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I.

INTRODUCTION

A serious, statistically important disorder characterized by the development after


the twentieth week of gestation of hypertension, with proteinuria or edema or both.
These symptoms should be progressive in severity to actually make the diagnosis of
pregnancy-induced hypertension. If coma or convulsionnot caused by coincidental
neurologic diseasecomplicates the course of the illness, it is then called eclampsia.
Guided by our enlarging view of Severe preeclampsia, nurses are in a prime
position for aiding in promoting the optimal level of wellness in our patients. This begins
with thorough assessments. Blood pressure measurements should be accurate, and
never be treated as trivial. Other objective assessment data may include monitoring
pertinent laboratory values, proteinuria, and fetal surveillance. Subjective data such as
visual disturbances and headaches, which may be precursors to seizures, should also
be assessed. All of these assessments are important.
Nurses also should relish their role as patient advocates and patient educators.
As patient advocates, and armed with the knowledge of recent research, nurses are in a
position to promote care that is both evidence-based and appropriate. As patient
educators, nurses are able to increase their patients' ability to understand and
participate in their own care to achieve the optimal level of wellness.
A database of hospital discharge data from approximately 300,000 deliveries in
the United States found the overall incidence of severe preeclampsia was about 1
percent of pregnancies. Studies of preeclampsia report about 5 percent of nulliparous
women develop preeclampsia and 40 to 50 percent of these women develop severe
disease. Chief causes of the maternal death are aspiration (pneumonia), cerebral
hemorrhage, cardiac failure with pulmonary edema, or obstetrical hemorrhage
associated with premature separation of the placenta.
In the Philippines, according to Department of Health, Maternal Mortality Rate
(MMR) is 162 out of 10,000 live births (Family Planning Survey 2010). Maternal deaths
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account for 14% of deaths among women. For the past five years all of the causes of
maternal deaths exhibited an upward trend. Preeclampsia showed an increasing trend
of 6.89%; 20%; 40%; and 100%. Ten women die everyday in the Philippines from
pregnancy and childbirth related causes but for every mother who dies, roughly 20 more
suffer serious disease and disability. The UNFPA office in the Philippines declared that
family planning can help prevent maternal deaths by 35%. (http://hb4110.net/wpcontent/uploads/KIT_MATERNAL%20HEALTH_BASIC%20STATS.doc.)
Treatment of preeclampsia depends on the severity of the symptoms
encountered, the philosophy of the physician, and the understanding of the compliance
of the client. She and her family deserve careful teaching regarding her problem, its
observation, and its treatment. Regular, adequate prenatal care is the best insurance for
control of the complication. Magnesium sulfate is the first-line treatment of prevention of
primary and recurrent eclamptic seizures. It reduces transmission of nerve impulses
from brain to muscles.
We decided to use this as a subject for our case study because as what we all
know this kind of illness is said to be a silent killer if prompt medical attention is unmet.
That is why we want to know the root cause of such disease in order for us to know how
we could intervene and play our role as a nurse. We believe that by studying this case
we will gain more information and knowledge about the disease and will lead us to a
certain perception as to how we will manage and care if ever we will experience again
patients with the same disease.

II.

OBJECTIVES

General Objectives:

This study done by group 2 of Midwifery-2 aims to present all the details about
Pre-eclampsia; its causative factors, its damage to the human physiology, and its
underlying complications if left untreated. This can be achieved through research, with
the use of the patients hospital records, article references and other materials, and
through interviewing the patient during hospitalization; also, to formulate a complete and
comprehensive definition of the diagnosis.
This study also aims to understand the medical principles that accompany
Preeclampsia. With this, we hope this will lead to insights on appropriate nursing care
and management that a patient with the same such ailments will need in the future.

Specific Objectives:
The specific aims of this study are:

Establish a good interpersonal therapeutic relationship with the patient as

well as her family and significant others;


Formulate an introduction related to the condition being studied, which
includes implication to nursing practice, research and education;
Obtain patients data of the patients physical condition as wel as her
overall body system functioning;
Assess patients background, such as medical history and family structure
as well as its function that could have affected that patients current health
status;
Assess the condition of the client through physical examination using
cephalocaudal approach;
Define the complete diagnosis of the patient coming from the different
references
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Discuss the human anatomy and physiology of the systems involves in the

disease process of our client;


Trace the pathophysiology of the disease from the possible cause
Identify the symptoms, predisposing and precipitating factors that
contribute to the present illness of the client;
Determine various laboratory and diagnostic examination used in relation
to the disease with its corresponding nursing intervention;
Research the medications administered to the patient;
Identify the different medical and nursing management that was carried
out to the patient.
Make appropriate nursing care plans for the patient
Health teachings that must be given to the patient
Determine clients prognosis on the disease
Present all the references used in the case study

III.

ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM
The Heart
The heart lies in the mediastinum, behind the body of the sternum. The shape of
the heart tends to resemble the chest.

The heart has chambers divided into four

cavities with the right and left chambers (atria and the ventricles) separated by the
septum.
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The Blood Vessels

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 oxygenated blood.
Small arteries are called arterioles. Veins, on the other hand are vessels that carries
blood toward the heart. It contains the deoxygenated blood. Small veins are called
venules. Often, very large venous spaces are called sinuses. Lastly, capillaries are
microscopic vessels that carry blood from small arteries 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:
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 prevents tearing
of the vessel wall during body movement.

Tunica media is a smooth muscle,

sandwiched together with a layer of elastic connective tissue. It permits changes of the
blood vessel diameter. It allows the constriction and dilation of the vessels. Last but not
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the least is the tunica intima. Tunica intima, which 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, which 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

There are two circulatory routes of blood as it flows through the blood vessels:
the systemic and the pulmonary circulation. In systemic circulation, blood flows 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 pulmonary circulation on the other
hand, venous blood moves from the right atrium to right 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
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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 the
vasomotor control mechanism. Like most physiological control mechanisms, it consists
of many parts. An area in the medulla called vasomotor center/ vasoconstrictor center
will, when stimulated initiate an impulse outflow via sympathetic fibers that ends in
smooth muscle surrounding resistance vessels, arterioles, and veins of the blood
reservoir causing their constriction thus the vasomotor control 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 the Blood
Venous return refers to the amount of blood that is returned to the heart by the
way of veins. Various factors influence venous return, including the operation 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. Changes in the total volume of blood
vessels can also alter the venous return.
The return 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 the
total volume of blood, the 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 constancy 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 bodys retention of the water.

The primary mechanisms for altering the water retention in the body- they are the
endocrine reflexes 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 urine 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 volume will become.
Another mechanism that changes the blood plasma volume is the renninangiotensin mechanism of aldosterone secretion. Renin is an enzyme that is released
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 retention by the
kidney, which in turn stimulates the osmotic flow of water to the kidney tubules back into
the blood plasma- but only when ADH is present to permit the movement of water. Thus,
low blood pressure increases the secretion of aldosterone, 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 complements the volume-increasing effects of the
mechanism and thus also promotes an increase in overall blood flow. Precision of blood
volume control contributes to the precision in controlling venous return, which in return
yields to the precise overall control of blood circulation

EXOCRINE SYSTEM

The exocrine systems main function is to regulate the volume and composition
of body fluids and excrete unwanted materials, but it is not the only system in the body
that is able to excrete unnecessary substances.

Kidneys

The kidneys resemble the lima beans in shape. The average-sized kidney
measures around 11cm by 7cm by 3cm. The left kidney is often larger than the right.
The kidneys are highly vascular organs. Approximately, one-fifth of the blood pumped
from the heart goes to the kidneys. The kidneys process blood plasma and form urine
from waste to be excreted and removed from the body. These functions are vital
because they maintain the homeostatic balance of the body. The kidneys maintain the

fluid-electrolyte and acid-base balance. In addition, they also influence the rate of
secretion of the hormones ADH and aldosterone.
Microscopic functional units called nephrons make up the bulk of the kidney. The
nephron is uniquely suited to its function of blood plasma processing and urine function.
A nephron contains certain structures in which fluid flows through them and they are as
follows: renal corpuscle, Bowmans capsule, proximal convulted tubule, Loop of Henle,
distal convoluted tubule and the collecting tube. The Bowmans capsule is a cup-shaped
mouth of a nephron. It is usually formed by two layers of epithelial cells. Fluids,
electrolytes and waste 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 bodys well-known capillary network and is surely one of
the most important ones for survival. Glomerulus and Bowmans capsule together are
called renal corpuscle.

The permeability of the glomerular endothelium increases

sufficiently to allow plasma proteins to filter out into the capsule.

ENDOCRINE SYSTEM
The endocrine system performs their regulatory functions by means of chemical
messenger sent to specific cells. The endocrine system, secreting cells send hormones
by way of the bloodstream to signal specific target cells throughout the body. Hormones
diffuse into the blood to be carried to nearly every point in the body. The endocrine
glands secrete their products, hormones, directly into the blood. There are two

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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 the cholesterol. Non-steroid hormones are further subdivided
into two: protein hormones and glycoprotein hormones.
Aldosterone
Its primary function is the maintenance of the sodium homeostasis in the blood
by increasing 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 secretion is controlled by the rennin- angiotensin mechanism.
Estrogen
It is secreted by the cells of the ovarian cells that promote and maintain the
female 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 neurohypophysis (posterior pituitary); it literally opposes the
formation and production 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

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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
provides protection and nutrition to the developing offspring. The most essential organ
is the ovary which carries the ova. The uterus, the fallopian tubes and the vulva are
accessory organs.
Ovaries
It is an almond-shape organ. It contains the ova and is responsible in expelling
the ova. It also produces estrogen and progesterone.
Fallopian Tubes
It usually measures approximately 10- 12 cm. It has two parts: the ampullae and
the fimbriae. The ampullae which is the largest part is where the fertilization takes place.
The fimbriae on the other hand, are responsible for the transportation of the ovum from
ovary to uterus. It holds the ovary.
Uterus

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The uterus is a pear-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 gives nourishment to the growing fetus.

IV.

OVERVIEW OF THE DISEASE

Definition
Pre- eclampsia is a pregnancy specific hypertensive disease with multisystem
involvement. It usually occurs after the 20 th week gestation. It is the most common
hypertensive disorder that causes significant complications during pregnancy, occurring
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at a rate 2% to 7%. It is the occurrence of new-onset hypertension (systolic of 140+ and


a diastolic of 90+) plus new-onset proteinuria. Proteinuria is defined by the extraction of
300mg or more in a 24 hour urine catch or 1+ on a dipstick. In the absence of
proteinuria the following associated with the Pre-eclampsia can be diagnostic:

Thrombocytopenia
Impaired Liver Function
New onset of Renal Disease
Pulmonary Disease
New onset of Visual Disturbances

Etiology
Although there is unknown cause of pre-eclampsia, there are certain risk factors
such as:

Extreme of age such as younger than 17 and older than 35


Primigravidas
Prior History of pre-eclampsia in earlier pregnancies
Multiple Pregnancies
Obesity
African American

Classifications
1. Mild Preeclampsia
o 140/90
o Proteinuria is +1 or +2 on dipstick reading
o No hyperreflexia Noted
o Liver Enzyme may be elevated soon
o Edema may or may not present
Home Care
If a womens preeclampsia is considered mild enough for home care the
following are monitored:

BP, weight, protein in the urine is checked daily


Weight gains of 3lbs. in 24 hours in a 3 day period is cause of concern
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Remote non-stress test are performed on daily or biweekly basis


It is extremely important to report to physician if worsening signs of Preeclampsia
develops

Hospital Care

The women is placed on bedrest


She is weigh daily
She is assessed for visual disturbances
Persistent headache
Epigastric pain
Worsening edema
BP is checked at least 4 times daily

The following tests are performed in hospital:

Fetal movement record


Nonstress test
Ultrasonography every 3 or4 weeks
Biophysical profile
Amniocentesis to determine fetal lung maturity

2. Severe
o 160/110 and over twice at least 4 to 6 hours apart
o Cerebral or visual disturbances (scotomata)
o Epigastric Pain
o Pulmonary edema
o Thrombocytopenia (platelet count less than 10,000)
o Impaired liver function as indicated by abnormally elevated blood
concentration of liver enzymes
o Hyperreflexia
Hospital care of severe preeclampsia
Complete Bed rest. Seizure inducing stimuli must be reduced
High protein , moderate sodium diet is given
Anticonvulsants such as Mag Sulf is treatment of choice. Increased levels of mag
sulfate include diminished reflexes, decreased respirations, difficulty swallowing,
drooling is indicative of toxic levels.

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Electrolyte and fluid replacement. Iv lines are kept open in case they are needed
for drug therapy.
Corticosteroids, betamethasone or dexamethasone is administered if the fetus
has an immature lung profile.
Antihypertensives is given for systolic of 160 to 180 mm hg of higher, and
diastolic

105-110

mm

hg

or

higher

(Hydralazine

is

most

commonly

used)Methyldopa is for chronic hypertension in pregnancy

Labor induction:

Labor may be induced by IV oxytocin when there is evidence of fetal

maturity and cervical readiness


Severe cases may require c-section
The woman may receive mag sulfate and Pitocin simultaneously
If an epidural block is used it should be done by someone skilled in
preeclampsia Spinal or epidural anesthesia is contraindicated if there is
coagulopathy or platelet count lower than 50,000/mm
Oxygen may be administered to woman during labor according to fetal
response
Birth should be in the Sims or semi-sitting position

Postpartum management:
Although the woman with preeclampsia usually improves rapidly after giving
birth, there is still a risk for seizure during the 48 hrs postpartum.
Medical Management: the only cure for preeclampsia is to give birth.
Bed rest, must be complete in non-stimulating environment.
Diet: a high protein diet with moderate sodium
Anticonvulsant medication: magnesium sulfate is the treatment of
choice for convulsion, its depressant quality reduces

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Nursing Management:
Assessment during hospitalization include:

Assess BP every 1 to 4 hrs


Temperature is taken every 4 hours, if elevated then 2 hrs
Fetal heart rate
Urinary output, measure every voiding. Output should be 700 ml or greater in 24

hours, or at least 30 ml/hr


Urine protein checked hourly if cath is in place. Readings of +3 or 4+ indicate
loss of 5g of protein in 24 hours
The woman should be weighed daily at the same time everyday, with the same

article of clothing. If she is on strict bed rest this might be contraindicated


Pulmonary edema, observe for coughing
Deep tendon reflex
Ask about the presence of headaches
Ask about visual disturbances
Ask about epigastric pain

Laboratory tests:

Daily tests of hematocrit to measure hemoconcentration


Bun, creatinine and uric acid levels to assess kidney functioning
Clotting studies for signs of thrombocytopenia or DIC
Liver enzymes
Magnesium levels

Environment considerations:

Maintain a quiet , low stimulating room


Should be in a private room
Eliminate phone, unless preplanned
Limit visitors
Woman should maintain the left lateral position with side rails up

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