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I.

INTRODUCTION

1. Description of the Disease

Pre-eclampsia is a medical condition where hypertension arises during pregnancy


(pregnancy-induced hypertension) in association with significant amounts of protein in
the urine. Because pre-eclampsia refers to a set of symptoms rather than any causative
factor, it is established that there are many different causes for the syndrome. It also
appears likely that there is a substance or substances from the placenta that may cause
endothelial dysfunction in the maternal blood vessels of susceptible women. While blood
pressure elevation is the most visible sign of the disease, it involves generalized damage
to the maternal endothelium and kidneys and liver, with the release of vasopressive
factors only secondary to the original damage.

Pregnancy induced hypertension (PIH) is a condition in which vasospasm occurs


during pregnancy in both small and large arteries. It is usually developed during the first
20 weeks. It is unique to pregnancy and occurs in 5% to 7% of pregnancies in the United
States (Pillitteri, 2003 p. 426). Despite years of research, the cause of the disorder is still
unknown. Originally it was called toxemia because researchers’ pictures a toxin of
something 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 is further classified as gestational hypertension, mild preeclampsia, severe


preeclampsia and eclampsia. Gestational hypertension develops when a woman is said to
have an elevated blood pressure (140/90 mmHg) but has no edema or proteinuria. A
woman is said to be mildly preeclamptic when the blood pressure rises to 140/90 mmHg,
taken on tow occasions at least 6 hours apart. The diastole value of blood pressure is
extremely important because it best indicates the degree of peripheral arterial spasms.
Aside from hypertension, she has also proteinuria and edema. This mild preeclamptic
passes through severe when the blood pressure has risen to 160/110 mmHg or over.
Proteinuria and extensive edema are also present. Eclampsia is the most severe
classification of PIH. Degeneration of a woman’s condition from severe preeclampsia to
eclamspia occurs when cerebral irritation from increasing cerebral edema becomes so
acute that seizures occur.

Pre-eclampsia, as stated above is the combination of high blood pressure


(hypertension), swelling (edema), and protein in the urine (albuminuria, proteinuria)
developing after the 20th week of pregnancy. This disease can cause the blood pressure
to rise and puts the pregnant woman at risk of stroke or impaired kidney function,
impaired liver function, blood clotting problems, pulmonary edema (fluid on the lungs),
seizures and, in severe forms, maternal and infant death.

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Statistics

Hypertensive diseases in pregnancy, particularly pre eclampsia remain important causes


of maternal mortality and morbidity worldwide. The prevalence of PIH is 43.1 per 1,000 single
ton pregnancies in a retrospective population based study of 200,000 live births in North
Carolina, USA. For the past ten years, PIH was the major cause of maternal mortality in
England and wales, and 56% of deaths due to PIH were attributable to pre eclampsia. The
Philippine Obstetrical and Gynecological Society Committee on Nationwide 2003 statistics
reported that 18.42 percent of maternal deaths were due to PIH and one of the top3 causes of
prenatal mortality was PIH. Clearly, any attempt to curb maternal and perinatal mortality and
morbidity was due to hypertensive states will not only result in less deprivation of financial and
maternal sources.

In the district hospital where the patient was confined there were approximately 15% of
the cesarean patients were diagnosed with Pregnancy Induced Hypertension from the year 2009
up to the present.

Reasons for Choosing the Case:

The group had chosen the Pregnancy Induced hypertension (PIH) as the case to be
studied. The researchers agreed and decide for this case because the patient is recently admitted
at that time and the student nurses could still have a better assessment and monitoring for a
length of time. This is an advantage for the group in facilitating and scrutinizing the cause of
certain hypertension during pregnancy. Eventually, it will give us a better understanding of the
disease and know the importance of being a competent student nurses as how we provide health
teachings and perform our independent nursing functions. May this study will also be a future
reference that may help other researchers/student nurses in doing/completing their requirements.

Current Trends:

Weight-Loss Surgery Significantly Reduces Risk of Hypertensive Disorders in Pregnancy

ScienceDaily (Apr. 14, 2010) — Obese women who have bariatric surgery before getting
pregnant are at significantly lower risk for developing dangerous hypertensive disorders during
pregnancy than those who don't, according to a study of medical insurance records by Johns
Hopkins experts. Hypertensive disorders in pregnancy -- which include gestational
hypertension, preeclampsia and eclampsia -- complicate an estimated 7 percent of pregnancies in
the United States. Researchers say they are much more common in obese women, who make up
a third of women of childbearing age.
"We have long known that women who have these blood pressure disorders are not only
at an increased risk for pregnancy complications in themselves and their babies, but also for
chronic diseases in the future," says Wendy L. Bennett, M.D., M.P.H., assistant professor of
medicine at the Johns Hopkins University School of Medicine and a study leader. "Can we

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prevent the development of these disorders in pregnancy with bariatric surgery? These findings
suggest the answer may be 'yes.'"
Results of the research are published online in the British Medical Journal.
For the study, Bennett and her colleagues looked at five years of data from Blue Cross
Blue Shield insurance records and identified 585 women who had bariatric surgery and delivered
a baby. The sample included 269 women who had babies some time before having weight-loss
surgery and 316 who had the surgery before getting pregnant. More than 80 percent of the
women chose gastric bypass surgery over other, less common weight-loss operations.
The researchers found an 80 percent reduction in the risk of preeclampsia and eclampsia
among women who had surgery before pregnancy, along with a 74 percent reduction in the risk
of gestational hypertension and a 61 percent reduction in the risk of chronic hypertension in
pregnancy, all of which are known to cause pregnancy complications.
Bennett cautions that not every obese woman is a candidate for bariatric surgery. And not
every obese woman wants to undergo the operation, which itself carries risks of complications.
Moreover, insurance companies don't always cover the surgery, and when they do, it's typically
not unless a woman has a body-mass index (BMI) of more than 40 or a BMI of more than 35
with a co-morbidity such as diabetes or sleep apnea, she says.
One limitation of the study is that the insurance data did not include information on fetal
outcomes, so researchers can't say what, if any, effect bariatric surgery may have on babies born
to women who have undergone the operation, Bennett says. Babies born to mothers with
preeclampsia or eclampsia may arrive prematurely which can lead to complications up to and
including fetal death.
Nevertheless, Bennett says her study suggests that insurance companies "should be
covering gastric bypass surgery in women of childbearing age because of the potential to reduce
complications if we can reduce their weight before they become pregnant." Treating the obesity
before pregnancy, she adds, also has the potential of saving a lot of money on treatment of
complications in mothers, fetuses and newborns."
Bennett says her findings are intended to open a discussion between doctors and obese
patients who wish to become pregnant about the risks and benefits associated with bariatric
surgery. Once they become pregnant, women who have undergone weight-loss surgery will need
to be closely monitored to make sure they and their fetuses are getting enough nutrition.
Prior research has shown that rates of gestational diabetes (which also causes complications in
pregnancy) decreases after bariatric surgery, and that weight loss can increase fertility in obese
women.
2. Objectives

General Objective: After three weeks of accomplishing the case study, the student nurses will
be able to apply the concepts of nursing process on the care of the patient with pregnancy
induced hypertension.

Learning Objectives: After a week of accomplishing this case study, the student nurses will be
able to:

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Cognitive:

 Define pregnancy induced hypertension.


 Analyze and interpret laboratory results and relate them to the pathology of the diseases.
 Grasp knowledge about the advancement of the complication, their effects and
manifestations.
 Identify the modifiable and non-modifiable factors as well as the signs and symptoms of
the stated complication, treatment and preventions of pregnancy induced hypertension.
 Identify the treatment modalities available.
 Formulate nursing diagnoses related and significant to patient’s condition.

Affective:

 Empathize with the patient’s current condition.


 Provide comfort to the client as she copes up with her current situation.

Psychomotor:

 Perform cephalocaudal assessment.


 Interview the patient and significant others of the disease condition.
 Formulate nursing care plan.
 Demonstrate to the significant other the appropriate interventions to the patient.
 Assist the significant other on how to be acquainted with the patient’s actual condition.
 Provide health teachings to the support people that would help improve the patient’s
condition and administer medications as ordered and explain the need and purpose of the
treatment.
 Document pertinent data and information about the patient.

II. NURSING HISTORY

1. Personal History
a. Demographic Data
Mrs. X is a 40 year old, Filipino citizen, plain housewife and married. She is born on
December 25, 1969 at Balanga Bataan, and the youngest daughter among the seven siblings. She
is currently living in Lubao, Pampanga together with her husband, and their two sons, ages
twelve and five years old.

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She was admitted at a district hospital in Pampanga last August 01, 2010 with an
admitting diagnosis of mild pre-eclampsia and cough. She was discharged last August 6, 2010.

b. Socioeconomic and Cultural Factors


Mrs. X has finished her primary education in Bataan Elementary School. She was not
able to finished high school due to financial constraints. She is married to Mr. X who is 40 years
old. He finished 2nd year college and currently working as a laborer and had a monthly income of
Php 6,000. Mr. X’ vices were smoking and drinking occasionally. They were both a Roman
Catholic and attend mass every Sunday together with their two sons. Their expenses are
approximately Php 3,000 for food, Php 2,000 for food, Php 500 for water bill, Php 500 for
electric bill and the money left was for their savings and some left for their medical needs.
According to Mrs. X, she often visits the nearest health center in case one of the family
members got sick and also for the immunization of her children. She often eats vegetables, fish,
fatty and salty foods especially pork with salted shrimp (binagoongang baboy).She is not
selective in terms of food, but one thing that she does not eat is the chicken skin. Every time she
wakes up at 5am in the morning, she cleans their house, cooks food and does other household
chores. She takes a bath twice a day. She does not have any vices and manages her stress by
simply watching television and by playing with her younger son. She sleeps usually sleeps at
10pm.

MATERNAL-CHILD HEALTH HISTORY

a. Maternal Obstetric Record


Mrs. X is married since she was 27 years old. Her last menstruation was November
15, 2009. Upon the day of assessment, she has a GPTPALM of Gravida (2), Para (3), Term (3),
Preterm (0), Abortion (0), Living children (2), Multiple Gestations (0). She is currently 38weeks
and 5 days pregnant on the day of assessment. She is expected to deliver her baby on August 22,
2010. Her first delivery was NSD (Normal Spontaneous Delivery). On her second child, she was
CS (Caesarian Section) due to nuccal cord at the same district hospital last August 3, 2005.

b. Antepartal/Prenatal preparation

During Mrs. X’ pregnancy, she had her monthly check-up in order to monitor her
condition as well as the baby’s condition . She eats mostly vegetables like togue, fruits like
papaya, fishes and meat products such as skinless chicken as well as fatty and salty foods
especially pork with salted shrimp (binagoongang baboy) . She does not drink coffee ever since
instead she drinks milk and water. She uses ordinary soap for her perineal hygiene. She was
taking Aldomet 250 mg TID, Cefalexin and ferrous sulfate since March 4,2010 as advised by her
doctor.

c. Significant trimestral changes (1st TO 3rd trimester)

During the first trimester of Mrs. X’s pregnancy, she experienced frequent headaches and
dizziness which continued until the third trimester. She usually sleeps in order to relieve her from
the said conditions. On the end of her first trimester she experienced an increased in her blood
pressure which is 170/120 mmHg, this is the reason for prescribing the Aldomet. During the

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course of her second trimester of pregnancy her blood pressure went down to 160/90 mmHg.
And the blood pressure of the patient in the third trimester improved to 140/100 mmHg. Right
after the surgery Aldomet was changed into Hydralazine as ordered by the physician.

2. Family Health History


Mrs. X said that both of her grandparents on her father’s side, and grandmother on her
mother’s side died unknowingly. Her grandfather on her mother’s side died because of accident.
The eldest brother of her father died due to diabetes mellitus and old age. Her father’s 2nd brother
and sister died due to old age too. On her mother’s side, all of them are still alive and doesn’t
have any diseases. All of the patient’s brothers and sisters are healthy too and doesn’t have any
diseases.

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Family health illness and history

Lolo Lola A Lolo B Lola B


A

1st Uncle 2nd Father


81 Auntie C
78 74 Uncle
Auntie A Mother Auntie B

58 52 51 50 47 Brother A 42 Brother B
Sister A Sister B Sister C Sister D PT 40

Legend:
Female
Male
Deceased (due to old age)
Deceased (unknown)
Deceased (due to heart attack)
Deceased (due to Diabetes Mellitus)
Deceased (accident)
PT Patient
Hypertension
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3. History of Past Illness
Mrs. X had an appendectomy last July 10, 2009. She experienced cough and colds once a
year. She does not experienced PIH during her first and second pregnancy. She has a complete
shot of Tetanus Toxoid vaccine.

4. History of Present Illness


She was diagnosed with Pregnancy Induced Hypertension on the third trimester of
pregnancy on her third baby. Prior to admission she complained of having pain on the nape and
cough. She was admitted to Escolastica Romero District Hospital last Aug. 01, 2010 at around
11:45 pm. She was admitted in the OB Ward. She was diagnosed to have a mild pre-eclampsia
and a cough.

III. PHYSICAL ASSESSMENT (IPPA-CEPHALOCAUDAL APPROACH)

August 3, 2010

General Appearance
Seen patient on a supine position with an ongoing IVF of # 1 D5 LRS at 200 cc level
regulated at 30 gtts/ min infusing well at her left arm. Patient is conscious, awake and coherent.
She wearing gray shirt without sleeves and diaper and was drape from waist below.

B – engorge, lactating
U – 1 fingerbreadth below umbilicus
B – 25 cc level
B – 2 times flatus
L – rubra, minimal amount, 1 diaper since after the operation, scanty
E – abdominal midline incision
S – striae gravidarum at both thigh
H – no presence of Homan’s sign
E – taking hold phase as evidence by touching the baby and let the baby stay with her side at all
times

Vital Signs:

Temperature – 37.1 °C
Respiratory rate – 19 breaths per minute
Pulse rate – 87 beats per minute
Blood pressure – 130/70

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CEPHALOCAUDAL ASSESSMENT

Day 1 August 3, 2010

SKIN
• Dark brown skin

• Has fair complexion

• Dark armpit

• Presence of scars on her extremities

• Skin goes back after 2 seconds


HAIR
• Hair is black in color

• Long and evenly distributed

• With no presence of dandruff and flakes


NAILS
• Long and dirty nails in both extremities

• Hard and immobile

• Smooth and firm nailbeds in both extremities

• With capillary refill of less than 2 seconds


HEAD
• Round and with no nodules or masses palpated

• Symmetrical facial features


NECK
• With normal range of motion

• Symmetrical in shape

• Centered head position

• Absence of swollen lymph nodes upon palpation


EYES
• Symmetrically aligned to ears

• Thick, and evenly distributed eyebrows

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• Eyelashes are evenly space

• Pale conjunctive

• Pupil equally round and reactive to light and accommodation (PERRLA)

• With eyebags

• With droopy eyelids


EARS
• Symmetrically aligned to eyes

• With no presence of cerumen on both ears

• Pinna recoils after being folded

• No tenderness felt when palpated


MOUTH AND THROAT
• Outer lips is pale and dry

• Uvula is positioned in the midline

• Tongue is pink

• No noted sores and lesions


NOSE
• Smooth and symmetrical in appearance

• With no pain and lesions upon palpation


THORAX AND BACK
• With equal chest symmetry

• No pain felt when palpated

• With no presence of adventitious sound (crackles/rales) upon auscultation


BREAST
• Relatively equal with right breast is slight variation

• Presence of striae

• Smooth skin surface

• Dark brown areolas and nipples

• With whitish discharge

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• Slightly tender upon palpation

• No palpable masses
CARDIOVASCULAR
• Absence of murmurs
ABDOMEN
• Presence of transverse incision
MUSCULOSKELETAL/EXTREMITIES
• Head can be turned laterally against resistance

• Able shrug shoulder against resistance

• Non pitting edema (Grade 1) on both extremities


August 4, 2010

General Appearance
Seen patient sitting on bed with an ongoing IVF of # 2 D5LRS at 400 cc level regulated
at 30 gtts/min. She is conscious, awake and coherent. The patient is wearing red sando and
checkered short. She is also breastfeeding her child.

B - engorge, lactating
U – 2 fingerbreadth below umbilicus
B – voided 2 times
B – has her bowel movement (1)
L – rubra, minimal amount, 1 diaper since after the operation,and 1 sanitary napkin, scanty
E – abdominal midline incision
S – striae gravidarum at both thigh
H – no presence of Homan’s sign
E – taking hold phase as evidence by touching the baby and let the baby stay with her side at all
times

Vital Signs:

Temperature – 36.7 °C
Respiratory rate – 17 breaths per minute
Pulse rate – 80 beats per minute
Blood pressure – 130/70

CEPHALOCAUDAL ASSESSMENT

Day 2 August 4, 2010

SKIN
• Dark brown skin

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• Has fair complexion

• Dark armpit

• Presence of scars on her extremities

• Skin goes back after 2 seconds


HAIR
• Hair is black in color

• Long and evenly distributed

• With no presence of dandruff and flakes


NAILS
• Short and clean nails

• Hard and immobile

• Smooth and firm nailbeds in both extremities

• With capillary refill of less than 2 seconds


HEAD
• Round and with no nodules or masses palpated

• Symmetrical facial features


NECK
• With normal range of motion

• Symmetrical in shape

• Centered head position

• Absence of swollen lymph nodes upon palpation


EYES
• Symmetrically aligned to ears

• Thick, and evenly distributed eyebrows

• Eyelashes are evenly space

• Pink conjunctive

• Pupil equally round and reactive to light and accommodation (PERRLA)

• With eyebags

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• With droopy eyelids
EARS
• Symmetrically aligned to eyes

• With no presence of cerumen on both ears

• Pinna recoils after being folded

• No tenderness felt when palpated


MOUTH AND THROAT
• Outer lips is pink and moist.

• Uvula is positioned in the midline

• Tongue is pink

• No noted sores and lesions


NOSE
• Smooth and symmetrical in appearance

• With no pain and lesions upon palpation


THORAX AND BACK
• With equal chest symmetry

• No pain felt when palpated

• With no presence of adventitious sound (carackles/rales) upon auscultation


BREAST
• Relatively equal with right breast is slight variation

• Presence of striae

• Smooth skin surface

• Dark brown areolas and nipples

• With whitish discharge

• Slightly tender upon palpation

• No palpable masses
CARDIOVASCULAR
• Absence of murmurs
ABDOMEN

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• Presences of transverse incision
MUSCULOSKELETAL/EXTREMITIES
• Head can be turned laterally against resistance

• Able shrug shoulder against resistance

• Non pitting edema (Grade 1) on both extremities


IV. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose Ordered Values Interpretation of
Procedures Date (units used the Results
Results in the
were hospital)
released
Hemoglobin To measure of D.O. 106 gm/L 140-180 Below-normal
the total amount August 1, gm/L hemoglobin
of hemoglobin in 2010 levels. This may
the blood. The D.R. lead to anemia
hgb is the main August 2, that can be result
intracellular 2010 of excessive
protein of bleeding.
erythrocytes, it
carries oxygen to
and removes
carbon dioxide
from RBC’s.

To monitor
ongoing bleeding
to check its
severity.

Hematocrit This is done to D.O. 0.32 0.37-0.47 Decreased


determine the August 1, hematocrit level
presence of 2010 this may indicates
infection and D.R. anemia that can be
inflammation. August 2, caused by iron

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2010 deficiency.

To determine any D.O. 8.0x10 5-9x10 WBC count is at


WBC acute bacterial August 1, gm/L gm/L normal level. This
Leukocytes infection 2010 shows absence of
D.R. infection and
August 2, inflammation.
2010

Neutrophils or To determine any D.O. 0.64 0.40-0.60 Increased level of


polymorphonu acute bacterial August 1, neutrophils. May
clear cells infection or viral 2010 indicate presence
(Polys) infection. D.R. of acute bacterial
August 2, infection.
2010

Lymphocytes To determine any D.O. 0.36 0.20-0.40 Within normal


chronic bacterial August 1, range.
infection or viral 2010
infection. D.R.
August 2,
. 2010

Nursing Responsibilities:
• Explain the procedures; explain that slight discomfort may be felt when skin is punctured.

• Avoid stress if possible because altered physiologic status influences and changes normal
hemogram values.

• Dehydration can dramatically alter values, for example large volume of IV fluids can
dilute the blood and values will appear as lower counts. The presence of either of these
states should be communicated to the laboratory.

• Fasting is not necessary; however fat meals may alter some test result as a result of
lipidemia.

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• Apply manual pressure and dressings to the puncture site on removal of the needle.

• Monitor the puncture site for oozing or hematoma formation. Maintain pressure dressings
on the site if necessary. Notify physician of unusual problems with bleeding.

• Bruising on the puncture site is not uncommon; signs of inflammation are usual and
should be reported if the inflamed area appears larger, if red streaks develop or if
drainage occurs.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose Ordered/Date Values interpretation
Procedures Results were of the results
released
Urinalysis It is used to May 20, 2010 Color: yellow It can vary in Normal urine
detect urinary color from color.
tract pale (almost
infections colorless)
(UTI) and yellow to
other dark yellow.
disorders of
the urinary Transparency: Urine should Cloudy urine
tract. turbid be clear. or urine with
a high level of
sediment may
be present in
cases of
urinary tract
infection.

Sugar: normally Absence of


negative negative glucose in the
(absent) urine means it
did not
indicate
diabetes.

Albumin: Negative. Positive


positive albumin in the
urine may
indicate may
indicate
kidney
disease.

Reaction: Acidic (6.9-7) Normal urine


acidic (6.9) ph.

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Specific 1.003 to It means that
gravity: 1.010 1.030 the
concentration
of solutes in
the urine is
normal

Pus cells: 3.5 0-5/hpf Within


normal value

Epithelial Few Increased


cells: positive amount of
epithelial
cells indicate
inflammation
or infection of
urogenital
tract

Amorphous Normally Normal


urates: found in
positive acidic urine.

Mucus This is a Normal


Threads: common
positive finding in
urine since
the entire
urine system
is filled with
mucus

NURSING RESPONSIBILITIES FOR URINALYSIS:

Before:
 Verify the doctor’s order.
 Explain to the patient the importance of the procedure.
 The first morning sample is the most valuable because it is more concentrated and
more likely to yield abnormal results
 Assist the patient.

During:
 Provide privacy.
 Advise the patient to catch the midstream of the urine.
 Transport time for culture specimen must be minimized.

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 Handle specimen carefully.

After:
 Relay the results to the attending physician.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose Ordered/Date Values interpretation of
Procedures Results were the results
released
Pelvic For a better July 19, 2010 Within the A single live male
Ultrasound visualization enlarged fetus in breech
of the fetus as uterus is a presentation of
well as to single live about 35 weeks
know if there fetus in and 0 AOG.
are any breech Normohydramnios.
abnormalities presentation.
occurring The biparietal
inside the diameter is
uterus. measured as
84mm, a
femoral
length of
69mm and an
abdominal
circumference
of 313mm in
dm,

Nursing Responsibilities for ULTRASOUND (Pelvic)

Before:
1. Check doctor’s orders
2. Ask for the patient’s identification
3. Explain the procedure properly to the SO.
4. Instruct the client not to void prior the procedure.
During:

1. The patient lies on an examining table with the part of the body to be examined exposed.
2. A conductive gel is applied to the skin over the area under examination.
3. You lie quietly as the person performing the examination moves the transducer over the
skin surface while watching the monitor.
4. You may be asked to shift positions to obtain other views of the organ(s) under study.

After:

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1. Wait for the further results.
2. The patient can void.
3. Wait for the physician to interpret the results

V. THE PATIENT AND HER ILLNESS

ANATOMY AND PHYSIOLOGY

When most people hear the term cardiovascular system, they immediately think of the
heart. We have all felt our own heart "pound" from time to time, and we tend to get a bit nervous
when this happens. The crucial importance of the heart has been recognized for a long time.
However, the cardiovascular system is much more than just the heart, and from a scientific and
medical standpoint, it is important to understand why this system is so vital to life.

Most simply stated, the major function of the cardiovascular system is transportation.
Using blood as the transport vehicle, the system carries oxygen, nutrients, cell wastes, hormones,
and many other substances vital for body homeostasis to and from the cells. The force to move
the blood around the body is provided by the beating heart. The cardiovascular system can be
compared to a muscular pump equipped with one-way valves and a system of large and small
plumbing tubes within which the blood travels.

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HEART:
The heart is a muscular organ found in all vertebrates that is responsible for pumping
blood throughout the blood vessels by repeated, rhythmic contractions.
The heart is enclosed in a double-walled sac called the pericardium. The superficial part of this
sac is called the fibrous pericardium. This sac protects the heart, anchors its surrounding
structures, and prevents overfilling of the heart with blood. It is located anterior to the vertebral
column and posterior to the sternum. The size of the heart is about the size of a fist and has a
mass of between 250 grams and 350 grams. The heart is composed of three layers, all of which
are rich with blood vessels. The superficial layer, called the visceral layer, the middle layer,
called the myocardium, and the third layer which is called the endocardium. The heart has four
chambers, two superior atria and two inferior ventricles. The atria are the receiving chambers and
the ventricles are the discharging chambers. The pathway of blood through the heart consists of a
pulmonary circuit and a systemic circuit. Blood flows through the heart in one direction, from
the atrias to the ventricles, and out of the great arteries, or the aorta for example. This is done by
four valves which are the tricuspid atrioventicular valve, the mitral atrioventicular valve, the
aortic semilunar valve, and the pulmonary semilunar valve.
Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood
away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is
contrasted with pulmonary circulation.
Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-
depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart.
The term is contrasted with systemic circulation. A separate system known as the bronchial
circulation supplies blood to the tissue of the larger airways of the lung.

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Arteries are blood vessels that carry blood away from the heart. All arteries, with the
exception of the pulmonary and umbilical arteries, carry oxygenated blood.
Pulmonary arteries
The pulmonary arteries carry deoxygenated blood that has just returned from the body to
the heart towards the lungs, where carbon dioxide is exchanged for oxygen.
Systemic arteries
Systemic arteries can be subdivided into two types – muscular and elastic – according to
the relative compositions of elastic and muscle tissue in their tunica media as well as their size
and the makeup of the internal and external elastic lamina. The larger arteries (>10mm diameter)
are generally elastic and the smaller ones (0.1-10mm) tend to be muscular. Systemic arteries
deliver blood to the arterioles, and then to the capillaries, where nutrients and gasses are
exchanged.
The Aorta
The aorta is the root systemic artery. It receives blood directly from the left ventricle of the
heart via the aortic valve. As the aorta branches, and these arteries branch in turn, they become
successively smaller in diameter, down to the arteriole. The arterioles supply capillaries which in
turn empty into venules. The very first branches off of the aorta are the coronary arteries, which
supply blood to the heart muscle itself. These are followed by the branches off the aortic arch,
namely the brachiocephalic artery, the left common carotid and the left subclavian arteries.
Aorta the largest artery in the body, originating from the left ventricle of the heart and extends
down to the abdomen, where it branches off into two smaller arteries (the common iliacs). The
aorta brings oxygenated blood to all parts of the body in the systemic circulation.
The aorta is usually divided into five segments/sections:
 Ascending aorta—the section between the heart and the arch of aorta

 Arch of aorta—the peak part that looks somewhat like an inverted "U"

 Descending aorta—the section from the arch of aorta to the point where it divides into the
common iliac arteries
o Thoracic aorta—the half of the descending aorta above the diaphragm
o Abdominal aorta—the half of the descending aorta below the diaphragm

Arterioles
Arterioles, the smallest of the true arteries, help regulate blood pressure by the variable
contraction of the smooth muscle of their walls, and deliver blood to the capillaries.
Veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood
from the tissues back to the lungs; exceptions are the pulmonary and umbilical veins, both of
which carry oxygenated blood. Veins differ from arteries in structure and function; for
example,arteries are more muscular than veins and they carry blood away from the heart.
Veins are classified in a number of ways, including superficial vs. deep, pulmonary vs. systemic,
and large vs. small.
Superficial veins
Superficial veins are those whose course is close to the surface of the body, and have no
corresponding arteries.
Deep veins
Deep veins are deeper in the body and have corresponding arteries.

21
Pulmonary veins
The pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the
heart.
Systemic veins
Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart.
Atrium sometimes called auricle, refers to a chamber or space. It may be the atrium of the lateral
ventricle in the brain or the blood collection chamber of a heart. It has a thin-walled structure that
allows blood to return to the heart. There is at least one atrium in animals with a closed
circulatory system.
Right atrium is one of four chambers (two atria and two ventricles) in the human heart. It
receives deoxygenated blood from the superior and inferior vena cava and the coronary sinus,
and pumps it into the right ventricle through the tricuspid valve. Attached to the right atrium is
the right auricular appendix.
Left atrium is one of the four chambers in the human heart. It receives oxygenated blood
from the pulmonary veins, and pumps it into the left ventricle, via the atrioventricular valve.
Ventricle is a chamber which collects blood from an atrium (another heart chamber that is
smaller than a ventricle) and pumps it out of the heart.
Right ventricle is one of four chambers (two atria and two ventricles) in the human heart.
It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into
the pulmonary artery via the pulmonary valve and pulmonary trunk.
Left ventricle is one of four chambers (two atria and two ventricles) in the human heart. It
receives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta
via the aortic valve.

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23
24
Synthesis of the Disease

A. DEFINITION OF THE DISEASE

Pregnancy-induced hypertension (PIH) is a condition in which vasospasm occurs during


pregnancy. Signs of hypertension, proteinuria, and edema develop. It is classified as gestational
hypertension, pre-eclampsia (mild and severe) and eclampsia. The cause of this disorder is still
unknown despite of the years of research.

Pre-eclampsia is an abnormal condition of pregnancy characterized by the onset of acute


hypertension after the twenty-fourth week of gestation. The classic triad of pre-eclampsia is
characterized by abrupt hypertension (a sharp rise in blood pressure), proteinuria (the presence in
the urine of abnormally large quantities of protein, usually albumin) and edema (swelling) of the
hands, feet, and face. Pre-eclampsia is the most common complication of pregnancy. It occurs in
5% to 7% of pregnancies, most often in primigravidas.

Eclampsia is the final and most severe phase of preeclampsia and occurs when
preeclampsia is left untreated. Eclampsia involves convulsions (seizures) occurring with
pregnancy-associated high blood pressure and having no other cause. Eclampsia can cause coma
and even death of the mother and baby and can occur before, during or after childbirth. In short,
eclampsia means seizure or coma accompanied by signs and symptoms of pre-eclampsia.

B. PREDISPOSING AND PRECIPITATING FACTORS

The etiology of preeclampsia is not fully understood. The exact causes of preeclampsia
and eclampsia are not known, although some researchers suspect poor nutrition, high body fat or
insufficient blood flow to the uterus as possible causes. Other causes may include altered
cardiovascular reactivity, increased capillary permeability, widespread vasospasm and
hypertension.

Risk factors may include the following: previous history of preeclampsia, relative with a
history of preeclampsia, multiple fetuses, teenaged patient or patient older than 35 years,
primigravida, lower socioeconomic status, gestational diabetes, history of renal disease and
obesity prior to pregnancy.

C. PATHOLOGICAL CHANGES

The symptoms of preeclampsia affect almost all organs. The effects of preeclampsia are
primarily due to the vasospasm of blood vessels. Vascular spasm maybe caused byt the increased
cardiac output that injures the endothelial cells of the arteries and imbalance between
prostacyclin (vasodilator) and thromboxane (vasoconstrictor) leading to vasoconstriction of
blood vessels and blood pressure increases. Because of this, peripheral resistance increases and
the heart is forced to pump rapidly to supply blood to peripheral organs.

25
Peripheral resistance reduces blood supply to organs especially to the kidneys, brain and
placenta. Because of low blood and oxygen supply, degenerative changes occur within the
organs manifested by various symptoms. The effects of vasospasm are more on vascular, kidney
and interstitial effects. If accompanied by seizures, it is eclampsia.

In the kidneys, vasospasm leads to increased permeability of the glomerular membrane,


allowing albumin to escape into the urine (proteinuria). Other changes include a decreased
glomerular filtration leading to oliguria and increased kidney tubular reabsorption of sodium
leading to edema. Also, the osmotic pressure of the circulating blood falls and fluid diffuses from
the circulatory system into bodily fluid, rapid weight gain occurs. Poor placental perfusion may
reduce the fetal nutrient and oxygen supply putting the fetus at risk.

In preeclampsia, edema accumulates in the upper part of the body (face and hands).
Cerebral edema (swelling of the brain tissue due to an accumulation of fluid) can also occur as a
result of fluid retention in the brain. Symptoms of cerebral edema include blurred vision and
severe headache. Cerebral edema can lead to seizure which is the hallmark of eclampsia.

D. SIGNS AND SYMPTOMPS WITH RATIONALE

Triad of Symptoms (3 classic signs of preeclampsia)

1. Hypertension (systolic BP greater than 160 mm Hg or diastolic BP greater than


110 mm Hg)
 Vasospasm of blood vessels causes vasoconstriction and increased
peripheral resistance leading to an increase in blood pressure.
2. Proteinuria
 Vasospasm in the kidneys increases blood flow resistance leading to
increased permeability of the glomerular membrane because of back
pressure. This allows protein (albumin) to escape into the urine.
3. Edema
 Caused by an increased kidney tubular reabsorption of sodium and
sodium retains fluid causing edema. Fluid diffuses from the circulatory
system into the interstitial spaces because of decreased osmotic pressure
causing extensive edema.

Other symptoms associated with eclampsia:

 Rapid weight gain (over 2 lbs per week in the second trimester, 1 lb per
week in the third trimester)

 Caused by a significant increase in bodily fluid.

 Oliguria (decreased urine output)

26
 a decreased in glomerular filtration leads to a lowered urine output

 Puffy face, numb hands, and dependent areas such as ankles and lower
legs

 Caused by fluid retention in the upper portion of the body including the brain
(cerebral edema)

 Severe headache

 caused by the swelling of the brain tissue due to an accumulation of fluid(cerebral


edema) which increases pressure on the cerebral arteries

 Blurring of vision

 Spasm of the arteries in the retina leads to vision changes and the presence of
cerebral edema

 Epigastric pain and nausea

 caused by the vascular congestion and ischemia of the liver

 Impaired liver function (elevated hepatic enzymes-alanine


aminotransferase (ALT) or aspartate aminotransferase (AST)

 due to decreased hepatic perfusion

 Thrombocytopenia

 due to platelet aggregation


 Fetal growth restriction
 due to decreased uteroplacental perfusion or placental ischemia

27
28
29
B. SYNTHESIS OF THE DISEASE (Client-Based)

b.1 Predisposing Factors and Precipitating Factors:

• history of hypertension
• age (40 years old)
• high fat and high salt diet

b.2 Signs and symptoms with rationale

• Hypertension- August 1, 2010 ( 140/110mmHg)


- vasoconstriction of blood vessels force he heart to pump blood and its
also due to the increase in the peripheral resistance; as a compensatory mechanism
there will be an increase in the heart rate because if the blood deficiency and then
hypertension occurs.

• Proteinuria- May 25, 2010 (1+)


- this was brought about by the increase permeability of glomerular
membranes that causes the albumin (a type of protein) to be excreted in the urine

• Edema- August 3,2010 (Non-pitting edema Grade 1 in the bipedal area)


- Due to the increased kidney tubular absorption of sodium, fluid shift to the
interstitial spaces and there by fluid retention happens, causing edema.

VI. THE PATIENT AND HIS CARE

1. Medical Management

A. IVF

Medical Management General Indications/ Date Client’s


Description Purpose ordered/Date Response to
performed/ Treatment
Date changed
or
discontinued
D5LRS D5LRS (5% Lactated DO: August The patient did
dextrose in Ringer’s 2,2010 not experience
Lactated Solution is any discomfort

30
Ringer’s often used for DD: August other than the
Solution fluid 3,2010 IV insertion
Belongs to the resuscitation and medication
hypertonic after a blood administration
solutions; a loss due to upon the
combination of trauma, course of this
two solutions surgery, or a IV therapy.
(D5W and burn injury.
LR).

NURSING RESPONSIBILITIES:
Before:
• Verify doctor’s order.

• Explain the procedure and the need for IV infusion.

• Prepare necessary materials needed.

• Check IVF as prescribed.


During:
• Instruct patient to relax especially the hand where the needle is to be inserted (to avoid
reinsertion and facilitate easy insertion).

• Check IV level and the patency of the tubing if it is infusing.

After:
• Press the site where the needle was inserted and secure it with micropore.

• Check the site of hand where the needle is inserted if bulging is not visible. If so,
reinsertion is to be undertaken.

• Advise patient to avoid scratching the site less movement of the hand where the needle
was inserted to keep it in place.

• Instruct patient and significant others to inform the nurse on duty if bulging of the site is
visible.

• Observe the IV site at least every hour for signs of infiltration or other complications
fluid or electrolyte overload and air embolism.

• IVF regulation should be checked and monitored upon receiving patient.

• Always check the doctor’s order for new orders regarding the IVF supplement of the
patient.

• Always check if the IVF is infusing well and intact and monitor skin integrity.

31
B. Drugs

Generic Name and General Indications/Purpose Date Client’s


Brand Name Action Ordered/Date Response to
Performed/Date Treatment
Changed or
Discontinued
Hydralazine Acts directly Essential DO: August The patient’s
Apresoline on vascular hypertension alone 2,2010 blood
smooth or in combination -continued as of pressure
muscle to with other drugs. the day of our decreased
cause duty. from 140/100
vasodilatation, mmHg to
primarily 130/70
arteriolar, mmHg.
decreasing
peripheral
resistance;
maintains or
increases
renal and
cerebral blood
flow

NURSING RESPONSIBILITIES:
Before:

• Check Doctor’s Order


• Explain the procedure to the patient’s SO, the importance of the drug, its uses and effects.
• Prepare the right medication at the right time and with the right dosage.

During:

• Adhere to standard precautions


• Administer at the right route.
• Take with food

After:

• Document what has been done.

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Generic Name General Action Indications/Purpose Date Client’s
and Brand Ordered/Date Response to
Name Performed/Date Treatment
Changed or
Discontinued
Diclofenac Inhibits Acute or long-term DO: August After taking the
Voltaren prostaglandin treatment of mild to 2,2010 medicine, the
synthetase to moderate pain. -continued as of client’s pain
cause the day of our was relieved.
antipyretic and duty.
anti-
inflammatory
effects; the
exact
mechanism is
unknown

NURSING RESPONSIBILITIES:

Before:
• Check the doctor’s order.
• Explain the procedure to the patient’s SO, the importance of the drug, its uses, and
effects.
• Prepare the right medication at the right time and with the right dosage.

During:
• Adhere to standard precautions.
• Administer at the right route.

After:
• Document what has been done.

33
Generic Name General Action Indications/Purpose Date Client’s
and Brand Ordered/Date Response to
Name Performed/Date Treatment
Changed or
Discontinued
Cefuroxime Bactericidal: To reduce the DO: August 2, There were no
Ceftin Inhibits development of 2010 signs of
synthesis of drug-resistant -continued as of infection seen in
bacterial cell bacteria and the day of our the patient.
wall, causing cell maintain the duty.
death effectiveness tablets
and other
antibacterial drugs,
Cefuroxime Axetil
tablets should be
used only to treat or
prevent infections
that are proven or
strongly suspected to
be caused by
susceptible bacteria.

NURSING RESPONSIBILITIES:
Before:

• Check Doctor’s Order


• Explain the procedure to the patient’s SO, the importance of the drug, its uses and effects.
• Prepare the right medication at the right time and with the right dosage.

During:

• Adhere to standard precautions


• Administer at the right route.

After:

34
• If you get severe or watery diarrhea, do not treat yourself. Call your prescriber or health
care professional for advice.
• Document what has been done.

Generic Name General Action Indications/Purpose Date Client’s


and Brand Ordered/Date Response to
Name Performed/Date Treatment
Changed or
Discontinued
Nifedipine Inhibits the Used to treat high DO: August 2, The patient did
Calcibloc movement of blood pressure and 2010 not experience
calcium ions some forms of chest -continued as of chest pains.
across the pain known as the day of our
membranes of angina. This duty.
cardiac and medication works by
arterial muscle relaxing blood
cells; lead to vessels and
decreased decreasing the
cardiac work, pressure on the heart.
decreased
cardiac energy
consumption and
increased
delivery of
oxygen to
myocardial cells

NURSING RESPONSIBILITIES:

Before:

• Check Doctor’s Order


• Explain the procedure to the patient’s SO, the importance of the drug, its uses and effects.
• Prepare the right medication at the right time and with the right dosage.

During:

• Adhere to standard precautions


• Administer at the right route.
• May be taken with or without food.

After:

35
• Document what has been done.

Generic Name General Action Indications/Purpose Date Client’s


and Brand Ordered/Date Response to
Name Performed/Date Treatment
Changed or
Discontinued
Salbutamol Selective beta2- Treat shortness of DO: August 2, After taking the
Ventolin adrenoreceptor breath in patients 2010 medication the
stimulant drug. with severe -continued as of client is relieve
This has a breathing difficulty the day of our from difficulty
relaxant effect duty. of breathing.
on the smooth
muscle in the
medium and
smaller airways.

NURSING RESPONSIBILITIES:

Before:

• Check Doctor’s Order


• Explain the procedure to the patient’s SO, the importance of the drug, its uses and effects.
• Prepare the right medication at the right time and with the right dosage.

During:

• Adhere to standard precautions


• Administer at the right route.

After:

• Document what has been done.


C. Diet

Type of Diet General Indication or Date Client’s Response


Description Purpose Ordered/Date and/or reaction to the
Performed/Dat diet
e Changed or
discontinued

36
NPO Nothing by This was ordered DO: August 2, Patient was able to
mouth, no till the patient 2010 comply with the diet
foods or has no (+) flatus. DD: August 3, regimen.
drinks is 2010
allowed to be
given to the
patient, also a
type of diet
modification
and fluid
restriction

Nursing responsibilities:
• Check doctor’s order
• Identify the type of diet
• Explain the reason of such diet to the patient, as well as with the patient’s significant
other.
• Remove all foods bedside.
• If the client eats or drinks, the physician should be notified at once

Type of Diet General Indication or Date Client’s Response


Description Purpose Ordered/Date and/or reaction to the
Performed/Dat diet
e Changed or
discontinued

Soft Diet Very similar To prepare the DO: August 3, Patient was able to
to the regular body to assume a 2010\ comply with the diet
diet except regular diet and DD: August 4, regimen.
that the texture to determine if 2010
of the foods the body can
has been now tolerate
modified. solid foods
The soft diet
consists of
foods that are
easily
digestible,
mildly
seasoned and

37
tender.

Nursing responsibilities:

• Check for the physician’s order.


• Explain the reason of such diet to the patient, as well as with the patient’s significant
other.
• Instruct the patient on what specific foods she can take.
• Serve small, frequent meals to avoid overwhelming the client with large amount of
foods.
• Offer alternatives in terms the client cannot or will not eat.

Type of Diet General Indication or Date Client’s Response


Description Purpose Ordered/Date and/or reaction to the
Performed/Dat diet
e Changed or
discontinued

Diet as The patient Ordered when DO: August 4, Patient was able to
Tolerated can take the client’s 2010 comply with the diet
anything by appetite, ability regimen.
mouth as long to eat and
as she can tolerance for
tolerate it. certain foods
Adequate in may change; For
all nutrients increase body
according to resistance,
the standards muscle strength
and is used for and regular
patients functioning of
requiring no the body; to meet
dietary the needed daily
modifications. requirements of
nutrition of the
patient

38
Nursing responsibilities:

• Check doctor’s order.


• Explain the reason of such diet to the patient, as well as with he patient’s significant
other.
• Instruct the patient on what specific foods she can take.
• Serve small, frequent meals to avoid overwhelming the client with large amount of
foods.
• Offer alternatives in terms the client cannot or will not eat.

D. Activity

Type of General Indication or Date ordered/ Client’s


activity/Exercise description purpose Date Response and/
Performed/ or Reaction to
Date Changed the Activity
or discontinued
Flat on bed This is the usual The purpose of DO: August 2, Patient
position ordered this is to prevent 2010 maintained a flat-
for post-op. spinal headache DD: August 3, on-bed position
patient is 2010
positioned flat on
bed; the head is
erect or slightly
flexed.

Nursing responsibilities:
• Check for the physician’s order.
• Explain the procedure and the reason to the patient.
• Assist the patient in assuming the position ordered.
• Check for any complications like bed sores
• Remove all unnecessary objects to the patient’s bed to provide comfort

Type of General Indication or Date ordered/ Client’s


activity/Exercise description purpose Date Response and/
Performed/ or Reaction to

39
Date Changed the Activity
or discontinued
Turn side to side Patient may To prevent DO: August 3, Patient was able
change position venous stasis. 2010 to tolerate the
periodically and DD: August 3, activity
gradually 2010

Nursing responsibilities:
• Check doctor’s order.
• Explain the procedure and the reason to the patient.
• Assist the patient in assuming the position ordered.
• Remove all unnecessary objects to the patient’s bed to provide comfort
• Observe if the patient can tolerate it.
Type of General Indication or Date ordered/ Client’s
activity/Exercise description purpose Date Response and/
Performed/ or Reaction to
Date Changed the Activity
or discontinued
Ambulate A patient can do To have adequate DO: August 3, The pt. was able
the things she muscle strength 2010 to ambulate after
can like standing and promote slowly rising
and sitting circulation from the bed to
sitting position

Nursing responsibilities:
• Explain to the client how you are going to assist, why ambulation is necessary, and
how she can cooperate.
• Ensure the client is appropriately dressed to walk
• Prepare the client for ambulation.
• Ensure safety while assisting client to ambulate.
• Encourage client to ambulate independently if she is able.
• Remain physically close to the client in case assistance is needed at any point

SURGICAL MANAGEMANT (Cesarean Section Delivery)


Date Performed: August 2, 2010
A. Description

40
A C-section delivery is performed when a vaginal birth is not possible or is not safe for the
mother or child.

Surgery is usually done while the woman is awake but numbed from the chest to the feet. This is
done by giving her apidural or spinal anesthesia.

The surgeon makes a cut across the belly just above the pubic area. The uterus and amniotic sac
are opened, and the baby is delivered.

The health care team clears the baby’s mouth and nose of fluids, and the umbilical cord is
clamped and cut. The pediatrician or nurse makes sure that the infant’s breathing is normal and
that the baby is stable.

The mother is awake, and she can hear and see her baby.

The decision to have a C-section delivery can depend on the obstetrician, the delivery location,
and the woman’s past deliveries or medical history. Some reasons for having C-section instead
of vaginal delivery are:

Reasons related to the baby:

• Abnormal position of the baby in the uterus feet-first (breech presentation)

Reasons related to the mother:

• Severe illness in the mother, including heart disease, toxemia, preeclampsia or eclampsia

Bilateral Tubal Ligation

Tubal ligation for woman seeking out a safe, effective, permanent and convenient form of
contraception may be a good option. The most common form of surgical sterilization procedure
used for woman today is called a tubal ligation, often referred to as “having your tubes tied”. A
tubal ligation procedure prevents the egg and sperm from meeting and you from becoming
pregnant.

Tubal ligation is a permanent and highly effective form of birth control. If you have the desired
number of children and never will desire more, permanent sterilization is worth considering.

A tubal ligation typically is performed via a small incision in your belly button. It can either be
performed after delivery or at a latter time. When a tubal ligation is performed after delivery it is
called a post-partum tubal ligation and does not require laparoscopy. If you have a tubal ligation
and you are not pregnant, it is usually performed by laparoscopic surgery. All forms of tubal
ligation require either burning, cutting, clamping or tying the mid section of your fallopian tubes.

41
B. instrument and/or Equipment Used
Instruments quantity
Curve clamps 6
Allis 3
Bobcock 2
Thumb forcep 1
Tissue forcep 1
Needle holder 2
Metzenbaum 1
Straight scissor 1
Bandage scissor 1
Blade holder(#3) 1
Blade(#21) 1
Chromic 1/0 2
Chromic 2/0 1
Vicryl 2/0 1
Plain Gut 2/0 1
Cotton Tie 4
Abdo Pack 4

C. Nursing Responsibilities before, during and after the Procedure


Before:

1. Proper draping of the client


2. Prepare the instruments needed for the procedure
3. Provide emotional support to the mother

During:

1. Skin preparation of the client


2. Maintain the sterility of the area.
3. Assist the surgeon in the operation
4. Make sure all the instruments are all ready.
5. The instrument should be complete before closing of the incision.

After:
1. Assess the vital signs of the patient every 30 minutes.
2. Monitor the patient’s urine output and vaginal discharge.

D. Client’s Response to the Surgery


The patient did not have any abnormal bleeding and other abnormalities. The
patient only felt pain in the incision site.

42
VII. NURSING CARE PLAN

PROBLEM # 1 Acute Pain r/t disruption of skin, tissue and muscle integrity, secondary to surgical procedure (CS)

Assessment Nursing Scientific Objectives Nursing Rationale Evaluation


Diagnosis Explanation Interventions
Subjective: Acute pain Unpleasant sensory After 4 hours >Evaluate pain >Provides >Did the
related to and emotional of NI, the regularly noting information patient pain
“Minsan disruption of experience arising patient pain characteristics, about need for reduced from
sumusumpong ang skin, tissue from actual or will be or effectiveness 5/10 to 2/10?
location,
sugat sa tahi ko, and muscle potential tissue reduced or of interventions.
sobrang mahapdi” integrity. controlled intensity (0-10 >Did the
damage due to post
from pain scale). patient agree
abdominal surgery
Objective: that results to acute scale of 5/10 with the
to 2/10. >Assist patient >Positioning interventions
pain. to find position
 Pain scale of 5/10 affects the provided?
of relief. ability to rest
 Facial grimace and relax. >Did the
patient was
>Provide >Promotes able to
 Guarding diversional
behavior relaxation and express
activities such may relieve herself
as listening to pain and through
 Excessive music and back
perspiration enhance communicati
rubbing. circulation. on of how
 Vital signs taken importance
>Encourage >Promotes rest is?
as follow: early good circulation
ambulation and faster >Did the
BP–130/70mmHg
wound healing. patient
comply with
>Support lower >Prevents health
abdomen during undue strain teachings

42
coughing and and dehiscence provided?
deep breathing on operative
by splinting site.
using a pillow.

>Schedule >Prevents
adequate rest fatigue and
periods. conserves
energy for
faster healing.

>Discuss the >Provides


importance of elements
nutritious diets necessary for
and adequate tissue
fluid intake. regeneration or
healing.

>Administer >To
analgesic as decrease/reduce
indicated by the the pain
physician immediately.

43
PROBLEM # 2 DISTURBED SLEEP PATTERN R/T PAIN DUE TO POST SURGICAL PROCEDURE (CS)

Assessment Nursing Scientific Objectives Nursing Rationale Evaluation


Diagnosis Explanation Interventions
Cues: Disturbed Due to the actual After 4 hours >Provide her >To promote > Did she feel
sleep pattern tissue damage that of nursing new and clean sleep and the urge to
Subjective: related to pain was brought about interventions, linen relaxation sleep
“ Mangaga ku nabengi due to post by the post surgical the pain scale
kasi masakit ini” surgical procedure done, the will reduce >Assist her in >To promote >How many
procedure patient manifest pain from 5/10 to changing circulation of hours did she
( I was crying last (CS) and irritability that 2/10 and the position from blood sleep?
night because of the contributed to the client will side to side
pain I was disturbance of sleep sleep every 1-2 >Was the
experiencing) and relaxation. hours pain reduced?

Objective: >Place pillow on >To support her >Did she


the client’s body cooperate
 Appeared back while on with the
drowsy lateral position interventions
 With eye bags >Assist in leg provided??
 Seen patient exercises such >To prevent
yawning as rotating legs, venous stasis
 With droopy flexion,
eyelids extension of
 With pain scale lower
of 5/10 extremities
 With facial
>demonstrate
grimaces
deep pursed-lip >To promote
 With guarding breathing venous return
behavior in the exercise while and relaxation
abdomen splinting the
 Appeared incision site
irritable

44
>provide calm,
quiet To promote
environment by sleep and
minimizing relaxation
noise and
visitors

>provide
diversional >To promote
activities such sleep and
as providing relaxation
back rub, head
massage and
music

>Administer >To reduce her


mefenamic acid pain
500mg TID
after meals as
ordered

45
PROBLEM # 3 Risk for INFECTION r/t destruction of microbial barriers secondary to surgical procedure (CS)

Assessment Nursing Scientific Objectives Nursing Rationale Evaluation


Diagnosis Explanation Interventions
Cues: Risk for Broken Skin due to After 4 hours >Teach mother > Hand washing >Did she
infection r/t CS results to of nursing to wash hands reduces the risk perform
Subjective: Ø destruction of exposure to interventions, often and after for infection proper hand
microbial environment where the patient will administering washing?
Objective: barriers pathogens can be able to self-care.
secondary to penetrate the skin Identify
 Incision site on surgical easily leading to risk interventions >Discuss to the >To impart to >Was she
the lower procedure for infection. to reduce risk mother the the patient able to
abdominal ( CS) for infection following signs when wound identify signs
midline and of infection: becomes of infection?
demonstrate redness, infected and
proper wound swelling, when to sought
care increased pain medical care
or purulent
drainage on the
site and fever

>Demonstrate >To know if the >Did she


and allow patient really perform
return understand the proper wound
demonstration principle of care?
of wound care wound care

>demonstrate >To prevent >Was she


and encourage exposure to the able to do
proper dressing environment proper wound
dressing?

46
> Administer >To inhibit >Did she
Cefuroxime synthesis of cooperate
500mg 1 cap bacterial cell with the
every 6 hours wall, causing intervention
as ordered after cell death provided?
meals

47
III. DISCHARGE PLAN

M: Instructed Mrs. X to take Ferrous Sulfate 300mg once a day, Methyldopa 500mg every 6
hours, Multivitamin 1 capsule BID, Buscopan 10mg TID, Cefuroxime axetil 500mg TID,
Azithromycin 500mg BID. All of these are per orem.

E: Exercise as tolerated

T:

H:
 Instructed patient to relax and not think about problem.
 Instructed to promote adequate rest and they should provide a quiet environment
 Complied to the diet of soft diet with low salt, low fat, low sodium, low calorie, and with
frequent small feedings
 She should maintain adequate nutrition and fluid balance
 She should not do strenuous activities
 Instructed to keep fluids within clients reach and encourage frequent intake of fluid
 Instructed patient to change position slowly
 Instructed patient to take a bath regularly, to provide optimal skin care
 Instructed patient to take frequent oral care as well as eye care to prevent injury from
dryness
 Encouraged patient to loose weight

O:

D: Her diet first is nothing per orem, followed by a soft diet with low salt, low fat, low sodium,
low calorie with frequent small feedings.

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IX. LEARNING DERIVED FROM THE STUDY

Case Study is not that easy since it takes a lot of effort, thinking and especially
patience. As I reach the another step of our level, I’m taking more responsibilities for finding
authoritative and reliable information, also taking more accurate information from general to
specific.

We chose our patient because we believe that she needs more attention regarding his
health status and as student nurses, we had the opportunity to apply all the nursing skills that we
have learned from the school. The deep analysis of etiologies, mechanisms, and manifestations
of disease and functional changes in abnormal conditions made me more challenged.

Through this case study, we have developed our level of self confidence, skills and our
level of understanding to build good relationship to our patient and her SO at the same time, to
share insights too. We won’t be able to finish it without the unity of each and everyone of our
group and through the support and guidance of our clinical instructor. And through this, we came
up with this we so called “fruit of our work”. May this paper will illustrate a clearer meaning of
Pregnancy induced hypertension that may contribute a unique and valuable method of eliciting
phenomena of interest to nursing.

Emmalyn B. Azarcon

In our hospital duty, we are assigned to do a case study. I learned a lot in this case study
and I became more independent than before. I learned how important to value the things that we
have now. As a group, we have to give our best shot and we must do our responsibilities to finish
this case study. I learned also in this case study, like the concepts regarding the complications of
Pregnancy Induced Hypertension, how to prevent it and many more. Through this case study, we
have practiced what we have learned like the physical assessment, vital signs taking, therapeutic
communication and more. And to end this, I would like to thank GOD for always guiding and
helping us.
Rudora N. Badeo

Another journey starts this semester, this journey has full of requirements one of this was
this case study. At first it’s like we’re not yet ready to make this requirement but we have to. On
our first day of our duty we already saw a pt. with an interesting case to be studied. We have
picked this because we think it was easier than the other case. But I think the more harder you
think the more challenging it is. It will sharpen your knowledge about it. Another thing is that,
this case study makes us realize how important discipline and cooperation is. Cooperation of the
team members was a big factor even though this group was just new we did our best to cooperate
with each other. Our group will not come up with this kind of requirement without discipline and
cooperation. This study help me to be more aware of what may happen to us and to our relatives
we can help them prevent to have such disease.
Jasper Lance Bautista

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In our hospital duty we are assigned and required to do a case study for the whole group.
I learned a lot in this case study I became more serious in every task and I become more
independent than before. It made me realized how important our life and we need to value the
things that we have. I learned also on this case study, like concepts regarding the disease
Pregnancy Induced Hypertension, the complications of it, how to prevent it, and many more.
Being a group, all we need is cooperation, trust, unity, and respect with one another. As a
group we have to work hard and give our best shot we must do our responsibilities and task to
finish this Case Study. Through this study we have practice what we have learned like physical
assessment, vital signs taking, therapeutic communication, and much more.
And to end this, I would like to thank GOD for always guiding, and helping us. Without
his supervision I think we wouldn’t make it. Thank you Lord!

Caren Cheenee Cabrera

For this case study, I have learned that one cannot do such accomplishments without the
help of others. Group effort makes everything different, we do not only finish a project, but more
than that we build a relationship, a relationship not only bounded because of certain projects but
also by the love and care for each other. And the most important, is that the knowledge that we
have attained from here will be used not only for the betterment of us, students, but also for other
people who suffers from this disease that we can help through the knowledge that we have
gained from here.

Riel Nico Cao

Case study is not just a requirement to be passed or submitted for this subject but it is a
learning and experience to us to be a good nurse someday. For this case study, I learned to be
responsible for the task they gave me and I learned also how to cooperate with them.
As a student nurse, I have the knowledge on how to gain the trust of our patient by
having a good interaction with her. As a student nurse, we must learn to be patient and calm
always when doing some procedure and most of all, to have confidence when doing it. I thank
God for helping us finish this case study. Without His supervision, we would not finish and make
it. Thank you God!
Jenzie Jea J. Elevazo

In doing this case study it was not that easy, we don’t have enough time so we have to
make time and give extra effort. But in doing this requirement I learned so many things such as
understand one another, we tested our patience when we where about to meet the deadline for
this requirement. We practiced our cooperation and compiled our knowledge base on what we
experienced. Aside from that, the patient that we choose in our case study gave us knowledge
and learning experience in doing this study. I realize how thankful I am of having this kind of
experience even if it was a tiring one and at least I could say that we exerted all our efforts and
gave our time to conceptualize this requirement.

Mary Grace Lagman

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The case we handled was quite familiar since we have already tackled it on our past
subjects. Doing the case study was not that difficult because we only need to manage our time
finish it.

Achilles Mikael M. Naeg

I always believe in the saying that if you have a chance or an opportunity to take
something take you know will be memorable, and then grab it, because you may never know on
just how it may transform you, on how it will change and touch people around you and this
experience will teach a lot of life saving task that a student nurse must do. Same thing goes with
the accomplishment of our last case study. During the time of nurse-patient interactions,
conducting interview and assessment, I learned that it’s not only the physical and the mental
aspect that should be applied but the emotional aspect as well and I learned how to be closer or
establish a deeper rapport to our patient. With this case study, where our chosen patient is
suffering from a gallbladder problem, gave me awareness n to how economic, environmental and
health problems goes hand in hand. Having the sense of awareness thus moved me to further
study of the disease so to provide the appropriate nursing intervention towards promoting
wellness and especially to be able to inform other as well of to what I know so to reduce or
lessen the occurrence of such disease. Other than that, this case study accomplishment gave me
the sense of self-fulfillment because I am assured that it is not only the knowledge, skills and our
time tried to instill and/or provide them, but also indeed made a direct influence to them and left
a significant mark that can eventually make a big impact in their lives more so with regards to
health and wellness aspect that can help to live their life to the better.

Mary Clarisse V. Parico

Group activity/work is a challenging one. There are a lot of things that is needed to be
considered. If one fails to do his/her part, everything else will follow.
But, on the other hand, group activities give us an opportunity to know other people
better and have new friends. It molds our personality to be matured enough to understand other
people and to have an initiative to help our groupmates.
Cooperation is what I really observed to be the most important factor that will help a
group to work properly and finish the activity successfully. With the help of each member of the
group, the difficult part of the activity will be easier. Despite of some problems that had occurred
while we are doing the video, I am glad that it was done.
Working with your groupmates can be considered a memorable one. We are all sharing
memories which are all worth remembering. And I do believe that we had enjoyed each other’s
company. And I think that’s the essence of the groupwork, to be responsible in the assigned task
to us but at the same time, learns to enjoy every single moment.
At the end of this case study, I have learned a lot about pregnancy induced hypertension.
May this study help me in the future.

Jane Kamille B. Pineda

51
For this case study, I learned a lot because our rotation is already in the operating room I
learn to recall the concepts that our previous C. I thought us about normal and abnormal delivery.
It is so fun and exciting to be expose on OB ward and at the same time in OR because you will
appreciate it. This time doing this case study is not that difficult unlike before because we need
only to apply what was thought to us. But also we need to do our part just to finish this case
study and be very patient in doing this.

Joelyn L. Tongol

I was able to learn a lot about our chosen case, breech presentation. We were able to help
the patient by giving some health teachings such as the importance of breastfeeding and
performing necessary interventions about the proper way of cleaning of her wound. Case study
was proven to be not just a mere requirement thing for us to pass. I had learned its importance as
a part of related learning experience in delivering care outside the school where in we are already
to rend care in the hospital proper. It made me realized how important the role of a student-nurse
is performs in bridging the gap between the health care provider and the patient. I felt the unity
within our group and we are happy to the fact that we were able to finish our second case study
which is one of our requirements. I am hoping that we will able to defend our case study well.

Sheila Marie T. Yumul

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X. REFERENCES

Burton, Gwendolyn and Engelkirk, Paul.Microbiology for the health sciences 8th ed. 2007. Lippincott
William and Wilkins

Black and Hawks. Medical and surgical Nursing 8th ed. 2008 Elsevier and Saunders

Doenges, Mariloyn,et.al. Nurse’s Pocket Guide 11th ed.2006. LA. Davis Company

Karch, Amy Nursing Drug Guide 2010 Lippincott Williams and Wilkins

Seeley, Rod, et.al Essentials of Anatomy and Physiology 6th ed.2007 Mc. Graw Hill Int’l.

Pillitteri, Adele, Maternal & Child Health Nursing Vol.2 5th ed.2007. Lippincott Williams and Wilkins

Caudal, Ma. Lourdes Basic Nutrition & Diet Therapy revised ed,2008.

Online Sources:

http://www.cureresearch.com/p/preeclampsia/stats-country.htm

http://www.nursingcrib.com

http://pregnancy.about.com/od/cesareansection/a/csectionrisks

http://www.cdc.gov/nip/publications/vis/vis-ppv.pdf

http://wiki.answers.com
http://www.sciencedaily.com

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