bedrest during Minimizes
acute phase. stimulation/promotes
relaxation.

3. Assist patient with Patient may also


ambulation as needed. experience episodes of
postural hypotension,
causing weakness
when ambulating.

4. Minimize vasoconstricting Activities that increase


activities that may vasoconstriction
aggravate headache. accentuate the
headache in the
presence of increased
cerebral vascular
pressure.

Nursing Diagnosis Nursing Interventions Rationale

Page | 29
Activity 1. Instruct patient in Energy-saving techniques
Intolerance energy-conserving reduce the energy
related to techniques, e.g., using expenditure, thereby assisting
generalized chair when showering, in equalization of oxygen
weakness, sitting to brush teeth or supply and demand.
imbalance comb hair, carrying out
between activities at a slower
oxygen supply pace.
and demand. Gradual activity progression
2. Encourage progressive prevents a sudden increase in
activity/self-care when cardiac workload. Providing
tolerated. Provide assistance only as needed
assistance as needed. encourages independence in
performing activities.

Nursing
Diagnosis Nursing Interventions Rationale
Knowledge 1. Define and specify the desired Provides a basis for
deficit blood pressure limits. Describe understanding blood
hypertension and its effect on pressure elevation, and
related to
the heart, blood vessels, describes commonly used
lack of kidneys, and brain. medical terms.
information Understanding that high
blood pressure can occur
about the
without symptoms is the
disease center allows patients to
process continue treatment, even
when it feels good.

2. Assist patients in identifying the


Risk factors that have
risk factors that can be
been shown to contribute
modified, for example, obesity,
to hypertension and
a diet high in sodium, saturated
cardiovascular and renal
fat, and cholesterol, sedentary
disease.
lifestyle, smoking, alcohol
consumption, and stress
lifestyle.

Ideal Nursing Interventions for Preeclampsia:

Page | 30
Nursing Diagnosis Nursing Interventions Rationale

High risk of seizures in 1. Monitor blood The pressure over 110


pregnant women pressure every 4 mmHg diastole and
related hours. systole 160 or more an
to decreased organ indication of PIH.
function (vasospasm
and increased blood 2. Record the patient's The decline of
pressure). level of consciousness as an
consciousness. indication
of decreasedcerebral
blood flow.
3. Assess signs
of eclampsia (hyper The symptoms are a
active, the patellar manifestation of changes
reflexes,decreased pul in the brain, kidney, heart
se and respiration, and lung that precedes
epigastric pain and seizure status.
oliguria).

4. Monitor for signs and


symptoms of labor or Seizures will increase the
uterine contractions. sensitivity of the uterus,
which will allow the
delivery.
5. Collaboration with the
medical team in the Anti-hypertension to
provision of anti- lower blood pressure.
hypertension.

Page | 31
Nursing Diagnosis Nursing Interventions Rationale

High risk of fetal 1. Monitor fetal heart Increased fetal heart rate
distress related to rate as indicated. as an indication of
changes in the hypoxia, premature and
placenta. solusio placenta.

2. Review on fetal Decrease in placental


growth. function may be caused by
hypertension, causing
IUGR.

3. Explain the signs of Pregnant women may


solusio placenta know the signs and
(abdominal pain, symptoms of solutio
bleeding, uterine placenta. Pregnant women
tension, decreased fe can learn from hypoxia in
tal activity). the fetus.

4. Collaboration with the Ultrasound and NST to a


medical ultrasound known state / welfare of
and NST. the fetus.

Page | 32
Nursing Diagnosis Nursing Interventions Rationale

Impaired sense of 1. Assess the patient's The threshold of pain


comfort (pain) related pain intensity level. everyone is different, thus
to uterine contractions. will be able to determine
appropriate action
treatment with the patient's
response to pain.

2. Explain the causes of Pregnant women can


pain. understand the causes of
pain.

3. Help the pregnant To distract the patient.


woman by rubbing /
massage on the
painful part.

Page | 33
NURSING CARE PLAN

Cues Nursing Objectives Nursing Interventions Rationale Evaluation


Diagnosis
S: Sakit kaayo Acute Pain At the end of 1 Independent: After of 1 hr. of
akong tahi as related to hr. of nursing 1. Reposition client, Relaxes muscles, nursing care,
verbalized by the surgical incision care, the patient reduce noxious and redirects the patient:
will: stimuli, and offer attention away
patient as evidenced by
comfort measures, from painful Identified and
facial mask of Identify and e.g. back rubs sensations used
O: - Facial pain use appropriate
Grimaces appropriate 2. Encourage use of Promotes comfort, interventions
interventions breathing and and reduces to manage
- Rated Pain as to manage relaxation techniques unpleasant pain/discomfo
9 in a pain scale pain/discomfo and distraction distractions, rt
rt (stimulation of enhancing sense
of 1-10, 10 being
cutaneous tissue) of well-being Verbalized
the highest Verbalize lessening of
lessening of 3. Encourage adequate To prevent fatigue level of pain
level of pain rest period
Appeared
Appear 4. Encourage early To prevent relaxed, able
relaxed, able ambulation pooling of blood to sleep/rest
to sleep/rest which prevents appropriately
appropriately blood clots
Dependent:
1. Administer Promotes comfort,
analgesics as which improves
prescribed by the psychological
doctor status and
enhances mobility

Page | 34
NURSING CARE PLAN

Cues Nursing Objectives Nursing Interventions Rationale Evaluation


Diagnosis
S: Ga paspas Decreased At the end of 2 Independent: After 2 hr. of
ang akong cardiac output 1. Keep client on bed Decreases oxygen
hr. ofnursing nursing care,
kasing2x as related to altered and in position of consumption
care, the patient comfort the patient was
verbalized by the heart rate
patient. (106bpm), as will display able to display
2. Decrease stimuli; To promote
evidenced by hemodynamic provide quiet adequate rest hemodynamic
O:- BP: 160/100 tachycardia and environment
stability (heart stability (heart
mmHg increased blood
pressure, rate will 3. Encourage deep To reduce anxiety rate decreased
- RR: 24cpm patients report of breathing exercise
decrease from from 106 bpm
palpations; r/t
106 bpm to 100 4. Encourage changing To reduce risk for to 100 bpm, BP
- PR: 106bpm decreased positions slowly orthostatic
venous return as bpm, BP from from 160/100 to
hypotension
- Lower evidenced by 160/100 to (120/80)
extremities lower extremities 5. Give information To provide
120/80)
edema edema, SOB about positive signs encouragement
(24cpm) of improvement

Dependent:
6. Administer To treat
antihypertensive drug hypertension
as prescribed by the
doctor.

Page | 35
NURSING CARE PLAN

Cues Nursing Objectives Nursing Interventions Rationale Evaluation


Diagnosis
S: Risk for infection After series of Independent: After 30 min of
related to post nursing 1. Teach patient to wash Hand washing nursing
hands often, especially reduces the risks for
O:- Post surgical surgical incision interventions before toileting, before infection interventions,
incision the client meals and before and client was able
should: after administering self- to identify the
Risk Factors care risk factors
(Nanda) Short Term 2. Discuss to patients the To impart to the present in her
Environmental Identify the following signs of patient when the condition, able
Factor risk factors infection -redness, wound become to gain
Decreased present in the swelling, increased infected and when to knowledge on
tissue clients pain, or purulent sought medical care
drainage on the site effective
perfusion condition
and fever prevention of
Decreased Clients partial
wound healing understanding infection and
3. Demonstrate and allow To know if the full
time about infection return demonstration of patient really
and its risk wound care understand the understanding
factors principle of proper to the risk of
wound care infection
Long Term
4. Monitor vital signs Temperature
Effective
elevation and
prevention of tachycardia may
infection to the reflect developing
client sepsis
Clients full
understanding Dependent:
to the risk of 1. Administer antibiotics To prevent infection
infection as prescribed by the
doctor

Page | 36
Actual nursing management (DAR)

> Received Awake sitting on bed IVF of D5LR 1L


D @ 900cc
level regulated @ 10 gtts/min
> BP= 160/100 FHB= 134
>1+ mild pitting, slight indentationnoted
A > Vital signs monitored and recorded
> On complete bed rest toilet privilege
>Kept on left lateral decubitus position
>Encouraged deep breathing exercise
> Advised to increase greens in diet like
ampalaya&malunggay leaves
> Encouraged to have adequate rest and sleep
> Health teachings imparted with emphasis on
a) Sodium restriction
b) Avoiding foods rich in oil and fats
c) Limiting daily activities and exercises
d) Proper nutrition
e) Compliance to medication
f) Proper hygiene
> Kept back dry
R > Able to rest well
>Endorsed with latest BP= 160/100

Page | 37
Discharge Plan:

Exercise
1. Encouragepatients on deep breathing exercises.
2. Move extremities when lying.
3. Elevate the head part when sleeping, to promote increase peripheral circulation
4. Encourage overall passive and active exercises program during pregnancy to
prevent need for cesarean birth.
5. Exercises like tailor sitting, squatting, kegel exercise, pelvic rocking, and abdominal
muscle contraction will promote easy delivery.

Treatment:
1. Use of drugs
2. Catheterization
3. Obtaining labs. (CBC, platelets count, liver function, BUN and creatinine, and fibrin
degregation)

Health Teachings imparted with emphasis on:


1. Sodium restriction.
2. Avoiding foods rich in oil and fats.
3. Encourage patient to limit her daily activities and exercises.

Diet:
1. Low fats and sodium diet, restriction if possible.
2. High in protein, calcium and iron.
3. Adequate fluid intake

Sex:
1. Limit sexual activity
2. Sexual intercourse at 2nd trimester should be avoided.

Page | 38
VIII. REFERRALS AND FOLLOW-UP:

Instructed the client to come back one week after discharged for further follow-up
and evaluation of the clients health condition. This is very important so that the health
condition of the client will be evaluated if there is better improvement. The physician
should see and examine the physical appearance of the client.

IX: EVALUATION AND IMPLICATIONS:

This care study enables us to further our learning association with disease
condition of the patient. From it, we have gained knowledge in the progression of the
disease and the reaction of the body to maintain homeostasis and how eventually it
causes harm.

Through this, we actually improved our understanding and skills in the


management of the patient through the experiences weve had in implementing our
care. It also enhanced our confidence in intervening because of the input gained form
our research.

Case studies are a way of getting familiar or get acquainted not only with the
patient but also on his or her condition. It provides concrete examples of how the
theoretical knowledge learned during lectures was applied. How the concepts of the
various disease conditions were manifested through the client. It allows the opportunity
to facilitate the acquisition of knowledge through the experiences gained in
management and in caring for the patient. As a result, it is a must that case studies
should be made not just for requirement purposes but also for the pursuit of knowledge.

In general, the case study promoted learning through the research and actual
experiences and made us more knowledgeable in caring for the patient and that can
really be used in our chosen field.

Page | 39
X. Bibliography

120 Diseases (The essential Guide to more than 120 Medical Conditions,
syndromes, and diseases) by Prof. Peter Abrahams 2007 pp. 158

Essentials of pathophysiology by Carol Mattson Porth RN, MSN, PhDPp.605-613

Manual of Nursing Practice by Lippincott 10thed.Pp. 1201-1212

Maternal and child health nursing by Adele Pillitteri 5th edition; volume 1
page 426-433;page 329-332

WWW.MEDSCAPE.COM

WWW.WIKIPEDIA.ORG

http://nursingcrib.com

Page | 40