Nursingcasestudy.blogspot.com
I. INTRODUCTION
get. It is marked by high blood pressure accompanied with a high level of protein in the
urine. Women with preeclampsia will often also have swelling in the feet, legs, and
hands. Preeclampsia, when present, usually appears during the second half of pregnancy,
generally in the latter part of the second or in the third trimesters, although it can occur
earlier.
• Abdominal pain
• Severe headaches
• A change in reflexes
• Dizziness
The exact causes of preeclampsia are not known, although some researchers
suspect poor nutrition, high body fat, or insufficient blood flow to the uterus as possible
causes.
The only real cure for preeclampsia and eclampsia is the birth of the baby. Mild
preeclampsia (blood pressure greater than 140/90) that occurs after 20 weeks of gestation
in a woman who did not have hypertension before; and/or having a small amount of
protein in the urine can be managed with careful hospital or in-home observation along
process on how pre-eclampsia occurs and for them to fully understand and be reminded
and may be as high as 18% in some settings in Africa (2) If the rate of life threatening
eclamptic convulsions (0.1% of all deliveries) is applied to all deliveries from countries
considered to be the least developed, 50,000 cases of women experiencing this serious
Nurse-Centered Objectives
Upon completion of this case study, the student nurse should be able to:
2. Formulate significant nursing diagnosis, with the significantly related nursing care
plan.
3. Identify the different medications administered for this disease their indications,
4. Identify the laboratory and diagnostic procedure done with the pre-eclamptic
Client-Centered Objectives
Upon completion of this case study, the client should be able to:
3. Learn and understand why such laboratory examinations are being done.
II. NURSING HISTORY
Mrs. Ob, a 39 years old housewife and first time mother, who currently
resides at Guagua Pampanga with her husband Mr. Gyne. She was born a Filipina
on November 9, 1969 in Sta. Rita Guagua Pampanga. The patient was admitted at
a Regional Hospital with a chief complaint of abdominal pain, last November 15,
construction site. She graduated at a Public High School. And she didn’t continue
Mrs. Ob was raised as a Roman Catholic, were she learned about religious
values but she still believes in super natural forces and superstitious beliefs. When
it comes in health matters, she seeks the help of a albularyo and uses herbal
medicines to treat any member of the family who has an ailment. But when
serious matters arise she still refers to medical professionals for help.
her family. The location of their house is not easily accessible to hospitals, health
centers and other government institutions. Mrs. Ob did not report any problems
Mrs. Ob was married to Mrs. Gyne at the age of 33 years old. She has a
last November 18, 2008 at around 10:00 in the evening, she delivered her 1st child
When Mrs. Ob was still pregnant, she only consulted once in a district
gravidarum, linea nigra, and melasma. She also experienced nausea and vomiting,
Father
Mother
Patient
Legend:
hypertension
died of old age
pneumonia
asthma
deceased
π pre eclampsia
side, the grandmother died from Hypertension and the father was died from Pneumonia.
The mother is not experiencing any health problems but the father has hypertension and
asthma. The patient, upon admission has elevated blood pressure and is suffering from
SKIN
• brown skin generally uniform in color except in areas exposed to the sun
HEAD
• no infestations
EYES
• white sclera
• when looking straight ahead, the client can see objects in the periphery
EARS
• symmetrically aligned
• no lesions or discoloration
NOSE
• no discharge or flaring
• outer lips uniform pink color with symmetric contour, soft and moist
NECK
• head centered
BREAST
• firm
CARDIOVASCULAR
• BP 180/100 mmHg
• PR 114
• reported palpitations
RESPIRATORY/CHEST
• chest symmetric
GASTROINTESTINAL/ABDOMEN
• no tenderness
URINARY
REPRODUCTIVE
• G1P1
MUSCULOSKELETAL/EXTREMITIES
• no bone deformities
• no tenderness
NEUROLOGIC
• oriented
• conscious
• displayed anxiety
PHYSICAL ASSESSMENT
SKIN
• brown skin generally uniform in color except in areas exposed to the sun
HEAD
• rounded
HAIR
• evenly distributed
• no infestations
EYES
• white sclera
• no discharge
EARS
• symmetrically aligned
• no lesions or discoloration
• no discharge
• symmetric contour
NECK
• head centered
• milk letdown
CARDIOVASCULAR
• BP 160/100 mmHg
• PR 106
RESPIRATORY/CHEST
• chest symmetric
GASTROINTESTINAL/ABDOMEN
URINARY
• yellowish urine
REPRODUCTIVE
• G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
• equal strength
• no bone deformities
• no tenderness
NEUROLOGIC
• oriented
• conscious
PHYSICAL ASSESSMENT
SKIN
• brown skin generally uniform in color except in areas exposed to the sun
HEAD
• rounded
HAIR
• no infestations
EYES
• anicteric sclera
• no discharge
EARS
• symmetrically aligned
• no lesions or discoloration
• no discharge or flaring
NECK
• milk letdown
CARDIOVASCULAR
• BP 150/100 mmHg
• PR 96
• chest symmetric
• right and left shoulders and right and left hips are at the same height
GASTROINTESTINAL/ABDOMEN
• rounded contour
URINARY
• yellowish urine
REPRODUCTIVE
• G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
• equal strength
• no tenderness
NEUROLOGIC
• oriented
• conscious
DIAGNOSTIC AND LABORATORY PROCEDURES
Date
Ordered and
Diagnostic or Analysis and
Indication or Date Normal
Laboratory Results Interpretation
Purpose Results Values
Procedure of Results
were
released
WBC Count To determine November 8.0 5-10 x No infection or
inflammation is present.
Pre-operation
assessment of
the patient.
normal
because of the
increase in
plasma volume
during
pregnancy.
Hemoglobin Pre-operation November 96 120- The result
sample of
blood contains
96 g of
hemoglobin.
Decreased
hemoglobin on
pregnant is
normal
because of
their increase
in plasma
volume.
Hematocrit Pre-operation November 0.29 0.37-0.47 The result
sample of
blood
contains .29 g
of hemoglobin.
Decreased
hematocrit on
pregnant is
normal
because of
their increase
in plasma
volume.
• Explain to the patient that the WBC test is used to detect an infection or
inflammation.
• Tell the patient that the test requires a blood sample. Explain who will perform
• Explain to the patient that he may experience slight discomfort from the needle
• Inform the patient that he should avoid strenuous exercise for 24 hours before the
test. Also tell him that he should avoid eating a heavy meal before the test.
• If the patient is being treated for an infection, advise him that this test will be
• Notify the laboratory and physician of medications the patient is taking that may
During
After
• Inform the patient that he may resume his usual diet, activity and medications
• A patient with severe leucopenia, they have little or no resistance to infection and
Before
• Explain to the patient that RBC count is used to evaluate the number of RBCs and
• Tell the patient that the test requires a blood sample. Explain who will perform
• Explain to the patient that he may experience slight discomfort from the needle
• Inform the patients that he need not restrict foods and fluids
During
After
Hemoglobin
Before
• Explain to the patient that the hbg test is used to detect anemia or polycythemia or
• Tell the patient that the test requires a blood sample. Explain who will perform
• Explain to the patient that he may experience slight discomfort from the needle
After
Hematocrit
Before
• Explain to the patient that hct is tested to detect anemia and other abnormal
conditions
• Tell the patient that the test requires a blood sample. Explain who will perform
• Explain to the patient that he may experience slight discomfort from the needle
• Inform the patients that he need not restrict foods and fluids
During
After
lack of clear diagnostic criteria for the disease and its subtypes. Consequently, several
studies have included a variety of other conditions that do not necessarily reflect an
spiral arterioles, is the common starting point in the genesis of pre-eclampsia, which
activates placental factors and induces systemic hemodynamic changes. The maternal
coagulation cascade and loss of vascular integrity. Pre-eclampsia has effects on most
maternal organ systems, but predominantly on the vasculature of the kidneys, liver and
brain.
V. THE PATIENT AND HIS CARE
1. Medical Management
electrolytes. minimal
the cesarean
operation.
Nursing Responsibilities:
• Tell the patient that she might feel a discomfort from the tourniquet and the IV
insertion
b. Pharmacotherapy
Brand name and Date ordered/ Route of General action Client response
Frequency of
Administration
Mefenamic 11-19-08 P.O., 500mg, Inhibits Patient was
synthesis by pain.
decreasing the
activity of the
enzyme,
cyclooxygenase,
which results in
decreased
formation of
prostaglandin
precursors
Cephalosporin 11-19-08 I.V., 750mg, q8 Inhibits bacterial The patient did
Cefuroxime cell wall not acquire
penicillin- adverse
(PBPs) which in
final
transpeptidation
step of
peptidoglycan
synthesis in
bacterial cell
walls, thus
inhibiting cell
wall
biosynthesis.
Bacteria
eventually lyse
due to ongoing
activity of cell
wall autolytic
enzymes
(autolysins and
murein
hydrolases)
assembly is
arrested.
hemoglobin, to treatment
transportation of reaction.
oxygen via
hemoglobin.
Nifedipine 11-19-08 P.O., 10mg, BID Inhibits calcium The patient
voltage-sensitive adverse
smooth muscle
and myocardium
during
depolarization,
producing a
relaxation of
coronary
vascular smooth
muscle and
coronary
vasodilation;
increases
myocardial
oxygen delivery
in patients with
vasospastic
angina
c. Diet
fasting blood
sugar.bcs intake
of food can
increase
glucose level
Clear Liquid 11-19-08 A diet of clear This diet reduce The patient
d. Exercise
Description Response
pregnancy complaints.
VI. NURSING CARE PLAN
nga daw ung related to sensory nursing environment management. met AEB pt
sumusigaw siya” arising from post pt rate the pain -Encouraged to -to reduce tension from 8 to 5 in a
section. 10 exercise
upon movement
muna dapat image related to abdominal nursing client to looked/ incorporate patient
mabuntis kc pregnancy AEB wound due to intervention, the touch the changes into recognized and
papangit ung changes in surgery, a new patient will able affected body body image. verbalized
tsaka bat ang develops that change of body -to bring back body changes.
-presence of to the pt
emotional
recovery.
-Assist pt to
identify positive
behavior
Cues Nursing Scientific Objective Nursing Rationale Expected
diagnoses Explanation intervention outcomes
S: “bumibilis Decreased Pregnancy After 4 hrs of -Keep client on - decreases Goal Met AEB
nga tibok ng cardiac output Induced nursing bed and in oxygen within 4 hrs. of
puso ko” related to altered Hypertension is a intervention, the position of consumption nursing
verbalized by heart rate (111 condition in patient will comfort intervention the
report of occur. It is caused stability (heart stimuli; provide adequate rest 111 bpm to 100
O: -with the
palpations; by altered cardiac rate will decrease quiet env’t bpm, BP from
tenderness of
(r/t) decreased output that injures from 111 bpm to -to reduce 140/100 to
abdominal are
venous return endothelial cells 100 bpm, BP -Encouraged anxiety 120/80 (Normal
-facial grimaces AEB edema of the arteries. from 140/100 to deep breathing BP)
improvement changes in
cardiac pressures
activities that
may stimulate
valsalva
response (rectal
stimulation,
bearing down
B.M)
O- decreased related to post to disturbance of intervention, the about safe and make beneficial verbalized
ambulation of CS delivery. normal bowel patient will risky practices choices when understanding
the patient bcs movements verbalize for managing need arises. about
through colon.
- Promote
limits of constrictions of
ability.
surgery Integrity related from the nursing hand hygiene. spread of the patient was
to surgery cesarean section intervention, the infection. able to knew
moisture.
-Apply
dressing healing
VIII. Discharge Plan
comfortable pair of white shirt and white pajama and a pair of flat slip-ons while being
sealed on a chair cuddling her baby boy. Her hair was untidy and up in a ponytail with
visible infestations. She was oriented enough to follow instructions and answers
Methods
M- Instructed the patient to take the following home medication as ordered by the
physician:
Ferrous Sulfate OD
exercise.
T- n/a
H- Instructed patient to take a bath everyday. Emphasize the importance of breast
feeding.
Nurses can help the nation achieve National Health Goals. These goals speak
directly to both fetus and the mother because pregnancy is a high risk factor for them.
Close monitoring in pregnant women and health teaching as much as possible about
Studies shows that there is no certain facts that will give us the idea where pre-
eclampsia arise. But there so many factors that could prevent this complication such as
diet modifications, proper compliance with the health care providers, proper exercise.
And if the complication is already present, proper monitoring, proper diet and drug
With this study, the student nurses were able to gain more knowledge and wider
view and perspective of the complication of pregnancy which is pre-eclampsia. Thus, the
student nurses would like recommend and share some pointers on how to deal with
To the government, primarily they should allocate sufficient budget to sustain and
provide better facilities. They must be responsible enough to create awareness program
To the health care team, they should righteously implementing basic and ideal
procedures regardless of the health care facilities where they belong. They must observe
and always remember to keep in line with their duties towards both the mother and the
To the community and the family, that they must be insufficient coordination with
the government and the health care team regarding promotion of health before, during,