Preeclampsia, also referred to as toxemia, is a condition that pregnant women can get. 3 Cardinal Signs: 1.) Hypertension 2.) Proteinuria 3.) Edema

In addition, symptoms of preeclampsia can include: ‡ Rapid weight gain caused by a significant increase in bodily fluid ‡ Abdominal pain ‡ Severe headaches ‡ A change in reflexes ‡ Reduced output of urine or no urine ‡ Dizziness ‡ Excessive vomiting and nausea

1. Mild Preeclampsia - blood pressure greater than 140/90 2. Severe Preeclampsia blood pressure greater than 160/110



Ms. XYZ Brgy. Buao Gandara, Samar Female Single November 11,2009 Gandara, Samar 20 years old Filipino Roman Catholic September 21, 2009 8:20am New Dr. Ramos High Blood Pressure

Patient was admitted at Gandara District Hospital last September 11, 2009 due to UTI. She had a normal blood pressure last September 17, 2009. When she had labored, her blood pressure in Gandara District Hospital was 200/130 mmHg. She was given Captropil 25g tab ½ tab OD, and Digoxin 0.25mg tab ½ tab OD. Persistence of increase blood pressure was referred at Samar Provincial Hospital for further evaluation and management hence admitted.


Pre-eclampsia (pre and post-partum)

PAST HEALTH HISTORY Ms. XYZ had complete immunizations during childhood.

FAMILY HEALTH HISTORY Ms. XYZ s MOTHER had a history hypertension while she was pregnant.



Ms. XYZ is 20-year old primigravida. She is conscious and coherent upon assessment. She has edema on her face and has difficulty upon ambulation.

VITAL SIGNS BP: 170/120 PR: 105 bpm

RR: 22 cpm Temp.: 37 C


NORMAL FINDINGS Evenly distributed, thick, silky, resilient hair Rounded, absence of nodules or masses Round and brown in color, symmetrical with no masses and involuntary movements Eyebrows evenly distributed, eyelashes equally distributed, no discoloration of eyelids, pupil black in color and equal in size No discharge, auricles symmetrical, able to hear clearly and sounds can be heard on both ears No discharge, color uniform to skin, not tender, no lesion Lips are pink in color, white, shiny tooth enamel, gum and surface of the tongue are pink

ACTUAL FINDINGS Shiny, evenly distributed Rounded, no injuries, absence of nodules Symmetrical with no masses and involuntary movements, edematous Eyebrows evenly distributed, pupil black in color and equal in size


Head Face

Normal Edema is due to increased tubular reabsorption of sodium Normal



No discharge, auricles symmetrical, able to hear clearly



No discharge, not tender, no lesions No bad odor, teeth is clean and white, gums pink in color






Varies from light to deep brown, no edema, skin temp. is in normal range Smooth fingernails and toenails texture Head centered, coordinated head movement, no discomfort No deformities No adventitious breath sounds Full pulsation, thrusting quality upon auscultation Rounded shape, slightly unequal in size, areola is round, nipples are not inverted, no discharge except in pregnant or breastfeeding women Unblemished skin, no evidence of enlargement of liver or spleen, symmetric movement caused by respiration Wide variation of pubic hair, no lesions, no inflammation No deformities

Light brown , dry skin

Decreased fluid intake


Upper extremities Lungs Heart Breast

Smooth fingernails and toenails texture, short nails without nail polish Head centered, coordinated head movement, no discomfort No deformities No adventitious breath sounds Full pulsation, thrusting quality upon auscultation Rounded shape, slightly unequal in size, areola is round, nipples are not inverted, presence of milk coming out from the breast Presence of linea negra, presence of striae gravidarum, fundus is firm and below the umbilicus Presence of episiotomy, presence of vaginal discharge No deformities



Normal Normal Normal Normal



Genitals Lower extremities

Normal Normal



CARDIOVASCULAR SYSTEM The cardiovascular/circulatory system transports food, hormones, metabolic wastes, and gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system include: ‡ Blood: consisting of liquid plasma and cells ‡ Blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange occurs.) ‡ Heart: a muscular pump to move the blood


The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies left of the chest midline the heart, along with the pulmonary (to and from the lungs) and systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated blood. Internally, the heart is divided into four hollow chambers, two on the left and two on the right. The upper chambers of the heart, the atria receive blood via veins. Passing through valves (atrioventricular valves), Blood then enters the lower chambers, the ventricles. Ventricular contraction forces blood into the arteries.

One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular contraction and relaxation, and a short pause. The cardiac cycle consists of two parts: systole (contraction of the heart muscle in the ventricles) and diastole (relaxation of the ventricular heart muscles).



NAME OF DRUG Captopril 25mg Or 1tab 30min X 2 doses BID

INDICATION Hypertension

MECHANISM OF ACTION Inhibits ACE, preventing conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium and water retention and lowers blood pressure.

ADVERSE REACTION Leukopenia, Agranulocytosis, Pancytopenia, thrombocytopenia

CONTRAINDICATION & CAUTION ‡Patients with hypersensitivity to drug and other ACE inhibitors ‡Patients with impaired renal function or serious autoimmune disease and those who have been expose to other drugs that affect WBC counts or immune response.

NURSING CONSIDERATION ‡Monitor patient s blood pressure and pulse rate frequently. ‡Drug causes the most frequent occurrence of cough, compared with other ACE inhibitors.

PATIENT S TEACHINGS ‡Instruct patient to take drug 1hr before meals; food in the GI tract may reduce absorption. ‡Inform patient that lightheadedness is possible especially during the first few days of therapy. Tell her to rise slowly to minimize this effect and to report occurrence to prescriber. If fainting occurs, she should stop drug and call prescriber immediately. ‡Advise patient to report signs of infection such as fever and sore throat. ‡Inform client that taste of food maybe diminished during first month of therapy

Methyldopa 250mg BID


Stimulates the central alphaadrenergic receptors that results in a decreased sympathetic outflow to the heart, kidneys, and peripheral vasculature.

Peripheral edema, anxiety, nightmares, drowsiness, headache, dry mouth, drug fever and mental depression.

‡Patients who are hypersensitive to drug or any component of the formulation. Active hepatic disease, liver disorders. ‡Use cautiously in patients with history of impaired hepatic function or sulfite sensitivity and in breastfeeding women.

‡Monitor patient s BP regularly. ‡Monitor CBC with differential counts before therapy and periodically after. ‡Observe for and report involuntary choreoathetoid movements. Drug may have to be stopped.

‡Tell patient not to suddenly stop taking drug, but to notify prescriber if unpleasant adverse reactions occur. ‡Instruct patient to report signs and symptoms of infection. ‡Tell patient to check his weight daily and notify the prescriber if she gains more than 5lbs. Sodium and water retention may occur but can be relieved with diuretics. ‡Warn the patient that drug may impair ability to perform tasks that require mental alertness, particularly at start of therapy. A oncedaily dose at bedtime minimizes daytime drowsiness. ‡Inform patient that low BP and dizziness on standing can be minimized by rising slowly and avoiding sudden position changes.

NAME OF DRUG Amlodipine 5mg OD

INDICATION Mild and moderate hypertension

MECHANISM OF ACTION Decreases peripheral vascular resistance thus promoting a decrease in blood pressure

ADVERSE REACTION ‡Reflex tachycardia ‡Marked hypotension

CONTRAINDICATION & CAUTION ‡Patients with severe hypotension ‡Patients with liver disease, CHF, aortic stenosis, and lactation

NURSING CONSIDERATION ‡Monitor liver function test results before therapy starts, after 12weeks, whenever the dosage increases and periodically during therapy. ‡Reduce dose or stop drug if AST or ALT levels increase to more than 3 times the upper limit of normal and stay elevated. ‡Assess the patient for myalgias, muscle tenderness or weakness, and marked elevation of CPK level. Stop drug if CPK level exceeds 10 times the upper limit of normal. ‡Stop drug if patient has evidence of myopathy or has a condition that increases the risk of renal failure

PATIENT S TEACHINGS ‡Advice patient to promptly report unexplained muscle pain, tenderness, or weakness, especially if accompanied by malaise or fever. ‡Urge patient to continue appropriate diet, exercise and weight loss regimens.

NAME OF DRUG Hydralazine 5mg IVTT

INDICATION Essential hypertension, preeclamsia and eclampsia

MECHANISM OF ACTION Unknown. A direct-acting peripheral vasodilator that relaxes arteriolar smooth muscles.

ADVERSE REACTION Headache, dizziness, orthostatic hypotension, tachycardia, edema, nausea, vomiting, diarrhea

CONTRAINDICATION & CAUTION ‡Patients hypersensitive to drug ‡With coronary artery disease or mitral valvular rheumatic heart disease ‡Use cautiously in patients with suspected cardiac disease

NURSING CONSIDERATION ‡Monitor patient s BP, pulse rate and body weight frequently. Drug may be given with diuretics and beta blockers to decrease sodium retention and tachycardia and to prevent angina attacks. ‡Monitor patient closely for signs and symptoms of lupuslike syndrome and notify prescriber immediately if they develop. ‡Improve patient compliance by giving drug b.i.d. Check with prescriber.

PATIENT S TEACHINGS ‡Instruct patient to take oral form with meals to increase absorption. ‡Inform patient that low BP and dizziness upon standing can be minimized by standing slowly and avoiding sudden position changes. ‡Tell woman of childbearing age to notify prescriber if she suspects pregnancy. Drug will need to be stopped. ‡Tell patient to notify prescriber of unexplained prolonged general tiredness or fever, muscle or joint aching or chest pain.

NAME OF DRUG Furosemide 1amp IV

INDICATION Edema and hypertension

MECHANISM OF ACTION A potent loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle

ADVERSE REACTION ‡Headache ‡Dizziness ‡Paresthesia ‡Weakness ‡Restlessness ‡Fever ‡Orthostatic hypotension ‡Nausea and vomiting ‡Diarrhea ‡Constipation

CONTRAINDICATION & CAUTION ‡Patients hypersensitive to drug and with anuria. ‡Use cautiously in patients with hepatic cirrhosis and in those allergic to sulfonamides. Use during pregnancy only if potential benefits to mother clearly outweigh risks to fetus.

NURSING CONSIDERATION ‡To prevent nocturia, P.O. and I.M. preparations in the morning. Give second dose in early afternoon. ‡Monitor weight, BP, and Pulse rate routinely with long-term use and during rapid diuresis. ‡Monitor fluid intake and output and electrolyte, BUN, and carbon dioxide levels frequently. ‡Watch for signs of hypokalemia such as muscle weakness and cramps. ‡Drug may not be well absorbed orally in patients with severe heart failure. ‡Monitor uric acid level especially in patients with a history of gout.

PATIENT S TEACHINGS ‡Advice patient to take drug with food to prevent GI upset, and to take drug in morning to prevent need to urinate at night. If patient needs second dose, tell her to take it early in the afternoon, 6 to 8 hours after morning dose. ‡Inform patient of possible potassium and magnesium supplements. ‡Instruct patient to stand slowly to prevent dizziness.


INDICATION Heart failure, paroxysmal supraventricular tachycardia, atrial fibrillation and flutter

MECHANISM OF ACTION Inhibits sodiumpotassiumactivated adenosine triphosphatase, promoting movement of calcium from from extracellular to intracellular cytoplasm and strenghthening myocardial contraction.

ADVERSE REACTION ‡Fatigue ‡Generalized muscle weakness ‡Headache ‡Malaise ‡Dizziness ‡Nausea and vomiting ‡Stupor ‡Paresthesia

CONTRAINDICATION & CAUTION ‡Patients hypersensitive to drug and in those with digitalis-induced toxicity, ventricular fibrillation, or ventricular tachycardia unless caused by heart failure.

NURSING CONSIDERATION ‡Before giving loading dose, obtain baseline data and ask patient about use of cardiac glycosides within the previous 2 to 3 weeks. ‡Before giving drug, take apical-radial pulse for 1 minute. Record and notify prescriber of significant changes. ‡Excessive slowing of pulse rate maybe a sign of digitalis toxicity. Withhold drug and notify prescriber.

PATIENT S TEACHINGS ‡Tell patient to report pulse less than 60 bpm or more than 110 bpm or skipped beats or other rhythm changes. ‡Instruct patient to report adverse reactions promptly. Nausea and vomiting, diarrhea, appetite loss, and visual disturbances may be early indicators of toxicity. ‡Encourage patient to eat potassiumrich foods. ‡Tell patient not to substitute one brand for another.


NORMAL FINDINGS Hemoglobin Hematocrit WBC Segmenter Lymphocytes Blood uric acid Creatinine Triglycerides HDL LDL Fasting Blood Sugar Cholesterol 120-160 gms/L 0.36-0.46 5-10X10/L 0.40-0.60 0.20-0.35 200-320 mmol/L 44-80 mmol/L 1.71-2.28 mmol/L 0.77-1.66 mmol/L Up to 3.9 mmol/L 4.2-6.4 mmol/L Up to 6.7 mmol/L

ACTUAL FINDINGS 115.8gms/L 0.35 7.2X10/L 0.68 0.32 490.5 mmol/L 127 mmol/L 2.02 mmol/L 1.16 mmol/L 4.88 mmol/L 5.07 mmol/L 6.95 mmol/L

Baseline laboratory test information is useful in the early diagnosis of preeclampsia because it can be compared with later results to evaluate progression and severity of the disease. Hematocrit, hemoglobin and platelets levels are monitored closely for changes indicating worsening of the patient¶s status. Because hepatic involvement is a possible complication, serum glucose level are monitored if liver function tests indicate elevated liver enzymes. Renal laboratory assessments include monitoring trends in serum creatinine and BUN levels. As renal function becomes compromised, renal excretion of creatinine and other waste products decreases. As renal excretion decreases, serum creatinine levels, BUN, and uric acid increases.



NURSING DIAGNOSIS Decreased cardiac output related to decreased venous return


Subjective: y Dyspnea y Fatigue Objective: y Variation in blood pressure readings y Edema y Restlessness y Postural hypotension

At the end of the shift, the patient will participate in activities that reduce blood pressure or cardiac workload.

NURSING INTERVENTION S 1. Monitor blood pressure of the patient.







Observe skin color, moisture, and temperature. Encourage changing positions slowly, dangling legs before standing. Give skin care and assist with frequent position changes. Provide calm, restful surroundings , minimize unnecessary noise.

Comparison of pressures provides a more complete picture of vascular involvement. Presence of pallor, cool, moist skin maybe due to peripheral vasoconstriction. To reduce risk for orthostatic hypotension.

Goal met as evidenced by patient is able to participate in activities that reduce blood pressure or cardiac work load.

To prevent development of pressure sores.

Help reduce sympathetic stimulation and promotes relaxation.


NURSING DIAGNOSIS Deficient fluid volume related to decreased fluid intake


NURSING INTERVENTIONS Weigh patient routinely.



Subjective: y Thirst y Weakness Objective: y Dry skin y Decreased urine output y Postural hypotension

At the end of the 1. shift, the patient will be able to maintain fluid volume at functional level as evidenced by 2. normal urine output, stable vital signs and good skin turgor. 3.

Sudden significant weight gain reflects fluid retention. Urine output is a sensitive indicator of circulatory blood volume. Adequate nutrition reduces incidence of hypovolemia and hypoperfusion. To prevent injury from dryness.

Monitor intake and output.

Goal met as evidenced by patient has normal urine output, stable vital signs, and good skin turgor.

Reassess dietary intake of proteins and calories.


Provide frequent oral care as well as eye care.

CUES Subjective: ³Diri ako ginaganahan pagkaon´ as verbalized by the patient. ‡Lack of interest in food Objective: ‡Weakness ‡Insufficient food intake

NURSING DIAGNOSIS Risk for imbalance nutrition less than body requirements related to insufficient intake to meet the metabolic demands

GOAL At the end of the shift (311pm), the patient will be able to demonstrate behaviors, lifestyle changes to regain or maintain appropriate weight.

NURSING INTERVENTIONS 1. Note total daily intake including calorie intake, patterns and times of eating.

RATIONALE To reveal changes that should be made in patient¶s dietary intake. (NANDA 10th edition, p. 371) To enhance food satisfaction and stimulate appetite. (NANDA 10th edition, p. 372) To stimulate appetite. (NANDA 10th edition, p.372) Limiting fluids 1hour prior to meal decreases possibility of early satiety. (NANDA 10th edition, p.373) To enhance intake. (NANDA 10th edition, p.372)


2. Use flavoring agents such as lemon or herbs if salt is restricted. 3. Encourage client to choose foods that are appealing. 4. Promote adequate timely fluid intake.

Goal met as evidenced by patient was able to eat food sufficient enough to meet her metabolic needs.

5. Promote pleasant, relaxing environment including socialization when possible.

CUES Subjective: y ³Madali la ak kapuyon´ as verbalized by the patient. Objective: y Observed difficulty in ambulation y Grimaced face during ambulation y Respiratory rate of 22 cpm

NURSING DIAGNOSIS Activity intolerance related to bed rest secondary to preeclampsia

GOAL Within the 8hour shift, the patient will be able to perform at least one activity of daily living.

NURSING INTERVENTIONS 1. Monitor current potential for desired activities.

RATIONALE Provide baseline for planning activities and increased in activities.



Assist patient with self-care activities as needed. Let the patient determine how much assistance is needed.

Goal met as evidenced by patient was able to comb her hair and eat her food Allows the patient on her own. to have some control and choice in plan.


Vital signs Monitor vital signs before and increase with after activity. activity and should return to baseline within 57 minutes after activity. Encourage rest as needed in between activities. Planned rests assist in maintaining and increasing activity tolerance. Allows proper resting period for the patient¶s body to recuperate.



Provide for a quiet, nonstimulating environment.

CUES Subjective: ‡³Kinukurian ako paglalakat.´ as verbalized by the patient. Objective: ‡Inability to walk independently ‡Grimaced face during ambulation

NURSING DIAGNOSIS Self-care deficit related to decreased strength and endurance as evidenced by inability to ambulate independently

GOAL At the end of a 2-hour nursing intervention, the patient will to demonstrate techniques to meet self-care needs and identify or use available resources.

NURSING INTERVENTIONS 1. Assess patient¶s psychological status.

RATIONALE Physical pain experience may be compounded by mental pain that interferes with client¶s desire and motivation to assume autonomy. Improves selfesteem; increases feelings of wellbeing.


Goal met as evidenced by patient was able to meet self-care needs such as mouth care without assistance.

2. Offer assistance as needed with hygiene such as mouth care, back rubs, and perineal care. 3. Offer choices when possible such as selection of juices, destination during ambulation.

Allows some autonomy, even though patient depends on professional assistance.

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