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PREECLAMPSIA

INTRODUCTION

Preeclampsia is a major cause of maternal and perinatal morbidity and mortality. It accounts
to 28.4% of maternal morbidity and mortality in the Philippines according to DOH (as of Feb. 2008).
The condition — sometimes referred to as pregnancy-induced hypertension — is defined by high
blood pressure and excess protein in the urine after 20 weeks of pregnancy.

Often, preeclampsia causes only modest increases in blood pressure. Left untreated,
however, preeclampsia can lead to serious — even fatal — complications for both mother and
baby.
The only cure for preeclampsia is delivery of the baby. If preeclampsia develops near the end of
your pregnancy, delivery is the obvious solution. If you're diagnosed with preeclampsia earlier in
your pregnancy, you and your doctor face the delicate task of prolonging your pregnancy to allow
your baby more time to mature, without putting you or your baby at risk of serious complications.

The signs of preeclampsia are elevated blood pressure (hypertension) and the presence of
excess protein in your urine (proteinuria) after 20 weeks of pregnancy. The excess protein is related
to problems with your kidneys. Your doctor may identify these signs of preeclampsia at one of your
regular prenatal visits.

Other signs and symptoms of preeclampsia — which can develop gradually or strike
suddenly, often in the last few weeks of pregnancy — may include:
• Severe headaches
• Changes in vision, including temporary loss of vision, blurred vision or light sensitivity
• Upper abdominal pain, usually under the ribs on the right side
• Nausea or vomiting
• Dizziness
• Decreased urine output
• Sudden weight gain, typically more than 2 pounds a week

Swelling (edema), particularly in the face and hands, often accompanies preeclampsia as
well. Swelling isn't considered a reliable sign of preeclampsia, however, because it also occurs in
many normal pregnancies.

CAUSES
Preeclampsia used to be called toxemia because it was thought to be caused by a toxin in a
pregnant woman's bloodstream. Although this theory has been debunked, researchers have yet to
determine what causes preeclampsia. Possible causes may include:
• Insufficient blood flow to the uterus
• Damage to the blood vessels
• A problem with the immune system
RISK FACTORS
Preeclampsia develops only during pregnancy. Risk factors include:
• History of preeclampsia. A personal or family history of preeclampsia increases your risk of
developing the condition.
• First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy or
your first pregnancy with a new partner.
• Age. The risk of preeclampsia is higher for pregnant women who are older than age 35.
• Obesity. The risk of preeclampsia is higher if you're obese.
• Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or
other multiples.
• Gestational diabetes. Women who develop gestational diabetes have a higher risk of
developing preeclampsia as the pregnancy progresses.
• History of certain conditions. Having certain conditions before you become pregnant — such as
chronic high blood pressure, diabetes, kidney disease or lupus — increases the risk of
preeclampsia.

OBJECTIVES

GENERAL
1. To enhance skills in handling patient with pre-eclampsia.
2. To have an additional knowledge and information about pre-eclampsia.
3. To perform appropriate management by utilizing the nursing process.

SPECIFIC
1. To define what is pre-eclampsia.
2. To discuss the anatomy and physiology of pre-eclampsia.
3. To know the etiology, risk factors and its complication.
4. To plan and execute appropriate nursing interventions.
5. To evaluate the effectiveness of discharge planning.
6. To create awareness about pre-eclampsia to the client and to the family members.

DEMOGRAPHIC
A. PERSONAL DATA
Name:XY
Age:31
Sex: FEMALE
Date of birth: NOVEMBER 1, 1977
Place of birth: MONTALBAN, RIZAL
Civil status: MARRIED
Religion: CATHOLIC
Nationality: FILIPINO

ADMISSION
Date: NOVEMBER 22, 2008
Room: 3016-F2
Diagnosis: G5P4, 32 WEEKS AOG
Attending physician:DR. ALMA F. FONTE-RAMIREZ

ADMITTING HISTORY
XY was 8th month pregnant when she was rushed to East Avenue Hospital in Quezon City
on the November 22, 2008. Upon admission, she had pain, headache, bloodshow but no signs of
seizure. She was conscious and coherent, not in cardio respiratory distress. With Bp of 190/110,
afebrile, with retractions with clear breath sounds and positive bipedal edema. She had a previous
consultation in Infirmary hospital in Montalban. She had a normal spontaneous delivery last
November 22, 2008, she delivered twin boys.

Past Medical Hospitalization


Appendectomy 1999

Family Medical History


The patient has a family history of hypertension. According to XY, both her parents have
hypertension.

Social History
XY, 31 years old, who resides with her husband in Montalban Rizal. According to her though
their income is still insufficient for them, she is still happy and contented. With regard to their
community, she said that the environment is peaceful and their neighbors are very accommodating.
According to her that part of her leisure is chatting with her neighbors.

GORDON’S PATTERN
Person Approach

PSYCHOLOGICAL
• Self Perception Pattern
XY is a very jolly individual. She seems very satisfied to the life that she has. Just being
with her partner she feels complete and secure. She is very appreciative even on the simple things
being done to her, especially with her husband. Though they’re having some problems on their
finances she maintains the composure of being fine and happy. Her family, especially her twins is
her inspiration right now. She entrusts everything on the Lord. She sees problems as test of
courage and faith to Him.

• Role Relationship Pattern


XY resides with her family including her parents in Montalban, Rizal. With regard to
decision making, it is both of them who decide on whatever actions to be done. She owned a
house with 2 bedrooms .She lives in a community of very friendly and accommodating
neighborhood.. In fact in her free time, she chats with her neighbors. Health center in their place is
very accessible for them. Unlike the wet market, it will take them 15-20 mins to get there.

• Coping Perceptual Pattern


XY has a good vision & hearing. In regards to her mental status, she’s being forgetful at
time. She feels pain and discomfort due to her recent delivery.

• Coping Stress Tolerance Pattern


She is a jolly person that is why coping with stress is not a problem with her. She manages
it by simply diverting it to other things like talking to friends, watching TV, listening to radio, etc…
Her husband has always been the first person she asks for help when she is stressed out or feeling
down. Also, they just keep a positive outlook and a strong faith to the Lord whenever things are
going really bad.

PSYCHOSOCIAL - Intimacy vs. Isolation


Characterized by the development of an intimate loving relationship with another.
PSYCHOSEXUAL - has reached the stage of genital
COGNITIVE - has reached the stage of formal operations.

• Value Belief Pattern


XY is a catholic. Her husband was an Iglesia ni Cristo member, but was later on was
converted when they got married. With her family, they hear mass every Sunday. She has observed
the closeness of their family when she was still young. Now that she has her own, she wants that
close family ties be observed. She always tells her kids to be a good person, study well and be
God-fearing. She is very satisfied with her life especially now that their twins.

ELIMINATION
She has a regular bowel movement and she micturates regularly. In regards to the amount
and character, everything is regular and normal. No discomfort or any pain being felt. She is clean
and seems to practice good hygiene routine.

REST AND ACTIVITY


• Activity Exercise Pattern
Doing household chores and her work are the only form of exercise she has. These keep
her in good shape. Her leisure activities are just watching TV, listening to radio and chatting with
her neighbors. She wakes up early around 4am to prepare things for her kids. She cooks her food
but when she has no time she just buys outside. The usual food intake would be composed of fish
and vegetables. In terms of hygiene, she observes good hygienic practice all the time. She takes a
bath everyday. Their place is just a room with bathroom.

• Sleep Rest Pattern


XY has a regular bed time. She has 8 hours of sleep everyday. This is enough for her to do
her tasks for the next day. Making use of any aids is not needed anymore.

SAFE ENVIRONMENT
The patient has no allergies on any medications and/ foods. In regards with her skin
integrity there are no evident lesions. It appears to be some how smooth.

OXYGENATION
XY has no difficulty in breathing.

NUTRITION
XY cooks their food but there would be times that she buys outside. Her favorite foods
would be anything with fish and vegetables. There is nothing in particular that she dislikes. She eats
three times a day with snacks in the afternoon. She has a big appetite. There are times that quantity
and quality of food is being sacrificed because of tight budgeting.
PHYSICAL ASSESSMENT

GENERAL ASSESMENT:
VITAL SIGNS (11/23/08):
BP 180/100
PR 83
RR 22
TEMP 36.8 C
HEIGHT 5’1”
WEIGHT 140 lbs

Patient conscious and coherent, able to understand and respond to questions appropriately
and reasonably quickly. No signs of respiratory distress. Skin appears to be dry with some visible
scars at both upper and lower extremities. She has a medium built frame, short stature with
apparent globular abdomen. She sat comfortably with a slouched posture, no involuntary
movements shown. Dressed in a simple red/ black duster, appear to be neat. However, fingers on
both hands and feet are noticeably unclean. No odor of body and breath noted. She covers her
mouth the whole time of the conversation, conscious of her uneven lower teeth and the absence of
upper incisors. Manner of speaking is quite unclear. She also has asymmetrical facial features, due
to her Bell’s Palsy/ facial hemiparesis.

SPECIFIC ASSESMENT:
PARTS TECHNIQUE NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
HEAD AND FACE
Skull Inspection Proportional to body Proportional to the Normal Findings
size patients size
Palpation Smooth, uniform Absence of nodules or Normal Findings
consistency, masses
absence of nodules
or masses
Scalp Inspection Smooth contour Smooth contour Normal Findings
Palpation No lesions Absence in lesions, Normal Findings
No mass mass, and area of
No area of tenderness
tenderness
Hair Inspection Evenly distributed Evenly distributed with Normal
Condition No gray hair a number of gray hair Gray hair is influenced by
decreased in melanocytes
due to aging process
No Seborrhea, No seborrhea, Normal Findings
dermatitis dermatitis
Smooth and shiny Smooth and shiny Normal Findings
Face Inspection Symmetrical facial Asymmetrical Bell’s Palsy (facial
feature hemiparesis due to
oedema of 7th /facial
cranial nerve)
- occurred when she was
5y/o, no continuous
treatment / therapy done

EYES
Eye Inspection Skin Intact; Skin intact Normal Findings
Condition no discharge; No discharge
no discoloration No discoloration
Lids close Lids close
symmetrically symmetrically

Sclera Inspection Clear Clear Normal Findings


No shrunken eyeballs Protruding/ bulging Bell’s Palsy (facial
eyeball (R) hemiparesis due to oedema
of 7th /facial cranial nerve)
- occurred when she was
5y/o, no continuous
treatment / therapy done
No dark circles under With slightly dark Lack of sleep
the eye circles under the
eyes
white and clear; Sclera is white w/ Normal Findings
capillaries sometimes prominences of
evident; capillaries.
Pupil Inspection Constrict with close Constricts with close Normal Findings
light light
Dilates with distant Dilates with distant Normal Findings
light (PERLA) light
Conjuctiva Inspection Pinkish in color and Extremely pale There is paleness due to
moist anemia because liver is
already damage thus
production of globin (which
is a type of proteins) that is
essential in forming
hemoglobin is altered.
Vision Inspection Both eyes focus on Both eyes focus on Normal findings
objects clearly objects clearly
whether near or whether near or
distant - distant -
EMMETROPIA EMMETROPIA
EARS
Auricle Inspection Color same as facial skin Color same as facial skin Normal Findings
Symmetrical Symmetrical Normal Findings
Aligned with outer Aligned with outer canthus Normal Findings
canthus of eye of eye
Pinna recoils after it is Pinna recoils after it is Normal Findings
folded folded
Hearin Whisper Test Responds to normal Able to hear normal voice Normal Findings
g voice clearly
Activity
Nose Inspection Patent and symmetrical Patent and symmetrical Normal Findings

MOUTH
Lips Inspection Symmetry of Asymmetrical of Bell’s Palsy (facial
contour contour hemiparesis due to
oedema of 7th /facial
cranial nerve)
- occurred when she
was 5y/o, no continuous
treatment / therapy done
Tongue Inspection Pinkish to reddish in Pinkish to reddish in Normal Findings
color color
With frenulum at the With frenulum at the Normal Findings
center center
Teeth Inspection No dental caries With dental caries Dental carries, plaque
No plaque or With plaque and and cavities due to poor
cavities cavities dental hygiene.
Gums with no No lesions Normal Findings
lesions
32 permanent teeth - 28 permanent teeth Poor dental hygiene led
with irregularities in to cavities and decay.
growth
- upper incisors
missing
Absence of bleeding Absence of bleeding Normal Findings
Neck Inspection Proportional to the Proportional to the size Normal Findings
size of the body of the body
Palapation No palpable lymph No palpable lymph Normal Findings
nodes nodes
CHEST
Inspection Respiratory rate of RR – 22 bpm The RR was taken on a
16-20 breaths per sitting position, there was
min shortness of breath due
to mechanical
impingement on the
diaphragm.
No mass and are Absence of mass Normal Findings
of tenderness and are of
tenderness
Palpation Vesicular and Diminish breath Shallow breath may
bronchovesicular sounds produces diminish breath
breath sounds sounds due to pleural
effusion
Auscultation Absence of Absence of Normal Findings
adventitious and adventitious and
bronchial breath bronchial breath
sounds sounds
Lungs Auscultation Symmetric Symmetric contour, Normal Findings
contour, no no lesions, scars
lesions, scars and and rashes
rashes
Abdomen Inspection Unblemished skin Unblemished skin Normal Findings
Uniform color Uniform color
Flat, Distended (bulging Distention is present
rounded(convex), flanks); abdominal because of portal
or girth of 93.98cm hypertension resulting to
scaphoid(concave) accumulation of fluid in
the peritoneal cavity
thus, the weight of fluid
pushes against the side
walls.
Auscultation Audible bowel Absence of bowel Normal Findings
sounds sounds
Absence of arterial Absence of arterial
bruit bruits
Absence of friction Absence of friction
rub rub
Percussion Tympany over the Tympanitic over the The tympany over the
stomach and gas umbilicus and dull umbilicus occurs in
filled bowels; over the lateral ascites because bowel
dullness, abdomen and flank floats to the top of the
especially over the areas. abdominal fluid at the
liver and spleen, or level of the fluid
full bladder meniscus.
Palpation No tenderness; tenderness noted; There is discomfort upon
consistent tension increase tension palpation because of
abdominal distention.
UPPER EXTREMITIES
Arms and Inspection Symmetric, absence of Symmetric, absence of Normal findings
Hands lesions, mass and mass and area of
area of tenderness tenderness
- presence of scars noted
Palpation Warm moist skin, Dry and scaly skin, Presence of dry
pules palpable Palpable bilateral pulses and scaly skin is
bilateral 2+ due to the
restriction of
fluid intake and
excessive fluid
loss.
Fingers Inspection Complete number of Five fingers on both hands Normal findings
digits
Nails Inspection Shiny, smooth, convex Pallor, smooth, convex Pallor is due to
curvature poor circulation
Nails are unclean Unclean nails
due to poor
body hygiene
Palpation of Capillary Refill time Capillary refill time is about Slight delay in
Capillary less than 3 seconds 4 seconds capillary refill
Refill Test time is due to
circulatory
impairment
LOWER EXTREMITIES
Skin Inspection Absence of coldness Absence of coldness and Normal findings
and clamminess clamminess
No lesions No lesions
No bleeding No bleeding
Palpation No mass Absence of masses Normal findings
Legs Inspection Complete legs (left Both two legs are complete Normal findings
and right leg) (left and right)
No mass and lesions Bipedal edema increased
Weak popliteal pulse noted plasma volume
and sodium
retention
Pinkish in color Pallor Pallor is due to
poor circulation
Nails Inspection Hard Hard Normal findings
Complete toe nails Complete toe nails Normal findings
Nails are unclean Unclean nails
due to poor
body hygiene
Palpation in Capillary Refill time Capillary refill time is about Slight delay in
capillary less than 3 seconds 4 seconds capillary refill
refill time time is due to
circulatory
impairment
DIAGNOSTIC EXAMINATION

1. CBC count
• Microangiopathic hemolytic anemia (HELLP)
• Thrombocytopenia / Platelet count less than 100,000
• Hemoconcentration may occur in severe preeclampsia.
2. Liver function tests: Transaminase levels are elevated from hepatocellular injury and in HELLP
syndrome.
3. Serum creatinine level: levels are elevated due to decreased intravascular volume and
decreased glomerular filtration rate (GFR).
4. Urinalysis
• Proteinuria is one of the diagnostic criteria for preeclampsia.
• Proteinuria is defined as greater than or equal to 1+ protein on urine dipstick.
Alternatively, protein concentration of 300 mg/L or more on urine dipstick.
• Proteinuria is also defined as 300 mg or more of protein in a 24-hour urine sample.
5. Elevated PT, aPTT, fibrin split products, and decreased fibrinogen
6. Disseminated intravascular coagulopathy testing
7. Uric acid
• Uric acid levels are increased in preeclampsia.
• Serial levels may be useful to indicate disease progression.
8. Increase in blood pressure

CLINICAL MICROSCOPY

Laboratory Laboratory Normal value Interpretatio Remarks


Test result n of result
I. Physical
A. Color Yellow Light yellow - Abnormal Often associated with
amber bile pigments chiefly
retention of bilirubin
B. Transparency Cloudy Clear Abnormal Suggestive of pyuria
and slight hematuria.
C. Specific 1.015 1.015- 1.030 Normal
Gravity
D. Reaction 6.0 pH -4.8-7.7 Normal
E. Protein Positive Negative Abnormal Indicator of kidney
dysfunction;
suggestive of pre-
eclampsia
F. Sugar Negative Negative Normal

II. Microscopic
A. RBC( Red 1 - 3/hpf 0-2/hpf Above the Slight increase is
Blood Cell) normal suggestive of bleeding but
range assumption is to be renal
in origin.
B. WBC(White 15 – 20/hpf 0-5/hpf Above the Conclusive of renal
Blood Cell) normal disease.
range
C. Epithelial Cells Many Moderate Abnormal Seen in cases of acute
tubular necrosis
D. Mucus Threads Moderate Few present Abnormal Suggestive of advanced
renal disease
E. Bacteria Moderate Few present Abnormal Urinary tract infection is
present.
F. Crystals Few A, Urates - Few Normal
G. Cost none none Normal

III. Biochemical
A. Urobilinogen --- 1.20
B. Nitrate --- Negative
C. Blood --- Negative
D. Bilirubin --- Negative
E. Ketone --- Negative
F. Leukocyte --- Negative

IV. Remarks ---


Ca oxalate ---
crystalates

CLINICAL CHEMISTRY

Laboratory Test Laboratory Normal Value Interpretatio Remarks


Results n of Result
BUN 3.7 2.5- 5.1mmol/L Normal
(Blood Urea
Nitrogen)
Creatinine 69umol/L 53-115 umol/L Normal
Alp --- 35-125 u/L Normal
SGOT (AST) 48 HIGH 15–37 u/L Abnormal Transaminase levels are
elevated from
hepatocellular injury
SGPT (ALT) 37 30-65 u/L Normal

ANATOMY
CARDIOVASCULAR SYSTEM

The cardiovascular system is sometimes called the blood-


vascular or simply the circulatory system. It consists of the
heart, which is a muscular pumping device, and a closed
system of vessels called arteries, veins, and capillaries. As
the name implies, blood contained in the circulatory system
is pumped by the heart around a closed circle or circuit of
vessels as it passes again and again through the various
"circulations" of the body.

The vital role of the cardiovascular system in maintaining homeostasis depends on the continuous
and controlled movement of blood through the thousands of miles of capillaries that permeate every
tissue and reach every cell in the body. It is in the microscopic
capillaries that blood performs its ultimate transport function.
Nutrients and other essential materials pass from capillary blood
into fluids surrounding the cells as waste products are removed.

Heart

The heart is a muscular pump that provides the force necessary


to circulate the blood to all the tissues in the body. Its function is
vital because, to survive, the tissues need a continuous supply of
oxygen and nutrients, and metabolic waste products have to be
removed. Deprived of these necessities, cells soon undergo
irreversible changes that lead to death. While blood is the transport medium, the heart is the organ
that keeps the blood moving through the vessels.

It is located between the lungs in the middle of the chest, behind and slightly to the left of the
breastbone (sternum). A double-layered membrane called the pericardium surrounds the heart like
a sac. The outer layer of the pericardium surrounds the roots of the heart's major blood vessels and
is attached by ligaments to your spinal column, diaphragm, and other parts of your body. The inner
layer of the pericardium is attached to the heart muscle. A coating of fluid separates the two layers
of membrane, letting the heart move as it beats, yet still be attached to your body.
Blood

Blood is actually a tissue. It is thick because it is made


up of a variety of cells, each having a different job. In fact,
blood is actually about 80% water and 20% solid.

• Platelets, which help the blood to clot. Clotting


stops the blood from flowing out of the body
when a vein or artery is broken. Platelets are
also called thrombocytes.
• Red blood cells, which carry oxygen. Of the 3
types of blood cells, red blood cells are the most plentiful. In fact, a healthy adult has about
35 trillion of them. The body creates these cells at a rate of about 2.4 million a second, and
they each have a life span of about 120 days. Red blood cells are also called erythrocytes.
• White blood cells, which ward off infection. These cells, which come in many shapes and
sizes, are vital to the immune system. When the body is fighting off infection, it makes them
in ever-increasing numbers. Still, compared to the number of red blood cells in the body, the
number of white blood cells is low. Most healthy adults have about 700 times as many red
blood cells as white ones. White blood cells are also called leukocytes. Blood also contains
hormones, fats, carbohydrates, proteins, and gases.
Blood carries oxygen from the lungs and nutrients from the digestive tract to the body’s
cells. It also carries away carbon dioxide and all of the waste products that the body does
not need. (The kidneys filter and clean the blood.) Blood also
• Helps keep your body at the right temperature
• Carries hormones to the body’s cells
• Sends antibodies to fight infection
• Contains clotting factors to help the blood to clot and the body’s tissues to heal

Blood Vessels

Blood vessels are the channels or conduits through which blood is distributed to body tissues. The
vessels make up two closed systems of tubes that begin and end at the heart. One system, the
pulmonary vessels, transports blood from the right ventricle to the lungs and back to the left atrium.
The other system, the systemic vessels, carries blood from the left ventricle to the tissues in all
parts of the body and then returns the blood to the right atrium. Based on their structure and
function, blood vessels are classified as arteries, capillaries, or veins.

a. Arteries
Arteries carry blood away from the heart. Pulmonary arteries
transport blood that has low oxygen content from the right ventricle
to the lungs. Systemic arteries transport oxygenated blood from the
left ventricle to the body tissues. Blood is pumped from the
ventricles into large elastic arteries that branch repeatedly into
smaller and smaller arteries until the branching results in
microscopic arteries called arterioles. The arterioles play a key role
in regulating blood flow into the tissue capillaries. About 10 percent of the total blood volume is in
the systemic arterial system at any given time.
The wall of an artery consists of three layers. The innermost layer, the tunica intima (also called
tunica interna), is simple squamous epithelium surrounded by a connective tissue basement
membrane with elastic fibers. The middle layer, the tunica media, is primarily smooth muscle and is
usually the thickest layer. It not only provides support for the vessel but also changes vessel
diameter to regulate blood flow and blood pressure. The outermost layer, which attaches the vessel
to the surrounding tissue, is the tunica externa or tunica adventitia. This layer is connective tissue
with varying amounts of elastic and collagenous fibers. The connective tissue in this layer is quite
dense where it is adjacent to the tunic media, but it changes to loose connective tissue near the
periphery of the vessel.

b. Capillaries
Capillaries, the smallest and most numerous of the blood
vessels, form the connection between the vessels that
carry blood away from the heart (arteries) and the vessels
that return blood to the heart (veins). The primary function
of capillaries is the exchange of materials between the
blood and tissue cells. Smooth muscle cells in the
arterioles where they branch to form capillaries regulate
blood flow from the arterioles into the capillaries.

c. Veins
Veins carry blood toward the heart. After blood passes
through the capillaries, it enters the smallest veins, called
venules. From the venules, it flows into progressively
larger and larger veins until it reaches the heart. In the
pulmonary circuit, the pulmonary veins transport blood
from the lungs to the left atrium of the heart. This blood
has a high oxygen content because it has just been
oxygenated in the lungs. Systemic veins transport blood
from the body tissue to the right atrium of the heart. This
blood has a reduced oxygen content because the oxygen
has been used for metabolic activities in the tissue cells.
The walls of veins have the same three layers as the
arteries. Although all the layers are present, there is less
smooth muscle and connective tissue. This makes the
walls of veins thinner than those of arteries, which is
related to the fact that blood in the veins has less pressure
than in the arteries. Because the walls of the veins are
thinner and less rigid than arteries, veins can hold more
blood.

Blood Flow

Blood flow refers to the movement of blood through the vessels from arteries to the capillaries and
then into the veins. Pressure is a measure of the force that the blood exerts against the vessel walls
as it moves the blood through the vessels. Like all fluids, blood flows from a high pressure area to a
region with lower pressure. Blood flows in the same direction as the decreasing pressure gradient:
arteries to capillaries to veins.

The rate, or velocity, of blood flow varies inversely with the total cross-sectional area of the blood
vessels. As the total cross-sectional area of the vessels increases, the velocity of flow decreases.
Blood flow is slowest in the capillaries, which allows time for exchange of gases and nutrients.

Resistance is a force that opposes the flow of a fluid. In blood vessels, most of the resistance is due
to vessel diameter. As vessel diameter decreases, the resistance increases and blood flow
decreases.
Very little pressure remains by the time blood leaves the capillaries and enters the venules. Blood
flow through the veins is not the direct result of ventricular contraction. Instead, venous return
depends on skeletal muscle action, respiratory movements, and constriction of smooth muscle in
venous walls.

Pulse and Blood Pressure

Pulse refers to the rhythmic expansion of an artery that is caused by ejection of blood from the
ventricle. It can be felt where an artery is close to the surface and rests on something firm.

In common usage, the term blood pressure refers to arterial blood pressure, the pressure in the
aorta and its branches. Systolic pressure is due to ventricular contraction. Diastolic pressure occurs
during cardiac relaxation. Pulse pressure is the difference between systolic pressure and diastolic
pressure. Blood pressure is measured with a sphygmomanometer and is recorded as the systolic
pressure over the diastolic pressure. Four major factors interact to affect blood pressure: cardiac
output, blood volume, peripheral resistance, and viscosity. When these factors increase, blood
pressure also increases.

The blood vessels of the body are functionally divided into two distinctive circuits: pulmonary circuit
and systemic circuit. The pump for the pulmonary circuit, which circulates blood through the lungs,
is the right ventricle. The left ventricle is the pump for
the systemic circuit, which provides the blood supply
for the tissue cells of the body.

a. Pulmonary Circuit
Pulmonary circulation transports oxygen-poor blood
from the right ventricle to the lungs where blood picks
up a new blood supply. Then it returns the oxygen-
rich blood to the left atrium.

b. Systemic Circuit
The systemic circulation provides the functional blood
supply to all body tissue. It carries oxygen and
nutrients to the cells and picks up carbon dioxide and
waste products. Systemic circulation carries
oxygenated blood from the left ventricle, through the
arteries, to the capillaries in the tissues of the body.
From the tissue capillaries, the deoxygenated blood returns through a system of veins to the right
atrium of the heart.

LIVER
The liver is an organ present in vertebrates and some other animals. It plays a major role in
metabolism and has a number of functions in the body, including glycogen storage, decomposition
of red blood cells, plasma protein synthesis, and detoxification. This organ also is the largest gland
in the human body. It lies below the diaphragm in the thoracic region of the abdomen. It produces
bile, an alkaline compound which aids in digestion, via the emulsification of lipids. It also performs
and regulates a wide variety of high-volume biochemical reactions requiring very specialized
tissues.

KIDNEY

The kidneys are organs that filter wastes (such as urea) from the blood and excrete them, along
with water, as urine. In humans, the kidneys are located in the posterior part of the abdomen. There
is one on each side of the spine; the right kidney sits just below the liver, the left below the
diaphragm and adjacent to the spleen. Above each kidney is an adrenal gland (also called the
suprarenal gland). The asymmetry within the abdominal cavity caused by the liver results in the
right kidney being slightly lower than the left one while the left kidney is located slightly more
medial.

a. Homeostasis
The kidney is one of the major organs involved in whole-body homeostasis. Among its homeostatic
functions are acid-base balance, regulation of electrolyte concentrations, control of blood volume,
and regulation of blood pressure. The kidneys accomplish these homeostatic functions
independently and through coordination with other organs, particularly those of the endocrine
system. The kidney communicates with these organs through hormones secreted into the
bloodstream.

b. Acid-base balance
The kidneys regulate the pH, by eliminating H ions concentration called augmentation mineral ion
concentration, and water composition of the blood.

c. Blood pressure
Sodium ions are controlled in a homeostatic process involving aldosterone which increases sodium
ion reabsorption in the distal convoluted tubules.

When blood pressure becomes low, a proteolytic enzyme called Renin is secreted by cells of the
juxtaglomerular apparatus (part of the distal convoluted tubule) which are sensitive to pressure.
Renin acts on a blood protein, angiotensinogen, converting it to angiotensin I (10 amino acids).
Angiotensin I is then converted by the Angiotensin-converting enzyme (ACE) in the lung capillaries
to Angiotensin II (8 amino acids), which stimulates the secretion of Aldosterone by the adrenal
cortex, which then affects the renal tubules.

Aldosterone stimulates an increase in the reabsorption of sodium ions from the kidney tubules
which causes an increase in the volume of water that is reabsorbed from the tubule. This increase
in water reabsorption increases the volume of blood which ultimately raises the blood pressure.

d. Plasma volume
Any significant rise or drop in plasma osmolality is detected by the hypothalamus, which
communicates directly with the posterior pituitary gland. A rise in osmolality causes the gland to
secrete antidiuretic hormone, resulting in water reabsorption by the kidney and an increase in urine
concentration. The two factors work
together to return the plasma
osmolality to its normal levels.
Hormone secretion
The kidneys secrete a variety of
hormones, including erythropoietin,
urodilatin, renin and vitamin D.

ANGIOTENSIN
Angiotensin is an oligopeptide in the
blood that causes vasoconstriction,
increased blood pressure, and
release of aldosterone from the
adrenal cortex. It is a powerful
dipsogen. It is derived from the
precursor molecule angiotensinogen,
a serum globulin produced in the liver.
It plays an important role in the renin-
angiotensin system. Renin's primary
function is therefore to eventually
cause an increase in blood pressure,
leading to restoration of perfusion
pressure in the kidneys.

Types of Angiotensin

a. Angiotensin I
Angiotensin I is formed by the action of renin on angiotensinogen. Renin is produced in the kidneys
in response to both decreased intra-renal blood pressure at the juxtaglomerular cells, or decreased
delivery of Na+ and Cl- to the macula densa. If more Na+ is sensed, renin release is decreased.
Renin cleaves the peptide bond between the leucine (Leu) and valine (Val) residues on
angiotensinogen, creating the ten amino acid peptide (des-Asp) angiotensin I.

b. Angiotensin II
Angiotensin I is converted to angiotensin II through removal of two terminal residues by the enzyme
Angiotensin-converting enzyme (ACE, or kinase), which is found predominantly in the capillaries of
the lung. ACE is actually found all over the body, but has its highest density in the lung due to the
high density of capillary beds there. Angiotensin II acts as an endocrine, autocrine/ paracrine, and
intracrine hormone. ACE is a target for inactivation by ACE inhibitor drugs, which decrease the rate
of angiotensin II production. Angiotensin II increases blood pressure by stimulating the Gq protein in
vascular smooth muscle cells (which in turn activates contraction by an IP3-dependent
mechanism). ACE inhibitor drugs are major drugs against hypertension.

c. Angiotensin III
Angiotensin III has 40% of the pressor activity of Angiotensin II, but 100% of the aldosterone-
producing activity.
d. Angiotensin IV
Angiotensin IV is a hexapeptide which, like angiotensin III, has some lesser activity.

Cardiovascular effects
It is a potent direct vasoconstrictor, constricting arteries and veins and increasing blood pressure.

Renal effects
Angiotensin II has a direct effect on the proximal tubules to increase Na+ absorption. Although it
slightly inhibits glomerular filtration by indirectly (through sympathetic effects) and directly
stimulating mesangial cell constriction, its overall
effect is to increase the glomerular filtration rate by
increasing the renal perfusion pressure via efferent
renal arteriole constriction. Angiotensin II causes the
release of prostaglandins from the kidneys.

Glomerular filtration rate (GFR)


Glomerular filtration rate (GFR) is a test used to
check how well the kidneys are working. Specifically,
it estimates how much blood passes through the tiny
filters in the kidneys, called glomeruli, each minute.
Glomerular filtration is the process by which the
kidneys filter the blood, removing excess wastes and
fluids. Glomerular filtration rate (GFR) is a
calculation that determines how well the blood is
filtered by the kidneys, which is one way to measure
remaining kidney function.

HYPERTENSION

Vasospasm  effects on vascular system  vasoconstriction  impaired organ perfusion 


hypertension

EDEMA

It is the medical term for when excess fluid collects in your tissue. It's normal to have a certain
amount of this swelling during pregnancy because you retain more water while you are pregnant,
and certain changes in your blood chemistry cause some fluid to shift into your tissue.

When one is pregnant, the growing uterus puts pressure on the pelvic veins and on the vena cava
(a large vein on the right side of your body that receives blood from your lower limbs and carries it
back to the heart). The pressure slows down circulation and causes blood to pool in your legs,
forcing fluid from your veins into the tissues of your feet and ankles. This increased pressure is
relieved when you lie on your side. And since the vena cava is on the right side of your body, left-
sided rest works best.

A certain amount of edema is normal in the ankles and feet during pregnancy. However, swelling in
of face or puffiness around the eyes, more than slight swelling of the hands, or excessive or sudden
swelling of feet or ankles could be a sign of preeclampsia, a serious condition. A
Edema forms in people with kidney disease primarily for one of two reasons: either a heavy loss of
protein in the urine or impaired kidney (renal) function. In the first situation, the people have normal
or fairly normal kidney function. The heavy loss of protein in the urine (over 3.0 grams per day) is
termed the nephrotic syndrome and results in a reduction in the concentration of albumin in the
blood (hypoalbuminemia). Since albumin helps to maintain blood volume in the blood vessels, a
reduction of fluid in the blood vessels occurs. The kidneys then register that there is depletion of
blood volume and, therefore, attempt to retain salt. Consequently, fluid moves into the interstitial
spaces, thereby causing pitting edema.

People who have kidney diseases that impair renal function develop edema because of a limitation
in the kidneys' ability to excrete sodium into the urine. Thus, people with kidney failure from
whatever cause will develop edema if their intake of sodium exceeds the ability of their kidneys to
excrete the sodium.

Vasospasm  effects on the interstitial tissues  fluid diffusion from vascular space into interstitial
space  edema

ALBUMINURIA/ PROTEINURIA

The presence of excessive protein (chiefly albumin but also globulin) in the urine; usually a
symptom of kidney disorder.

Vasospasm  effects on renal system  reduced glomerular filtration rate; increased glomerular
membrane permeability  increased serum blood urea nitrogen and creatinine levels  oliguria
and protenuria

PATHOPHYSIOLOGY
BOOK BASED
NORMAL PLACENTAL DEVELOPMENT
From 9-12 weeks gestation the uterine spiral arteries are
transformed from thick-walled, muscular vessels, to more
flaccid tubes to accommodate a 10-fold increase in uterine
blood flow to support the pregnancy

Uterine spiral artery remodeling takes place by


the invasion of trophoblast cells into the uterine
lining.

These trophoblasts enter the arterial walls and


replace parts of the vascular endothelium so that
smooth muscle is lost and the artery dilates

An immune response facilitates normal placental


development:
 In the uterine decidua, maternal lymphocytes and
macrophages assist the trophoblasts to invade into the
uterine myometrium and the spiral arteries.
The mechanism by which preeclampsia occurs is not certain, and the diagnosis may represent a
diversity of pathophysiologies that proceed to a common final pathway. The inciting event is believe
to be placental hypoperfusion, which may result because the uteroplacental spiral arterioles are
abnormally formed, leaving them highly sensitive to vasoconstriction. Both maternal and paternal
factors have been implicated in the development of preeclampsia.

Placental hypoperfusion leads by an unclear pathway to the release of systemic vasoactive


compounds that cause an exaggerated inflammatory response, vasoconstriction, endothelial
damage, capillary leak, hypercoagulability, and platelet dysfunction, all of which contribute to organ
dysfunction and the various clinical features of the disease.

Preeclampsia is a state of high systemic vascular resistance with normal or relatively low
intravascular volume.

TWO-STAGE MODEL OF THE PATHOPHYSIOLOGY OF PREECLAMPSIA

PLACENTAL PATHOPHYSIOLOGY
STAGE 1

Trophoblasts fail to completely remodel the uterine


Theoretical basis for incomplete remodeling:
spiral arteries.
> Production failure of endothelial adhesion
> Remodeling either absent or
molecules from trophoblasts or
> Remodeling limited to the superficial
> Failure of/ or weak signaling of immune
portion of the artery located in the decidua, rather
cells by trophoblasts prevents deep invasion
than extending into the inner third of the
necessary for normal artery remodeling.
myometrium.

Poor placentation, or a decreased capacity of the


uteroplacental circulation. This causes placental
hypoxia, resulting in oxidative stress.
MULTISYSTEMIC, MATERNAL SYNDROME
(EVIDENCE OF MATERNAL DISEASE PROCESS)
Stage 2 begins when maternal clinical features
STAGE appear.
2
> Cause is most likely related to the hypoxic and dysfunctional placenta releasing
factors into the maternal circulation resulting from cell death. These factors target the
maternal endothelium, causing vascular damage

Perfusion is reduced to virtually every organ

With maternal endothelial damage:


> Decreased production of vasodilators (prostacyclin and nitric oxide)
> Inactivation of circulating nitric oxide (vasodilator)

VASOSPASM

Poor tissue perfusion to all Increases total peripheral Increases endothelial cell
maternal organs resistance resulting in permeability, (“leaky
elevated blood pressure capillaries”) fluid shifts from
* Vasospasm causes poor intravascular to intracellular
tissue perfusion to all organs, space resulting in:
* Vasospasm and endothelial
leading to organ dysfunction. > Decreased plasma volume,
damage upset the delicate increased hematocrit
* Decreased perfusion to the
balance between > Generalized tissue and organ
kidney results in decreased
vasoconstrictors and edema
glomerular filtration, allowing
vasodilators. This imbalance
protein, mainly
causes generalized * Vasospasm of maternal blood
albumin, to be lost into the
vasoconstriction, which vessels causes damage to
urine. Oliguria develops as the
increases peripheral vascular endothelial cells, causing them
disease worsens
resistance, resulting in to become more permeable.
hypertension Fluid “leaks” out of the blood
vessels into the tissues,
causing tissue and organ
edema
CLIENT BASED:

Risk factors of Pre-eclampsia includes:


• History of preeclampsia. A personal or family history of preeclampsia increases your
risk of developing the condition.
• First pregnancy. The risk of developing preeclampsia is highest during your first
pregnancy or your first pregnancy with a new partner.
• Age. The risk of preeclampsia is higher for pregnant women who are older than age
35.
• Obesity. The risk of preeclampsia is higher if you're obese.
• Multiple pregnancy. Preeclampsia is more common in women who are
carrying twins, triplets or other multiples.
• Gestational diabetes. Women who develop gestational diabetes have a higher risk of
developing preeclampsia as the pregnancy
progresses. FACTOR RISK RATIO
• History of certain conditions. Having Family history of PIH 5:1
certain conditions before you become pregnant
— such as chronic high blood pressure, diabetes, Diabetes mellitus 2:1
kidney disease or lupus — increases the risk of Twin gestation 4:1
preeclampsia.
Client reported of having chronic HPN before pregnancy

Family history also reveals HPN of both parents

Client is also in multiple pregnancies/ carrying twins


> Multiple pregnancy doubles the risk of preeclampsia. The placental
mass is large in multiple pregnancy. Hypoxia or reperfusion injury during
placentation might account for the endothelial damage that is
increasingly recognized as playing a part in the client’s pathogenesis of
preeclampsia.

The placenta doesn't grow normally in the first half of pregnancy/ blood
vessels that go to the placenta don't grow properly. This means not
enough blood reaches the placenta in the second half of pregnancy/
placenta doesn't get enough blood from the client.

The unhealthy placenta sends harmful chemicals back into the client’s
bloodstream. The chemicals damage the lining of the blood vessels,
causing high blood pressure, problems with the kidneys, and swelling.
NURSING CARE PLAN

CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATION


DIAGNOSI PLANNING INTERVENTION
S

Subjective: Altered Tissue Increased After 8 hours of Independent:


Perfusion r/t cardiac output continuous • Take v/s every 1 – 2 • To detect early Goal met.
vasoconstricti nursing hours initially, then signs of After 8 hours of
on of blood Injury of intervention every 4 hours after decreased continuous
vessels endothelial cells patient will the patient becomes cerebral nursing
of the arteries maintain or stable. perfusion or ICP. intervention
Objective: improve current patient’s LOC
BP:180/100 Reduced LOC. • Elevate head of improved as
RR:28 responsiveness patient’s bed 30 • To promote evidenced by the
PR:114 to blood degrees. venous drainage latter regaining
pressure reducing cerebral sense of
changes edema. orientation.
• Keep patients head
Vasoconstriction in neutral alignment. • To keep the
carotid flow
unobstructed,
• Keep the thereby
environment and promoting
patient quiet. perfusion.

• Measure accurate • Reduce increase


intake and output. in ICP.

Dependent:
• Administer diuretics • To prevent
such as mannitol, as volume overload
ordered. or deficit.
• To prevent
increased ICP.

CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATIO


DIAGNOSI PLANNING INTERVENTION N
S

Subjective: Acute pain r/t Episiotomy Short term: Independent: Goal met.
“Masakit pa to episiotomy. • Assess perineum for • To verify extent of After 8 hours of
rin po ang Cellular Injury After 8 hours of edema. wound. continuous
sugat ko.”as continuous nursing
verbalized by Vasodilation nursing • Apply ice pack for intervention
the patient. intervention the 20mins.remove for at • Cold compress the mother
Vasoconstriction mother will state least 10mins. Before constricts blood stated that
Objective: that discomfort reapplying. vessels therefore discomfort has
Facial Increase has decreased. reduces pain. decreased as
Grimacing Vascular • Teach mother to evidenced by
Pain scale of 7 permeability squeeze buttocks absence of
BP:180/100 together before • To prevent pressure facial grimace
RR:28 Inflammation sitting, release after on the area. pain scale of 0.
PR:114 sitting.
Pain
• Encourage mother to
practice kegel • Kegel exercise is
exercise. deisgned to
strengthen
pubococcygeal
Dependent: muscles.
• Administer analgesic
as ordered.
• Relief of pain.
CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATIO
DIAGNOSI PLANNING INTERVENTION N
S

Subjective: Activity Increase Cardiac Short term: Independent: Goal met.


“Konting intolerance output • Discuss with patient • Which will improve After 8 hours of
galaw ko lng related to After 8 hours of the need for activity. physical and continuous
po kinakapos imbalance Increased continuous psychosocial well- nursing
na po ako ng oxygen supply Peripheral nursing being. intervention
hininga”as and demand. resistance intervention the • Evaluate current the patient
verbalized by patient will limitations/degree of • Provides comparative expresses
the client. vasoconstriction report deficit in light of baseline. satisfaction
measureable usual status. with increase in
Objective: Decreased increase in activity level.
RR:28 Blood Supply activity • Monitor physiologic
PR:114 To intolerance responses to • To ensure return to
organs(kidney, increased activity normal a few minutes
pancreas, (including after exercising.
Liver, brain) respirations, heart
rate and rhythm, and
Tissue hypoxia blood pressure).

• Adjust activities. • To prevent


overexertion.
• Support and
encourage activity to • This helps develop
patient’s level of the patient’s
tolerance. independence.
CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATIO
DIAGNOSI PLANNING INTERVENTION N
S

Subjective: Excess fluid Vasoconstriction Short term: Independent: Goal met;


volume r/t to • Monitor v/s and • Changed parameters After 8 hours of
increased Increase After 8 hours of breath sounds at may indicate altered continuous
isotonic fluid hydrostatic continuous least every 4 hours; fluid or electrolyte nursing
Objective: retention. pressure nursing record and report status. intervention
Urine output intervention changes. the patient
of <30ml/hr Fluid from the patient will verbalized
Pitting capillaries verbalize • If oral fluids are • Patient involvement understanding
Edema:3 accumulate into understanding of allowed, help patient encourages of fluid and
seconds interstitial space individual dietary make a schedule for compliance. dietary
Lower and fluid fluid intake restrictions as
extremities: Edema restrictions. . evidenced by
Bipedal formation • Explain the reasons • To prevent patient plans
Edema for fluid and dietary dehydration. own menu and
restrictions. selects food
low in sodium
• Provide mouth care and potassium.
every 4 hours. • To enhance patients
understanding and
compliance.
• Provide sour hard
candy. • To decrease thirst
and improve taste.
Dependent:
• Administer • To promote fluid
medications. excretion.
NURSING
CUES DIAGNOSIS INFEREN PLANNI NURSING INTERVENTION RATIONALE EVALUATIO
CE NG N

Subjective Self care Delivery Short Independent: Goal met


: deficit: ↓ term: Within 1 hour
bathing/hygie (Tissue Within 1 • Assist within meeting client’s • To assist in dealing with of continuous
“Hndi pa. ne related to trauma) hour of needs when he is unable to meet current situation nursing
Ang hirap pain Pain continuou own needs intervention
din kasi ↓ s nursing • Develop plan of care appropriate the patient
tumayo Hesitation interventi to patient’s situation, scheduling demonstrated
papuntang to move on the activities to conform to patient’s techniques to
CR kaya ↓ patient usual schedule. • To enhance commitment meet self care
minsan Inability to will to plan, optimizing needs.
ngpapapun access demonstr • Promote client’s relative’s outcomes and supporting
as na lang bathroom, ate participation in problem recovery and health
ako”, as wash body technique identification and desired goals promotion.
verbalized and dry s to meet and decision making
by the oneself self care • To discover barriers to
patient. ↓ needs. participation in regimen
Self care • Plan time for listening to patient’s and to work on problem
Objective: deficit on concerns solutions
hygiene
• Inability • To recognize that today’s
to wash • Practice and promote short-term success is as important
body goal setting and achievement as any long-term goal,
• Inability accepting ability to do
to access one thing at a time, and
bathroom conceptualization of self-
• Inability care in a broader scene.
to dry
body • Provide privacy and equipment • To enhance coordination
within easy reach during personal and continuity of care.
care activities.

• Provide for communication • To encourage patient and


among those who are involved in build on success
caring /assisting for patient.
CUES NURSING INFERENCE PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

Subjectiv Anxiety:mild The anxiety of Short term: Independent:


e: related to the patient is Goal met.
treat to brought about After 2 hours of • Note degree of • Understanding that After an hour of
"Hay. Ang health status the threat to her nursing anxiety and fear. feelings (which are nursing
taas nga health status intervention Inform patient/SO that based on stressful intervention
ng presyon because of being patient’s feelings are normal situation plus an patient’s anxiety
ko, pano pre-eclamptic anxiety will be and encourage oxygen imbalance was reduced as
ba yan," during the latter reduce expression of feelings that is being treated) evidence by
As part of are normal may help relaxed voice and
verbalized pregnancy. the patient regain absence of
by the some feeling of tension.
patient • Explain disease control over emotions
process and
Objective procedures within • Allays anxiety related
: level of patient's to the unknown and
ability to understand reduces the fears
- and handle the concerning personal
Restlessne information. Review safety. In the early
ss current situations and phases of the illness,
- Irritability the measures being explanations need to
- Voice taken to remedy the be short and
quivering problems repeated frequently
- because the patient
Sympathet will have a reduced
ic • Stay with the patient attention span
stimulation or make arrangements
e.g for someone else to be • Helpful in reducing
sweating there during acute anxiety associated
attack with perceived
abandonment in
presence of severe
• Provide comfort dyspnea/feelings of
measures, e.g back impending doom
rub, position changes • Aids in reducing
stress and redirecting
attention to enhance
• Assist patient to relaxation and coping
identify helpful abilities
behaviors e.g
assuming position of • Gives patient
comfort, focused measure of control to
breathing, relaxation reduce anxiety and
techniques muscle tension

• Support patient/SO in
dealing with the
realities of the • Coping mechanisms
situation, especially in and participation in
planning for long treatment regimen
recovery period. may be enhanced as
Involve patient in patient learns to deal
planning and with the outcomes of
participating in care the illness and
regains some sense
• Develop activity of control
program within limits
of physical ability
• Provides a healthy
outlet for energy
generated by feelings
DRUG STUDY

DRUG NAME ACTION INDICATIO CONTRAINDIC ADVERSE NURSING


N ATION EFFECT RESPONSIBI
LITY
Mefenamic Acid Anti-inflammatory, Short-term relief Contraindicated in: CNS: drowsiness, > Administer with
500 mg/cap analgesic, and anti- of mild to hypersensitivity to drug, insomnia, dizziness, meals, food, or milk
D: q6 for pain pyretic activities moderate pain GI inflammation, or vertigo, unsteady to minimize GI
related to inhibition ulceration. Safe use in gait, nervousness, adverse effects.
Drug Class: of prostaglandin children < 14y, during confusion, headache, > Use of drug for a
NSAID synthesis. pregnancy (Category status epilepticus period exceeding 1
C), and in nursing with overdose. wk is not
Brand names: mothers not recommended
Apo-Mefenamic established. GI: Severe diarrhea, > Patients who
Ponstan GI inflammation, develop severe
Ponstel Caution use in: history ulceration, and diarrhea and
of renal or hepatic bleeding; nausea, vomiting should be
disease; blood vomiting, abdominal assessed for
dyscrasias; asthma; cramps, flatus, dehydration and
diabetes mellitus; constipation. electrolyte
hypersensitivity to imbalance.
aspirin. Hematologic: > Patients on long-
prolonged term therapy should
prothrombin time, have periodic blood
severe autoimmune counts. Hct and
hemolytic anemia Hgb, and renal
(long-term use), function tests.
leucopenia, >Mefenamic acid
eosinophilia, should be
agranulocytosis, discontinued
Thrombocytopenic promptly if diarrhea,
purpura, dark stool,
megaloblastic hematemesis,
anemia, bone ecchymoses,
marrow hypoplasia. epistaxis, or rash
occur and should
Renal: nephrotoxicity, not be used
dysuria, albuminuria, thereafter. Advise
hematuria, elevation patients to report
of BUN. these signs to the
physician.
Skin: Urticaria, rash, > Advise patient to
facial edema. notify physician if
persistent GI
Other: Eye irritation, discomfort, sore
loss of color vision throat, fever, or
(reversible), blurred malaise occurs.
vision, ear pain,
perspiration,
increased need for
insulin in diabetic
patients, hepatic
toxicity, palpitation,
dyspnea; acute
exacerbation of
asthma;
bronchoconstriction
(in patients sensitive
to aspirin).
Ferrous Sulfate Elevate serum iron > Iron deficiency Contraindicated in CNS: coma and > Give drug with
D: 1 tab OD concentration, > Iron Supplement patients with death with overdose meals (avoiding
which helps to form hemosiderosis primary milk, eggs, coffee
Drug Class: Hgb or trapped in hemochromatosis, GI: GI upset, and tea) if GI
Iron Preparation reticuloendothelial hemolytic aneuria anorexia, nausea and discomfort is
cells for storage (unless patient also vomiting, constipation severe, slowly
Brand names: and eventual has IDA), peptic increase to build up
Apo-FeSO4 conversion to ulceration, ulcerative tolerance
Feosol usable form of iron colitis or regional > Warn patient that
Fer-Gen-Sol enteritic and in those stool may be dark
Fer-In-Sol receiving repeated or green
blood transfusion > Arrane for
periodic monitoring
of Hct and Hgb
levels
> Report severe GI
upset, lethargy,
rapid respirations,
constipation
Cephalexine HCl Bactericidal: > Respiratory tract Contraindicated in GI: Nausea, vomiting, > Ask patient about
(Cephalexine Inhibits synthesis of infections caused patients hypersensitive diarrhea, anorexia, post reaction to
Monohydrae) bacterial cell wall, by Streptococcus to cephalosporins or abdominal pain, cephalosporins or
D: 1 tab OD causing cell death Pneumoniae penicillins flatulence, penicillin therapy
> Skin and skin pseudomembranous before giving 1st
Drug Class: structure infections Caution: renal failure, colitis dose
Antibiotic (Staphylococcus lactation, pregnancy > Obtain specimen
Cephalosporin and streptococcus) Hematologic: Bone for culture and
(first generation) > Otitis Media marrow depression sensivity tests
> Bone infections before giving 1st
Brand names: > GU infections Hypersensitivity: dose. Therapy may
Apo-Cephalex Ranging from rash to begin while
Keflex fever to anaphylaxis awaiting results.
Novo-Lexin > Take drug with
Other: food
Superinfections > Complete full
course of drug even
if feel better
> Report: severe
diarrhea with blood,
rash/ hives, DOB,
unusual tiredness,
fatigue, unusual
bleeding/ bruising
Amoxicillin Trihydrate Bactericidal: > Infections due to Contraindicated with GI: glossitis, > Give in oral
500 mg/cap Inhibits synthesis of susceptible strains allergies to penicillins, stomatitis, gastritis, preparations only,
D: q8 for 7 days bacterial cell wall, of Haemophillus cephalosporins or other sore mouth, nausea, not affected by food
causing cell death influenza, allergens vomiting, diarrhea, > Take full course
Drug Class: Escherichia Coli abdominal pain of therapy
Antibiotic (penicillin > Helicobacter Caution: renal > Report: unusual
– ampicillin type) pylori infection in disorders, lactation Hypersensitivity: bleeding/ bruising,
combination with rash, fever, sore throat, fever,
Brand names: other agents wheezing, rash, hives, severe
Amoxil > Chlamydia anaphylaxis diarrhea, DOB
Apo- Amoxi Trachomatis in
Dispermox pregnancy Other:
Novamoxin Superinfections
Nu-Amoxi
Trimox
Methylergonovine A partial agonist or > Routine Contraindicated with CNS: Dizziness, > Monitor
Maleate antagonist at alpha management after allergy to headache postpartum women
125 mg/tab receptors; as a result, delivery of the methylergonovine, for BP changes and
D: q8 for 3 days it increases the placenta hypertension, CV: Transient amount and
strength, duration, and > Treatment of toxaemia, lactation, hypertension character of vaginal
Drug Class: frequency of uterine postpartum atony and pregnancy bleeding
Oxytoxic contractions hemorrhage, GI: Nausea > Drug should not
subinvolution of Caution: sepsis, be needed for
Brand names: uterus obliterative vascular longer than one
Methergine > Uterine stimulation disease, hepatic or week
during the second renal impairment > Discontinue if
stage of labor signs of toxicity
following the delivery occurs
of the anterior > Report: DOB,
shoulder, under strict headache, numb/
medical supervison cold extremities,
severe abdominal
cramping
Metronidazole Bactericidal: Inhibits > Acute infection with Contraindicated with CNS: Headache, > Take full course of
500 mg/tab DNA synthesis in susceptible anaerobic hypersensitivity to dizziness, ataxia drug therapy, take
D: q8 for 7 days specific (obligate) bacteria metronidazole, drug with food if GI
anaerobes, causing > Acute intestinal pregnancy GI: unpleasant upset occurs
Drug Class: cell death; amebiasis metallic taste, > Don’t drink alcohol
Antibiotic antiprotozoal – > Amebic liver Caution: CNS anorexia, nausea, (beverages containg
Antibacterial trichomonacidal, abscess diseases, hepatic vomiting, diarrhea alcohol; cough
Amebicide amebicidal > Trichomoniasis disease, candidiasis, syrup), severe
Antiprotozoal > Preoperative, blood dyscrasias, GU: darkening of the reactions my occur
intraoperative, post- lactation urine > Urine may be
Brand names: operative prophylaxis darker in color
Apo- for patients > Report: svere GI
metronidazole undergoing colorectal upset, dizziness,
Flagyl surgery unusual fatigue/
MetroGel > Prophylaxis for weakness, fever,
NidaGel patients undergoing chills
Noritate gynaecologic,
Protostat abdominal surgery,
hepatic
encephalopathy,
antibiotic associated
pseudomembranous
colitis
Senna The laxative effect is Short term relief of Contraindicated in px Excessive bowel oBetween-meal
Concentrate due to the action of constipation; to with peptic ulceration, activity, perianal doses are
D: HS for 2 weeks sennosides and their prevent straining; to regional enteritis, irritation, abdominal preferable, butdrug
active metabolite, rhein evacuate the bowel ulcerative colitis, cramps, weakness, can be given with
Drug Class: anthrone, in the colon. for diagnostic hemosiderosis, dizziness, cathartic some foods,
Stimulant laxative The laxative effect is procedures; to primary dependence although absorption
realized by inhibition of remove ingested hemochromatosis or may be decreased.
Brand Name: water and electrolyte poisons from the haemolytic anemia oEnteric-coated
Black-Draught, absorption from the lower GI; as adjunct in and in those products reduce GI
Ex-lax,Senna- large intestine, which anthelmintic therapy receiving repeated upset but also
Gen, Senokot increases the volume blood transfusion reduce amount of
and pressure of the iron absorbed.
intestinal contents. oCheck for
This will stimulate the constipation, record
colon motility resulting color and amount of
in propulsive stools
contractions oTell patient to take
tablets with juice
(preferably orange
juice) or water, but
not with milk or
antacids.
DISCHARGE PLANNING

Discharge Planning is a process of preparing a client to leave one level of care for another

DISCHARGE CONSIDERATION:

Starts from the moment patient is admitted to the hospital, where length of stays are
considerably shortened.

INVOLVES THE FOLLOWING:

• Ongoing assessment to obtain comprehensive information about the clients ongoing


needs
• current health status; prognosis; surgery
• neighbors & friends; community health care & facilities
• stairways; bathroom/ hallways/ floorings; lightings; ambulatory devices
• ambulating; meal preparation; transportation
• wound care assistance, ostomies; tubes; IV medications
• equipment; supplies; medications; special foods required

MANAGEMENT & NURSING RESPONSIBILITIES:

Pre-eclampsia occurs only in the presence of a placenta. The management of pre-


eclampsia is complicated by the presence of the fetus. The only definitive therapy for
preeclampsia is delivery. After birth, most women will stabilize within 48 hours. However,
because of the risk of eclampsia during the first 24 to 48 hours, careful monitoring of vital signs,
level of consciousness, and DTRs and laboratory assessments are continued.

Nursing Responsibilities such as:


• Instructions of care
• Health teachings
• Advices on follow up, schedules of examination
• Referrals

Either in written form or verbally depending on clients or family members level of


education & maturity.

Discharge teaching should begin during the perinatal period, and continue throughout the
intrapartum and postpartum period. The main tasks of the caregiver who attends the postpartum
period is to measure and record blood pressure after delivery, to swiftly identify symptoms that
could be indicative of preeclampsia (headache, visual disturbances, epigastric pain), to protect
the woman from damage during fits, and to arrange transport to a hospital or referral centre in
case of a serious rise of blood pressure combined with these symptoms.

Attention should also be given to signs of emotional and physical fatigue and other
problems that might arise from them.
Community health nurses have the opportunity to have ongoing assessments as well as
caregivers in their environment. They can provide support and resources as needed.

DISCHARGE GOALS:

• Hemodynamically stable, free-of-seizure activity


• Condition, prognosis, therapeutic regimen understood
• Participating in care with plan in place for home monitoring/management

DISCHARGE SUMMARY OF PATIENT:

• Age: 31
• G5P4
• BP: 180/100
• HR: 83
• RR: 22
• Temp: 36.8 C
• Pale palpebral conjuctiva, anicteric sclera
• Supple neck, no clads
• Symmetrical chest expansion
• Clear breath sounds
• Globular abdomen with abdominal girth of 93.98cm
• (+) bipedal edema

Upon admission, the patient was placed on NPO temporarily and was hooked to IVF.
Vital signs were monitored. Laboratories were done. Patient underwent NSD. Patient tolerated
the procedure well and had routine post-op care. Patient eventually transferred to ward and
eventually cleared for discharged.

DISCHARGE INSTRUCTIONS:
M - MEDICATION
E - EXERCISE/ ENVIRONMENT
T - TREATMENT
H - HYGIENE/ HEALTH TEACHINGS
O - OUT-PATIENT FOLLOW-UPS
D - DIET
S - SPIRITUAL
MEDICATION REGIMEN

1. Explain medicines administration procedure (if any per Rx)


2. Uses, action of medicine, schedule & cycle, intervention to side effects
3. Alternative therapeutic medicines

Recognizing that there are finite limits to the amount of money and health care providers
available, desirable outcomes often compete for the resources.

High blood pressure and protein in the urine resolve after delivery, usually within a few
days. Severe hypertension should be treated, and some women will require a high blood
pressure medication after being discharged from the hospital. This can be discontinued when the
blood pressure returns to normal levels, usually within six weeks.

Blood pressure that continues to be elevated beyond 12 weeks after delivery is unlikely to
be related to preeclampsia and may require long-term treatment.

Reinforce importance of medication compliance to patient and her relatives; its time,
frequency, duration dosage and route.

Advice to report unusual manifestations and side effects of drugs to physician.

Monitor and evaluate effectiveness of medication regimen.

MEDICATION DOSAGE

Mefenamic Acid 1 tab, q6 for pain


500 mg/cap
Ferrous Sulfate 1 tab OD
Cephalexine HCl 1 tab OD
(Cephalexine Monohydrae)
Amoxicillin Trihydrate 1 tab, q8 for 7 days
500 mg/cap
Methylergonovine Maleate 1 tab, q8 for 3 days
125 mg/tab
Methergine Metronidazole 1 tab, q8 for 7 days
500 mg/tab
Senna Concentrate 1 tab, HS for 2 weeks

EXERCISE & ENVIRONMENT

Incorporating regimen to ADL such as:


1. Breathing
2. Walking
3. Calisthenics
4. Reading & other
5. Mental exercises
6. Relaxation

• After delivery, the mother needs time to rest, sleep, and regain her strength.
• After 3 weeks, the uterine lining is normally completely healed and a new endometrium
regenerated. At this point, most normal activities can be resumed, although strenuous
physical activity is usually restricted until after 6 weeks.
• Prolonged bedrest is neither necessary nor desirable. There are a few cautionary notes:
 While she may be up walking, strenuous physical activity will
increase her bleeding and is not a good idea.
 The first time she gets up, someone should be with her to
assist in getting her back down if she feels light-headed.
• Encourage the patient to do some exercise every morning such as a simple walking.
• Provide environment within normal room and body temperature.
• Maintain safe environment.
• Institute seizure precaution.
• Teach patient to perform passive range of motion exercises on patient’s extremities.
• Education about abdominal muscle tone and exercises is explained.

TREATMENT

• Management of adverse effects of medicines


 Knowledgeability of drugs
• Alternative therapeutic medicines
 Nursing care process and procedure, or referral to seek community health
services, or to the hospital.

Maternal temperature should be periodically assessed. Any persistent fever (>100.4 twice
over at least 6 hours) indicates the possibility of infection and should be investigated.

Blood pressure should also be checked several times during the first day and periodically
thereafter. Abnormally high blood pressure can indicate late-onset pre-eclampsia. Low blood
pressure may indicate hypovolemia.

HYGIENE AND HEALTH TEACHING

1. Refers to client’s ability


a. dressing up
b. eat
c. toilet activity
d. bathing (tub, shower, sponge)
2. Refers to ambulating (with or without aids)
3. Refers to transferring (assistance/ aide)
a. from bed to chair
b. in and out of bath
c. in and out of car
4. Refers to meal preparation
5. Refers to Transportation
6. Refers to shopping

Encourage and explain the importance of breast feeding to the client. Breastfeeding
especially the first milk, colostrum, can reduce postpartum bleeding/hemorrhage in the mother,
and to pass immunities and other benefits to the baby.

Advice client to let her child expose to mild sunlight in order to balance and avoid excess
bilirubin in the blood.

Mother and her support person are informed of abnormal signs or symptoms to watch for
in the first several days following discharge and given written instructions on how to receive
assistance if questions or emergencies arise.
It is important to establish bladder function early in the post partum phase. Because
bladder distention due to post partum bladder atony or urethral obstruction is common,
encourage the woman to void early and often.

Stress on proper oral and body hygiene.

Provide information to enhance self-care

OUT-PATIENT

1. Appointment schedule for follow-up checks


2. Inform relatives regarding importance of compliance on follow-up check up.
3. Instructions or requirements (if any) on scheduled follow-up
4. Clinic Schedules

DIET (collaborative)

Advice client to eat proper diet. Encourage her to eat more vegetables and frequent
intake of liquids. Advise her to eat food which are rich in protein, iron and vitamin C. Protein
helps to repair body tissues, iron provides formation of Red blood cells and ascorbic acid for
helping absorption of iron.

Refer to dietician for dietary instructions.

SPIRITUAL ASPECT

• Belief
• Faith
• Hope
• Verbalization with significant others