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BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING
City of Malaybalay

In Partial Fulfillment of the Course Requirements in


NCM 108

A Case Presentation on
PREECLAMPSIA, SEVERE, UNCONTROLLED

Presented by:
Group 2
Cagulada, Lharra Mae
Santillan, Cheerille
Telin, Marvin
Rachelle Villamor
Loweelyn Tortola
Junfelm Gomez
Nielmark Casite
Joy Homamoy
Ma. Zusette Doydora
Fe Auguis
Joshua Robosa
Marcher Palado

Clinical Instructor:
April Ahne C. Guibone, RN, MAN

December 12, 2014

TABLE OF CONTENTS
I.

II.
III.

IV.
V.
VI.

Introduction
a. Objectives of the CP
b. Patients Profile
c. Etiology of the Disease/ Anatomy and Physiology
Theoretical Framework
Nursing Care Plans
Assessment
Subjective
Objective
Signs and Symptoms
Laboratory Tests
Nursing Diagnosis
Planning
Implementation/ Nursing Interventions
Independent
Dependent
Evaluation
Discharge Plans
Follow-up Visit
Home Medication
Bibliography
Appendix

I- INTRODUCTION
Pregnancy- Induced Hypertension (PIH) is a condition in which vasospasm occurs
during pregnancies in both small and large arteries. Signs of hypertension, proteinuria, and
edema develop. It is a unique to pregnancy and occurs in 5% to 10% of pregnancies in the
United States. (Abramovici et al., 2000) Despite of years of research, the cause of the disorder is
still unknown. Originally it was called toxaemia because the researchers pictured a toxin of some
kind being produced by a woman in response to the foreign protein of the growing fetus, the
toxin leading to the typical symptoms. No such toxin has ever been identified.
PIH, a condition separate from chronic hypertension, tends to occur most frequently in
primiparas younger than 20 years of age and older than 40 years old, women from low
socioeconomic backgrounds (perhaps of poor nutrition), those who have had five or more
pregnancies, women of color, those who have hydramnios, or those who have an underlying
disease such as heart disease, diabetes with vessel or renal involvement, and essential
hypertension. (Addele Pilliteri, Maternal and Child Health Nursing 2003)
Ten percent of all pregnancies are complicated by hypertension. Eclampsia and
preeclampsia account for about half of these cases worldwide and have been recognized and
described for years despite the general lack of understanding of the disease. In the fifth century,
Hippocrates noted that headaches, convulsions, and drowsiness were ominous signs associated
with pregnancy. In 1619, Varandaeus coined the term eclampsia in a treatise on gynecology.
Preeclampsia refers to a set of symptoms rather than any causative factor, and there are many different
causes for the condition. Women with preeclampsia will often also have swelling in the feet, legs, and hands. 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.
Preeclampsia may develop from 20 weeks gestation till the final weeks of gestation. Its progress differs
among patients. Most cases are diagnosed pre-term. Preeclampsia may also occur up to six weeks post-partum. It
is the most common of the dangerous pregnancy complications; it may affect both the mother and the unborn
child. There are two categories of preeclampsia, mild and severe.

Mild Preeclampsia

Severe Preeclampsia

Blood pressure greater than 140/90 mmHg on 2 Blood pressure greater than 160/110 mmHg on 2
occasions 6 hours apart
occasions 6 hours apart
Proteinuria 0.3g of protein in a 24-hour urine sample or Proteinuria exceeding 2g in a 24-hour urine sample or
persistent 1-2+ protein measurement on urine dipstick
persistent 3-4+ protein measurement on urine dipstick
Increased serum creatinine (>1.2 mg/dL unless known
to be elevated previously)
Oliguria < 500 mL/24h
Cerebral or visual disturbances
Epigastric pain
Thrombocytopenia (platelet count < 100,000/mm)

A. Objectives
General Objectives
Our group aims to present a case study that will show a comprehensive discussion of
Severe Preeclampsia, for us to share knowledge to our audience and to gain further details about
the disease.

Specific Objectives
At the end of 2 hours, we will be able to:
1.

Define Severe Preeclampsia.

2.

Describe the causes, sign, and symptoms of the disease.

3.

Present a thorough general health assessment of the client which includes physical
assessment and family history.

4.

Discuss an overview anatomy and physiology of the system involved.

5.

Thoroughly discuss, explain, and elaborate the pathophysiology of the disease


process of the patients conditions.

6.

Determine the laboratory and diagnostic procedure done and its significance

7.

Described the different medications administered for the disease, their indications,
contraindications, side effects, and specific nursing responsibilities.

8.

Identify and discuss nursing care plans for the different problems identified.

9.

Discuss the discharge planning intended for the patient

B. Patients Profile
Demographic Data
A. Name

: Mrs. Pre-Eclampsia

b. Age

: 39 years old

c. Sex

: Female

d. Date of Birth

: July 07, 1975

e. Address

: Kibalaan Ginuyuran Valencia city

f. Religion

: Roman Catholic

g. Nationality

: Filipino

h. Civil status

: Married

i. Occupation

: House Keeper

j. Informant

: Mrs. Eclampsia

k. Relation

:Patient

l. Date of Admission : December 3, 2014


m. Time of admission : 6:45 PM
n. Attending Physician

: Dr. Victoria Galang

. Admitting Vital Signs

: BP: 160/100 mmHg RR: 26 cpm PR: 86 bpm T: 37.7C

p. Food Allergy

: No known food allergy

q. Drug Allergy

: No known drug allergy

r. Educational Attainment

: Elementary

s. Chief Complain

: Few days prior to admission patient had experience elevated BP.

t. Admitting Diagnosis

: Pregnancy Uterine Full Term, Pre eclampsia, Severe

A. History of Past Illness


Mrs. Preeclampsia had her complete vaccination in her childhood and had already
experienced mumps and measles during her pre-school years. She had no history of
hospitalizations due to any medical problems not until her present illness occurred. Normally,
she just uses over-the-counter drugs (paracetamol, biogesic, mefenamic acid, amoxicillin, etc.)
when experiencing common diseases such as moderate toothaches, cough, flu, and fever. Before
her pregnancy, she consumes alcoholic drinks occasionally. She had no history of smoking and
drug abuse, and she had no pre-existing hypertension. When she got pregnant, she normally eats
rice with meat and vegetable soup, and one fruit; supplied with regular glass of Anmum milk.
But the one food she cant stop her self eating is bulad, as said by the pt.
Mrs. Preeclampsias blood pressure reading were actually low during her first, second
and thrird prenatal check-ups last October, November, and December; with 90/50mmHg, 90/70
mmHg, and 100/60 mmHg respectively. Mrs. Preeclampsias mother had history of high blood
pressure and heart disease, which she wasnt able to recognize. Her elder sister experienced
hypertension during her first pregnancy, and delivered her baby via Caesarian Operation too.
Mrs. Preeclampsia stated that she had a lot of support system coming from her family,
relatives and friends. She is a Roman Catholic and makes it a point to visit and attend a mass
every Sunday with her husband. Their beliefs about life, their source for guidance in acting their
beliefs, and the relationship they have in exercising their faith is truly God-centered manner.

B. History of Present Illness


On December 3, 2014 at 10 in the morning, patient experienced slight pain with a scale of
2-3 from 0-10 pain scale. Since she is a nullipara, it was her first time to experience that pain and
didnt know whether if its normal abdominal pain of if it was that of the labors pain. Without
further ado, she went to Bluestar Lying Inn Clinic at Casisang, Malaybalay City with her sister,
and her IE measured 4cm. Calming back from the panic, she then went home at her sisters
house. At about 2pm, patient had blood show with a tolerable pain at 4-5 out of 0-10 pain scale.
At 6PM, the patient experienced severe abdominal pain at a pain scale of 8-9 over 10. IE was
done by the barangay midwife with 4-5cm cervical dilatation. At about 10PM, they went back to
Bluestar Lying Inn Clinic, her BP measured high at 140/80mmHg; so she was referred to Dra.
Galang at Bukidnon Provincial Medical Center.
At 1:30AM on February 17, 2013, she was admitted and diagnosed with Pregnancy
Uterine Full Term In Labor, Gravida 1 Para 0, Pre eclampsia, Severe; with an initial Blood
Pressure reading at 160/100mmHg. Mrs. Preeclampsia was then admitted to OB Ward at 6:30PM
and was monitored by the nurse-on-duty. Her wital signs and her babys fetal heart rate were
continuously monitored (FHT range from 140-155bpm). The doctor decided to perform E
Cesarean Operation.

Systems Involved
ASSESSMENT December 4, 2014 Thursday
A. DIGESTIVE SYSTEM
OBJECTIVE
General Appearance:
Slight weakness
Ambulatory
Dressing noted on abdomen
Skin:
Dry
Cold , Clammy
Good turgor
Eyeball:
Sunken
Moist
Tongue:
Dry
Venous Filling:
2 seconds
Capillary refill:
2 seconds
Nail bed:
Pale
Vital Signs:
Temperature- 37.2C
Pulse Rate- 96 bpm
Respiratory Rate-20 cpm
Blood pressure- 130/90
Intake and Output:
Intake-370cc
Output-500cc
Body Type:
Ectomorph
Abdomen:
Firm
Bowel sounds: 15

SUBJECTIVE
Pain:
P Sakit akong tiyan nga geoperahan
Q Sakit nga ngot-ngot
R tibook jud naku tiyan
S 9/10
T kanang galihok ko
Respiration:
normal raman sir akong pagginhawa.
as verbalized by Patient
Diet:
NPO
Elimination Pattern: Bowel Movement
Wala pako kalibang sukad tung
gioperahan ko, as verbalized by the
patient.

Note: D5LR @ 30gtts/min

B. CARDIOVASCULAR/ CIRCULATORY SYSTEM


OBJECTIVE
Vital Signs:
Temperature- 36.6C
Pulse Rate- 96 bpm
Respiratory Rate-20 cpm
Blood pressure- 130/90
Capillary refill:
2 seconds
Nail bed:
Pale
Edema: Non-pitting
Lower extremities
Varicosities:
Both legs
Intake and Output:
Intake-370cc
Output-500cc
Note: D5LR @ 30gtts/min

SUBJECTIVE
History of present illness:
Mother side of the patient had a history
of Hypertension
Do you experience any of the following:
Talagsa ga labad akong ulo as
verbalized by the patient.
Ug gapaminhod akong mga tiil as
verbalized by the patient

C. ELIMINATION
OBJECTIVE
Mobility and Dexterity:
Ambulatory
Slight weakness

Tubes/drainage/stoma:
indwelling FBC attached to urobag

SUBJECTIVE
Do you experience any of the following:
Wala pa ko kalibang gikan tong
naoperahan ko sir as verbalized by the
patient

Abdomen:
firm abdomen
Bowel sounds:
Hypoactive.Present
Urine Color:
Dark Amber
Note: D5LR @ 30gtts/min

ASSESSMENT December 5, 2014 Friday


A. DIGESTIVE SYSTEM
OBJECTIVE
General Appearance:
Slight weakness
Ambulatory
Dressing noted at abdomen
Skin:
Dry
Good turgor
Eyeball:
Sunken
Moist
Tongue:
Dry
Venous Filling:
2 seconds
Capillary refill:
2 seconds
Nail bed:
Pink

SUBJECTIVE
Pain:
P Sakit akong tiyan nga geoperahan
Q Sakit nga ngot-ngot
R tibook jud naku tiyan
S 8/10
T kanang galihok ko
Respiration:
normal raman sir akong pagginhawa.
as verbalized by Patient
Diet:
Soft Diet
Elimination Pattern: Bowel Movement
wala pako kalibang sukad tung
gioperahan ko, as verbalized by the
patient.

Vital Signs:
Temperature- 36.6C
Pulse Rate- 82bpm
Respiratory Rate-33cpm
Blood pressure- 120/80
Intake and Output:
Intake-750cc
Output-600cc
Body Type:
Ectomorph
Abdomen:
Firm
Bowel sounds: 10
Note: D5LR @ 30gtts/min
B. CARDIOVASCULAR/ CIRCULATORY SYSTEM
OBJECTIVE
Vital Signs:
Temperature- 36.6C
Pulse Rate- 82bpm
Respiratory Rate-33cpm
Blood pressure- 120/80
Capillary refill:
2 seconds
Nail bed:
Pink
Varicosities:
Both legs
Intake and Output:
Intake-750cc
Output-600cc
Note: D5LR @ 30gtts/min
C. ELIMINATION

SUBJECTIVE
History of present illness:
Mother side of the patient had a history
of Hypertension
Do you experience any of the following:
Talagsa ga labad akong ulo as
verbalized by the patient.
mao ra japon sir gapaminhod akong
mga tiil pero panagsa nlng as
verbalized by the patient

OBJECTIVE
Mobility and Dexterity:
Ambulatory
Slightly weakness

SUBJECTIVE
Do you experience any of the following:
Wala pa japon ko kalibang sir as
verbalized by the patient

Tubes/drainage/stoma:
indwelling FBC attached to urobag
Abdomen:
firm abdomen
Bowel sounds:
Hypoactive.Present
Urine Color:
Amber
Intake and Output:
Intake-750cc
Output-600cc

Note: D5LR @ 30gtts/min

Laboratory Results

Date:
December 3, 2014

Result

Normal
Findings

Significance

White Cell Count

11.6/L

5.0-10.0/L

Stress, mental/physical
Tissue damage (Caesarean Operation)

Red Cell Count

4.75mil/mm3

3.695.13mil/mm3

Normal; anemia, bleeding,


dehydration
smoking, congenital heart disease,
hypoxia

Hemoglobin

14.7g/dL

11.7-14.5g/dL

Due to low Oxygen levels in the


blood
Body not having as much fluids and
water as it should

Hematocrit

40.7vols%

34.1-44.3vols%

Normal; anemia, bleeding,


malnutrition
dehydration, erythrocytosis,
hypoxia

Platelet Count

224,000/ml

174,000390,000/ml

Normal; thrombocytopenia,
autoiimune disorders, risk of bleeding
is much higher
thrombocytosis, risk of forming
blood clots

Mean Corpuscular
Volume

85.7fL

81.5-96.7fL

Normal (Normocytic anemia) ;


microcytic. Small average RBC size
macrocytic, large average RBC size

Mean Corpuscular
Hemoglobin

30.9pg

26.5-33.5pg

Normal; small red cells would have


a lower value
macrocytic RBCs are large so tend
to have a higher MCH.

Mean Corpuscular
Hemoglobin
Concentration

36g/dL

31.9-36g/dL

Normal; May be low when MCV is


low; decreased MCHC values
(hypochromia) are seen in conditions
such as iron deficiency anemia and
thalassemia
Increased MCHC values
(hyperchromia) are seen in conditions

where the hemoglobin is more


concentrated inside the red cells, such
as autoimmune hemolytic anemia, in
burn patients, and hereditary
spherocytosis, a rare congenital
disorder
Segmenters

65%

43.4-76.2%

Normal; viral infection,


autoimmune diseases, some
medications and malignancy
Ongoing infection, an
inflammation, malignancy

Lymphocyte

35%

17.4-46.2%

Normal; usually not significant


acute infection especially viral
infections, leukemia, smoking
Significance

Urine Analysis
Color

Result

Normal
Findings

Yellow

Light Yellow- Amber

Transparency

Clear

Clear-Slightly
Hazy

Sugar (Glucose)

Negative

Negative

Specific Gravity

1.015

1.005-1.025

Protein

Negative

0-Trace

Pus Cells
RBC

0-3pvf
2-5HPF

0-4 pvf
0-3HPF

Epithelium

few

0-few

Normal; concentrated
is darker, kidney
stones may produce
blood in urine
Normal; transparent when freshly
voided but becomes turbid (cloudy)
upon standing
Normal; > stress, diabetes mellitus,
brain injury, myocardial infarction
Normal; (density) the higher the
concentration of solutes, the higher
the specific gravity
Normal; > nephritis, fever, severe
anemias, trauma and hyperthyroidism
Normal; infection
Infection/inflammation in the Urinary
Tract itself, trauma to the bladder or
kidney disease, trauma
Normal; > urinary tract infections,
inflammation, malignancies

C. Etiology of the Disease/ Anatomy and Physiology

PATHOPHYSIOLOGY
SEVERE PRE-ECLAMPSIA

Definition: A woman has severe pre-eclampsia when her blood rises to 160 mmHg systolic and
110 mmHg diastolic or above on at least two occassions 6 hours apart at bed rest. Marked
proteinuria, 3+ or 4+ on a random urine sample or more than 5g in a 24-hour sample, and
extensive edema are also present.

PRE DISPOSING FACTORS


Age: 39 y/o
Primipara
Family History of
Hypertension

PRECIPITATING FACTORS
Sedentary Lifestyle
Nutrition: High sodium diet
Husband is a smoker
Etiology:
Unknown

Vasospasm

Vascular Effects

Kidney Effects

Interstitial Effects

Vasoconstriction

Decreased glomeruli
filtration rate and increased
permeability of glomeruli
membranes

Diffusion of fluid
from bloodstream
into interstitial
tisssue

Poor organ
perfusion

Increased serum blood


urea nitrogen, uric
acid, and creatinine

Increased blood
pressure

Decreased urine
output and
proteinuria

Edema

II- THEORETICAL FRAMEWORK


CARE, CURE, CORE (3 CS)
By: Lydia Eloisa Hall

Lydia Hall Care Core Cure enumerated three aspects of the person as patient: the person
(core), the body (care), and the disease (cure). These aspects were envisioned as overlapping
circles that influence each other.
Hall clearly stated that the focus of nursing is the provision of intimate bodily care. She
reflected that the public has long recognized this as belonging exclusively to nursing. Being
expert in the area of body involved more than simply knowing how to provide intimate bodily
care. To be expert, the nurse must know how to modify care depending on the pathology and
treatment while considering the unique needs and personality of the patient.
Based on her view of the person as patient, Hall conceptualized nursing as having three
aspects, and delineated the area that is the specific domain of nursing, as well as those areas that
are shared with other professions. Hall believed that this model reflected the nature as a
professional interpersonal process. She visualized each of the three overlapping circles as an
aspect of the nursing process related to the patient, to the supporting sciences, and to the
underlying philosophical dynamics. The circles overlap and change in size as the patient
progresses through a medical crisis to the rehabilitative phase of the illness. In the acute care
phase, the cure is the largest. During the evaluation and follow-up phase, the care circle is
predominant.

Care
This is the part of the model reserved for nurses, and focused on performing that noble
task of nurturing the patients, meaning the component of this model is the motherly care
provided by nurses, which may include, but is not limited to provision of comfort measures,
provision of patient teaching activities and helping the patient meet their needs where help is
needed. This aspect provided the opportunity for closeness and required seeing the process as an
interpersonal relationship. Hands on care for patients produce an environment of comfort and
trust and promotes open communication between nurses and patients.
Cure
The second aspect of the nursing process is shared with medicine and is labeled as the
cure. Hall comments on the two ways that this medical aspect of nursing may be viewed; it
may be viewed as the nurse assisting the doctor by assuming medical tasks or functions. The
other view of this aspect of nursing is to see the nurse helping the patient through his or her
medical, surgical, and rehabilitative care in the role of comforter and nurturer.
Core

The third are that nursing shares with all of the helping professions is that of using
relationships for therapeutic effect the core. This area emphasizes the social, emotional,
spiritual, and intellectual needs of the patient in relation to family, institution, community and the
world. Knowledge foundational to the core was based on the social sciences and therapeutic use
of self. Through the closeness offered by the provision of intimate bodily care, the patient will
feel comfortable enough to explore with the nurse who he is, where he is, where he wants to go
and will take or refuse help in getting there the patient will make amazingly rapid progress
toward recovery and rehabilitation. Hall believed that through this process, the patient would
emerge as a whole person.

SELF-CARE MODEL
By: Dorothea Orem

1.
2.
3.
4.

Self-care comprises those activities performed independently by an individual to promote


and maintain person well-being
Self-care agency is the individuals ability to perform self-care activities
Self- care deficit occurs when the person cannot carry out self-care
The nurse then meets the self-care needs by acting or doing for; guiding, teaching,
supporting or providing the environment to promote patients ability
Wholly compensatory nursing system-Patient dependent
Partially compensatory- Patient can meet some needs but needs nursing assistance
Supportive educative-Patient can meet self-care requisites, but needs assistance with
decision making or knowledge

5.
6.
7.

IV.

HEALTH CARE SYSTEMS MODEL


By: Betty Neuman
1. The person is a complete system, with interrelated parts
2. Maintains balance and harmony between internal and external environment by adjusting
to stress and defending against tension-producing stimuli
3. Focuses on stress and stress reduction
4. Primarily concerned with effects of stress on health
5. Stressors are any forces that alter the systems stability
6. Flexible lines of resistance - Surround basic core
7. Internal factors that help defend against stressors
8. Normal line of resistance - Normal adaptation state
9. Flexible line of defense - Protective barrier, changing, affected by variables
10. Wellness is equilibrium
DISCHARGE PLANS

DISCHARGE GOALS:
1. Pain relieved/controlled.
2. Complications prevented/minimized.
3. Mobility/function regained or compensated for.
4. Surgical procedure, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge
M - Medications
Take home medication as prescribed by the Physician which includes the following:
Cefuroxime 500mg BID x 7 days
Mefenamic Acid 500mg TID x 7 days
Report any side effects & adverse reactions as indicated by the healthcare provider.
Check with physician about administration of other medications.
E - Environment/Exercise
Instruct patient to stay in calm, quiet environment.
Home environment must be free from slipping or accident hazards.
Dont try to take care of anyone other than your baby and yourself.
Remember, the more active you are, the more likely you are to have an increase in your
bleeding.
Get lots of rest. Take naps in the afternoon.
Increase your activities gradually.
Plan your activities so that you dont have to go up or down stairs more than necessary.
T - Treatment
Encourage to take Vitamin C and Iron Supplements.
Proper wound care at surgical site.
H Health Teachings
Encourage to increase fluid intake.
Proper hygiene.
Watch incision for signs of infection, such as increasing redness or drainage.
Hold a pillow against the incision when you laugh or cough and when you get up from a
lying or sitting position

Do postsurgical deep breathing and coughing exercises. Ask your doctor for instructions.
Dont lift anything heavier than your baby until your doctor tells you its okay.
Dont have sexual intercourse until after youve had a follow-up appointment with your
doctor and youve decided on a birth control method.

O Out Patient
Inform patient to have a follow-up check up after 1 week.
Inform patient to return after 1 week for removal of sutures.
When to Call Your Doctor?
Call your doctor right away if you have any of the following:
Fever of 38.0C or higher
Redness, pain, or drainage at your incision site
Repeated clots of blood (the size of a quarter or larger) passing from the vagina
Bleeding that requires a new sanitary pad every hour
Severe pain in the abdomen
Pain or urgency with urination
Trouble urinating or emptying your bladder
No bowel movement within 1 week after the birth of your baby

D- Diet

Encourage intake of foods rich in fiber such as green leafy vegetables.


Encourage increase intake of foods rich in Iron such as dark green leafy vegetables.
Low sodium and avoidance of fatty foods.
Encourage intake of foods rich in Vitamin C such as citrus.

V. BIBLIOGRAPHY
Books
Brunner and Suddarths Textbook of Medical and Surgical Nursing by Suzanne c. Smelter &
Brenda G. Bare 10th Edition Volume 1
Focus on Nursing Pharmacology 3rd Edition by Amy M. Karch
2010 Edition Delmar Nurses Drug Handbook by George R. Spratto and Adrienne L. Woods
Concise Pocket Medical Dictionary 2nd Edition by UN Panda
Nurses Pocket Guide 9th Edition by Merilynn E. Doenges
Pathophysiology Made Incredibly Easily 3rd Edition
Websters New World Dictionary of the American Language Students Edition
Fundamentals of Nursing 7th Edition by Barbara Kozier
Principles of anatomy and Physiology 9th Edition by tortora and Grabowski