Jose Rizal University Mandaluyong City College of Nursing

In Partial Fulfillment of Requirements In NCM104 Group 2A Submitted By: Castillo, Ruby Casuco, Ara Julieta Celestial, Feliciano Cruz, Marygil De Castro, Karla Mae De Jorge, Ahlyssa

Introduction Pre-eclampsia is a disorder that occurs only during pregnancy and the post partum period and affects both the mother and the newborn baby. This condition is a serious complication of pregnancy associated with the development of high blood pressure and protein in the urine occurs after 20 weeks of gestation in the late 2nd to 3rd trimester or to middle late pregnancy. Preeclampsia is usually categorized as mild or severe in terms of management. A pregnant woman with a severe pre- eclampsia develops a rise in blood pressure with at least 160 mm Hg of systolic blood pressure or a diastolic blood pressure of 110 mm Hg, proteinuria of greater than +2 (100 mg/ dl) +3 (300 mg/ dl), oliguria less than 400 to 500 ml of urine output over 24 hours, cerebral or visual disturbances, such as altered level of consciousness, severe headache, or blurred vision , hepatic involvement, including epigastric pain or elevated liver enzymes, thrombocytopenia with a platelet count of less than 100, 000/ cubic millimeter, pulmonary or cardiac involvement. Other Signs and symptoms of pre- eclampsia are upper abdominal pain right side usually under ribs, dizziness, sudden weight gain, and swelling in the face and hands (edema).(Maternal and Child Health Nursing by: Wong, Ladewig) The exact cause of pre- eclampsia remains unknown, it affects all the major systems of the body, and it may lead to serious or even fetal complications for both mother and baby. Delivery of the baby and removal of the placenta is the only known cure for pre eclampsia. Women with a history of pre eclampsia are at risk. Pre- eclampsia a hypertensive disorder in pregnancy is one of the most common causes of maternal morbidity and mortality rate. It accounts to 28.4 % of maternal morbidity and mortality in the Philippines according to Department of Health (DOH) as of February 2009.

Globally, Pre-eclampsia and other hypertensive disorder of pregnancy are a leading cause of maternal and infant illness and death. By conservative estimates, these disorders are responsible for 76,000 maternal and 500,000 infant deaths each year. Approximately 5-7 % of all pregnancy is complicated by pre eclampsia, less than one in 100 women with pre- eclampsia will develop eclampsia or convulsions (seizures). Up to 20% of all pregnancy is complicated by a high blood pressure, Pre-eclampsia and eclampsia may account for up to 20% of all deaths that occur in pregnant in a nationwide population based on cohort study.(www.answers.com)After birth the symptoms of pre-eclampsia resolve quickly, usually within 48 hours. The nursing care of the woman with hypertensive disease differs from that required in the usual postpartum period in a number of respects. Careful assessment of the woman with a hypertensive disorder continues throughout the postpartum period. Nursing care will include monitoring of vital signs, increased amount of intravenous fluids intrapartially, postpartum and subsequent monitoring of intake and output and close monitoring of symptoms. BP is measured at least every 4 hours of 48hrs or more frequently as the womans condition warrants. Even if no convulsions occurred before the birth, they may occur within this period.(Maternal and Child Health Nursing by: Pilliterri) Magnesium sulfate infusion may be continued 24 hours after the birth. Assessments for effects and side effects continue until the medication is discontinued.(Maternal and Child Health Nursing by: Pilliterri)

References: Maternal and child Nursing Purpose and Objectives Ladewig By: Wong and www.answers.com Purpose: www.google.com

The Level IV students of Bachelor of Science in Nursing section A402 group 2A of Jose Rizal University aim to present the nursing care of a client with pre-eclampsia.

Specific objectives: Student: 1. To develop the student critical thinking 2. To apply important theories learned in the classroom. 3. To be able to formulate nursing care for a client having this kind of problem. 4. To raise the level of patient on health problems that she may encounter. Patient: 1. To be able to understand the health problems. 2. To seek immediate care when the problem arises. 3. To be able to learn to some information about health condition.

Scope and Limitations Our client always experienced severe preeclampsia during her pregnancies. Preeclampsia is a disorder that occurs only during pregnancy. This condition is a serious complication of pregnancy associated with the development f high blood pressure and protein in the urine occurs after 20 weeks of gestation, in the late 2nd and 3rd trimester or to middle late pregnancy. A pregnant woman with a severe preeclampsia develops a rise in blood pressure with at least 160 mmHg of systolic blood pressure or a diastolic blood pressure of 100 mmHg, proteinuria of greater than +2 (100 mg/dl) +3 (300 mg/dl) oliguria less than 400 to 500 ml of urine output over 24 hours, severe headache, blurred vision, hepatic involvement including epigastric pain or elevated liver enzymes, sudden weight gain and swelling in the face and hands (edema).

Some of our members handled her case in the Delivery Room last June 22, 2011 on their 73 shift starting from 9:45-12:50 pm. We conducted our interview during her second day (June 23, 2011) in the OB Ward around 2 oclock in the afternoon. Mom Y is a 33 years old, weighing 91.4 kg with the height of 56 and she is living with her common law husband. And she always experienced severe preeclampsia during her pregnancy. We collected our data through observations, interview by using an openended question, physical assessment by using Inspection, Palpation,

Percussion, and Auscultation (IPPA) and also by viewing our clients chart.

Our case is all about severe preeclampsia we decided to pursue this type of case because we think severe preeclampsia is a very interesting case most especially our client who experienced the said condition starting from her first pregnancy up to her last pregnancy. She delivered her three children even though she knew that shes at high risk and experiencing severe preeclampsia with the help of Manghihilot. And also we come up in this case because we wanted to learn more about severe preeclampsia.

Nursing Theoretical Framework Dorothea Orems Self-Care Deficit Theory Orem proposes that the purpose of nursing is to help people meet their self-care needs. TERMS Self-Care: learned behaviors that a person performs for self (when able) that contribute to health Self-Care deficit: a relationship between actions a person should take for healthy functioning and the capability for action Self-Care requisites: needs that are universal or associated with development or deviation from health Self-Care demand: therapeutic actions to meet needs Agency: capability to engage in self-care

The essence of Orems three-part nursing theory focuses on persons in relations. The theory of self-care focuses on the self; the theory of self-care deficit focuses on you and me; and the theory of nursing systems focuses on we, persons in community. Orems general theory, the self-care

deficit theory, integrates the theory of self-care, the theory of self-care deficit, and the theory of nursing systems. Self-care is the voluntary regulation of ones own human functioning and development that is necessary for individuals to maintain life, health, and well-being. Self-care activities are learned as the person matures and are affected by the cultural beliefs, habits, and customs of the family and society. A persons age, developmental state, or state of health can affect the ability to perform self-care activities. For example, a parent or guardian must maintain continuous therapeutic care for a child. Nursing is concerned with the persons need for self-care action to sustain life and health, recover from disease or injury, and cope with their effects. In Orems view, nursing care may be offered to individual and multiperson units, but only persons have self-care requisites. The nurse cares for, assists, or does something for the client to achieve the health results that the client desires.

Orem implies that health is a state a person that is characterized by soundness or wholeness of developed human structures and of bodily and mental functioning. Well-being, which is used in the sense if individuals perceived condition of existence, is associated with health. Orem refers to the physical, psychological, interpersonal, and social aspects of health but indicates that they are inseparable in the person: Health describes the state of wholeness or integrity of human beings. If there is acceptance of the real unity if individual human beings, there should be no difficulty in recognizing structural and functional differentiation within the unity. Orem views individuals as moving toward maturation and achievement of the individuals human potential.

Orem suggests that some people may have self-care requisites associated with development or with deviation from health. Self-care requisites are essential enduring requisites, and situation-specific requisites are associated with existent or predicted internal or external conditions of functioning and development. All people have the following universal self-care requisites: 1. Maintenance of sufficient air, water, and food intake; 2. Provision of care associated with elimination processes and excrements; 3. Maintenance of a balance between activity and rest and between solitude and social interaction; 4. Prevention of hazards to life, functioning, and well-being; and 5. Promotion of human functioning and development within social groups in accord with potential, known limitations, and the desire to be normal.

Identified self-care requisites require actions known as therapeutic self-care demands. Therapeutic self-care demands can be determined by:

1. Identifying all existing or possible self-care requisites; 2. Identifying methods for meeting self-care requisites, keeping in mind basic conditioning factors that condition the values of patients self-care agency and therapeutic self-care demands, as well as the means that are valid for meeting self-care requisites and in regulating self-care agency at particular times; and

3. Designing, implementing, and evaluating a plan of action. Orem terms this use of nursing process determining a system of nursing. The theory of nursing systems involves an interpersonal unity in a particular time-space localization. This unity is formed by nurses, persons who have entered into an agreement to accept and participate in nursing, and the relatives or persons who are responsible for the individuals who require nursing. Thus, candidates for nursing care are clients who have insufficient current or projected and Capable for providing self-care. It is the need for compensatory action or for action to help in the development or regulation of self-care abilities that is the basis for a nursing relationship. Other concepts and theories that have been derived from the self-care deficit theory include self-care agency, dependent care, and dependent care agency.

Orems theory emphasizes a role for the nurse when the client is unable to provide for his or her own self-care requisites. Nursing interventions may be aimed at maintaining health, preventing illness, or restoring health, and they may involve actions for or with the client. The theory, which is compatible with the traditional medical model, has been widely used in practice and education and recently has been the basis for research. However, although more than 140 journal articles using Orems self-care deficit nursing theory have been identified, most are descriptive and do not test the theory.

CHAPTER 1 ASSESSMENT

A. Nursing Health History

1. Biographic Data Mom Y is 33 years old, G7P7 (T7P0A0L7), housewife and living with her second common law husband at Malabon City. Her first common law husband is from General Santos City and she had five children with him, while she and her two child lives with her second common law husband. Mom Y educational attainment is high school undergraduate (3rd year high school). She didnt pursue her study because of financial problem. Mom Y is Roman Catholic and Filipino in race. She was admitted for the first time at Pagamutang Bayan ng Malbon and delivered her seventh baby. This is her fourth time to deliver in the hospital while three of her children delivered at home attended by manghihilot.

2. Chief Complains

As we conducted our interview on June 23, 2011 at 2:00 oclock in the afternoon, we asked Mom Y what she felt on the said time masakit yung tahi ko at likod ko dahil hindi ako makahiga nang maayos kasi tatlo kami sa dalawang kama as verbalized by Mom Y.

3. Medical Diagnosis Admitting Diagnosis: G7P6 (6-0-0-6) Pregnancy uterine 41 6/7 AOG cephalic in LOA; severe pre eclampsia Final Diagnosis: G7P7 (7-0-0-7) Pregnancy uterine full term cephalic delivered to a live baby boy APGAR scoring 9.10; birth weight is 36 lbs., birth length is 48 cm.

Mom Y delivered a full term live baby boy through Normal Spontaneous Vaginal Delivery; 41 6/7 AOG through LMP. APGAR score was 9 and 10 respectively. Baby boys weight is 3.6 kg, head circumference of 34 cm, chest circumference of 34 cm, and body length of 48 cm.

4. History of Present Illness Two hours prior to admission, Mom Y was taking her breakfast when she suddenly felt lower abdominal pain and uterine contraction, wherein the interval was 3 minutes, strong intensity and 75 seconds duration so she hurriedly went to the hospital at 9 a.m. accompanied by her common law husband and she had her labor for almost 3 hours. As Mom Y admitted, on June 22, 2011 at 9:45 AM she was diagnosed with pre eclampsia with a BP of 200/100 mm Hg. The doctor ordered Magnesium Sulfate 5g TIM on alternate buttocks for 10 minutes to prevent convulsion,

and hydralazine 5 mg TIV. After an hour upon observation, her BP is still the same, so the doctor set up CS delivery for her and then Mom Y signed her consent letter. While waiting her schedule time for CS procedure, Mom Y force to delivered her baby boy, so she had delivered it in the stretcher in the labor room. Then she immediately transferred to the delivery room.

5. Past Medical History As Mom Y claimed that she is hypertensive and diagnosed with severe preeclampsia since she was pregnant with her first baby sixteen years ago. She took calciblock for the maintenance of her blood pressure as prescribed by her attended physician, but she did not maintain her blood pressure which is 150/100 mm Hg because of financial constrains. During Mom Ys pregnancy, she completed her tetanus toxoid immunization but the last is unrecalled. Mom Y claimed that she had no allergy with foods and medications. Mom Y, delivered her first baby at the hospital in General Santos City through normal spontaneous vaginal delivery (NSVD) in 1994, and diagnosed with severe preeclampsia. During her second pregnancy, she delivered her baby at home through NSVD attended by manghihilot in 1997. On her third pregnancy, she delivered her baby at Fabella Hospital through NSVD in 1999, diagnosed with severe preeclampsia, her fourth pregnancy; she delivered her baby at home through NSVD attended by manghihilot in 2002, and same with her fifth and sixth baby with a three years gap. And last September 21, 2010, she delivered a full term baby boy through NSVD and diagnosed with severe preeclampsia.

Mom Y verbalized about the immunization of her children kumpleto naman sa bakuna yung mga anak ko pero hindi ko na matandaan yung mga taon kung kalian sila nabakunahan at kung ano yung mga ibinigay na bakuna sa kanila

6. Obstetrical History A. Menstrual History Mom Y had her menarche at age of 15 years old. She had her normal menses interval of 30 days of cycle, and a regular menses usually about 3-4 days monthly. She used pasador instead of sanitary napkin and she consumed 8 pasador per day fully soaked of blood. Mom Y felt pain sa tuwing unang araw nang regla ko sumasakit ang puson ko pero nawawala din naman as verbalized by the client. B. Obstetrical Score: G7P7 (7007) Mom Y. delivered her 7th baby at Pagamutang Bayan ng Malabon with Normal Spontaneous Vaginal Delivery at 12:50 pm June 23, 2011. She had a 1st degree laceration. She gave birth to a full term baby boy in a cephalic presentation with the birth weight of 3.6 kg and 48 cm in length.
Type Gravida 1 Gravida 2 Delivery NSVD NSVD of Place being Year 1994 1997 Complication Severe preeclampsia Possible complication is maternal and

delivered General Santos Hospital Home

fetal infection because she delivered at home attended only by Gravida 3 Gravida 4 NSVD NSVD Fabella Hospital Home 1999 2002 manghihilot Severe Preeclampsia Possible complication is maternal and fetal infection because she delivered at home attended only by Gravida 5 NSVD Home 2005 manghihilot Possible complication is maternal and fetal infection because she delivered at home attended only by Gravida 6 NSVD Home 2008 manghihilot Possible

complication is maternal and fetal infection because she delivered at home attended only by Gravida 7 NSVD Pagamutang Bayan Malabon ng 2011 manghihilot Severe Preeclampsia

7. Socio-Economic History Mom Y.s family is living in a studio type of house made of light materials but it is small for the family members; her common law husband, and her sixth child which is 2 years old. They lived in a congested type of neighborhood. Her common law husband is a construction worker on a contractual basis which earns a minimum salary of P390 Php per day. Mom Y verbalized minimum lang yung sahod ng asawa ko kaya kulang pa din panggastos tulad ng renta sa bahay,pambayad sa tubig at ilaw at pagkain namin. They have a small sari-sari store where it serves as their source of income especially when her husband ended his contract. Their water supply is from NAWASA and their electricity is from MERALCO. Their drainage is closed and their garbage was placed in a plastic bag and collected every night.

Mom Y claimed that she is not a smoker and even drinking alcoholic liquors and used elicit drugs. Her leisure is watching television, watch over the store, and videoke. Mom Y claimed that she wants to eat fried chicken at least once a week. 8. Family Health History Genogram

HP N

Mom Y

Interpretation: Mom Y grandfather has hypertension and died due to aging but she did not know the date as her grandfather died. Mom Y mother inherited hypertension from her grandfather. Mom Ys father has diabetes mellitus.

3. Review of Systems

1. Subjective Data a. Gordons Pattern of Functioning

Pattern 1.Health perception management

Before hospitalization Yung bago ako manganak nakakaramdam ako ng pagkahilo, basta masakit yung ulo ko, Tapos medyo nahihirapan na kong huminga parang lagi

During hospitalization Masakit yung tahi ko, hindi ako masyadong galaw ng galaw at tayu ng tayo para hindi sumaket as verbalized by Mom Y. When she was asked if

Interpretation Before she was hospitalized, Mom Y was not aware regarding about the disease that worsens her health condition; she cant follow the medications because they cant afford it.

Implications care Most woman experience some degree of

of

discomfort during post partum period, and to reduce it to a tolerable level, Mom Y should take care for herself by using both nonpharmacologic and pharmacologic interventions that promotes comfort. (Reference: Maternity Nursing by: Deitra L. Lowdermilk Page:479-480)

akong pagod As she follows the verbalized by the client. When she was asked about medications ordered by physicians she

how she managed said hindi lahat that situation she said nagpapahinga ako, hihiga tapos iinom ng gamot (calciblock), She eats anything that is served to her, has no cough and colds. She didnt use tobacco and kasi kulang yung pera namin Whenever there is sick in the family she also consult for manghihilot believing that these might cure their illness.

B. Maternal assessment Antepartum Assessment Upon performing the Leopolds Maneuver during Mom Ys prenatal check up the fetus is in cephalic presentation, longitudinal, positive engagement, full flexion, and fetal heart rate is 143BPM which is normal. During the pregnancy of Mom Y she experienced breast changes such as breast tenderness, tingling, feeling of fullness, increase size and pigmentation of her areola. Mom Y experienced frequent urination, nausea and vomiting, amenorrhea, fatigue, uterine enlargement and quickening. She also observed increase pigmentation of the skin like linea nigra and striae gravidarum during her pregnancy.

Intrapartal Assessment During the labor of Mom Y as the membrane ruptured it is foul smelly and had thick meconium stain. And upon taking her BP, she is diagnosed with pre eclampsia because her BP is 200/100, so the doctor orders to administer MgSO4 to prevent convulsion. Mom Y experienced difficulty of breathing, so she was given oxygen about 5 L/m to facilitate comfort upon delivering the baby. As she delivered her baby, she had laceration. Mom Y delivered normally.

Postpartum Assessment As Mom Y brought to the ward, upon taking her BP it is 150/100. She also experienced pain on her vagina as a because of her laceration. She only takes some medications to relieved pain like Mefenamic acid 250 mg to relieved pain.

I.

Objective Data

A. Mini-mental Status Examination

I.

General Appearance as of June 23, 2011

Parts

Normal findings

Actual Findings Patients appearance is appropriate with age, oriented, awake, coherent, normal, and symmetrical facial features. She was wearing a dress and was properly groomed. She was responsive and eye contact was established during the interview

Interpretation

Analysis

General appearance and Client appears to be behavior her stated chronologic age. Body build is proportional. Client is cooperative and purposeful in her interactions

Normal

II. Parts

Level of Consciousness Normal findings Actual Findings Client is apathetic but oriented to what is happening at the time of interview and physical assessment Interpretation Analysis

Level of Client is alert and consciousness oriented to what is happening at the time of interview and physical assessment

Normal

III. Physical Assessment

Parts Normal findings Blood pressure Normal BP of Mom Y is <150/100 MmHg

Actual Findings

Interpretation

150/100 mmHg

Abnormal

Temperature

35.4-37.4C (95.899.4F) obtained 5 Minutes time for accurate measurement. . (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes

Abnormal 38 C

Pulse Rate

Normal pulse rate is 60100bpm (Fundamentals of Nursing by Barbara Kozier, et al. 55 BPM Decrease

Analysis Vasospasm leads to vascular effects results to vasoconstriction leading vasoconstriction resulting to poor organ perfusion as a result of increased BP. 1. A woman may show a slight increase in temperature during the first 24 hours after birth because of dehydration that occurred during labor, this temperature will return to normal. 2. Inflammatory response due to tissue trauma. 3. Effects of maternal hormone. Interstitial effects leads to diffusion of fluid in blood stream into interstitial tissue results to decrease plasma volume and increase Hematocrit leading to generalized edema resulting to poor peripheral pulse

Respiratory Rate

16-20 breaths per minute, no use of accessory muscles when breathing, respirations should be even, not labored and regular and no cough noted. (Weber: Nurses Handbook of Health Assessment)

Normal 20 CPM

Parts SKIN

Techniques

Normal findings

Actual Findings

Interpretation

Analysis

Color and Inspection pigments

Light to deep brown

deep brown

Normal

Lesions

Inspection

No lesions, scars or No lesions, scars Normal inflammation or inflammation

Smooth Texture Moisture Mobility and turgor Palpation Smooth Moist Palpation Palpation Moist The skin springs back to its previous state after being pinched Normal The skin springs back to its Normal previous state after being pinched Bipedal nonpitting edema Normal

HAIR Color Texture Other findings Inspection Inspection Inspection Black Straight hair/curly No lits present and lice No lits and lice Black Straight hair/curly Normal Normal Normal

present SCALP Distributio Inspection n of hair Lesions Other findings NAILS Nail bed Inspection color Inspection Shape Inspection Lesions No inflammation of No Normal the skin around the inflammation of nails the skin around the nails Firm Firm Normal Interstitial effects leads to diffusion of fluid in blood stream into interstitial tissue results to decrease plasma volume and increase Hematocrit leading to generalized edema resulting to poor capillary refill Pink Concave shape Pink Concave shape Normal Normal Inspection Inspection Hair is evenly Hair is evenly Normal distributed and silky. distributed and silky. No inflammations, Normal lumps or masses. No inflammations, lumps or masses.

Thickness Capillary refill

Palpation Palpation

Normal capillary Capillary refill Abnormal refill which is 2 to 3 is 4 seconds seconds

HEAD Size Inspection Proportion to the Proportion to the Normal body and the skull is body and the rounded and smooth skull is rounded and smooth Symmetrical Normal Symmetrical

Symmetry FACE Size

Inspection

Inspection

Non edematous

Presence of +3 Abnormal (6mm) pitting edema

Skin color

Inspection

Light to deep brown

Kidneys are desperatel y trying to increase the blood volume by reabsorbin g as much water and salt as they can, from the fluid that they have filtered out of the blood. They return this reabsorbe d fluid and salt to the circulation. However, since there isn't enough albumin and salt in the circulation to hold this reabsorbe d water,

Texture Facial movement

Inspection Inspection

Smooth Symmetric movement facial

deep brown

Normal

Smooth Symmetric facial movement NECK Position Inspection

Normal Normal

much of it leaks out into the tissues. The kidneys keep reabsorbin g water at one end of the process, the water keeps leaking out of the capillaries at the other end, and the mother sees rapid swelling in her ankles, and rapid weight gain (from the extra water in her tissues).

Positioned at the Pos itioned at Normal center and can move the center and freely can move freely Symmetrical Smooth without Symmetrical Normal Normal

Symmetr y Range of

Inspection Inspection

movement Smooth discomfort movement

movemen ts

Palpation

symmetric and without midline position discomfort symmetric and midline position

NOSE Color Shape Discharge s EYES Color Symmetr y Inspection Inspection Same with the facial Same with the Normal color facial color Symmetrical at the Symmetrical at Normal level of the eyes the level of the eyes Symmetric to the Normal head. No discharge Symmetric to and inflammation the head. No discharge and inflammation Inspection Inspection Inspection Same with the facial Same with the Normal color facial color Symmetric No discharges Symmetric No discharges Normal Normal

Inspection Shape and size

MOUTH Lips Symmetr y TEETH AND GUMS Color Inspection Inspection Inspection Pinkish Symmetric Pinkish Symmetric Normal Normal

Inspection

Presence of 32 pearly Absence of both Normal whitish teeth with lower 3rd molar smooth surfaces and edges. Gums are pink moist Gums are pink and firm with tight moist and firm Normal

Gums

margins to the tooth. with tight No lesion or masses margins to the tooth. No lesion or masses

TONGUE Position Inspection Positioned at the Positioned at the Normal center and can move center and can freely move freely Dull red Smooth Can move freely No lesions inflammation Dull red Smooth Can move freely Normal Normal Normal

Color Texture Mobility Lesions

Inspection Inspection Inspection Inspection

or No lesions or Normal inflammation Thorax is Normal smooth, rounded and symmetric. Respiration is regular. No wheezing heard. Breast is round; Normal texture is smooth with no edema. There are linear marks. No lifts or Normal heaves. No murmurs. Light to deep Normal brown Normal Protruding abdomen

THORAX Inspection Thorax is smooth, AND Auscultation rounded and LUNGS symmetric. Respiration is regular. No wheezing heard. BREAST S Inspection Palpation Breast is round.

HEART ABDOM EN

Inspection No lifts or heaves. Palpation No murmurs. Auscultation Inspection Light to deep brown Protruding abdomen

Color Inspection Size

UPPER

AND LOWER EXTREM Inspection ITIES Inspection Size Inspection Symmetry Distributio Inspection n of hair Skin color

Equal size Symmetrical Evenly distributed Symmetrical No lesions, Evenly deformities or distributed inflammation No lesions, deformities or inflammation Normal Normal Normal Presence of bipedal edema Abnormal Kidneys are desperatel y trying to increase the blood volume by reabsorbin g as much water and salt as they can, from the fluid that they have filtered out of the blood. They return this reabsorbe d fluid and salt to the circulation. However, since there isn't enough albumin and salt in the circulation to hold this reabsorbe d water, much of it leaks out into the tissues. The kidneys keep

reabsorbin g water at one end of the process, the water keeps leaking out of the capillaries at the other end, and the mother sees rapid swelling in her ankles, and rapid weight gain (from the extra water in her tissues).

B. Laboratory Examination The laboratory examination last June 23, 2011 TEST REFERNCE VALUE OBTAINED VALUE CLINICAL MANIFESTATIONS Normal Normal Turbid urine may contain red or white cells, bacteria, fat or chyle and may reflect renal infection. Proteinuria is probably the most important indicator of renal SIGNIFICANCE OF CHANGES

Macroscopic Exam Color Light yellow Light yellow to amber Transparency Clear Turbid

pH Specific Gravity Protein

4.5-8.0 1.005-1.035 None

6.0 1.010 + positive +3

Average (Normal) Average (Normal) Increase

disease. The urine of all pregnant women is routinely checked for proteinuria, which can be indicator of preeclampsia. Leukocytes Albumin Sugar Microscopic Exam Epithelial Cells Pus or WBC Negative None + +3 (-) Normal Increase Increase with WBC result are clinically significant and indicates urinary tract infection.

0-5/high Few power focus 0-4/ high 4-6 power focus

RBC

0-3/high power focus

1-2

Normal

HEMATOLOGY REPORT TEST REFERNCE OBTAINED VALUE VALUE Hemoglobin (F) 120- 113 150g/mL (M) 140180g/mL Hematocrit (F) 38-48 g/ml 37 (M) 40-54 g/ml 4-6x1012 5-10 0.45-0.65 0.20-0.35 0.02-0.03 150-350x10/L A Rh (D) 4.27 9.2 0.80 0.20 100% 278 Positive

Erythrocyte Count Leukocyte Count DIFFERENTIAL Segmenter Lymphocyte Eosinophil THROMBOCYTE COUNT BLOOD GROUP

CLINICAL SIGNIFICANCE OF MANIFESTATIONS CHANGES Decreased Decreased hemoglobin on pregnant is normal because of their increase in plasma volume. Decreased Decreased in hematocrit on pregnant is normal because of that increase in plasma volume. Normal . Normal Increased Normal Normal

4. Comprehensive Definition and Description of the Disease

A. Anatomy and Physiology Cardiovascular System

The heart is one of the most important organs in the entire human body. It is really nothing more than a pump, composed of muscle which pumps blood throughout the body, beating approximately 72 times per minute of our lives. The heart pumps the blood, which carries all the

vital materials which help our bodies function and removes the waste products that we do not need. For example, the brain requires oxygen and glucose, which, if not received continuously, will cause it to loose consciousness. Muscles need oxygen, glucose and amino acids, as well as the proper ratio of sodium, calcium and potassium salts in order to contract normally. The heart is essentially a muscle (a little larger than the fist). Like any other muscle in the human body, it contracts and expands. That is, each times the heart contracts it does so with all its force. There are two upper chambers, called the right and left atria, and two lower chambers, called the right and left ventricles. The Right Atrium, as it is called, receives blood from the upper and lower body through the superior vena cava and the inferior vena cava, respectively, and from the heart muscle itself through the coronary sinus. The right atrium is the larger of the two atria, having very thin walls. The right atrium opens into the right ventricle through the right atrioventicular valve (tricuspid), which only allows the blood to flow from the atria into the ventricle, but not in the reverse direction. The right ventricle pumps the blood to the lungs to be reoxygenated. The left atrium receives blood from the lungs via the four pulmonary veins. It is smaller than the right atrium, but has thicker walls. The valve between the left atrium and the left ventricle, the left atrioventicular valve (bicuspid), is smaller than the tricuspid. It opens into the left ventricle and again is a one way valve. The left ventricle pumps the blood throughout the body. It is the Aorta, the largest artery in the body, which originates from the left ventricle. The Heart works as a pump moving blood around in our bodies to nourish every cell. Used blood, that is blood that has already been to the cells and has given up its nutrients to them, is drawn from the body by the right half of the heart, and then sent to the lungs to be reoxygenated. Blood that has been reoxygenated by the lungs is drawn into the left side of the heart and then pumped into the blood stream.

B. Pathophysiology Book-based Schematic Diagram

Patient-Based Schematic Signs and Symptoms =Elevated BP (210/100,180/100,150/90 before child birth) Risk Factors
=Past Medical History (Hypertention)

=Edema on face and extremities (+3) =Decrease urine output (oliguria) < 30ml/hour

=Family History ( Hypertensive mother) =Sedentary lifestyle (diet:increase intake of sodium, increase protein intake, increase fat) decrease physical activity, increase level of stress

=Weight gain (lbs) more than the desired weight gain during pregnancy

=Multiparity (6-0-0-6) obesity (increase weight)

CHAPTER II PLANNING

A. List of Identified Nursing Diagnosis According to Priority 1. Ineffective peripheral tissue perfusion related to diffusion of fluid into interstitial tissue 2. Acute pain related to stimulation of nerve endings 3. Knowledge deficient related to information misinterpretation 4. Non compliance to medication related to financial constraint 5. Imbalance nutrition more than body requirements related to excessive intake in relationship to metabolic 6. Impaired parenting related to limited cognitive functioning 7. Sedentary lifestyle related to lack of interest / resources 8. Risk for infection related to invasion of pathogenic organisms 9. Risk for infection related to fear in defecating

B. List of Priority Nursing Diagnosis

Priority Problem Ineffective tissue perfusion related to diffusion of fluid into Rationale Health threatening problems, such as acute illness and

interstitial tissue

decreased coping ability are assigned medium priority because they may result in delayed development or cause destructive

Acute pain related to nerve ending stimulation

physical or emotional changes According to Kalishs expanded hierarchy. In an expansion of Maslows model. Pain avoidance as part of survival needs

Deficient knowledge related to information misinterpretation

which is the first stage in Kalishs expanded hierarchy. Deficient knowledge is part of safety and belongingness which is 2nd stage of Maslows hierarchy

Reference: Fundamentals of Nursing 8th Edition, Vol.1 page 190

C. Nursing Care Plan

CHAPTER III IMPLEMENTATION A. Medical Management I. Drug Study

Drug Generic Name Trade Name Patients Dose Classification Action Indication Contraindication Adverse Effects Nursing Responsibilities

Mefenamic Acid Mefenamic Acid Ponstel 250 mg nonsteroidal anti-inflammatory inhibits prostaglandin synthesis by interfering with cyclooxygenase needed for biosynthesis; possesses analgesic, antiinflammatory, antipyretic properties; uses: mild-tomoderate pain, dysmenorrhea, inflammatory disease. Relief of moderate pain when therapy will not exceed 1 wk With hypersensitivity to mefenamic acid , aspirin allergy, asthma, renal or hepatic impairment, peptic ulcer disease, GI bleeding Headaches, Vomiting, Diarrhea , haematuria, blurred vision, skin rash, itching and swelling, sore throat and fever. Monitor GI bleeding accordingly Give w/ milk to prevent GI upset Take drug w/ food Do not take drug longer than 1 wk Diccontinue if rash, diarrhea, or digestive prob. occur Avoid driving bec. Dizziness can occur Report sore throat fever, rash, itching wt. gain swelling ankles and finger, severe diarrhea

DRUG NAME GENERIC NAME PATIENTS DOSAGE: CLASSIFICATION: ACTION INDICATION

Hydralazine Apresoline 5mg T.I.V. Peripheral Dilator Antihypertensive a direct acting peripheral vasodilator that relaxes anterior smooth muscle Preclampsia/ eclampsia -initially 5to 10 mg IV followed by 5- to 10- mg IV doses q 20-30minutes p.r.n ; or 0.5 to 10mg/hour IV infusion Parenteral severe essential hypertension when drug cannot be given orally or when need to lower BP is urgent -contra indicated in patients hypertensive to the drug -contraindicated in those with coronary artery disease or mital valvular rheumatic heart disease -use caususly in patients with suspected cariac disease, stroke or severe renal impairment and in those taking over anti hypertensive CNS:headache, peripheral neuritis, diziness CV: angina pertosis, palpitation, tachychardia or thostic hypotension, edema, flushing SKIN: rushes -monitor patients Blood pressure, pulse rate, and body weight frequently. Drug may be given with diuretic and beta blockers todecrease sodium retension and tachycardia and prevent angina attack -Elderly patients may be more sensitive to drug hypotensive effect - monitor CBC, Jupus erythematasus cell preparation and antinuclear antibodies -monitor patient closely for signs and symptoms of lupus lik syndrome -improve patients compliance by giving drug b.i.d. check with prescribed

CONTRAINDICATI ON

ADVERSE EFFECT

NURSING RESPONSIBILITIES

Drug Generic Name Trade Name Patients Dose Classification Action Indication

CEFUROXIME CEFUROXIME Zinnat, Zinacef 1-5 g TIV Antibiotic Second generation cephalosporins that inhibits cell wall synthesis, promoting osmotic instability; usually bactericidal. It is effective for the treatment of penicillinase- producingNeisseria gonorrhoea(PPNG). Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitis media, pharyngitis/tonsilliti s, sinusitis, lower respiratory tract infections, skin and soft tissue infections, urinary tract infections, and is used for surgical prophylaxis, reducing or eliminating infection Contraindicated in patients hypersensitive to the drug or other cephalosporins Use cautiously in patients hypersensitive top penicillin because of possibility of cross sensitivity with other beta-lactam antibiotics.

Contraindication

Adverse Effects

CV: Phlebitis, thrombophlebitis GI: pseudomembraneous colitis, nausea,anorexia, vomiting, diarrhea Hematologic:Transient neutropenia, eosinophilia, haemolytic anemia,
thrombocytopenia

Skin: Maculopopular and erythema rashes, urticaria, pain Other: hypersensitivity reactions, serum sickness, anaphylaxis
Nursing Responsibilities Before administration, ask patient if he is allergic to penicillins or cephalosporins. Obtain specimen for culture and sensitivity test before giving first dose For I. M administration, inject deep into a large muscle , such as the gluteus maximus or the lateral aspect of the thigh. Inspect IM and IV injection sites frequently for signs of phlebitis. Report onset of loose stools or diarrhea. Although pseudomembranous colitis. Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant change

Drug Generic Name Trade Name Patients Dose Classification Action

CEFALEXIN Cefalexin Ceporex, Keflex 500 mg PO Antibiotic A broad spectrum antibiotic of the cephalosporin group. Used in mild to moderate infections of respiratory tract, skin and soft tissue infections. Also in otitis media and urinary tract infections. It is of particular value where other first line antibiotics have failed. It has a poor activity against H. infuenzae.

Indication Contraindication Adverse Effects

Nursing Responsibilities

GU infection caused by E. Coli, P. Mirabilis, Klebsiella Hypersensitivity to penicillins. Sensitive to a cephalosporin. Pregnancy and lactation. A dose reduction may be necessary in renal impairment. Gastro-intestinal disturbances (diarrhoea, nausea, vomiting), hypersensitivity reactions including rash, headache, nervousness, sleep disturbances, confusion, and dizziness. Pseudomembranous colitis is a potentially fatal complication and if suspected then drug must be stopped immediately. As with aection ll broad-spectrum antibiotics fungal superinfection can occur. Arrange for culture sensitivity test of infection before and during therary Give drug w/ meals; arrange for small frequent meals if GI complication occur Discard drug after 14 days Complete the full course of drug even if the patient feel better Ask pt. to report severe diarrhea w/ blood, pus or mucus; rash or hives, difficulty of breathing

Drug Generic Name Trade Name Patients Dose Classification Action

Indication Contraindication

Adverse Effects

Nursing Responsibilities

Syntocinon Oxytocin Syntocinon 20 units 30 gtts/min, incorporated w/ D5LR Hormone Synthetic version of endogenous hormone produced in the hypothalamus and stored in the posterior pituitary gland; stimulates the uterus, especially the gravid uterus just before parturition and causes myoepithelium of the lacteal glands to contract, w/ results in milk ejection in lactating women To initiate or improve uterine contractions to achieve Cephalopelvic disproportion Unfavourable fetal position and presentation Obstetric emergencies that favour surgical intervention Prolonged use in severe toxemia uterine inertia hypertonic uterine patterns induction or augmentation of labor when vaginal delivery is contraindicated previous caesarean section CV: arrhythmias, PVCs, hypertension, subarachoid hemorrhage Fetal effects: fetal bradycardia, neonatal jaundice, low APGAR score GI: nausea and vomiting GU: postpartum hemorrhage, uterine rupture, pelvic hematoma, uterine hypertonicity Hypersensitivity: anaphylactic reaction Check for the history of any contraindication Assess for FHT, fetal position , uterine tone, timing and rate of contraction reflexes, CBC, bleeding studies, UO Regulate rate of oxytocin to establish uterine contraction that are similar to normal labor Monitor rate & strength of contraction Monitor maternal BP Notify physician w/ any sign of hypertensive emergency Drug teaching

Drug

Mefenamic Acid

Generic Name Trade Name Patients Dose Classification Action Indication Contraindication Adverse Effects Nursing Responsibilities

Magnesium Sulfate Epson Salt 5g Antiepileptic Prevents or control seizure by blocking neuromuscular transmission Preeclampsia or eclampsia Allergy w/ magnesium products; heart block; myocardial damage; abdominal pain, nausea and vomiting or other symptom of appendicitis; Hepatitis Palpitation; magnesium intoxication(flushing, sweating, hypotension, depressed reflexes ,flaccid paralysis, hypothermia, circulatory collapse, cardiac and CNS depression; hypocalcemia, w/ tetany (secondary to treatment of eclampsia) Check for history of allergy Physical assessment Reserve IV use in eclampsia for immediate life threatening situation Give IM route by deep IM injection of the undilated (50%) solution for adult Monitor knee jerk reflex before repeated parenteral administration Maintain urine output at a level of 100 ml q4 during parenteral administration Report sweating, flushing, muscle tremors or twitching, inability to move extremities

DRUG NAME GENERIC NAME PATIENTS DOSAGE: CLASSIFICATION: ACTION INDICATION

FUROSEMIDE (fur-oh'se-mide) Fumide , Furomide , Lasix, Luramide

20 mg PO ELECTROLYTIC AND WATER BALANCE AGENT; LOOP DIURETIC Rapid-acting potent sulfonamide "loop" diuretic and antihypertensive with pharmacologic effects and uses almost identical to those of ethacrynic acid. Exact mode of action not clearly defined; decreases renal vascular resistance and may increase renal blood flow Treatment of edema associated with CHF, cirrhosis of liver, and kidney disease, including nephrotic syndrome. May be used for management of hypertension, alone or in combination with other antihypertensive agents, and for treatment of hypercalcemia. Has been used concomitantly with mannitol for treatment of severe cerebral edema, particularly in meningitis. Contraindicated withallergy to furosemide, sulfonamides, allergy to tartazine ; anuria, severe renal failure; hepatic come, pregnanc; lactation Use continuously with SLE, gout and diabetes mellitus CV: Postural hypotension, dizziness with excessive diuresis, acute hypotensive episodes, circulatory collapse. Metabolic: Hypovolemia, dehydration, hyponatremia hypokalemia, hypochloremia metabolic alkalosis, hypomagnesemia, hypocalcemia (tetany), hyperglycemia, glycosuria, elevated BUN, hyperuricemia. GI: Nausea, vomiting, oral and gastric burning, anorexia, diarrhea, constipation, abdominal cramping, acute pancreatitis, jaundice. Urogenital: Allergic interstitial nephritis, irreversible renal failure, urinary frequency. Hematologic: Anemia, leukopenia, thrombocytopenic purpura; aplastic anemia, agranulocytosis (rare). Special Senses: Tinnitus, vertigo, feeling of fullness in ears, hearing loss (rarely

CONTRAINDICATI ON ADVERSE EFFECT

NURSING RESPONSIBILITIES

permanent), blurred vision. Skin: Pruritus, urticaria, exfoliative dermatitis, purpura, photosensitivity, porphyria cutanea tarde, necrotizing angiitis (vasculitis). Body as a Whole: Increased perspiration; paresthesias; activation of SLE, muscle spasms, weakness; thrombophlebitis, pain at IM injection site. Observe patients receiving parenteral drug carefully; closely monitor BP and vital signs. Sudden death from cardiac arrest has been reported. Monitor BP during periods of diuresis and through period of dosage adjustment. Observe older adults closely during period of brisk diuresis. Sudden alteration in fluid and electrolyte balance may precipitate significant adverse reactions. Report symptoms to physician. Lab tests: Obtain frequent blood count, serum and urine electrolytes, CO2, BUN, blood sugar, and uric acid values during first few months of therapy and periodically thereafter. Monitor for S&S of hypokalemia. Monitor I&O ratio and pattern. Report decrease or unusual increase in output. Excessive diuresis can result in dehydration and hypovolemia, circulatory collapse, and hypotension. Weigh patient daily under standard conditions. Monitor urine and blood glucose & HbA1C closely in diabetics and patients with decompensated hepatic cirrhosis. Drug may cause hyperglycemia.

Drug Trade Name Generic Name Classification Patients Dose Actions

Indication Contraindication

Adverse Effects

Nursing Responsibilities

Magnesium Sulfate Magnesium Sulfate Epsom salt Antiepileptic, electrolyte and laxative 5 grams Cofactor of many enzyme systems involved in neurochemical transmission and muscular excitability; prevents or controls seizures by blocking neuromuscular transmission; attracts and retains water in the intestinal lumen and distends the bowel to promote mass movement and relieve constipation. IM: Preeclampsia or eclampsia Contraindicated with allergy to magnesium products; heart block, myocardial damage; abdominal pain, nausea and vomiting or other symptoms of appendicitis; acute surgical abdomen, fecal impaction, intestinal and biliary tract obstruction, hepatitis. Do not give during 2 hr preceding delivery because of risk of magnesium toxicity in the neonate. CNS: Weakness, dizziness, fainting, sweating (PO) CV: Palpitations GI: Excessive bowel activity, perianal irritation (PO) Metabolic: Magnesium intoxication (flushing, sweating, hypotension, depressed reflexes, flaccid paralysis, hypothermia, circulatory collapse, cardiac and CNS depression - parenteral); hypocalcemia with tetany (secondary to treatment of eclampsia - parenteral) Reserve IV use in eclampsia for immediate life-threatening situations. Give IM route by deep IM injection of the undiluted (50%) solution for adults; dilute to a 20% solution for children. Give oral magnesium sulfate as a laxative only as a temporary measure. Arrange for dietary measures (fiber, fluids), exercise, and environmental control to return to normal bowel activity. Do not give oral magnesium sulfate with abdominal pain, nausea, or vomiting. Monitor bowel function; if diarrhea and cramping occur, discontinue oral drug. Maintain urine output at a level of 100 ml every 4 hr during parenteral administration.

b. Treatment Continue medications ordered by the physician and bed rest. c. Diet/ Activity / Exercise Low sodium low fat diet ordered by the physician. B. Surgical Management Episiorrhaphy Perineal area heals rapidly you can assure a woman that this discomfort is normal and does not usually last longer than 5-6 days. Many physicians ordered a soothing cream or anesthetic spray to be applied to the suture line to relief tension in the area. Explain that the suture is made of an absorbable material so will not need to be remove. Sutures usually dissolve within 10 days.

C. Patients Daily Progress Notes CHAPTER IV EVALUATION Discharge Planning Instruction Medication Ferrous Sulfate (FeSO4) iron supplement OD Mefenamic acid 500g pain reliever - OD Cefalexin 500g antibiotic - TID

Exercise Abdominal breathing tighten abdominal muscles Kegel exercise tighten perineal muscle

Chin to chest strengthen abdominal muscles Arm raising - return of breast and abdominal muscles tone

Treatment Bed rest Most important principle of care because it reduces the blood pressure of Mrs. Y and free from physical and emotional stress. Promote Good Nutrition Daily intake of vitamin and iron supplements for 4 to 6 weeks postpartum is recommended for breastfeeding mothers, like Mrs. Y to ensure nutritious milk supply to the infant, overcome iron and vitamin deficiency and aid in tissue healing and regeneration. Administer Medications Mrs. Y is instructed to take her medicines such as Ferrous Sulfate(FeSO4) for iron supplement and should be taken once a day, Mefenamic acid 500g for pain reliever and must be taken 1 capsule every 6hrs as needed, and Cefalexin 500g for antibiotic should be taken 1 capsule TID. Daily Perineal Hygiene Mrs. Y is instructed regarding proper perineal care and the importance of perineal hygiene. That it is done to prevent infection, to ease Mrs. Y and eliminate odor.

Health Teaching

Out- Patient Discharge (Follow-up Check up) Mrs. Y was instructed to continue the medications at home to promote wellness. Continue breastfeeding was recommended to her because it is the most nutritious food for the infant, easy accessible, can help her to prevent from having cancer and from becoming pregnant.

She was also instructed to have proper perineal hygiene to prevent from having infection and to promote healing of wound in the perineum.

Diet Mrs. Y is prescribed by her doctor to have low fat dairy products with reduced contents of saturated and total-fat, fruits, vegetables and foods which are grilled and streamed. She is also recommended to have low salt dietary intake to prevent more fluid retention. BIBLIOGRAPHY Maternal and Child Health Nursing------------------------Adelle Pelliterri Diagnostic Test (A prescribers guide to test selection)--Lippincott Williams and Wilkins Drug Handbook 2010-----------------------------------------Lippincott Williams Fundamentals of Nursing-------------------------------------Kozier and Erbs Pathophysiology------------------------------------------------Delmar Delmar Pediatric Nursing Care Plans----------------------Karla L. Luxner Maternity Nursing----------------------------------------------Deitra and lowdermilk Diagnostic and laboratory Test------------------------------Mosby Elsevier