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Republic of the Philippines TARLAC STATE UNIVERSITY COLLEGE OF NURSING Lucinda C

ampus, Brgy. Ungot, Tarlac City Philippines 2300 Tel.no: (045) 982-6062 Fax: (04
5) 982-0110
A CASE PRESENTATION ON PRE-ECLAMPSIA Presented to the Faculty of Tarlac State Un
iversity College of Nursing
In Partial Fulfilment of Requirements of the Subject NCM 105 R.L.E.
Presented by: Paras, Caselyn G. BSN IV A Group A2 Batch 2006-2010
January 2010
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I. INTRODUCTION Pre-eclampsia, also referred to as toxemia, is a medical conditi
on where hypertension arises in pregnancy (pregnancy-induced hypertension) in as
sociation with significant amounts of protein in the urine. Preeclampsia refers
to a set of symptoms rather than any causative factor, and there are many differ
ent causes for the condition. Women with preeclampsia will often also have swell
ing in the feet, legs, and hands. In addition symptoms of preeclampsia can inclu
de: • • • • • • • Rapid weight gain caused by a significant increase in bodily f
luid Abdominal pain Severe headaches A change in reflexes Reduced output of urin
e or no urine Dizziness Excessive vomiting and nausea
Pre-eclampsia may develop from 20 weeks gestation. Its progress differs among pa
tients. Most cases are diagnosed pre-term. Pre-eclampsia may also occur up to si
x weeks post-partum. It is the most common of the dangerous pregnancy complicati
ons; it may affect both the mother and the unborn child. There are 2 categories
of preeclampsia, mild and severe. Severe preeclampsia is defined as the followin
g: • • • • blood pressure greater than 160 mm Hg systolic or 110 mm Hg diastolic
on 2 occasions 6 hours apart proteinuria exceeding 2 g in a 24-hour period or 2
-4+ on dipstick testing increased serum creatinine (> 1.2 mg/dL unless known to
be elevated previously) oliguria ≤500 mL/24 h 2
• • • • • •
cerebral or visual disturbances epigastric pain elevated liver enzymes thrombocy
topenia (platelet count < 100,000/mm3) retinal hemorrhages, exudates, or papille
dema pulmonary edema
Preeclampsia has been described as a disease of theories, because the cause is u
nknown. Some theories include • endothelial cell injury, • ejection phenomenon (
insufficient production of blocking antibodies), • compromised placental perfusi
on, • altered vascular reactivity, • imbalance between prostacyclin and thrombox
ane, • decreased glomerular filtration rate with retention of salt and water, •
decreased intravascular volume, • increased central nervous system irritability,
• disseminated intravascular coagulation, • uterine muscle stretch (ischemia),
• dietary factors, and • genetic factors. A database of hospital discharge data
from approximately 300,000 deliveries in the United States found the overall inc
idence of severe preeclampsia was about 1 percent of pregnancies. Studies of pre
eclampsia report about 5 percent of nulliparous women develop preeclampsia and 4
0 to 50 percent of these women develop severe disease. In the Philippines, accor
ding to Department of Health, Maternal Mortality Rate(MMR) is 162 out of 10,000
live births (Family Planning Survey 2006). 3
Maternal deaths account for 14% of deaths among women. For the past five years a
ll of the causes of maternal deaths exhibited an upward trend. Preeclampsia show
ed an increasing trend of 6.89%; 20%; 40%; and 100%. Ten women die every day in
the Philippines from pregnancy and childbirth related causes but for every mothe
r who dies, roughly 20 more suffer serious disease and disability. The UNFPA off
ice in the Philippines declared that family planning can help prevent maternal d
eaths by 35%. (http://hb4110.net/wpcontent/uploads/KIT_MATERNAL%20HEALTH_BASIC %
20STATS.doc.) The only known treatments for eclampsia or advancing pre-eclampsia
are abortion or delivery, either by labor induction or Caesarean section (and t
herefore delivery of the placenta). Magnesium sulfate is the first-line treatmen
t of prevention of primary and recurrent eclamptic seizures (it reduces transmis
sion of nerve impulses from brain to muscles). The mother and her family deserve
careful teaching regarding the problem, its observation, and its treatment. Reg
ular, adequate prenatal care is the best insurance for control of the complicati
on.
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Importance of the case study In the part of the client This case will inform the
client of what her condition is all about. It will also lessen the burden of th
e client increasing her awareness about the whole course of treatments. And also
, the client will be able to familiarize herself about the importance taking car
e of her own self through the use of medical regimens. In the part of the studen
t The student will gain more information and knowledge about the disease and wil
l lead to a certain new facts about the said condition, such as cause of disease
, pathophysiology, manifestations, related factors as well as the proper nursing
care management and medical regimens to be rendered. This acquired information
may also help the students on how to properly manage and care for patients with
the same state. On the side of the College of Nursing This study could be a used
as a guide for the students and it can be a source of facts and information to
students of different colleges and especially to the students of College of Nurs
ing. On the side of nursing profession This study will serve as a basis in gathe
ring facts and sets of information with regards to pre-eclampsia.
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OBJECTIVES GENERAL OBJECTIVES Client Centered • • • To assess the health of the
patient To develop, implement, and evaluate plans for health promotion To provid
e client education and involve patient in implementing therapeutic regimen to pr
omote understanding and compliance. Nurse Centered • • To apply the nursing proc
ess in the care of the hospitalized patient To describe effects of illness on in
dividuals and family members’ roles and functions SPECIFIC OBJECTIVES Client-Cen
tered • • • • • Discuss indications for and management of a pregnant clients Dis
cuss nursing implications for medications commonly prescribed for pregnant Descr
ibe nursing care for the client Use the nursing process to provide individualize
d care for clients who has experienced pre- eclampsia. Support client and family
, and encourage them to ask questions so that information could be clarified and
understood Nurse-Centered • • • • Identify major risk factors influencing the s
aid condition. Identify the risk factor contributing to the occurrence of the di
sease. Learn the pathophysiology and manifestations of pre-eclampsia. Identify c
ommon diagnostic tests used for the said condition and their nursing implication
s. 6

Identify and describe nursing measure to promote awareness in the condition
II. NURSING PROCESS A. Assessment Data 1. Personal Data a. Demographic Data Name
: Ms. Chi Age: 23 years old Sex: Female Civil Status: Single Occupation: None Re
ligious Affiliation: Roman Catholic Address: Gerona, Tarlac Date of Birth: Janua
ry 25, 1987 Place of Birth: Gerona, Tarlac Nationality: Filipino Usual Source of
Medical Care: Health Center and Hospital Date and Time of Admission: January 09
, 2010/3:35 am Chief Complain: labor pains Vital signs on admission: Temp: 38.1°
C BP: 160/100 mmHg PR: 88 bpm RR: 30 cpm Admitting Impression/Diagnosis: G1P0 PU
FT pregnancy uteri to consider pre-eclampsia Surgical Procedure: low transverse
cesarean section Date and Time of operation: January 11, 2010/2:00 pm Final Diag
nosis: pregnancy uteri delivered via primary cesarean section to a live 7
baby girl arrest in cervical dilatation filled medical induction G1P1, pre- ecla
mpsia 2. Environmental Status The family is composed of eight members living wit
hin the house. According to the patient, their house was made from concrete mate
rials and has four bedrooms. They were able to clean the house on a regular basi
s. Communal water system is the primary source of drinking. They also have their
own comfort room inside the house. Transportation available in the family is a
tricycle. The location of their house is not easily accessible to hospitals, but
a health center was near their house. Ms. Chi did not report any problems regar
ding her environment which interfered to her pregnancy. 3. Lifestyle The patient
usually wakes up eight to nine in the morning and helps her mother and sister i
n cleaning the house or preparing the food. Hobbies and/or recreational activiti
es were talking with her brother and sisters, texting or watching television and
sometimes playing “bingo” and card games. The patient does not smoke and drink
alcoholic beverages. PAST HEALTH HISTORY Ms.Chi experienced measles, mumps, and
chickenpox as a child. She also experienced diarrhea, fever, cough, colds and se
lf-medicates with over the counter medications like paracetamol and cough medica
tions before she became pregnant. She has completed all her immunizations and in
cluding two shots of tetanus toxoid during her prenatal visits. She has no known
allergies. She was never been hospitalized before. This was the first time pati
ent she was admitted in the hospital. She has taken prescribed ferrous sulfate r
egularly at home. 8
PRESENT HISTORY Three days prior to admission, the patient experienced labor pai
ns. She went to the health center that day for her prenatal visit. The health ca
re worker advised her to have her delivery at the hospital because she has a hig
h blood pressure. The health worker also instructed her that when contractions b
ecame frequent with long durations she must go immediately at the hospital. 3:35
am of January 09, she complained of labor pain. She was admitted at Tarlac Prov
incial Hospital for further evaluation and tests. After being seen and examined
by her attending physician, high blood pressure, and pitting edema of about 2mm
prior to her admission were noted and diagnosed G1P0 PUFT to consider severe pre
eclampsia.
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GENOGRAM
Maternal Side
Pater nal Side
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13 AREAS OF ASSESSMEN SOCIAL STATUS Ms. Chi is 22 years of age, a high school un
dergraduate and lives in Gerona, Tarlac together with her family. According to h
er, she has a good relationship with her family. She talks to her family and abl
e to interact with other patient. Her family was there to give her support and t
o show their love for her. She is not engaged in any organizations in their comm
unity according to her Norms Social functioning of an individual is to form rela
tionships with others. Social support is a perception that one has an emotional
and tangible resource to fall on when needed; perceived social support is being
followed by the family to express the love of the family, financial aspect is on
e of the normal constraints in the family. (Nursing fundamentals by Daniels; an
introduction to health and physical assessment in nursing by D’Amico and Barbari
to) Social responsibilities include forming new friendships and assuming some co
mmunity activities. As the role of woman has change, many women now choose to as
sume active careers and civic roles in society in addition to their roles as mot
her and or/wife. (Fundamentals of Nursing by Kozier) Interpretation The client w
as able to manage to interact with others. She was cooperative during the interv
iew. Emotional Status After surgical procedure the client verbalized pain on the
surgical incision with a pain scale of 7 out of 10. Though the father of her ch
ild was not there during her delivery, her family especially her mother was ther
e always to support and comfort her emotionally.
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Norms A normal person regarding emotions has the ability to manage stress and to
express emotions appropriately. It involves the ability to recognize, accept an
d express feelings and to accept one’s limitation. Normal coping pattern or emot
ions stability could include acceptance of the problem, adjustment to it, expres
sing of self-perception and self-control of emotions, probable temporary use of
defense mechanism and support system (Fundamentals of Nursing by Kozier). Carryi
ng out emotional feelings through words and facial expressions are normal signs
of present physical condition (Nursing Fundamentals by Daniels) Interpretation C
lient was able to cope with problems because her family was there to support and
comfort her emotionally. MENTAL STATE a. General Appearance and Behavior Patien
t’s appearance is appropriate with age, oriented, awake, coherent, normal, and s
ymmetrical facial features. She was wearing a t-shirt and jogging pants and was
properly groomed. She was responsive and eye contact was established during the
interview. b. Level of Consciousness The client was conscious and coherent. She
was responsive during the interview. Ms. Chi was aware of her present condition.
c. Orientation The client stated properly the date, place and time. She can ide
ntify things or names being asked and able to answer all questions asked. 2
d. Speech The client speaks Tagalog and Ilokano. She is able to read and speaks
clearly and utter words that easily to understand. Norms Clients should be able
to reason, to find meaning, and make judgment from information, to demonstrate r
ational thinking and perceive realistically. Appearance and behavior; posture mu
st be relaxed. Clients should be dressed appropriately with the season, age, and
gender. Grooming and hygiene should be proper and neat. Client should typically
be able to state their name, location, the date, month, season, and time of the
day. Ability to form words (articulation) should be understood and clear. (An I
ntroduction to Health and Physical Assessment in Nursing by D’Amico and Barbarit
o; Physical Examination and Health Assessment by Carolyn Jarvis) The content of
the client message should make sense. The ability to read and write should match
the client’s educational level. The client should be able to correctly respond
to questions and to identify all the objects as requested. The client should be
able to evaluate and act appropriately in situations requiring judgment. (Health
assessment and physical examination 3rd edition by Mary Ellen Zator Estes) Anes
thetics are agents that interfere with nerve conduction and thereby diminish pai
n and sensation. General anesthetics are drugs causing a partial or complete los
s of consciousness. While regional anesthetics block nerve conduction only in th
e area to which they are applied and do not cause a loss of consciousness. (Phar
macological Aspects of Nursing Care 7th Edition by Broyles, Reiss and Evans) 3
Interpretation The client’s level of consciousness, orientation and speech is no
rmal. BODY TEMPERATURE Here’s a table showing the body temperature of the client
: Date January13, 2010 January 13, 2010 January 13, 2010 Norms For axillary rout
e, it should range from 35.4-37.4C (95.8-99.4F) obtained 5 minutes time for accu
rate measurement. . (Health assessment and physical examination 3rd edition by M
ary Ellen Zator Estes) Interpretation The client’s temperature assessed via axil
lary route and obtained in five minutes was found to be within the normal range.
RESPIRATORY STATUS The client has a regular breathing pattern. Bulging of the I
CS was not seen as well as retractions in the intercostals spaces. The use of ac
cessory muscles was not seen while the client is breathing. The table below show
s the respiratory rate of the client after the surgery: Date January 13, 2010 Ja
nuary 13, 2010 January 13, 2010 Time 3 pm 6 pm 10 pm Respiratory Rate 19 20 20 I
nterpretation Normal Normal Normal Time 3:00 pm 6:00 pm 10:00 pm Temperature (C)
37.4 37.2 37.3 Interpretation Normal Normal Normal
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Her respirations were normally heard by the unaided ear a 2-4 centimeters from t
he client’s nose with absent nasal flaring. There were no pulsations as well as
masses and tenderness. There were no rales, wheezes or stridor heard. Norms The
normal findings of respiratory status for an adult include the following: 16-20
breaths per minute, no use of accessory muscles when breathing, respirations sho
uld be even, not labored and regular and no cough noted. (Weber: Nurse’s Handboo
k of Health Assessment) Interpretation The client’s respiratory status after was
found to be within the normal range. CIRCULATORY STATUS Ms. Chi has pale lips i
ncluding the nail beds, palm, soles of the feet and her conjunctiva. Her pulse (
radial) has a regular rhythm. For the capillary refill time, it ranges from 3-4
seconds. The table below shows the pulse rate of the client as well as her blood
pressure. Date Time Pulse Rate Blood (beats/min) Pressure January 13, 2010 Janu
ary 13, 2010 January 13, 2010 January 13, 2010 January 13, 2010 Norms Both pulse
and blood pressure are measurements that determine the blood volume of ejected
blood into the arterial system with each ventricular contraction. Normal adult B
P is <120/80mmHg and pulse rate is 60-100bpm. 5 3:00 pm 6:00 pm 8:00 pm 9:00 pm
10:00 pm 86 83 86 88 85 (mmHg) 160/100 160/120 160/130 160/120 160/110 Normal PR
, High BP Normal PR, High BP Normal PR, High BP Normal PR, High BP Normal PR, Hi
gh BP Interpretation
Capillary refill is at speed of 4-5seconds. Lips, conjunctiva, gums, nail beds a
nd palms are should be pinkish in colour. (Fundamentals of Nursing by Barbara Ko
zier, et al.) Interpretation The client’s pulse rate is within the normal range,
but her blood pressure is above normal and having a capillary refill of 3-4 sec
onds; pale lips, conjunctiva, soles of the feet, nail beds and palms indicate po
or circulation which may be due to vasoconstriction or loss of blood because of
the operation held. NUTRITIONAL STATUS Before admission, Ms. Chi’s typical intak
e of rice is about 3 cups with favorite viand fish with 1-2 cups of vegetables L
unch foods are usually vegetables paired with rice. During dinner she eats eithe
r a fish dish paired with rice or a combination of vegetable and fish dish and r
ice. According to her she loves eating “pinakbet”. She takes ferrous sulfate eve
ry day. She drinks an average of 8-10 glasses a day. Upon admission, the ordered
diet for her was low salt low fat diet, then changed to NPO on January 10, 2010
. And at 8:00 am of January 12, 2010 the doctor ordered soft diet (low fat and l
ow salt). Norms: Normal human being usually eats 3 times per day and a fluid int
ake of 8 10 glasses of water. Nutrients must be taken equally according to their
standards. There should be no problem regarding food and drug allergies and any
thing associated with nutrition. Nutritional of patient is a good determinant of
a possible heart condition. Nutrition can be a prevention and treatment for som
e diseases. . (Kozier et. al., Fundamentals of Nursing 7th edition) Interpretati
on Ms. Chi can still eat food which is normal.
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ELIMINATION STATUS Prior to hospitalization, the client said that she defecates
regularly, or even twice day. Her stool differs from soft to hard and is dark br
own in color. She voids at least 4 to 5 times a day with yellowish urine output
if she suppresses the urge to void and clear if she void immediately when she fe
els the urge of voiding. According to her, she did not void and defecate immedia
tely the day of her surgery even once. She was able to defecate the next day for
only once. Stool was brown semi-formed. Norms Feces are normally brown in color
and soft but formed. Black tarry stool is abnormal. Iron salts, bleeding from t
he upper gastrointestinal tract, diet high in red meat could be the possible cau
ses. Although peoples patterns of urination are highly individual, most people v
oid about 4-5 times a day. (B.Kozier, Fundamentals of Nursing 7th edition). Inte
rpretation The client’s lack of bowel movement and urination for the first five
hour post-operatively is the result of her anesthesia. Dark brown stool is norma
l because patient is taking ferrous sulfate . SENSORY PERCEPTION Vision Ms. Chi
said that she was able to see far and near objects without difficulty but someti
mes she has blurring of vision. Her eyes moved smoothly and symmetrically when a
sked to follow the finger of the student during the examination. The cornea is m
oist and shiny. Her pupils were found to be black, round and equal in diameter,
and dilates normally. Client’s eyes constricts as a reaction to the light during
the examination. The conjunctivas were found to be pale during the assessment.
Hearing The external ears match the skin color of the client and were positioned
centrally in proportion with the head. The external ears were elastic and cool
to 7
touch. There were no found obstructions in the ear canals. She has no dry cerume
n observed. The patient was able to hear clear sounds in both ears in response t
o the voice whisper test with a distance of about one foot away. Smell The patie
nt’s external nose was located symmetrically in the midline of the face. The nos
trils are patent. The nasal mucosa was observed to be red and with no deviations
and no discharges. The patient was able to smell and distinguish different odor
s as the client identifies odors such as of the alcohol and perfume. Taste The t
ongue is in the middle of the mouth. Buccal mucosa was found to be pale. Her ton
gue is pink and moist. Touch She was able to perceive light touch, superficial p
ain and temperature accurately. Norms Eyes – eyebrows, eyelashes should be equal
ly distributed and symmetrically aligned. Eyelashes should be slightly curled ou
tward. Eyelids should be intact, no discharge, no discoloration, close symmetric
ally and blinks bilaterally. Sclera should appear whit or dirty white in appeara
nce. Palpebral conjuntiva should be pink or red in color. Pupils should constric
t when illuminated. Mostly eyes should be coordinated, move in unison, with para
llel alignment. Vision, a person can read from a magazine or newspaper at a dist
ance of 36 cm without use of corrective lenses and able to identify colors. Ears
– auricles’ color must be same as facial skin, symmetrical, aligned with the ou
ter canthus of the eyes and 10 degrees from vertical, not tender. Pinna recoils
after it is folded. Ear canals sometimes have dry cerumen or sticks wet cerumen.
He was able to hear sounds on both ears. Nose – external nose is symmetric and
straight, no discharge or flaring, not tender, no lesions, air moves freely when
breaths though the nares. Nasal 8
cavities should be clear, no lesions, pink in color, nasal septum intact. Fronta
l and maxillary sinuses are not tender. Mouth – lips are uniform in color, pink
in color, soft, moist, symmetric in contour. Teeth are 32 for adult, white in co
lor, with pink gums, moist, no lesions. Tongue, uvula, oropharynx should be pink
, moist, no lesions and discharge. Touch – should feel light touch, sensation. M
ust be able to discriminate between hot and cold sensations and address a correc
t facial expression on the given stimuli. (Fundamentals Analysis The patient has
a normal tactile perception, normal sense of smell and hearing without any obvi
ous manifestations of abnormalities present. Pale conjunctiva and buccal mucosa
indicates poor circulation which may be due to blood loss. Blurring of vision ca
n be caused by vasoconstriction which can be related to hypoxia of the vessels o
f the head. MOTOR STABILITY Post-operatively the patient looked weak. She cannot
tolerate long standing and walking. She was able to move slowly and sit at the
edge of the bed. She showed some discomfort upon moving. Norms The client should
be able to enter the assessment area via independent ambulation, structural def
ects should be absent, and no indications of discomfort during performance of mo
vements should be present. There should be symmetry with the other parts of the
body. Walking is initiative in one smooth and rhythmic fashion; the lower limbs
are able to bear fully body weight during the phase of muscle contraction especi
ally against moderate external resistance normal muscle strength allows for comp
lete voluntary ROM against both gravity and 9 of Nursing, Kozier; Physical Exami
nation and Health Assessment, Estes)
moderate to full resistance. There should no involuntary movements of muscle pre
sent (Health assessment and physical examination 3rd edition by Mary Ellen Zator
Estes) Interpretation Post-operatively the client had difficulty in moving beca
use she was in pain and weak. STATE of SKIN APPENDAGES The patient has light bro
wn skin all over the body. Increased pigmentation was observed on sun-exposed ar
eas such as the neck, arms, and legs. Presence of striae at hypogastric and ilia
c regions, linea nigra and surgical incision are noted. Pallor was observed on h
er face including her conjunctiva, lips, palms, soles of her feet and nail beds.
When her skin was pinched it returned to its normal state immediately. Her hair
was found to be straight, oily, thick and equally distributed. Her nails were f
ound to be not properly trimmed and traces of dirt are noted. Her capillary refi
ll was 3-4 seconds. Her skin was observed to be without the presence of bruises.
Pitting edema grade 2 were observed on the patient’s lower extremities. Norms N
ormal skin is a uniform whitish pink or brown color, depending on the patient’s
race. Pallor is due to decrease visibility of the normal oxyhemoglobin. This can
occur when the patient has a decreased blood flow in the superficial vessels, a
s in shock or syncope, or when there is a decreased amount of serum oxyhemoglobi
n as in anemia. No skin lesson should be present. Normally, the skin is dry with
a minimum respiration. It should be smooth, even and firm except when there is
a significant hair growth. It should return to its original contour when pinched
. (M.E.Z. Estes, Health Assessment and Physical Examination 3rd edition)
10
Normally the nails have a pink cast in light-skinned individual and brown in dar
k-skinned individual. Capillary refill is an indicator of peripheral circulation
. Normal capillary refill may vary with age but color should return to normal wi
thin 2 to 3 seconds.(M.E.Z. Estes, Health Assessment and Physical Examination 3r
d edition) Interpretation The patient’s pale body parts (conjunctiva, lips, palm
s, nail beds and sole s of the feet) indicate poor circulation which may be due
to loss of blood because of the operation held. Presence of edema is abnormal. S
TATE OF REST AND PHYSICAL COMFORT Before hospitalization, she regularly sleeps f
or about 10 hours and does not take a nap in the afternoon. After the surgery, M
s. Chi said that she can feel pain on her surgical site that disturbs her sleepi
ng, she also state that he noisy environment of the hospital is another reason.
Norms: Adults generally sleep 6-8 hours per night. About 20% of sleep is rapid e
ye movement. The complete sleep cycle is about 1.5 hours in adults. Maintaining
a regular sleep-wake rhythm is more important than the number of hours actually
slept. (Kozier et. al., Fundamentals of Nursing 7th edition) Interpretation: Cli
ent’s sleeping pattern was altered due to surgical operation and the noisy envir
onment.
REPRODUCTIVE STATE Ms. Chi had her menarche when she was 12 years old. She has a
regular 28 days menstrual cycle. Her menstrual period last 7 days, 2 nd and 3rd
day is commonly has the heaviest menstrual discharge. She consumes 3 pads of 11
sanitary napkin a day during menses. Ms. Chi is 37 weeks pregnant; primigravida.
Norms: The female reproductive cycle begins at menarche, the onset of menstruat
ion, which occurs between 9 and 16yrs of age, and ends at menopause, which occur
s between 45 and 55 yrs of age. The cycle ends just before the next menstrual pe
riod. Menstrual cycles normally range from about 25 to 36 days. Only 10 to 15% o
f women have cycles that are exactly 28 days. Menstrual bleeding lasts 3 to 7 da
ys, averaging 5 days. Blood loss during a cycle usually ranges from ½ to 2½ ounc
es. A sanitary pad or tampon, depending on the type, can hold up to an ounce of
blood. . (Kozier et. al., Fundamentals of Nursing 7th edition) (http://www.merck
.com/mmhe/print/sec22/ch241/ch241e.html) Interpretation: The client reproductive
status is normal.
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Diagnostic/Laboratory Procedure Hematology
Date Results Date Results: January 10, 2010/ 12:15 am
Indications/Purposes
Results
Normal Values (units used in the hospital)
Analysis /Interpretation of Results > below normal Decreased Hgb count on pregna
nt is normal because of the increase in plasma volume during pregnancy
Specimens of venous blood are taken for a CBC which includes Hemoglobin and Hema
tocrit measurements, RBC indices and diferential white cell count.
Hemoglobin: 107
120-180 g/L
Hematocrit: 0.345
0.370- 0/510 L/L
> below normal Decreased hematocrit on pregnant is normal because of their incre
ase in plasma
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volume. WBC count: 16.8 3.98-10 x 109 g/L >Abnormally high due to presence of in
fection or inflammation RBC count: 4.96 Lymphocytes: 3.0 0.6-4.1 10.0-58.5%L > N
ormal 4.20-6.30 T/L >Normal
MCV: 69.5 MCH: 21.6 MCHC: 310 Platelet: 322 Date Hemoglobin:
80-97 fl 26.0- 32.0 pg 310-360 g/L 140-440 G/L
>below Normal >below normal >Normal >Normal > below normal
25
Results: January 13, 2010/ 11:58 am
34
Decreased Hgb count on pregnant is normal because of the increase in plasma volu
me during pregnancy
Hematocrit: 0.104 WBC count: 31.8 RBC count: 1.49
> below normal
>infection or Inflammation is present. >Decreased RBC count on pregnant is norma
l because of the increase in
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plasma volume during pregnancy. Lymphocytes: 4.1 MCV: 69.7 MCH: 22.86 MCHC: 327
Platelet: 300 Hemoglobin: Date Results: January 14, 2010/ 6:34 am 49 >below Norm
al >below normal >Normal >Normal > below normal Decreased hgb on pregnant is nor
mal because of their increase in plasma volume. Hematocrit: 0.144 > below normal
Decreased hematocrit on > Normal
27
pregnant is normal because of their increase in plasma WBC count: 31.0 RBC count
: 1.49 Lymphocytes: 3.6 MCV: 72.1 MCH: 24.5 MCHC: 340 Platelet: 404 >below Norma
l >below normal >Normal >Normal > Normal >Abnormally high due to >below Normal
Nursing responsibility: Before:
28
1. Explain the purpose of the test and the procedure for collection of blood. Cl
ient mat experience anxiety about the procedure, especially if it is perceived a
s being intrusive or if they fear unknown to the result. A clear explanation wil
l facilitate cooperation on the part of the client. 2. Inform the client of the
time period before the results will be available. During: 1. Use the correct pro
cedure for obtaining the blood. 2. Aseptic technique should be use in collection
to prevent contamination that can cause inaccurate results. 3. Ensure correct l
abelling, storage and transportation of the specimen to avoid invalid test resul
ts. After: 1. Report results to the appropriate health team members. 2. Compare
the previous and current test results and modifies nursing interventions as need
ed.
DIAGNOSTIC/LABO RATORY PROCEDURE
DATE RESULTS
INDICATION/S OR PURPOSE/S
RESULTS
ANALYSIS OR INTERPRETATION OF THE RESULTS
29
Blood Typing and cross matching
Date Result: January 18, 2010
Used to determine the blood type of the client and compatibility of a donor’s bl
ood with that of a recipient after he specimens have been matched for major bloo
d type
Blood type “O” RH “+” Compatible
The client was blood type O+ and compatible wih donor’s blood.
Date Result: January 18, 2010
Blood type “O” RH “+” Compatible
The client was blood type O+ and compatible wih donor’s blood.
Nursing responsibility: Before:
30
3. Explain the purpose of the test and the procedure for collection of blood. Cl
ient mat experience anxiety about the procedure, especially if it is perceived a
s being intrusive or if they fear unknown to the result. A clear explanation wil
l facilitate cooperation on the part of the client. 4. Inform the client of the
time period before the results will be available. During: 4. Use the correct pro
cedure for obtaining the blood. 5. Aseptic technique should be use in collection
to prevent contamination that can cause inaccurate results. 6. Ensure correct l
abelling, storage and transportation of the specimen to avoid invalid test resul
ts. After: 3. Report results to the appropriate health team members.
31
ANATOMY AND PHYSIOLOGY CARDIOVASCULAR SYSTEM The Heart The heart lies in the med
iastinum, behind the body of the sternum. The shape of the heart tends to resemb
le the chest. The heart has chambers divided into four cavities with the right a
nd left chambers (atria and the ventricles) separated by the septum. The Blood V
essels
There are 3 types of blood vessels: the arteries, the veins and the capillaries.
An artery is a vessel that carries blood away from the heart. It carries oxygen
ated blood. Small arteries are called arterioles. Veins, on the other hand are v
essels that carries blood toward the heart. It contains the deoxygenated blood.
Small veins are called venules. Often, very large venous spaces are called sinus
es. Lastly, capillaries are microscopic vessels that carry blood from small arte
ries to small veins (arterioles to venules) and back to the heart. The walls of
the blood vessels, the arteries and veins have three main layers:
24
tunica adventitia, tunica media and tunica intima. Tunica adventitia which is a
fibrous type of vessel is a connective tissue that helps hold vessels open and p
revents tearing of the vessel wall during body movement. Tunica media is a smoot
h muscle, sandwiched together with a layer of elastic connective tissue. It perm
its changes of the blood vessel diameter. It allows the constriction and dilatio
n of the vessels. Last but not the least is the tunica intima. Tunica intima, wh
ich in Latin means inner coat, is made up of endothelium that is continuous with
the endothelium that lines the heart. In arteries, it provides a smooth lining.
However in veins it maintains the one-way flow of the blood. The endothelium, w
hich makes up the thin coat of the capillary, is important because the thinness
of the capillary wall allows the exchange of materials between the blood plasma
and the interstitial fluid of the surrounding tissues. Circulation of the blood
in blood vessels
25
There are two circulatory routes of blood as it flows through the blood vessels:
the systemic and the pulmonary circulation. In systemic circulation, blood flow
s from the left ventricle of the heart through blood vessels to all parts of the
body (except gas exchange tissues of lungs) and back to the atrium. In pulmonar
y circulation on the other hand, venous blood moves from the right atrium to rig
ht ventricle to pulmonary artery to lung arterioles and capillaries where gases
exchanged; oxygenated blood returns to the left atrium via pulmonary veins; from
left atrium, blood enters the left ventricle. Vasomotor Control Mechanism Blood
distribution patterns, as well as BP can be influenced by factors that control
changes in the diameter of arterioles. Such factor might be said to constitute t
he vasomotor control mechanism. Like most physiological control mechanisms, it c
onsists of many parts. An area in the medulla called vasomotor center/ vasoconst
rictor center will, when stimulated initiate an impulse outflow via sympathetic
fibers that ends in smooth muscle surrounding resistance vessels, arterioles, an
d veins of “the blood reservoir” causing their constriction thus the vasomotor c
ontrol mechanism plays an important role both in the maintenance of the general
BP and in the distribution of blood to areas of special need. Venous return of t
he Blood Venous return refers to the amount of blood that is returned to the hea
rt by the way of veins. Various factors influence venous return, including the o
peration of venous pumps that maintains the pressure gradients necessary to keep
blood moving into the central veins and from there the atria of the heart. Chan
ges in the total volume of blood vessels can also alter the venous return. The r
eturn of venous blood to the heart can be influenced by the factors that change
the total volume of blood in the circulatory pathway. Stated simply, the more th
e total volume of blood, the 26
greater the volume of blood returned to the heart. The mechanism that change the
total blood volume most quickly, making them most useful in maintaining constan
cy of blood flow, are those that cause water to quickly move into the plasma or
out of the plasma. Most of the mechanisms that accomplish such changes in plasma
volume operate by altering the body’s retention of the water. The primary mecha
nisms for altering the water retention in the body- they are the endocrine refle
xes in the body. One is the ADH mechanism is released in the neurohypophysis and
acts on the kidneys in a way that reduces the amount of water lost by the body.
ADH does this by increasing the amount of water that kidneys reabsorb from urin
e before the urine is excreted from the body. The more ADH is secreted, the more
water will be reabsorbed into the blood, and the greater the blood plasma volum
e will become. Another mechanism that changes the blood plasma volume is the ren
ninangiotensin mechanism of aldosterone secretion. Renin is an enzyme that is re
leased when the blood pressure in the kidney is low. Renin triggers a series of
events that leads to the secretion of aldosterone. Aldosterone promotes sodium r
etention by the kidney, which in turn stimulates the osmotic flow of water to th
e kidney tubules back into the blood plasma- but only when ADH is present to per
mit the movement of water. Thus, low blood pressure increases the secretion of a
ldosterone, which in turn stimulates the retention of water and thus an increase
in blood volume. Another effect of reninangiotensin is the vasoconstriction of
blood vessels caused by an intermediate compound called angiotensin II. This com
plements the volume-increasing effects of the mechanism and thus also promotes a
n increase in overall blood flow. Precision of blood volume control contributes
to the precision in controlling venous return, which in return yields to the pre
cise overall control of blood circulation EXOCRINE SYSTEM 27
The exocrine system’s main function is to regulate the volume and composition of
body fluids and excrete unwanted materials, but it is not the only system in th
e body that is able to excrete unnecessary substances. Kidneys The kidneys resem
ble the lima beans in shape. The average-sized kidney measures around 11cm by 7c
m by 3cm. The left kidney is often larger than the right. The kidneys are highly
vascular organs. Approximately, one-fifth of the blood pumped fromthe heart goe
s to the kidneys. The kidneys process blood plasma and form urine from waste to
be excreted and emoved from the body. These functions are vital because they mai
ntain the homeostatic balance of the body. The kidneys maintain the fluid-electr
olyte and acid-base balance. In addition, they also influence the rate of secret
ion of the hormones ADH and aldosterone. Microscopic functional units called nep
hrons make up the bulk of the kidney. The nephron is uniquely suited to its func
tion of blood plasma processing and urine function. A nephron contains certain s
tructures in which fluid flows through them and they are as follows: renal corpu
scle, Bowman’s capsule, proximal convulted tubule, Loop of Henle, distal convolu
ted tubule and the collecting tube. The Bowman’s capsule is a cup-shaped mouth o
f a nephron. It is usually formed by two layers of epithelial cells. Fluids, ele
ctrolytes and waste 28
products that pass through the porous glomerular capillaries and enter the space
that constitute the glomerular filtrate, which will be processed in the nephron
to form urine. The Glomerulus is the body’s well-known capillary network and is
surely one of the most important ones for survival. Glomerulus and Bowman’s cap
sule together are called renal corpuscle. The permeability of the glomerular end
othelium increases sufficiently to allow plasma proteins to filter out into the
capsule. ENDOCRINE SYSTEM The endocrine system performs their regulatory functio
ns by means of chemical messenger sent to specific cells. The endocrine system,
secreting cells send hormones by way of the bloodstream to signal specific targe
t cells throughout the body. Hormones diffuse into the blood to be carried to ne
arly every point in the body. The endocrine glands secrete their products, hormo
nes, directly into the blood. There are two classifications of hormones: steroid
hormones and non-steroid hormones. The steroid hormones which are manufactured
by the endocrine cells from cholesterol, is an important lipid in the human body
. Non-steroid hormones are synthesized primarily from amino acids rather from th
e cholesterol. Non-steroid hormones are further subdivided into two: protein hor
mones and glycoprotein hormones. Aldosterone Its primary function is the mainten
ance of the sodium homeostasis in the blood byincreasing the sodium reabsorption
in the kidneys. It is secreted from the adrenal cortex; it triggers the release
of ADH which results to the conservation of water by the kidney. Aldosterone se
cretion is controlled by the rennin- angiotensin mechanism. Estrogen
29
It is secreted by the cells of the ovarian cells that promote and maintain the f
emale sexual characteristics. Progesterone It is secreted by the corpus luteum.
It is also known as a pregnancy- promoting steroid and it prevents the expulsion
of the fetus in the uterus. Anti-diuretic hormone (ADH) It is secreted in the n
eurohypophysis (posterior pituitary); it literally opposes the formation and pro
duction of a large urine volume. It helps the body to retain and conserve water
from the tubules of the kidney and returned to the blood. REPRODUCTIVE SYSTEM
The female reproductive system produces gametes may unite with a male gamete to
form the first cell of the offspring. The female reproductive system also provid
es protection and nutrition to the developing offspring. The most essential orga
n is the ovary which carries the ova. The uterus, the fallopian tubes and the vu
lva are accessory organs. 30
Ovaries It is an almond-shape organ. It contains the ova and is responsible in e
xpelling the ova. It also produces estrogen and progesterone. Fallopian Tubes It
usually measures approximately 10- 12 cm. It has two parts: the ampullae and th
e fimbriae. The ampullae which is the largest part is where the fertilization ta
kes place. The fimbriae on the other hand, are responsible for the transportatio
n of the ovum from ovary to uterus. It holds the ovary. Uterus The uterus is a p
ear-shaped organ and has three parts: the fundus (upper), corpus (body), and the
isthmus (lower). It is known as the organ for menstruation. When pregnant, it g
ives nourishment to the growing fetus.
31
BOOK-BASED PATHOPHYSIOLOGY
24
25
PATIENT-BASED PATHOPHYSIOLOGY
26
27
NURSING CARE PLANS January 13, 2010 Assessment S - Ø Planning Intervention Expec
ted Outcome After 4 hours of nursing intervention, the client will exhibit decre
ase in oxygen demand and ability to conserve energy. trendelenburg position. (To
promote venous return) >Maintain adequate ventilation.(To promote oxygenation a
nd good blood circulation) Diagnosis Ineffective tissue perfusion >Instruct clie
nt to sit and dangle the feet before standing.(To prevent
After 4 hours of nursing >Assist client in performing interventions, the client
will ADL. (To promote safety) exhibit decrease in oxygen
O - weak and pale in appearance - capillary refill of 3-4 seconds - RBC level= 1
.49 - Hgb level= 34 g/L - BP= 160/110 mmHg
demand
and
ability
to >Place the client in
conserve energy.
24
r/t decrease in RBC, hemoglobin and hematocrit level Scientific Explanation Due
to the procedure done, the client’s RBC level decreased causing ineffective tiss
ue perfusion.
orthostatic hypotension) >Advise client to increase intake of food rich in iron
and folate such as liver and green leafy vegetables. (Iron and folate are necess
ary for red blood cell production).
Assessment
Planning
Intervention
Expected Outcome
25
S - Ø After 4 hours of proper nursing intervention the O - weak and pale in appe
arance cannot tolerate long standing and walking independently - RBC level= 1.49
client will perform ADL with minimal to no assistance.
>Assist client during moving and on going in the comfort room or whenever needs
assistance. (Assisting client during moving ensures for client) >Assist client i
n comfortable position. (To improve comfort) >Assist with ADL as indicated to re
duce energy expenditure but avoid doing
The client will perform ADL with minimal assistance after 4 hours of proper nurs
ing intervention as evidenced by: assistance. >With ease in performing ADL >Can
tolerate short time of walking and standing with less fatigability. >Client verb
alization of increase in energy.
safety and additional support >Able to ambulate with least
Diagnosis Activity intolerance r/t body weakness secondary to low RBC level. Sci
entific Explanation
for what he can do for herself (to increases client’s independence) >Let the cli
ent do much of the activities (to increase self-reliance.) >Provided proper vent
ilation.
-.
26
Due
to
low
RBC
level
(To give enough oxygen supply) Health Teachings: >Instruct client to sit at the
edge of the bed then dangle her feet before standing. (To prevent orthostatic hy
potension) .>Encourage the client to get adequate rest and sleep. (To conserve e
nergy) >Encourage adequate rest periods before ambulation and meals (To reduce c
ardiac workload) >Instruct to refrain from performing unnecessary movements (To
promote rest) >Encourage passive ROM
(oxygen carrying capacity) oxygen supply into body tissue decreases which result
in body weakness.
27
exercises (To maintain muscle strength and joint range of motion) >Teach energy
conservation techniques (To reduce oxygen consumption, allowing more prolonged a
ctivity) >Encourage client to avoid over exertion and straining of activities (O
ver exertion of activities may cause fatigue)
Assessment O- postpartum surgery
Planning After 1-2 hrs of nursing intervention, the patient will
Intervention Independent: >stress proper hand
Expected Outcome After 1-2 hrs of nursing intervention, the patient was
28
able to know the preventive measures of wound healing Diagnosis Impaired Skin In
tegrity related to surgery Scientific Explanation The incision from the cesarean
section altered the skin integrity making it more susceptible to pathogens and
even the patients’ normal flora
hygiene. - to control the spread of infection >Encouraged to increase foods that
are rich in protein - to aid in tissue repair >Encouraged proper clothing -to m
aintained the proper skin moisture. >Apply appropriate Dressing -to help in woun
d healing
able to knew the preventive measures of wound healing
Drugs Name of Drug Generic: Date Administered 01/09/10 Route of Administration 5
00 mg tablet General action Its main Indications/ Purpose To relieve mild to Cli
ent’s reaction to medicine. Client’s
29
Paracetamol Brand Name: Biogesic Classifications: Non-opioid analgesic
4:00 am
mechanism of action is the inhibition of cyclooxygena se (COX), an enzyme respon
sible for the production of prostaglandin s, which are important mediators of in
flammation, pain and fever.
moderate pain. It is also used to bring down a high temperature.
temperature is 37.2
Nursing Responsibility: • • • Monitor for signs and symptoms of hepatotoxicity,
even with moderate acetaminophen doses, especially in individuals with poor nutr
ition. Do not take other medications containing acetaminophen without medical ad
vice; overdosing and chronic use can cause liver damage and other toxic effects.
Do not use for fever persisting longer than 3 days ,fever over 39.5° C(103° F),
or recurrent fever. Date Route of General action Indications/ Client’s reaction
Name of Drug
30
Generic name: Ferrous Sulfate Brand Name: Ferrous sulfate
Administered 01/11/10 10 am
Administration I cap OD
*Mineral for antianemia *Vital for hemoglobin regeneration, specifically it enab
les the RBC development and oxygen transport via hemoglobin It elevates the seru
m iron concentration, which then helps to form Hgb or trapped in the reticuloend
othelial cells for storage and eventual conversion to
Purpose Preventing or treating low levels of iron in the blood.
to medicine. Dark brown stool
31
a usable form of iron.. Nursing Responsibility: • • • Administer vitamins with f
ood to prevent GI upset. Caution on intake of chamomile, feverfew, peppermint an
d St. John’s wort for it interfere with the absorption of iron and other mineral
s. Increased effect of iron with vitamin C, decreased effect of tetracycline, an
tacids, penicillamine Date Administered 01/09/10 10 am Route of Administration 5
mg IVP General action Directly relaxes arteriolar smooth muscle. Indications/ P
urpose To reduce after load in severe CHF ( with nitrates); and severe essential
Brand Name: Apresoline, Classification: Antihypertensive Nursing Responsibility
: hypertension (parenteral to lower blood pressure quickly). Client’s reaction t
o medicine. No signs of irritation and adverse reactions.
Name of Drug Generic name: Hydrazaline Hydrochloride
32
• • • • •
Give slowly and repeat as necessary, generally q 4 to 6 hours. Switch to oral an
tihypertensive as soon as possible. Use cautiously in cardiac diseases, CVA, or
severe renal impairment and in those taking other hypertensive. Monitor patient’
s Vital signs and body weight frequently. Some clinicians combine hydralazine th
erapy with diuretics agents to decrease sodium retention and tachycardia, and to
prevent anginal attacks. Watch patient closely for signs of lupus erythematosus
-like syndrome (sore throat, fever, muscle and joint aches, skin rash). Call doc
tor immediately if any of these develops. Teach patient about his disease and th
erapy. Explain the importance of taking this drug as prescribed, even when he’s
feeling well. Tell outpatient not to discontinue this drug suddenly, but to call
the doctor if unpleasant adverse reactions occurs
• •
Instruct patient to check with doctor or pharmacist before taking OTC medication
s. Inform the patient that orthostatic hypotension can be minimized by rising sl
owly and avoiding sudden position Changes
Name of Drug Generic name: Magnesium Sulfate
Date Administered 01/09/10 10 am
Route of Administration 5 mg deep IM on each buocks
General action May decrease acetylcholine released by nerve impulses,
Indications/ Purpose Prevention or control of seizures in preeclampsia or eclamp
sia
Client’s reaction to medicine. No signs of irritation and adverse reactions.
33
Brand Name: Sulfamag Classification: Anticonvulsant, miscellaneous; and laxative
saline Nursing Responsibility: • • • • • • • •
but its anticonvulsant mechanism is unknown..
Use cautiously in impaired renal function, myocardial damage, and heart block, a
nd in women in labor. Drug can decrease the frequency and the force of uterine
contraction. Keep I.V. calcium glucanate available to reverse magnesium intoxic
ation; however, use cautiously in patients undergoing digitalization due to dang
er of arrhythmias. I.V. use: Monitor vital signs every 15 mins. When giving drug
I.V. Watch for respiratory depression and signs of heart block. Respirations sh
ould should be approximately 16/mins before each dose given. Monitor I & O. urin
e output should be 100ml or more in 4 hr period before each dose. Check blood ma
gnesium levels after repeated doses. Disappearance of knee-jerk and patellar ref
lexes is a sign of pending magnesium toxicity. Maximum infusion rate is 150mg/mi
n. rapid drip will induce uncomfortable feeling of heat.
34
• • •
Especially when given I.V. to toxemic mothers within 24 hrs before delivery,obse
rve neonates for signs of magnesium toxicity, including neuromuscular or respira
tory depression. Signs of hypermagnesemia begin to appear at blood levels of 4 m
Eq/L. Has been used as a tocolytic agent (suppresses uterine contractions) to i
nhibit premature labor. Date Administered 01/10/10 6 am Route of Administration
1g IVP General action Inhibits cell wall synthesis, promoting osmotic instabilit
y. Usually bactericidal. Indications/ Purpose Cefazolin is mainly used to treat
bacterial infections of the skin. It can also be used to treat moderately severe
bacterial infections. It is clinically effective against infections caused by s
taphylococci and streptococci species of Gram positive bacteria. These Client’s
reaction to medicine. No signs of irritation and adverse reactions.
Name of Drug Generic name: Cefazolin Brand Name Cefacidal, Classification: Antim
icrobial and antiparasitic agents
35
organisms are common on normal human skin. Nursing Responsibility: • • • • • • •
• • • • Use cautiously in impaired renal function and in those with history of
sensitivity to penicillin. Ask patient if he’s ever had any reaction to cephalos
porin or penicillin therapy before administering first dose Avoid doses greater
than 4 g daily in patients with severe renal impairment. Obtain specimen for cu
lture and sensitivity test before first dose. Therapy may begin pending test res
ults. Because of long duration of effect, most infections can be treated with do
se q 8 hrs. Not as painful as other cephalosporin when given I.M. I.V. use: alte
rnate injection sites if I.V. therapy last longer than 3 days Considered the fir
st-generation cephalosporin of choice by most authorities. With large doses or p
rolonged therapy, monitor for superinfection, especially in high risk patients.
Reconstituted cefazolin sodium is stable for 24 hrs at room temp. or 96 hours un
der refrigerator. About 40% - 70% of patients receiving cephalosporin shows a f
alse positive direct Coombs’ test; only a few of these indicate hemolytic anemia
. Name of Drug Generic name: Date Administered 01/11/10 Route of Administration
30 mg IVP General action The primary Indications/ Purpose Ketorolac is Client’s
reaction to medicine. The patient
36
Ketorolac Brand Name: Toradol Classification: non-steroidal antiinflammatory dru
g
12 am
mechanism of action responsible for ketorolac s antiinflammatory, antipyretic an
d analgesic effects is the inhibition of prostaglandin synthesis by competitive
blocking of the the enzyme cyclooxygenase (COX). Like most NSAIDs, ketorolac is
a non-selective COX inhibitor. As with other NSAIDs, the mechanism of the
indicated for short-term management of pain (up to five days maximum).
responded well with no signs of irritation and adverse reactions.
37
drug is associated with the chiral S form. Conversion of the R enantiomer into t
he S enantiomer has been shown to occur in the metabolism of buprofen; it is unk
nown whether it occurs in the metabolism of etorolac. Nursing Responsibility: •
• Use as a part of a regular analgesic schedule rather than on an as needed basi
s. If given on p.r.n. basis, base the size of a repeat dose on duration of pain
relief from previous dose. If the pain returns within 3-5 hours, the next dose
can be increased by up to 50% (as long as the total daily dose is not exceeded).
If the pain does not return for 8-12 hr, the next dose can be decreased by as m
uch as 50% or the dosing interval can be increased to q 8-12 hr.
38
• • • • • • • •
Shortening the dosing intervals recommended will lead to an increased frequency
and duration of side effects. Correct hypovolemia prior to administering. Protec
t the injection from light Document indications for therapy, onset, location, pa
in intensity/level, and characteristics of the symptoms. Note any previous exper
ience with NSAIDs and the results. Determine any renal or liver dysfunction; ass
ess hydration. Avoid alcohol, ASA, and all OTC agents without approval. Report
any unusual bruising/bleeding, weight gain, swelling of feet and ankle, increase
d joint pain, change in urine patterns or lack of response.
Name of Drug Generic name: Amlodipine Brand Name: Norvasc Classification: • Calc
ium
Date Administered 01/19/10 12 am
Route of Administration 10 mg tab OD
General action Amlodipine inhibits the transmembrane calcium influx with greater
effects on vascular smooth muscle than on cardiac
Indications/ Purpose Essential hypertension alone or in combination with other a
ntihypertensives.
Client’s reaction to medicine. No signs of irritation and adverse reactions.
39
• • •
Channel blocker Antianginal Antihypertensive
muscle. Its main action is to cause peripheral arterial vasodilatation and thera
py a reduction in after load and blood pressure. Hence, it reduces myocardial ox
ygen demand more by an indirect effect than direct on cardiac muscle. Reflex tac
hycarida does not occur due to slow onset of action.
Nursing Responsibility:
40
• • • • •
Monitor patient carefully (BP cardiac rhythm and output) while adjusting drug to
therapeutic dose; use special caution if patient has CHF. Monitor BP carefully
if patient is also on nitrates Monitor cardiac rhythm regularly during stabiliz
ation of dosage and periodically during long-term therapy. Administer drugs with
out regard to meals .Take with meals if upset stomach occurs Tell patient to rep
ort irregular heartbeat, shortness of breath, swelling of the hands or feet, pro
nounce dizziness, & constipation.
Name of Drug Generic name: Ascorbic acid (Vitamin C) Brand Name: Ascorbic acid C
lassification: Ant i –oxidant
Date Administered 01/13/10 12 am
Route of Administration 1 tab OD •
General action Toxicodynamics
Indications/ Purpose Ascorbic acid is recommended for prevention and treatment o
f scurvy (disorder caused by lack of vitamin C). Its parenteral administration i
s
Client’s reaction to medicine.
Hyperoxaluria may result after administration of ascorbic acid Ascorbic acid may
cause acidification of the urine, occassionally leading to precipitation of ura
te, cystine, or oxalate stones,
41
or other drugs in the urinary tract. Urinary calcium may increase, and urinary s
odium may decrease after 3 to 6 g of ascorbic acid daily. Ascorbic acid reported
ly may affect glycogenolysis and may be diabetogenic but this is controversial.
harmacodynamics P In humans, an exogenous source of ascorbic acid is required
for collagen formation and tissue repair. Vitamin C is a co-factor in many biol
ogical processes including the conversion of dopamine to noradrenaline, in the h
ydroxylation steps in
desirable for patients with an acute deficiency or for those absorption of orall
y ingested ascorbic acid uncertain. Symptoms of mild deficiency may include faul
ty bone and tooth development, gingivitis, bleeding gums, and loosened teeth. Fe
brile states, chronic illness and infection (pneumonia, whooping cough,
42
the synthesis of adrenal steroid hormones, in tyrosine metabolism, in the conver
sion of folic acid to folinic acid, in carbohydrate metabolism, in the synthesis
of lipids and proteins, in iron metabolism, in resistance to infection, and in
cellular respiration. Vitamin C may act as a free oxygen radical scavenger. The
usefulness of the antioxidant properties of vitamin C in reducing coronary heart
disease were found not to be significant. Nursing Responsibility: • Use cautiou
sly in G6PD deficiency.
tuberculosis, diphtheria, sinusitis, rheumatic fever, etc.) increase the need fo
r ascorbic..
43
• • • •
I.V. use: administer I.V. infusion cautiously in patients with renal insufficie
ncy. Avoid rapid I.V.administration. When administering for urine acidificatio
n, check urine pH to ensure efficacy. Protect solution from light
SURGICAL MANAGEMENT Name of Procedure Low transverse cesarean section Date perfo
rmed 01/11/10 Brief description A form of childbirth in which a surgical incisio
n is made through a mother s abdomen and uterus to deliver one or more babies. I
t is usually performed when a vaginal delivery would put the baby s or mother s
life or Indication/ purpose Caesarean section is recommended when vaginal delive
ry might pose a risk to the mother or babylike in case of pre-eclampsia Client’s
response to operation Live baby girl with apgar score 8/9
44
health at risk; although in recent times it has been also performed upon request
for births that would otherwise have been natural. Low transverse cesarean sect
ion is a type of cesarean section that involves a transverse cut just above the
edge of the bladder and results in less blood loss and is easier to repair. Nurs
ing Responsibility: Preoperative care: • • • • • Assess the client knowledge of
the procedure. The client is NPO after midnight. Relieving the patient’s and the
family’s anxiety about the outcome with reasonable information Encourage patien
t to commence deep breathing, coughing and leg exercises. Teach the client post
operative expectations. 45
Post operative care: • • • Monitor vital sign every 15 minutes until the client
is stable. Assess the need for pain relief. Assess the client for vaginal bleedi
ng.
Medical Management Medical Management Date Ordered General Description Indicatio
n & Purpose Client Response to Treatment IVF D5LRS 1L 30gtts/min January 09, 201
0 5% dextrose in lactated ringers Solution (Osmolarity of 527-hyprtonic, pH of 4
.9) free water, provides electrolytes. Also contains sodium lactate which is use
d in treating mild to administered by intravenous infusion for parenteral mainte
nance of routine daily fluid and requirement with minimal carbohydrates calories
and to correct or replace fluid losses due to change in the The patient respond
ed well with no signs of irritation and adverse reactions.
-provides calories and electrolyte
46
moderate metabolic acidosis. Nursing Responsibilities: • • • • • • • • • Check t
he doctor’s order Explain the procedure to the patient
patient’s diet (NPO) and during the cesarean operation.
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 an
d signs of edema Check if there is a back-flow of blood Check if there is bubble
s present in the tube Always Monitor V/S.
47
Evaluation Through assessment and data gathering, certain problems and needs of
the client post-operatively were identified. Problems on tissue perfusion, impai
red mobility (standing and walking) and impaired skin integrity were observed. N
ursing care plan was established to improve client’s status and recovery. Inform
ation and health teachings were imparted which led to increase client’s awarenes
s and knowledge with regards to her condition. The student gained additional inf
ormation about incomplete abortion including diagnostic examination, surgical an
d medical management needed and as well as the factors affecting the condition w
hich may help the group handle properly this kind of condition that the student
may possibly encounter again. lll. Conclusion From the above nursing problems pe
rceived and presented through prioritization and analysis of the gathered data a
nd proper assessment. Through the use of client focus nursing interventions and
by following to nursing standards, the perceived problems were managed well. Tru
ly, a clinical eye which is sensitive to client’s need for care was established.
Loyalty was observed in aiding the client’s needs, managing and taking a lead o
n advocating client’s interest and creating ways on how to ensure a quality of c
are. lV. Recommendation The following are recommended for the client to easily r
ecover after major surgery. Recommend the use of a heating pad or hot water bo
ttle on the abdomen to help relieve pain or discomfort. Encouraged her to begi
n using birth control immediately after the procedure. Encouraged her to take
her prescribed medication on right time and dosage. The patient should attend
OPD follow ups The patient should do exercise or activities advised by the doc
tor, and avoid activities that requires great physical strength.
Instructed to increase intake of food rich in iron like liver, green leafy veg
etables
and etc. 48
Encouraged to increase intake of food rich in protein and Vit. C.
Good perineal hygiene should be instructed to avoid infection
Instructed to have adequate rest and try to lower known stresses in life.
References Mosby’s Pocket Dictionary Maternal & Child Health Nursing, 4th Editio
n by Pillitteri Health assessment and physical examination 3rd edition by Mary E
llen Zator Estes http:// www.medicinenet.com http:// www.wrongdiagnosis.com http
:// www.umm.edu.com http:// www.doh.gov.ph http:// www.expectantmothers.com http
:// www.health.am/pregnancy/.com
49