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I. INTRODUCTION Mrs.

Ob, a 39 years old housewife and
first time mother, who currently resides at
Description of the Disease Guagua Pampanga with her husband Mr. Gyne.
She was born a Filipina on November 9, 1969 in
Preeclampsia, also referred to as toxemia, Sta. Rita Guagua Pampanga. The patient was
is a condition that pregnant women can get. It is admitted at a Regional Hospital with a chief
marked by high blood pressure accompanied with a complaint of abdominal pain, last November
high level of protein in the urine. Women with 15, 2008 at around 3:00 p.m.
preeclampsia will often also have swelling in the b.) Socio-Economic and Cultural Factors
feet, legs, and hands. Preeclampsia, when present, Mrs. Ob is plain housewife and her
usually appears during the second half of husband is an extra laborer on a construction
pregnancy, generally in the latter part of the site. She graduated at a Public High School.
second or in the third trimesters, although it can And she didn’t continue her college level due
occur earlier. to financial problem.
In addition symptoms of preeclampsia can include: Mrs. Ob was raised as a Roman
• Rapid weight gain caused by a significant Catholic, were she learned about religious
increase in bodily fluid values but she still believes in super natural
• Abdominal pain forces and superstitious beliefs. When it comes
• Severe headaches in health matters, she seeks the help of a
• A change in reflexes albularyo and uses herbal medicines to treat
any member of the family who has an ailment.
• Reduced output of urine or no urine
But when serious matters arise she still refers
• Dizziness to medical professionals for help.
• Excessive vomiting and nausea c.) Environmental factors

The exact causes of preeclampsia are not
known, although some researchers suspect poor
nutrition, high body fat, or insufficient blood flow to Ms. Ob resides at Guagua
the uterus as possible causes. Pampanga and occupies the ancestry
house of her family. The location of their
house is not easily accessible to hospitals,
The only real cure for preeclampsia and
health centers and other government
eclampsia is the birth of the baby. Mild
institutions. Mrs. Ob did not report any
preeclampsia (blood pressure greater than 140/90)
problems regarding her environment which
that occurs after 20 weeks of gestation in a woman
interfered to her pregnancy.
who did not have hypertension before; and/or
Maternal-child Health History
having a small amount of protein in the urine can
be managed with careful hospital or in-home
observation along with activity restriction. a.) Maternal – Obstetric record (for OB cases)
Mrs. Ob was married to Mrs. Gyne
at the age of 33 years old. She has a record
The group chose the case for the reason of T1P0A0L1M0 at her 39th week of
that they wanted to show the readers the process gestation. She underwent low transverse
on how pre-eclampsia occurs and for them to fully ceasarian section under a certain
understand and be reminded on one of the obstetrician at the regional hospital last
complications associated with pregnancy. November 18, 2008 at around 10:00 in the
evening, she delivered her 1st child who is
In developing countries: term baby with hyperbilirubinemia.
preeclampsia/eclampsia impact 4.4% of all b.) Antepartal/ Prenatal Preparation
deliveries (1) and may be as high as 18% in some When Mrs. Ob was still pregnant, she
settings in Africa (2) If the rate of life threatening only consulted once in a district hospital all
eclamptic convulsions (0.1% of all deliveries) is throughout.
applied to all deliveries from countries considered c.) Significant Trimestral Changes (1st to 3rd
to be the least developed, 50,000 cases of women trimester)
experiencing this serious complication can be Mrs. Ob rxperienced some changes in
expected each year. According to Safe her pregnancy, such as striae gravidarum,
Motherhood.org of the 585,000 maternal annually linea nigra, and melasma. She also
(3), 13%, or 76,050, are due to eclampsia. experienced nausea and vomiting, dizziness,
II. NURSING HISTORY and headache.

a.) Demographic Data
DIAGNOSTIC AND LABORATORY PROCEDURES

Date Ordered
Diagnostic or Analysis and
Indication or and Date
Laboratory Results Normal Values Interpretation of
Purpose Results were
Procedure Results
released
WBC Count To determine November 16, 8.0 5-10 x 109/L No infection or
infection or 2008 inflammation is
inflammation present.
Pre-operation
assessment of the
patient.

RBC Count Pre-operation November 16, 3.3 4.2-5.4 x 1012 Decreased RBC
assessment of the 2008 /L count on
patient. pregnant is
normal because
of the increase in
plasma volume
during
pregnancy.

Hemoglobin Pre-operation November 16, 96 120-160g/L The result
assessment of the 2008 indicates that a
patient. 1000 ml 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 16, 0.29 0.37-0.47 g/L The result
assessment of the 2008 indicates that a
patient. 1000 ml sample
of blood contains
.29 g of
hemoglobin.
Decreased
hematocrit on
pregnant is
normal because
of their increase
in plasma
volume.

Nursing Responsibilities During Different After
Laboratory Procedures • If a hematoma develops at the
venipuncture site, apply warm soaks. If the
White Blood Cell Count hematoma is large, monitor pulses distal
Before the venipuncture site.
• Explain to the patient that the WBC test is • Inform the patient that he may resume his
used to detect an infection or usual diet, activity and medications
inflammation. discontinued before the test, as ordered.
• Tell the patient that the test requires a • A patient with severe leucopenia, they
blood sample. Explain who will perform the have little or no resistance to infection and
venipuncture and when. requires protective isolation.
• Explain to the patient that he may
experience slight discomfort from the
needle puncture and the tourniquet. Red Blood Cell Count
• Inform the patient that he should avoid Before
strenuous exercise for 24 hours before the • Explain to the patient that RBC count is
test. Also tell him that he should avoid used to evaluate the number of RBCs and
eating a heavy meal before the test. to detect possible blood disorders.
• If the patient is being treated for an • Tell the patient that the test requires a
infection, advise him that this test will be blood sample. Explain who will perform the
repeated to monitor his progress. venipuncture and when.
• Notify the laboratory and physician of • Explain to the patient that he may
medications the patient is taking that may experience slight discomfort from the
affect test results: they may need to be needle puncture and the tourniquet.
restricted. • Inform the patients that he need not
restrict foods and fluids
During
• Ensure subdermal bleeding has stopped During
before removing pressure. • Ensure subdermal bleeding has stopped
before removing pressure.
• Explain to the patient that hct is tested to
After detect anemia and other abnormal
• If a hematoma develops at the conditions
venipuncture site, apply warm soaks. • Tell the patient that the test requires a
blood sample. Explain who will perform the
Hemoglobin venipuncture and when.
Before • Explain to the patient that he may
• Explain to the patient that the hbg test is experience slight discomfort from the
used to detect anemia or polycythemia or needle puncture and the tourniquet.
to assess his response to treatment. • Inform the patients that he need not
• Tell the patient that the test requires a restrict foods and fluids
blood sample. Explain who will perform the
venipuncture and when. During
• Explain to the patient that he may • Ensure subdermal bleeding has stopped
experience slight discomfort from the before removing pressure.
needle puncture and the tourniquet.
After
During • If a hematoma develops at the
• Ensure subdermal bleeding has stopped venipuncture site, apply warm soaks.
before removing pressure. III. THE PATIENT AND HIS ILLNESS

After
• If a hematoma develops at the venipuncture Efforts to unravel the pathogenesis of pre-
site, apply warm soaks. eclampsia have been hampered by the lack of clear
diagnostic criteria for the disease and its subtypes.
Hematocrit Consequently, several studies have included a
Before variety of other conditions that do not necessarily
reflect an adverse pregnancy outcome.
cascade and loss of vascular integrity. Pre-
eclampsia has effects on most maternal organ
Abnormal placentation (stage 1), systems, but predominantly on the vasculature of
particularly lack of dilatation of the uterine spiral the kidneys, liver and brain.
arterioles, is the common starting point in the
genesis of pre-eclampsia, which compromises Nursing Responsibilities:
blood flow to the maternal–fetal interface. Reduced
placental perfusion activates placental factors and
induces systemic hemodynamic changes. The • Check the doctor’s order
maternal syndrome (stage 2) is a function of the • Explain the procedure to the patient
circulatory disturbance • Tell the patient that she might feel a discomfort
from the tourniquet and the IV insertion
• Check and monitor IVF regulation and level of
fluid
• Check if there is a need for removal and
replacement of fluid
• Check if the tube is in the vein and signs of
edema
• Check if there is a back-flow of blood
• Check if there is bubbles present in the tube
caused by systemic maternal endothelial • Always Monitor V/S.
cell dysfunction resulting in vascular reactivity,
activation of coagulation

VIII. Discharge Plan With this study, the student nurses were
able to gain more knowledge and wider view and
General Condition of client upon discharge perspective of the complication of pregnancy which
During nurse-patient interaction upon is pre-eclampsia. Thus, the student nurses would
discharge, the patient was wearing a comfortable like recommend and share some pointers on how
pair of white shirt and white pajama and a pair of to deal with different diseases with pregnancy
flat slip-ons while being sealed on a chair cuddling specifically pre-eclampsia.
her baby boy. Her hair was untidy and up in a
ponytail with visible infestations. She was oriented To the government, primarily they should
enough to follow instructions and answers allocate sufficient budget to sustain and provide
questions asked by the student nurse. better facilities. They must be responsible enough
Methods to create awareness program for care and
M- Instructed the patient to take the management for all the Filipino people.
following home medication as ordered by the
physician: To the health care team, they should
Mefenamic Acid 500mg PRN righteously implementing basic and ideal
Ferrous Sulfate OD procedures regardless of the health care facilities
Nifedipine 10mg BID where they belong. They must observe and always
E- Instructed patient to avoid strenuous remember to keep in line with their duties towards
activities. And practice deep breathing exercise. both the mother and the child during the
T- n/a pregnancy.
H- Instructed patient to take a bath
everyday. Emphasize the importance of breast To the community and the family, that they
feeding. must be insufficient coordination with the
O- Advice to visit or have a follow up government and the health care team regarding
check-up with her attending physician. promotion of health before, during, and after the
D- Low fat, Low salt diet. delivery of the baby.

IX. Conclusion
Chapter IV Discharge Planning
Nurses can help the nation achieve
National Health Goals. These goals speak directly
to both fetus and the mother because pregnancy is Medication
a high risk factor for them. Close monitoring in Drug to be continued, Hydralazine (Apresoline)
pregnant women and health teaching as much as oral. For maintenance, adjust dosage to the lowest
possible about pregnancy could definitely reduce effective levels.
life threatening complications.
Exercise
Studies shows that there is no certain facts
The client should limit the no. of stairs she
that will give us the idea where pre-eclampsia
climbs to one flight/dayfor the first week at home.
arise. But there so many factors that could prevent
Beginning the second week, if her lochial discharge
this complication such as diet modifications, proper
compliance with the health care providers, proper is normal, she may start to increase this activity.
exercise. And if the complication is already present, Limit stair climbing to only when necessary for first
proper monitoring, proper diet and drug two weeks.
compliance should be ruled in.
Treatment
X. Recommendations Advice client to monitor blood pressure, take
prescribed medications and perform wound care as
needed.
Health Teaching
Teaching should focus on action to maintain
comfort, to promote healing and restore wellness.
 avoid heavy work (lifting or straining) for
at least first 3 weeks after birth.
(it is usually advised that she doesn’t return to
an outside for at least 3 weeks (better 6
weeks) not only for her own health but also for
enjoyment of the early weeks with her
newborn. Explore with th client what she
consider heavy work)
 get lots of sleep. Sleep when baby sleeps.
(Client should at least 1 rest period a day and
try to get a good night’s sleep. She can rest
during the day when her newborn is sleeping.)
 take advantage of help from others.
 avoid having sexual intercourse at least a
month
 call your health care provider if you have
any of the warning signs of sickness:
(fever greater than100F, severe pain, redness
or swelling in the incision site, foul smelling
vaginal discharge, increase bleeding, back ache
or severe abdominal pain or cramping
(unrelieved by medication).)
 report increasing pain, swelling, or opening
or gaping of wound edges.
 teach the client how to change wound
dressings and perform wound care.
 instruct client to use pain medication as
ordered.
 emphasize the importance of hygiene and
hand washing to prevent infection

Out Patient follow-up
The client should return to her physician 2-4
weeks after.

Diet
The client’s diet is high protein and low sodium
diet.
VI. NURSING CARE PLAN
Cues Nursing Scientific Objective Nursing Rationale Expected
diagnoses Explanation intervention outcomes
S-“sumasakit nga Acute pain Unpleasant After 2-4 hr of - Provide quite -to promote pain Goal Partially
daw ung tahi niya related to sensory nursing environment management. met AEB pt
at sumusigaw postparum experience intervention, the rated the pain
siya” as the SO arising from post pt rate the pain -Encouraged to do -to reduce tension from 8 to 5 in a
verbalized surgical incision from 8 to 3 in a deep breathing pain scale of 1-
from cesarean pain scale of 1-10 exercise 10
O- facial grimaces section.
Rated pain as 8 in - Encouraged -to prevent fatigue
a pain scale of 1- adequate rest
10, 10 being the period
highest -to reduce pressure
Guarding - Encouraged to on the affected
behavior support the area
affected area
upon movement

Cues Nursing Scientific Objective Nursing Rationale Expected
diagnoses Explanation intervention outcomes
S-“ayoko na Disturbed body Severity of the After 2-4 hrs of -Encouraged -to begin to Goal met the
muna dapat image related to abdominal wound nursing client to looked/ incorporate patient recognized
mabuntis kc pregnancy AEB due to surgery, a intervention, the touch the affected changes into and verbalized
papangit ung changes in new type of patient will able to body area body image. understanding of
katawan ko tsaka appearance tissues develops understand the body changes.
bat ang itim ng that eventually change of body -Encourage the -to bring back the
pek-pek ko” as pt will causes scar image. client to have a usual physical
verbalized formation daily exercise. images.

O-presence of -Advised the SO -to feel that the
melasma to give support to patient still
-presence of the pt (especially worthy.
bipedal edema emotional
feelings)

-Assist pt to -to aid in
identify positive recovery.
behavior

Cues Nursing Scientific Objective Nursing Rationale Expected
diagnoses Explanation intervention outcomes
S: “bumibilis nga Decreased Pregnancy Induced After 4 hrs of -Keep client on - decreases Goal Met AEB
tibok ng puso cardiac output Hypertension is a nursing bed and in oxygen within 4 hrs. of
ko” verbalized by related to altered condition in which intervention, the position of consumption nursing
the patient heart rate (111 vasospasms occur. patient will comfort intervention the
bpm) AEB It is caused by display pt. HR decreased
tachycardia, pt’s altered cardiac hemodynamic -decrease stimuli; -to promote from 111 bpm to
O: -with the report of output that injures stability (heart provide quiet adequate rest 100 bpm, BP from
tenderness of palpations; endothelial cells of rate will decrease env’t 140/100 to
abdominal are (r/t) decreased the arteries. Blood from 111 bpm to -to reduce anxiety 120/80 (Normal
venous return vessels become 100 bpm, BP from -Encouraged deep BP)
-facial grimaces AEB edema less resistant to 140/100 to breathing
(ankle), SOB (28) pressor 120/80) exercise -to reduce risk for
substances. This orthostatic
-BP= 160/100
results to -Encouraged hypotension
mmhg
vasoconstriction changing
and increases BP positions slowly -to provide
RR= 28 cycles dramatically encouragement
per min. -give information
about positive
PR= 111 bpm signs of -to prevent in
improvement changes in cardiac
pressures or
-Instruct client to impede blow flow
avoid or limit
activities that
may stimulate
valsalva response
(rectal
stimulation,
bearing down
B.M)

Cues Nursing Scientific Objective Nursing Rationale Expected
diagnoses Explanation intervention outcomes
S- Risk for Constipation may After 4 hrs of - Educate patient/ - Information can Goal Met AEB the
constipation happen due to nursing SO about safe and help client to patient verbalized
O- decreased related to post CS disturbance of intervention, the risky practices for make beneficial understanding
ambulation of the delivery. normal bowel patient will managing choices when about constipation
patient bcs of movements verbalize constipation. need arises. and gained
pain and the because understanding the knowledge of
complete bed intestines were etiology and - Instruct balance appropriate
rest ordered of displaced during appropriate fiber and bulk in - To improve intervention.
the physician. surgical intervention if diet and fiber consistency of
procedure. constipation may supplements. stool and
occur. facilitate passage
- Promote through colon.
adequate fluid
intake, also - To promote soft
suggest drinking stool and
warm fluids. stimulate bowel
activity.
- Encourage
activity within
limits of individual -To stimulate
ability. constrictions of
the intestines

Cues Nursing Scientific Objective Nursing Rationale Expected
diagnoses Explanation intervention outcomes
O- postpartum Impaired Skin The incision from After 2-4 hrs of -stress proper - to control the Goal Met AEB the
surgery Integrity related the cesarean nursing hand hygiene. spread of infection. patient was able
to surgery section altered intervention, the to knew the
the skin integrity patient will able to -Encouraged to - to aid in tissue preventive
making it more know the increase foods repair measures of
susceptible to preventive that are rich in wound healing
pathogens and measures of protein
even the pt’s wound healing -to maintained the
normal flora -Encouraged proper skin
proper clothing moisture.

-Apply appropriate -to help in wound
dressing healing