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Post Partum Eclampsia

A Case Study Presented to the College of Nursing Of Metropolitan Medical Center

College of Arts, Science and Technology

In Partial Fulfillment of the Requirements

for Nursing Care Management 104

Submitted by:

Agaloos, Jojilyn
Ceña, Glaiza
Chua, Gerold
Demillo, Jeremy
Mutuc, Tami
Narvaez, Anjona
Lozano, Kathleen Kaye
Sabalza, Christine
Sutingco, Bon
Villalobos, Peter

Level III – A2

2st Semester (S.Y. 2017-2018)


TABLE OF CONTENTS

TITLE PAGE

ACKNOWLEDGEMENT ................................................................................................................................................. I

INTRODUCTION ........................................................................................................................................................... II

SCOPE AND DELIMITATION....................................................................................................................................... III

I. REVIEW OF ANATOMY AND PHYSIOLOGY .................................................................................................. 1

II. PATHOPHYSIOLOGY ............................................................................................................................................. 15

III. ASSESSMENT

1. Personal Data...................................................................................................................................................... 17

2. Family Background

a. Genogram ........................................................................................................................................................... 18

3. Health History

a. Past Health Hist ory............................................................................................................................................. 19

b. Present Health History ........................................................................................................................................ 19

c. Family Health History .......................................................................................................................................... 19

d. OB-Gyne History ................................................................................................................................................. 19

e. Personal/Social History ....................................................................................................................................... 19

4. Developmental Data

a. Erik Erickson ....................................................................................................................................................... 20

b. Robert Havighurst ............................................................................................................................................... 22

5. Patterns of Functioning ....................................................................................................................................... 23

6. Levels of Competencies ..................................................................................................................................... 26

7. Review of Systems ............................................................................................................................................. 28

8. Physical Assessment ......................................................................................................................................... 30

9. On-going appraisal ............................................................................................................................................. 33

10. Diagnostic Test................................................................................................................................................. 34

IV. MEDICAL AND SURGICAL MANAGEMENT

a. Treatment ........................................................................................................................................................... 39

b. Drug Study ......................................................................................................................................................... 43

V. NURSING CARE PLAN........................................................................................................................................... 46

VI. DISCHARGE PLAN ............................................................................................................................................... 57

I
ACKNOWLEDGEMENT

The Group A2 would like to express their deepest and sincerest gratitude to the following for their
invaluable support and guidance that made the completion of this study possible;

First and foremost, to their school Metropolitan Medical Center College of Arts, Science and
Technology for giving this opportunity to render quality nursing care outside of the institution that will help
the researchers in the near future.

To Aleli R. Cheng RN, MAN, Dean of Metropolitan Medical Center, College of Nursing, who gave
the permission to conduct this research.

To all the clinical Instructors in the faculty of College of Nursing who guided, shared their
knowledge, gave their insights about this research, and for their patience and immense knowledge in
completing this case study and especially who handled our group, for her never ending patience, guidance,
and support all throughout.

To the administrators, staff and personnel of San Lazaro Hospital for having us and gave us a
memorable experience when dealing with infectious diseases.

To the client and her family for their willingness to share their personal data for the fulfillment of this
study.

To researchers, for giving so much time and effort despite of differences and petty disagreements
they still completed this study.

To their parents, for without their utmost support, unending love and understanding and financial
support this research work could have not been conducted.

Lastly, to Heavenly Father, Creator, and Mentor, Hearer of Prayers, and Provider of all good
things, for the wisdom despite their limitations, He continuously poured His blessings and guidance,
provided strength and instilled determination from the beginning, progress, and completion of this task. May
He continue to shine His light upon them all and give them an unending grace.

I
INTRODUCTION

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


pregnancy. In this condition signs of hypertension, proteinuria and edema develop in pregnant and
postpartum women. Despite years of research and studies investigating the disease the cause of the
disorder is still seemingly idiopathic. Originally, this condition has been called the toxemia of pregnancy
because researchers depicted and hypothesized that a toxin of some kind being produces by a woman in
response to the foreign protein of the growing fetus, the toxin leading to the symptoms. Still, despite the
efforts in finding an explanation to the cause of pregnancy induced hypertension, no such toxin has ever
identified.

Postpartum hypertension is elevated blood pressure that occurs in women after childbirth. There
are many different reasons why this can occur. Some women who were diagnosed with preeclampsia (a
condition of losing protein in the urine, severe body/facial swelling and hypertension) during pregnancy will
often have higher blood pressure just after delivery which should come back to baseline on its own at up to
12 weeks postpartum. There are a few women that it can last for several months (usually 6 months) before
resolving.

Another cause of postpartum hypertension includes the "shifting" of fluids from the swollen tissues
back to the arteries. This extra fluid build-up in the body's tissues can be a result of hormonal changes that
occur in a woman after childbirth, from the administration of IV fluids during delivery, or from pain medication
effects.

Pregnancy –induced hypertension is an alarming condition which can affect both the welfare of the
mother and the child. Women who develop high blood pressure in pregnancy appear to have an elevated
risk high blood pressure and stoke in later life. Women with a history of high blood pressure in pregnancy,
known as gestational hypertension, were more likely than women with no history to develop high blood
pressure in later years. In terms of the welfare of the child in-utero, the fetus may be placed in distress due
to the presence of the condition, and complications from high blood pressure such as convulsions can
cause dire consequences.

Pregnancy induced hypertension is a condition which effects many women in the world. This is true
even for those expecting mothers in the Philippines. Studies of eclampsia report about 5 percent of
nulliparous women developed eclampsia and 40 to 50 percent of these women develop severe disease
worldwide. In the Philippines, according to Department of Health, Maternal Mortality Rate (MMR) is 162 out
of 10,000 live births (Family Planning Survey 2015).

Maternal deaths account for 14% of deaths among women. For the past five years all of the causes of
maternal deaths exhibited an upward trend. Eclampsia showed an increasing trend of 6.89%; 20%; 40%;
and 100%. Ten women die every day in the Philippines from pregnancy and childbirth related causes but for
every 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%.

II
SCOPE AND DELIMINATION

The scope of this study focuses on the disease post-partum eclampsia associated with pregnancy
induced hypertension which is based on the client’s condition.

This case study aims to define post-partum eclampsia associated with pregnancy induced
hypertension, discuss and interpret data gathered through theoretical analysis of Nursing History,
Developmental Data according to Erik Erickson and Robert Havighurst, Physical Assessment and
Laboratory Results, trace the pathophysiology of patients Lung Cancer, create an effective and efficient
nursing care plan, discuss the medications taken by the patient, its action, side effects, and nursing
responsibilities, and discuss the medical management for the patient.

The researchers’ selected one (1) patient during their Related Learning Experience at San Lazaro
Hospital dated April 30, 2018 – May 4, 2018 from 7:00AM to 2:00PM. Due to time constraints and busy
schedules for the said week, there were no good cases that had caught our interest. Nevertheless, on the
last day of the RLE, the researchers were able to select one (1) particular case.

The researchers sought permission of the patient and his brother to conduct a study that pertains
her history and medical records and had the chance to let the client sign the consent paper.

The information had been gathered through chart reading, interviews, and continuous observation
during the inclusive date of duty.

III
I. REVIEW OF ANATOMY AND PHYSIOLOGY

Placenta

Anatomy and Physiology of the Placenta

The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient
uptake, thermo-regulation, waste elimination, and gas exchange via the mother's blood supply; to fight
against internal infection; and to produce hormones which support pregnancy. The placenta provides
oxygen and nutrients to growing fetuses and removes waste products from the fetus's blood. The placenta
attaches to the wall of the uterus, and the fetus's umbilical cord develops from the placenta. These organs
connect the mother and the fetus. Placentas are a defining characteristic of placental mammals, but are
also found in marsupials and some non-mammals with varying levels of development.

The placenta functions as a fetomaternal organ with two components: the fetal placenta (Chorion
frondosum), which develops from the same blastocyst that forms the fetus, and the maternal placenta
(Decidua basalis), which develops from the maternal uterine tissue. It metabolises a number of substances
and can release metabolic products into maternal or fetal circulations.

Structure

Placental mammals, such as humans, have a chorioallantoic placenta that forms from the chorion
and allantois. In humans, the placenta averages 22 cm (9 inch) in length and 2–2.5 cm (0.8–1 inch) in
thickness, with the center being the thickest, and the edges being the thinnest. It typically weighs
approximately 500 grams (just over 1 lb). It has a dark reddish-blue or crimson color. It connects to the fetus
by an umbilical cord of approximately 55–60 cm (22–24 inch) in length, which contains two umbilical
arteries and one biliumcal vein. The umbilical cord inserts into the chorionic plate (has an eccentric
attachment). Vessels branch out over the surface of the placenta and further divide to form a network

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covered by a thin layer of cells. This results in the formation of villous tree structures. On the maternal
side, these villous tree structures are grouped into lobules called cotyledons. In humans, the placenta
usually has a disc shape, but size varies vastly between different mammalian species.

Physiology

Development

Placentation, The placenta begins to develop upon implantation of the blastocyst into the
maternal endometrium. The outer layer of the blastocyst becomes the trophoblast, which forms the outer
layer of the placenta. This outer layer is divided into two further layers: the underlying cytotrophoblast
layer and the overlying syncytiotrophoblast layer. The syncytiotrophoblast is a multinucleated
continuous cell layer that covers the surface of the placenta. It forms as a result of differentiation and fusion
of the underlying cytotrophoblast cells, a process that continues throughout placental development. The
syncytiotrophoblast (otherwise known as syncytium), thereby contributes to the barrier function of the
placenta.

The placenta grows throughout pregnancy. Development of the maternal blood supply to the placenta is
complete by the end of the first trimester of pregnancy week 14 (DM)

Functions

 Nutrition

Maternal side of a placenta shortly after birth.

The placenta intermediates the transfer of nutrients between mother and fetus. The perfusion of
the intervillous spaces of the placenta with maternal blood allows the transfer of nutrients and oxygen from
the mother to the fetus and the transfer of waste products and carbon dioxide back from the fetus to the
maternal blood. Nutrient transfer to the fetus can occur via both active and passive transport. Placental
nutrient metabolism was found to play a key role in limiting the transfer of some nutrients. Adverse
pregnancy situations, such as those involving maternal diabetes or obesity, can increase or decrease

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levels of nutrient transporters in the placenta potentially resulting in overgrowth or restricted growth of the
fetus.

Excretion

Waste products excreted from the fetus such as urea, uric acid, and creatinine are transferred to
the maternal blood by diffusion across the placenta.

Immunity

IgG antibodies can pass through the human placenta, thereby providing protection to the fetus in
utero. This transfer of antibodies begins as early as the 20th week of gestational age, and certainly by the
24th week. This passive immunity lingers for several months after birth, thus providing the newborn with a
carbon copy of the mother's long-term humoral immunity to see the infant through the crucial first months
of extrauterine life. IgM, however, cannot cross the placenta, which is why some infections acquired during
pregnancy can be hazardous for the fetus.

Furthermore, the placenta functions as a selective maternal-fetal barrier against transmission of


microbes. However, insufficiency in this function may still cause mother-to-child transmission of
infectious diseases.

Endocrine function

The first hormone released by the placenta is called the human chorionic gonadotropin
hormone. This is responsible for stopping the process at the end of menses when the Corpus luteum
ceases activity and atrophies. If hCG did not interrupt this process, it would lead to spontaneous abortion of
the fetus. The corpus luteum also produces and releases progesterone and estrogen, and hCG stimulates
it to increase the amount that it releases. hCG is the indicator of pregnancy that pregnancy tests look for.
These tests will work when menses has not occurred or after implantation has happened on days seven to
ten. hCG may also have an anti-antibody effect, protecting it from being rejected by the mother’s body. hCG
also assists the male fetus by stimulating the testes to produce testosterone, which is the hormone needed
to allow the sex organs of the male to grow.

Progesterone helps the embryo implant by assisting passage through the fallopian tubes. It also
affects the fallopian tubes and the uterus by stimulating an increase in secretions necessary for fetal
nutrition. Progesterone, like hCG, is necessary to prevent spontaneous abortion because it prevents
contractions of the uterus, and is necessary for implantation.

Estrogen is a crucial hormone in the process of proliferation. This involves the enlargement of the
breasts and uterus, allowing for growth of the fetus and production of milk. Estrogen is also responsible
for increased blood supply towards the end of pregnancy through vasodilation. The levels of estrogen
during pregnancy can increase so that they are thirty times what a non-pregnant woman mid-cycles
estrogen level would be.

Human placental lactogen is a hormone used in pregnancy to develop fetal metabolism and general
growth and development. Human placental lactogen works with Growth hormone to stimulate Insulin-like
growth factor production and regulating intermediary metabolism. In the fetus, hPL acts on lactogenic

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receptors to modulate embryonic development, metabolism and stimulate production of IGF, insulin,
surfactant and adrenocortical hormones. hPL values increase with multiple pregnancies, intact molar
pregnancy, diabetes and Rh incompatibility. They are decreased with toxemia, choriocarcinoma, and
Placental insufficiency.

Cloaking from immune system of mother

Immune tolerance in pregnancy

The placenta and fetus may be regarded as a foreign allograft inside the mother, and thus must
evade from attack by the mother's immune system.

For this purpose, the placenta uses several mechanisms:

 It secretes Neurokinin B-containing phosphocholine molecules. This is the same mechanism


used by parasitic nematodes to avoid detection by the immune system of their host.
 There is presence of small lymphocytic suppressor cells in the fetus that inhibit maternal cytotoxic
T cells by inhibiting the response to interleukin 2.

However, the Placental barrier is not the sole means to evade the immune system, as foreign fetal cells
also persist in the maternal circulation, on the other side of the placental barrier.

Other

The placenta also provides a reservoir of blood for the fetus, delivering blood to it in case of
hypotension and vice versa, comparable to a capacitor.

Physiology of the Liver

Digestion, The liver plays an active role in the process of digestion through the production of bile.
Bile is a mixture of water, bile salts, cholesterol, and the pigment bilirubin. Hepatocytes in the liver produce
bile, which then passes through the bile ducts to be stored in the gallbladder. When food containing fats
reaches the duodenum, the cells of the duodenum release the hormone cholecystokinin to stimulate the
gallbladder to release bile. Bile travels through the bile ducts and is released into the duodenum where it
emulsifies large masses of fat. The emulsification of fats by bile turns the large clumps of fat into smaller
pieces that have more surface area and are therefore easier for the body to digest.

Bilirubin present in bile is a product of the liver’s digestion of worn out red blood cells. Kupffer cells
in the liver catch and destroy old, worn out red blood cells and pass their components on to hepatocytes.
Hepatocytes metabolize hemoglobin, the red oxygen-carrying pigment of red blood cells, into the
components heme and globin. Globin protein is further broken down and used as an energy source for the
body. The iron-containing heme group cannot be recycled by the body and is converted into the pigment
bilirubin and added to bile to be excreted from the body. Bilirubin gives bile its distinctive greenish color.
Intestinal bacteria further convert bilirubin into the brown pigment stercobilin, which gives feces their brown
color.

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Metabolism, The hepatocytes of the liver are tasked with many of the important metabolic jobs
that support the cells of the body. Because all of the blood leaving the digestive system passes through the
hepatic portal vein, the liver is responsible for metabolizing carbohydrate, lipids, and proteins into
biologically useful materials.

Our digestive system breaks down carbohydrates into the monosaccharide glucose, which cells
use as a primary energy source. Blood entering the liver through the hepatic portal vein is extremely rich in
glucose from digested food. Hepatocytes absorb much of this glucose and store it as the macromolecule
glycogen, a branched polysaccharide that allows the hepatocytes to pack away large amounts of glucose
and quickly release glucose between meals. The absorption and release of glucose by the hepatocytes
helps to maintain homeostasis and protects the rest of the body from dangerous spikes and drops in the
blood glucose level. (See more about glucose in the body.)

Fatty acids in the blood passing through the liver are absorbed by hepatocytes and metabolized to
produce energy in the form of ATP. Glycerol, another lipid component, is converted into glucose by
hepatocytes through the process of gluconeogenesis. Hepatocytes can also produce lipids like cholesterol,
phospholipids, and lipoproteins that are used by other cells throughout the body. Much of the cholesterol
produced by hepatocytes gets excreted from the body as a component of bile.

Dietary proteins are broken down into their component amino acids by the digestive system before
being passed on to the hepatic portal vein. Amino acids entering the liver require metabolic processing
before they can be used as an energy source. Hepatocytes first remove the amine groups of the amino
acids and convert them into ammonia and eventually urea. Urea is less toxic than ammonia and can be
excreted in urine as a waste product of digestion. The remaining parts of the amino acids can be broken
down into ATP or converted into new glucose molecules through the process of gluconeogenesis.

Detoxification, As blood from the digestive organs passes through the hepatic portal circulation,
the hepatocytes of the liver monitor the contents of the blood and remove many potentially toxic substances
before they can reach the rest of the body. Enzymes in hepatocytes metabolize many of these toxins such
as alcohol and drugs into their inactive metabolites. And in order to keep hormone levels within homeostatic
limits, the liver also metabolizes and removes from circulation hormones produced by the body’s own
glands.

Storage, The liver provides storage of many essential nutrients, vitamins, and minerals obtained
from blood passing through the hepatic portal system. Glucose is transported into hepatocytes under the
influence of the hormone insulin and stored as the polysaccharide glycogen. Hepatocytes also absorb and
store fatty acids from digested triglycerides. The storage of these nutrients allows the liver to maintain the
homeostasis of blood glucose. Our liver also stores vitamins and minerals - such as vitamins A, D, E, K, and
B12, and the minerals iron and copper - in order to provide a constant supply of these essential substances
to the tissues of the body.

Unfortunately, one common hereditary disorder called hemochromatosis causes the liver to store
too much iron, potentially leading to liver disease. Modern DNA health testing can help you find out if you

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are genetically at higher risk of acquiring this condition or others like Gaucher disease ad alpha-1 antitrypsin
deficiency, all of which increase your risk of developing liver disease.

Production, The liver is responsible for the production of several vital protein components of blood
plasma: prothrombin, fibrinogen, and albumins. Prothrombin and fibrinogen proteins are coagulation factors
involved in the formation of blood clots. Albumins are proteins that maintain the isotonic environment of the
blood so that cells of the body do not gain or lose water in the presence of body fluids.

Immunity, The liver functions as an organ of the immune system through the function of the
Kupffer cells that line the sinusoids. Kupffer cells are a type of fixed macrophage that form part of the
mononuclear phagocyte system along with macrophages in the spleen and lymph nodes. Kupffer cells play
an important role by capturing and digesting bacteria, fungi, parasites, worn-out blood cells, and cellular
debris. The large volume of blood passing through the hepatic portal system and the liver allows Kupffer
cells to clean large volumes of blood very quickly.

Main structures of human brain

HINDBRAIN (RHOMBENCEPHALON)

Brainstem, Connecting the brain to the spinal cord, the brainstem is the most inferior portion of our
brain. Many of the most basic survival functions of the brain are controlled by the brainstem.

The brainstem is made of three regions: the medulla oblongata, the pons, and the midbrain. A net-
like structure of mixed gray and white matter known as the reticular formation is found in all three regions of
the brainstem. The reticular formation controls muscle tone in the body and acts as the switch between
consciousness and sleep in the brain.

The medulla oblongata is a roughly cylindrical mass of nervous tissue that connects to the spinal
cord on its inferior border and to the pons on its superior border. The medulla contains mostly white matter
that carries nerve signals ascending into the brain and descending into the spinal cord. Within the medulla
are several regions of gray matter that process involuntary body functions related to homeostasis. The
cardiovascular center of the medulla monitors blood pressure and oxygen levels and regulates heart rate to
provide sufficient oxygen supplies to the body’s tissues. The medullary rhythmicity center controls the rate of
breathing to provide oxygen to the body. Vomiting, sneezing, coughing, and swallowing reflexes are
coordinated in this region of the brain as well.

The pons is the region of the brainstem found superior to the medulla oblongata, inferior to the
midbrain, and anterior to the cerebellum. Together with the cerebellum, it forms what is called the
metencephalon. About an inch long and somewhat larger and wider than the medulla, the pons acts as the
bridge for nerve signals traveling to and from the cerebellum and carries signals between the superior
regions of the brain and the medulla and spinal cord.

Cerebellum, The cerebellum is a wrinkled, hemispherical region of the brain located posterior to
the brainstem and inferior to the cerebrum. The outer layer of the cerebellum, known as the cerebellar

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cortex, is made of tightly folded gray matter that provides the processing power of the cerebellum. Deep to
the cerebellar cortex is a tree-shaped layer of white matter called the arbor vitae, which means ‘tree of life’.
The arbor vitae connects the processing regions of cerebellar cortex to the rest of the brain and body.

The cerebellum helps to control motor functions such as balance, posture, and coordination of complex
muscle activities. The cerebellum receives sensory inputs from the muscles and joints of the body and uses
this information to keep the body balanced and to maintain posture. The cerebellum also controls the timing
and finesse of complex motor actions such as walking, writing, and speech.

MIDBRAIN (MESENCEPHALON)

The midbrain, also known as the mesencephalon, is the most superior region of the brainstem.
Found between the pons and the diencephalon, the midbrain can be further subdivided into 2 main regions:
the tectum and the cerebral peduncles.

 The tectum is the posterior region of the midbrain, containing relays for reflexes that involve
auditory and visual information. The pupillary reflex (adjustment for light intensity),
accommodation reflex (focus on near or far away objects), and startle reflexes are among the
many reflexes relayed through this region.
 Forming the anterior region of the midbrain, the cerebral peduncles contain many nerve tracts
and the substantia nigra. Nerve tracts passing through the cerebral peduncles connect regions
of the cerebrum and thalamus to the spinal cord and lower regions of the brainstem. The
substantia nigra is a region of dark melanin-containing neurons that is involved in the inhibition
of movement. Degeneration of the substantia nigra leads to a loss of motor control known as
Parkinson’s disease.

FOREBRAIN (PROSENCEPHALON)

Diencephalon, Superior and anterior to the midbrain is the region known as the interbrain, or
diencephalon. The thalamus, hypothalamus, and pineal glands make up the major regions of the
diencephalon.

The thalamus consists of a pair of oval masses of gray matter inferior to the lateral ventricles and
surrounding the third ventricle. Sensory neurons entering the brain from the peripheral nervous system form
relays with neurons in the thalamus that continue on to the cerebral cortex. In this way the thalamus acts
like the switchboard operator of the brain by routing sensory inputs to the correct regions of the cerebral
cortex. The thalamus has an important role in learning by routing sensory information into processing and
memory centers of the cerebrum.

The hypothalamus is a region of the brain located inferior to the thalamus and superior to the
pituitary gland. The hypothalamus acts as the brain’s control center for body temperature, hunger, thirst,
blood pressure, heart rate, and the production of hormones. In response to changes in the condition of the
body detected by sensory receptors, the hypothalamus sends signals to glands, smooth muscles, and the

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heart to counteract these changes. For example, in response to increases in body temperature, the
hypothalamus stimulates the secretion of sweat by sweat glands in the skin. The hypothalamus also sends
signals to the cerebral cortex to produce the feelings of hunger and thirst when the body is lacking food or
water. These signals stimulate the conscious mind to seek out food or water to correct this situation. The
hypothalamus also directly controls the pituitary gland by producing hormones. Some of these hormones,
such as oxytocin and antidiuretic hormone, are produced in the hypothalamus and stored in the posterior
pituitary gland. Other hormones, such as releasing and inhibiting hormones, are secreted into the blood to
stimulate or inhibit hormone production in the anterior pituitary gland.

The pineal gland is a small gland located posterior to the thalamus in a sub-region called the
epithalamus. The pineal gland produces the hormone melatonin. Light striking the retina of the eyes sends
signals to inhibit the function of the pineal gland. In the dark, the pineal gland secretes melatonin, which has
a sedative effect on the brain and helps to induce sleep. This function of the pineal gland helps to explain
why darkness is sleep-inducing and light tends to disturb sleep. Babies produce large amounts of melatonin,
allowing them to sleep as long as 16 hours per day. The pineal gland produces less melatonin as people
age, resulting in difficulty sleeping during adulthood.

Cerebrum, The largest region of the human brain, our cerebrum controls higher brain functions
such as language, logic, reasoning, and creativity. The cerebrum surrounds the diencephalon and is located
superior to the cerebellum and brainstem. A deep furrow known as the longitudinal fissure runs midsagittally
down the center of the cerebrum, dividing the cerebrum into the left and right hemispheres. Each
hemisphere can be further divided into 4 lobes: frontal, parietal, temporal, and occipital. The lobes are
named for the skull bones that cover them.

The surface of the cerebrum is a convoluted layer of gray matter known as the cerebral cortex.
Most of the processing of the cerebrum takes place within the cerebral cortex. The bulges of cortex are
called gyri (singular: gyrus) while the indentations are called sulci (singular: sulcus).

Deep to the cerebral cortex is a layer of cerebral white matter. White matter contains the
connections between the regions of the cerebrum as well as between the cerebrum and the rest of the body.
A band of white matter called the corpus callosum connects the left and right hemispheres of the cerebrum
and allows the hemispheres to communicate with each other.

Deep within the cerebral white matter are several regions of gray matter that make up the basal nuclei
and the limbic system. The basal nuclei, including the globus pallidus, striatum, and subthalamic nucleus,
work together with the substantia nigra of the midbrain to regulate and control muscle movements.
Specifically, these regions help to control muscle tone, posture, and subconscious skeletal muscle. The
limbic system is another group of deep gray matter regions, including the hippocampus and amygdala,
which are involved in memory, survival, and emotions. The limbic system helps the body to react to
emergency and highly emotional situations with fast, almost involuntary actions.

Meninges, Three layers of tissue, collectively known as the meninges, surround and protect the brain
and spinal cord.

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The dura mater forms the leathery, outermost layer of the meninges. Dense irregular connective tissue
made of tough collagen fibers gives the dura mater its strength. The dura mater forms a pocket around the
brain and spinal cord to hold the cerebrospinal fluid and prevent mechanical damage to the soft nervous
tissue. The name dura mater comes from the Latin for “tough mother,” due to its protective nature.

The arachnoid mater is found lining the inside of the dura mater. Much thinner and more delicate than
the dura mater, it contains many thin fibers that connect the dura mater and pia mater. The name arachnoid
mater comes from the Latin for “spider-like mother”, as its fibers resemble a spider web. Beneath the
arachnoid mater is a fluid-filled region known as the subarachnoid space.

As the innermost of the meningeal layers, the pia mater rests directly on the surface of the brain and
spinal cord. The pia mater’s many blood vessels provide nutrients and oxygen to the nervous tissue of the
brain. The pia mater also helps to regulate the flow of materials from the bloodstream and cerebrospinal
fluid into nervous tissue.

Cerebrospinal fluid (CSF) , a clear fluid that surrounds the brain and spinal cord – provides many
important functions to the central nervous system. Rather than being firmly anchored to their surrounding
bones, the brain and spinal cord float within the CSF. CSF fills the subarachnoid space and exerts pressure
on the outside of the brain and spinal cord. The pressure of the CSF acts as a stabilizer and shock absorber
for the brain and spinal cord as they float within the hollow spaces of the skull and vertebrae. Inside of the
brain, small CSF-filled cavities called ventricles expand under the pressure of CSF to lift and inflate the soft
brain tissue.

Cerebrospinal fluid is produced in the brain by capillaries lined with ependymal cells known as
choroid plexuses. Blood plasma passing through the capillaries is filtered by the ependymal cells and
released into the subarachnoid space as CSF. The CSF contains glucose, oxygen, and ions, which it helps
to distribute throughout the nervous tissue. CSF also transports waste products away from nervous tissues.

After circulating around the brain and spinal cord, CSF enters small structures known as arachnoid
villi where it is reabsorbed into the bloodstream. Arachnoid villi are finger-like extensions of the arachnoid
mater that pass through the dura mater and into the superior sagittal sinus. The superior sagittal sinus is a
vein that runs through the longitudinal fissure of the brain and carries blood and cerebrospinal fluid from the
brain back to the heart.

Physiology of the Brain

Metabolism, Despite weighing only about 3 pounds, the brain consumes as much as 20% of the
oxygen and glucose taken in by the body. Nervous tissue in the brain has a very high metabolic rate due to
the sheer number of decisions and processes taking place within the brain at any given time. Large volumes
of blood must be constantly delivered to the brain in order to maintain proper brain function. Any interruption
in the delivery of blood to the brain leads very quickly to dizziness, disorientation, and eventually
unconsciousness.

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Sensory, The brain receives information about the body’s condition and surroundings from all of
the sensory receptors in the body. All of this information is fed into sensory areas of the brain, which put this
information together to create a perception of the body’s internal and external conditions. Some of this
sensory information is autonomic sensory information that tells the brain subconsciously about the condition
of the body. Body temperature, heart rate, and blood pressure are all autonomic senses that the body
receives. Other information is somatic sensory information that the brain is consciously aware of. Touch,
sight, sound, and hearing are all examples of somatic senses.

Motor Control, Our brain directly controls almost all movement in the body. A region of the
cerebral cortex known as the motor area sends signals to the skeletal muscles to produce all voluntary
movements. The basal nuclei of the cerebrum and gray matter in the brainstem help to control these
movements subconsciously and prevent extraneous motions that are undesired. The cerebellum helps with
the timing and coordination of these movements during complex motions. Finally, smooth muscle tissue,
cardiac muscle tissue, and glands are stimulated by motor outputs of the autonomic regions of the brain.

Processing, Once sensory information has entered the brain, the association areas of the brain go
to work processing and analyzing this information. Sensory information is combined, evaluated, and
compared to prior experiences, providing the brain with an accurate picture of its conditions. The association
areas also work to develop plans of action that are sent to the brain’s motor regions in order to produce a
change in the body through muscles or glands. Association areas also work to create our thoughts, plans,
and personality.

Learning and Memory, The brain needs to store many different types of information that it
receives from the senses and that it develops through thinking in the association areas. Information in the
brain is stored in a few different ways depending on its source and how long it is needed. Our brain
maintains short-term memory to keep track of the tasks in which the brain is currently engaged. Short-term
memory is believed to consist of a group of neurons that stimulate each other in a loop to keep data in the
brain’s memory. New information replaces the old information in short-term memory within a few seconds or
minutes, unless the information gets moved to long-term memory.

Long-term memory is stored in the brain by the hippocampus. The hippocampus transfers information from
short-term memory to memory-storage regions of the brain, particularly in the cerebral cortex of the
temporal lobes. Memory related to motor skills (known as procedural memory) is stored by the cerebellum
and basal nuclei.

Homeostasis, The brain acts as the body’s control center by maintaining the homeostasis of many
diverse functions such as breathing, heart rate, body temperature, and hunger. The brainstem and the
hypothalamus are the brain structures most concerned with homeostasis.

In the brainstem, the medulla oblongata contains the cardiovascular center that monitors the levels
of dissolved carbon dioxide and oxygen in the blood, along with blood pressure. The cardiovascular center
adjusts the heart rate and blood vessel dilation to maintain healthy levels of dissolved gases in the blood

10
and to maintain a healthy blood pressure. The medullary rhythmicity center of the medulla monitors oxygen
and carbon dioxide levels in the blood and adjusts the rate of breathing to keep these levels in balance.

The hypothalamus controls the homeostasis of body temperature, blood pressure, sleep, thirst, and
hunger. Many autonomic sensory receptors for temperature, pressure, and chemicals feed into the
hypothalamus. The hypothalamus processes the sensory information that it receives and sends the output
to autonomic effectors in the body such as sweat glands, the heart, and the kidneys.

Sleep, While sleep may seem to be a time of rest for the brain, this organ is actually extremely
active during sleep. The hypothalamus maintains the body’s 24 hour biological clock, known as the
circadian clock. When the circadian clock indicates that the time for sleep has arrived, it sends signals to the
reticular activating system of the brainstem to reduce its stimulation of the cerebral cortex. Reduction in the
stimulation of the cerebral cortex leads to a sense of sleepiness and eventually leads to sleep.

In a state of sleep, the brain stops maintaining consciousness, reduces some of its sensitivity to
sensory input, relaxes skeletal muscles, and completes many administrative functions. These administrative
functions include the consolidation and storage of memory, dreaming, and development of nervous tissue.

There are two main stages of sleep: rapid eye movement (REM) and non-rapid eye movement
(NREM). During REM sleep, the body becomes paralyzed while the eyes move back and forth quickly.
Dreaming is common during REM sleep and it is believed that some memories are stored during this phase.
NREM sleep is a period of slow eye movement or no eye movement, culminating in a deep sleep of low
brain electrical activity. Dreaming during NREM sleep is rare, but memories are still processed and stored
during this time.

Reflexes, A reflex is a fast, involuntary reaction to a form of internal or external stimulus. Many
reflexes in the body are integrated in the brain, including the pupillary light reflex, coughing, and sneezing.
Many reflexes protect the body from harm. For instance, coughing and sneezing clear the airways of the
lungs. Other reflexes help the body respond to stimuli, such as adjusting the pupils to bright or dim light. All
reflexes happen quickly by bypassing the control centers of the cerebral cortex and integrating in the lower
regions of the brain such as the midbrain or limbic system.

Cardiovascular System Physiology

Functions of the Cardiovascular System

The cardiovascular system has three major functions: transportation of materials, protection from
pathogens, and regulation of the body’s homeostasis.

 Transportation: The cardiovascular system transports blood to almost all of the body’s
tissues. The blood delivers essential nutrients and oxygen and removes wastes and carbon
dioxide to be processed or removed from the body. Hormones are transported throughout the
body via the blood’s liquid plasma.

11
 Protection: The cardiovascular system protects the body through its white blood cells. White
blood cells clean up cellular debris and fight pathogens that have entered the body. Platelets
and red blood cells form scabs to seal wounds and prevent pathogens from entering the body
and liquids from leaking out. Blood also carries antibodies that provide specific immunity to
pathogens that the body has previously been exposed to or has been vaccinated against.
 Regulation: The cardiovascular system is instrumental in the body’s ability to maintain
homeostatic control of several internal conditions. Blood vessels help maintain a stable body
temperature by controlling the blood flow to the surface of the skin. Blood vessels near the
skin’s surface open during times of overheating to allow hot blood to dump its heat into the
body’s surroundings. In the case of hypothermia, these blood vessels constrict to keep blood
flowing only to vital organs in the body’s core. Blood also helps balance the body’s pH due to
the presence of bicarbonate ions, which act as a buffer solution. Finally, the albumins in blood
plasma help to balance the osmotic concentration of the body’s cells by maintaining an
isotonic environment.

The Circulatory Pump, The heart is a four-chambered “double pump,” where each side (left and
right) operates as a separate pump. The left and right sides of the heart are separated by a muscular wall of
tissue known as the septum of the heart. The right side of the heart receives deoxygenated blood from the
systemic veins and pumps it to the lungs for oxygenation. The left side of the heart receives oxygenated
blood from the lungs and pumps it through the systemic arteries to the tissues of the body. Each heartbeat
results in the simultaneous pumping of both sides of the heart, making the heart a very efficient pump.

Regulation of Blood Pressure, Several functions of the cardiovascular system can control blood
pressure. Certain hormones along with autonomic nerve signals from the brain affect the rate and strength
of heart contractions. Greater contractile force and heart rate lead to an increase in blood pressure. Blood
vessels can also affect blood pressure. Vasoconstriction decreases the diameter of an artery by contracting
the smooth muscle in the arterial wall. The sympathetic (fight or flight) division of the autonomic nervous
system causes vasoconstriction, which leads to increases in blood pressure and decreases in blood flow in
the constricted region. Vasodilation is the expansion of an artery as the smooth muscle in the arterial wall
relaxes after the fight-or-flight response wears off or under the effect of certain hormones or chemicals in the
blood. The volume of blood in the body also affects blood pressure. A higher volume of blood in the body
raises blood pressure by increasing the amount of blood pumped by each heartbeat. Thicker, more viscous
blood from clotting disorders can also raise blood pressure.

Hemostasis, Hemostasis, or the clotting of blood and formation of scabs, is managed by the
platelets of the blood. Platelets normally remain inactive in the blood until they reach damaged tissue or leak
out of the blood vessels through a wound. Once active, platelets change into a spiny ball shape and become
very sticky in order to latch on to damaged tissues. Platelets next release chemical clotting factors and
begin to produce the protein fibrin to act as structure for the blood clot. Platelets also begin sticking together
to form a platelet plug. The platelet plug will serve as a temporary seal to keep blood in the vessel and
foreign material out of the vessel until the cells of the blood vessel can repair the damage to the vessel wall.

12
KIDNEY

Anatomy and Physiology of the Kidneys

The kidneys are part of the urinary system. There are 2 kidneys deep inside the upper part of the
abdomen, one on either side of the spine under the lower ribs. The left kidney is slightly higher than the right
kidney.

There is an adrenal gland just above each kidney. These glands are part of the body’s endocrine
system, which is the group of glands and cells in the body that make and release hormones into the blood.
These hormones control many functions such as growth, reproduction, sleep, hunger and metabolism.

The ureters are thin tubes about 25–30 cm (10–12 inches) long that connect the kidneys to the
bladder. The urethra is a small tube that connects the bladder to the outside of the body.

Structure

The kidneys are bean-shaped organs, about the size of one’s fist. An adult kidney is about 12 cm
(4–5 inches) long, 6 cm (2–3 inches) wide and 3 cm (1–2 inches) thick.

13
Each kidney is surrounded by the renal capsule, which is a layer of fibrous tissue. A layer of fatty
tissue holds the kidneys in place against the muscle at the back of the abdomen. Outside the layer of fat is
Gerota’s fascia, or renal fascia. It is a thin, fibrous tissue.

The inside of the kidney is made up of an outer part called the cortex and an inner part called the medulla.
The renal pelvis is a hollow, funnel-shaped area in the centre of each kidney where urine collects.

The renal artery brings blood to the kidney, and the renal vein takes blood away from the kidney.
The area where the renal artery, renal vein and ureter enter the kidney is called the renal hilum.

Inside each kidney is a network of millions of small tubes called nephrons. Each nephron has
corpuscles and tubules. The corpuscles contain tiny blood vessels called glomeruli that filter the blood. A
glomerulus is surrounded by a layer of cells called Bowman’s capsule. Tubules are tiny tubes that collect the
waste materials and chemicals from the blood as it moves through the kidney.

Function

The main function of the kidneys is to filter extra water, impurities and wastes from the blood.

Blood from the body enters the kidneys through the renal arteries. The blood passes through the
nephrons, where waste products and extra water are removed. The clean blood is returned to the body
through the renal veins.

The waste products filtered from the blood are then concentrated into urine. The urine is collected
in the renal pelvis. The ureters move the urine to the bladder, where it is stored. Urine travels from the
bladder and out of the body through the urethra.

The kidneys also make certain hormones, which are substances that control certain body
functions. Hormones made by the kidneys are:

 Erythropoietin (EPO) stimulates the bone marrow to make red blood cells.
 Calcitriol, a form of vitamin D, helps the intestines absorb calcium from the diet.

Renin helps control blood pressure.

14
II. PATHOPHYSIOLOGY

Predisposing Factor Precipitating Factors


Age Diet (High LDL)
Sex Stress
Family History of DM
Family History of HPN

Change in Arteriole Bed

Increase in Intravascular Pressure

Increase cardiac contractility

Produces widespread vasoconstriction in the


peripheral arterioles

Endothelial Damage Vasospams Decrease renal perfusion

Increase endothelial Decrease in placental uterine Spontaneous natriusis


permeability flow

Increase in vasoconstrictors Protein = +4 Increase in angiotensin,


catacholomines

Platelet and fibrin deposition Intravascular volume


depletion

Increase Peripheral Further increase in blood


Resistance volume

15
Fibrinoid necrosis and intimal Fibrinoid necrosis and intimal
proliferation proliferation

Cerebral edema in the brain Headache Blurred Vision

Seizure

Elevated blood pressure

BP=150/90 mm Hg

16
1. PERSONAL DATA

Name: DJI
Age: 27 years old
Gender: Female
Birth Date: 9/26/1990
Birth Place: Zamboanga, Philippines
Marital Status: Single
Nationality: Filipino
Religion: Roman Catholic
Address: Montalban Rizal, Philippines
Educational Attainment: ---
Occupation: Cashier at 7-11
Ward/Room/Bed: Adult Female Ward, #224 Bed 2
Admission Date and Time: April 27,2018
Date Handled: May 3 2018
Admission No.: ---
Admitting Physician: Rontgene M. Solante MD
Admitting Diagnosis: Post Partum Eclampsia G1P1 S/P NSD, Varicella
Chief Complaint: Seizure
Informant: Patient

17
2. FAMILY BACKGROUND

A. GENOGRAM

The genogram depicts that The patient is 2nd to the eldest of


the 3 siblings. Their age ranges from 30 y/o as the eldest,
27y/o down to 25 y/o respectively. She had completed her
pre-natal care and varicella had occurred during her 9th
months of pregnancy.
On the patient paternal side, the family have hisory of
Hypertension. While on her maternal side she doesn’t recall
any diseases had occur.

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3. HEALTH HISTORY

A. PAST HEALTH HISTORY

The patient has no known history of seizure and allergies. She had a normal blood pressure before
and during pregnancy.

The patient is a non-smoker and a non-alcoholic person. After her previous admission from SLH
and after the delivery of her baby, she was given a take-home medication such as Lozartan of 100mg

B. PRESENT HEALTH HISTORY

Patient was admitted in SLH last April 21, 2018, G1P1(1001) associated with varicella and was
discharged last April 25,2018. According to the informants, the patient’s baby girl was left in the institution.

2 days prior to admission the patient experiences headache, dizziness, increased in saliva
production and blocked out which resulted to 5 episodes of seizure, then sought consultation at Amang
Rodriguez Hospital and was given unrecalled medication for seizure but was referred back in our institution
due to the reason that the patient was last seen in SLH and her previous records was in SLH.

C. FAMILY HISTORY

The patient is 2nd of the 3 siblings with the age from 30 y/o, 27 y/o, and 25 y/o respectively. She
had completed her pre-natal care. She acquired varicella during her 9th month of pregnancy.

On the paternal side, her family has a history of hypertension and her father smokes Tobacco.
While on her maternal side, she doesn’t recall any history of the said disease.

D. OB-GYNE HISTORY

The patient was diagnosed with varicella 2 weeks prior to her delivery. The patient had childhood
disease way back her grade school days. Patient had never encountered any hospitalization, accidents and
injuries. Patient had a full-immunization during her childhood days. Prior to her pregnancy, patient has a
regular menstrual cycles occurring 4-5 days a month, uses 3-5 full napkins during her first two days of her
menstruation. The patient takes OTC medications like buscopan venus to treat dysmenorrhea. The patient
never had a history of STD and never had used contraceptive prior to her pregnancy. The patient completed
her 9 months of pre-natal care at the nearest lying-in clinic within the vicinity of their house and was advised
to take ferrous folic acid, iron calcium and vitamin D. The patient has an obstetrical score of G1P1

E. PERSONAL/SOCIAL HISTORY

The patient works as a cashier in a convenience store. On a regular basis, she usually sleeps for 6-8 hours
even before her pregnancy. She also likes to watch television during free time and stays at home whenever
she is off from work. She also emphasized that she likes to eat home cooked foods especially vegetables
and drinks 6-8 glasses of water a day. The patient’s family are living in the province but whenever she has
time to visit, she would gladly visit her family. She also indicated that she drinks occasionally with her
friends before her pregnancy. She has a very good relationship with her family and friends and they have
communicated well since technology was easy nowadays.

19
4. DEVELOPMENTAL DATA

A. ERIK ERICKSON’S PSYCHOSOCIAL DEVELOPMENTAL STAGE

 Adulthood:18-40 years of age


 Ego Development Outcome: Intimacy vs. Isolation
 Basic strengths: Love

PSYCHOSOCIAL DEVELOPMENT

Erikson proposed that we are motivated by the need to achieve competence in certain areas of our
lives. According to psychosocial theory, we experience eight stages of development over our lifespan, from
infancy through late adulthood. At each stage there is a crisis or task that we need to resolve. Successful
completion of each developmental task results in a sense of competence and a healthy personality. Failure
to master these tasks leads to feelings of inadequacy.

Erikson also added to Freud's stages by discussing the cultural implications of development;
certain cultures may need to resolve the stages in different ways based upon their cultural and survival
needs.

Developmental Aspect Ms. J Analysis

Psychosocial Development Ms. J frequently goes out with her friends Ms.J has maintained positive
and tends to socialized with her co- communication with his family
workers in 7/11. She’d go to church every and friends and also to her
Sunday for weekly mass. church group.

COGNITIVE DEVELOPMENT

Adulthood thinking differs significantly from that of middle age and young adults. Adults are
typically more focused in specific directions, having gained insight and understanding from life events that
adolescents and young adults have not yet experienced. No longer viewing the world from an absolute and
fixed perspective, middle adults have learned how to make compromises, question the establishment, and
work through disputes. Younger people, on the hand, may still look for definitive answers.

Developmental Aspect Ms J Analysis

Cognitive Development Ms. J stated that she doesn’t finish her In this aspect, there has been a
college degree, but that doesn’t stop significant implication to her thinking
her in pursuing her dreams. abilities and knows how to look on
the positive side.

20
MORAL DEVELOPMENT

Adults continue to care about their children, spouse and society as a whole. Individuals have
developed their own personal set of ethics and morals that they use to drive their behavior. Most of the time,
their ethics and morals agree with social norms, practices and laws, but there can be conflicts between what
is socially acceptable and what an individual believes. According to post conventional morality, when these
conflicts occur, the individual should stay true to their own ethics.

It refers to a complex process not fully understood. Involves learning what ought to be and what is
not ought to be done, and moral means relating to right and wrong and according to Kohlberg this is the
reason on how individuals decide.

Developmental Aspect Ms.J Analysis

Moral Development Ms.J was able to achieve satisfaction The patient was able to define
in her career because with a sense of good ongoing success to self,
fulfillments and still pursuing her family and friends such as
dreams. She is proud to her siblings learning from her achievements.
due to their achievement. She view’s her life as an ongoing
and challenging life.

SPIRITUAL DEVELOPMENT

This involves the development of personality traits of a highly evolved spirit. These traits include
the ability to love and absence of selfishness. However, spirits incarnate for many different purposes and it
is not really possible to identify who among us is advanced spiritually and who is not.

It refers to the growth and development of an individual to their relationship with the universe and
their perceptions about the direction and meaning of life according to James Fowler that gives meaning to a
person’s life.

Developmental Aspect Ms.J Analysis

Spiritual Development Ms. J is a happy person and a good The patient was able to derive a
daughter to her parents. She gave sense of worth as viewing her
them support financially and She personal life. And also to the
stated that she likes to help out people around them.
especially to their church group when
they need help.

21
B. ROBERT HAVIGHURST’S DEVELOPMENTAL TASK THEORY

Havighurst’s main assertion is that development is continuous throughout the entire lifespan,
occurring in stages, where an individual moves from one stage to the next by means of successful
resolution of problems or performance of developmental tasks. These tasks are typically encountered by
most people in the culture where the individual belongs.

When people successfully accomplish and master these developmental tasks, they feel pride and
satisfaction, and consequently earn the approval of their community or society. This success provides a
sound foundation which allows them to accomplish developmental tasks that they will encounter at later
stages.

Conversely, when people fail to accomplishing a developmental task, they’re often unhappy and
are not accorded the desired approval by society, resulting in the subsequent experience of difficulty when
faced with succeeding developmental tasks.

Havighurst’s Developmental Tasks Theory suggests that we are active learners who continually
interact with a similarly active social environment.

Havighurst proposed a bio psychosocial model of development, wherein the developmental tasks
at each stage are influenced by an individual’s biology (physiological maturation and genetic makeup), his
psychology (personal values and goals), as well as his sociology (specific culture to which the individual
belongs).

Havighurst pointed out the importance of sensitive periods which he considered to be the ideal
teachable moments during which an individual demonstrates maturation at a level that is most conducive to
learning and successfully performing the developmental tasks.

Psychological factors that emerge from the individual’s maturing personality and psyche are
embodied in personal values and goals. These values and goals are another source of some developmental
tasks such as establishing one’s self-concept, developing relationships with peers of both sexes and
adjusting to retirement or to the loss of a spouse.

An enumeration of developmental tasks, therefore, will differ across cultures. Nevertheless,


Havighurst did propose a list of common critical developmental tasks, categorized into six stages of
development which offers a rough picture of what these specific developmental tasks are. Below is a partial
list of Havighurst’s developmental tasks.

Early Adulthood: 18-35 years of age

 Choosing a partner
 Establishing a family
 Managing a home
 Establishing a career

22
ADULTHOOD (18-35 YEARS ACTUAL ANALYSIS
OLD) DEVELOPMENTAL TASK

Choosing a partner The patient had already chosen a Task is achieved.


partner. She is happy, sincere
and focused on her partner.

Establishing a family The patient is active in Church Task is achieved.


together with her family and goes
to church every Sunday.

Managing a home Patient is not yet married to Task is achieved.


someone but does have an
significant others and a son. She
does a good job in maintain a
good healthy relationship with her
significant others.

Establishing a career Patient stated that she has still Task is achieved.
ways to go but she’s already
enjoying her job

5. PATTERNS OF FUNCTIONING

BEFORE ILLNESS DURING ILLNESS


PATTERN OF DURING ANALYSIS
FUNCTIONING HOSPITALIZATION

Eating The patients usual The patient gradually lost The patient eats like There’s no
diet: her appetite and can a normal person do. significant
consume half serving of But on a restriction changes in
her usual diet. of low salt low fat her eating
diet. only her
Breakfast: Breakfast: restriction in
A Cup of rice Toast salt and fatty
An Egg or Hotdog 1 cup of milk/milo foods due to
A One cup of coffee her post
eclampsia.
Lunch: Lunch:
A cup of rice A cup of rice

23
A cup of Vegetables A bowl of soup with meat
A portion of meat 2-3 glasses of water
2-3 glasses of water

Snacks: Snacks:
A slice or bread Cookies
A cup of juice drink A cup of juice drink
Seasonal Fruit Seasonal fruits
1-2 glasses of water 1-2 glasses of water

Dinner: Dinner:
A cup of rice A cup of rice with meat
A cup of vegetables and soup
Fish (fried or A slice of fruit
steamed) 3 glasses of water
3 glasses of water

PATTERN OF BEFORE ILLNESS DURING ILLNESS DURING ANALYSIS


FUNCTIONING HOSPTALIZATION

The patient usually The patient is gradually Approximately, the The patient’s
consume 8-9 losing her appetite and patient can drinking
Drinking
glasses of water. consume more than 8 consume a total of pattern has
Occasional drinking glasses of water. Drinks 1400cc of fluids. no noticeable
of soft drinks and 1 cup of coffee and 1 changes.
juice. Drinks 2 cup glass of milk in a day. Before
of coffee in a day. illness, she
can drink the
normal total
intake of a
person, while
during illness
n o significant
changes
were noted.

24
PATTERN OF BEFORE ILLNESS DURING ILLNESS DURING ANALYSIS
FUNCTIONING HOSPITALIZATION

Elimination/Urin The patient’s The patient’s elimination The patient is not on The patient’s
ation elimination and and urination pattern has a diaper. Defecates elimination
urination pattern is minimal changes. Voids once a day with a and urination
normal. Voids more more than 3 times a day brownish and semi- pattern
than 4 times a day (approximately 1200cc) solid form. before and
(approximately 1600 and defecates once a day during illness
cc) and defecates or every other day. doesn’t have
once a day with a any changes,
brownish color, while during
moist, semi-solid hospitalizatio
form, and moderate n no
in amount. significant
difference is
noticeable
related to her
illness.

PATTERN OF BEFORE ILLNESS DURING ILLNESS DURING ANALYSIS


FUNCTIONING HOSPTALIZATION

The patient’s The patient’s sleeping Patient sleeping The patient


sleeping pattern is pattern is still 7-8 hours pattern is always sleeping
Sleeping
usually 7-8 hours per day. interrupted, it pattern had
per day. became lesser than change due
normal. It became to her illness
6-7 hours per day.

25
PATTERN OF BEFORE ILLNESS DURING ILLNESS DURING ANALYSIS
FUNCTIONING HOSPITALIZATION

The patient can The patient can bathe The patient needs The bathing
bathe herself twice herself twice a day needs assistance in pattern of the
Bathing
a day. without assistance. giving TSB patient
significantly
changed due
to her
illness.

6. LEVELS OF COMPETENCIES

COMPETENCIES BEFORE ILLNESS DURING DURING ANALYSIS


ILLNESS HOSPTALIZATION

Physical The patient can do She seldom The patient cannot do Her physical
activities of daily walks due to grooming and bathing capabilities
living such as eating, fatigue relation in due to her post partum diminish due
grooming, bathing, her unstable BP fatigue and the to her illness
and walking as her so she prefers to patient’s illness and fatigue.
exercise. Outgoing lie down in bed. significantly diminish
person she is and the energy of the
loves to go to the patient.
malls with her family
and significant
others.
Emotional According to her According to her According to her Her emotion
family , she is an family the patient family, Due to her has changed
outgoing, talkative, seems easily be illness the patient because of of
and cheerful person agitated by small seems to become the disease
things. moody and agitated. effect and
hormonal
imbalance of
the patient.
(post partum
depression)

Social The patient is an Most of the time Though she is asleep There is a

26
outgoing person and patient is most of the time, when significant
loves to be with her sleeping or their relatives visits change in her
friends and co- resting. her, she talks to them socializing
worker. She is an (minimally) and most of skills due to
active member in the time will just stare her illness.
their church and at them watching what
treats each one they’re doing
member as her The patient is still
family. faithful and
understands that her
disease is God’s will.
She believes that her
mission in her life is
fulfilled. No negative
Spiritual Patient is a very No changes She can still follow changes on
religious person and aside from her instructions and still the patients
attends mass every memory. She can smart in answering belief on
Sunday with her recall past questions. Supreme
family. She rely on She still go out to Being despite
spiritual beliefs when church without of her
dealing with illness, assistance and disease.
death, tragedy and still participate in Already
wishes bible reading accepted the
when they visited will of God
her at home. She and
still have a good verbalizes,
memory to recall “Tanggap ko
events in their na e nasa
family’s life. lahi namen to
eh.”
Intellectual Expresses ideas and She can still During hospitalization, Before illness
feelings clearly and follow instruction no drastic changes and during
concisely. Learns and answers in a noted due to her illness has no
best by writing smart way. present illness. significant
changes.

27
7. REVIEW OF SYSTEMS Date assessed: 5-3-18

SYSTEM STUDENT NURSE PATIENT/RELATIVE

INTEGUMENTARY “mam, ngayon po ba nakakaranas po “nung mga nakaraang araw oo pero


ba sila ng pangangati sa balat nila?” ngayon wala naman, nung mga
nakaraang linggo lang sya makati.”

“nakakaramdam po ba kayo ng pag- Oo mainit nga young pakiramadam ko


init ng katawan?” ngayon e. (skin warm to touch; t=37.8)
CARDIOVASCULAR “Nakakaramdam po ba kayo ng “aahh, wala nman.”
pananakit ng dibdib? “

Clarify lang po natin mam a, wala po ” oo wala naman”


tayong chest pain o parang mabigat
na pakiramdam sa dibdib?

RESPIRATORY “ilang unan po ang gamit nila pag “mga isa, siguro, okay lang din minsan
natutulog? pag wala”

Minsan po ba nahihirapan silang Hindi, wala nman.


huminga or kinakapos ng hininga?
GASTROINTESTINAL “nakakaramdam po ba sila ng “ngayon wala naman.”
pananakit ng tiyan?

“Kumusta po ang pagkain niyo? May “Wala naman.”


problema ho ba or wala naman?”

Sa pagdumi po nila, okay naman po “simula nung 27 isang beses palang


ba, di naman po nahihirapan? ako dumudumi hanggang ngayon
wala pa din.”
GENITOURINARY “kamusta naman po ang pagihi nila? “sakto lang, kaso di pa ren ako
nakakapuunta ng banyo kaya pag
umiihi ako, nakabedpan lang .”

Kapag po ba umiihi sila, may “Medyo masakit pag umiihi ako dahil
pananakit na nararamdaman? ata sa tahi yun.”

MUSCULOSKELETAL “May pananakit po ba sa kasu- “wala naman, baka sa ngalay lang yun

28
kasuhan ninyo?” kasi matagal na ko nakahiga dito.

“Ano po nararamdaman niyo ngayon? “Oo parang nanghihina ako ng konti


May panghihina po ba?” tapos medyo ngalay .” (body
weakness, fatigue)

NEUROLOGIC
“nakakaranas po ba sila ng pananakit “kagabi sobrang sakit ng ulo ko, kahit
ng ulo o pagkahilo? hanggang ngayon masakit pa ren.

Pwede nyo po bang sabihin sakin Mga 7 lang ngayon, pero kagabi mga
kung gaano kasakit? 10 po yung 9 yung sakit.
pinaka tapos 1 yung hindi.

Mam kamusta po yung pakiramdam Bukod sa medyo masakit yung ulo ko,
nyo ngayon? medyo parang nababalisa lang ako
ngayon kasi di ko pa din nakikita yung
anak ko hanggang ngayon e. Di nga
ako makatulog ng ayos sa gabi kasi
iniisip ko yung baby ko.
HEMATOLOGIC “mam, tanong ko lang po kung normal “ah, hindi po, ngayon lang tumaas
na po bang tumataas ang bp niyo ?” yung bp ko nung pag ka anak ko lang,
pero nung Di pa ko nanganganak,
anemic talaga ako, mababa yung
dugo ko.”

LYMPHATIC “madalas po ba silang magkaubo or “hindi, Wala naman.”


magkasipon?”

29
8. PHYSICAL ASSESSMENT Date assessed: 5-3-18
Appearance: Lying on semi-fowlers position with an on-going IVF of D5LR 1 L at 350 cc level inserted via
right metacarpal vein regulated at 40 gtts/min. Patient was seen fatigue and experiencing body weakness.

Vital Signs: BP – 130/90mmHg; T – 37.8 C; PR – 81 bpm; RR – 23 cpm; O2 - 99%


BODY TECHNIQUE NORMAL ACTUAL ANALYSIS
PARTS USED FINDINGS FINDINGS
Skin Inspection Whitish pink or brown Has lesions Abnormal
in color, dark skin tone scabs seen on skin
depending on patient’s due to varicella
race; no evidence of
discoloration.
No lesions except for
birthmarks or nevi.
Palpation Pinched-up skin Warm skin when Abnormal
returns to its original touched -temperature above
position immediately. =T – 37.8 C the normal range
Dry with minimum due to an increase
perspiration; smooth, in the body's
even and firm; no temperature set-
edema present. point.

Hair Inspection Color varies from dark Normal


black to pale; evenly
distributed; no lesions
in scalp; thin, coarse,
straight, thick or curly
hair.
Nails Inspection Pink to brown cast, flat Pink to brown cast Normal
and slightly rounded.
2-3 seconds capillary
Palpation refill; smooth Capillary refill within 2- Normal
3 seconds and 99%
O2 saturation
Head Inspection Normocephalic and Normocephalic & Normal
symmetrical symmetrical

Palpation Nontender, without


smooth, nontender masses
without masses.

30
Face Inspection Facial features should Has lesions Abnormal
be symmetrical; shape scabs seen on skin
can be round, oval or due to chickenpox
slightly squared; no
involuntary
movements; no edema
and disproportion.
Neck Inspection Symmetrical neck able to perform ROM Normal
muscles; head in full without assistance
ROM without
discomfort

Palpation No palpable masses or No palpable lymph Normal


enlargement of lymph nodes
nodes and thyroid
glands.
Eyes Inspection Eyes are aligned; no Abnormal
involuntary movement -burning sensation - burning sensation
of either eyes due to fever
Both eyes move -mild blurring of vision
smoothly and - mild blurring of
symmetrically in each vision due to
6 cardinal sides eclampsia
No drooping, infections
or tumors
Pink and moist
conjunctiva
Pupil – deep black;
round, and equal in
diameter.
Ears Inspection The patient has no No hearing difficulty Normal
hearing difficulty
Nose Inspection Symmetrical in the Has lesion Abnormal
midline of the face; no scabs seen on skin
lesion, swelling, due to chickenpox
bleeding and masses

31
Mouth Inspection Lips – pink and moist Pink, no lesions Normal
with no evidence of
lesions or inflammation
Tongue – midline in
the mouth; pink, moist Dry lips Normal
and rough; no lesions
and swelling.
Gums – pale red; no
swelling or bleeding.
Chest & Inspection No accessory muscles Symmetrical Chest Abnormal
Thoracic are used in normal Expansion 23 cpm indicates
breathing No retractions tachypnea. this is
Symmetrical Chest RR – 23 cpm due to underlying
Expansion condition
No retractions

Auscultation Vesicular Breath Clear breath sounds Normal


Sounds on lungs, no heart
No Crackles on both murmurs heard
lungs
Abdomen Inspection/ Flat or rounded; birth marks Normal
Palpation/ Symmetrical stretch marks due to post delivery
Auscultation bilaterally; linea nigra on
No discoloration hypogastric and
symphisis pubis
Upper Inspection Able to perform full -Has lesions Abnormal
Extremities ROM -scabs seen on
No lesion, swelling or skin due to
inflammation chickenpox
-with mild numbness -mild numbness
due to decrease in
-swelling with pus on physical mobility
left wrist -thrombophlebitis
with septicaemia
due to IVT
underarms dark in complication
color -due to post
childbirth/delivery

32
Palpation Full and equal pulse Warm skin when Abnormal
on all extremities touched -temperature above
=T – 37.8 C the normal range
due to an increase
in the body's
temperature set-
point.
Lower Inspection Able to perform full -Has lesions Abnormal
Extremities ROM scabs seen on skin
No lesion, swelling or due to varicella
inflammation

Abnormal
Palpation Full and equal pulse -wrinkled skin layer on - wrinkled skin
on all extremities, no feet layer on feet due
edema present to post edema

9. ON-GOING APPRAISAL:

Date: May 3,2018 (Thursday )

We handled the patient on our second day of duty at San Lazaro Hospital Adult Female Ward, room 224
bed 2, the patient in a semi-fowlers position with an on-going IVF of D5LR 1 L at 350 cc level inserted via
right metacarpal vein regulated at 40 gtts/min. The patient was seen fatigue and experiencing body
weakness.
We took the initial vital sign at 0800H;
BP Temperature PR RR O2
130/90mmHg 37.8C 81 bpm 23cpm 99%

Date: May 4, 2018 ( Friday)


On our follow up interviewed the patient was still having up and down pattern of temp ranging from 37. 8
to 37.0 0 C; the patient was still lying on a semi fowler position with an on-going IVF of D5LR at 300 cc level
inserted via right metacarpal vein regulated at 40 gtts/min. As we took her vital signs at 1300H her BP was
130/90 mmHg; RR of 23 cpm and O2 of 99%. She also included that her husband was securing her Nuero
clearance so that she’ll be going home any time. We also asked her approval and signed our written
consent for this study to be presented by our group as our grand case in our finals period. She also allowed
our group to take her contact number in case we need further assessment for our case study.

BP Temperature PR RR O2
130/90mmHg 37-37.8C 80bpm 23cpm 99%

33
10. DIAGNOSTIC TEST

LIPID PROFILE
Lipid Profile: A lipid panel test is a blood test that measures levels of lipids, which are fats and fatty
substances, in the bloodstream.
Purpose: helps to assess a person's risk of developing cardiovascular diseases, including atherosclerosis,
hypertension, heart disease, heart attack and stroke, as well as evaluating the effectiveness of treatments
meant to help lower that risk.
Nursing Responsibility
Pretest Phase
Teach and communicate with the client.
 Type of sample needed
 How it will be collected
 Does it need fasting prior to procedure
Intratest Phase
 Use standard precautions maintain sterility.
 Provides emotional and physical support
 Ensures correct labeling, storage and transportation of specimen.
Post test Phase
 Compares previous and current test result.
Name: DGI Patient ID: 0000000001196193 Date requested: 04/28/2018
Age/Gender: 27/F Pavilion/Bed #: ADULT DEPT..(Pav 2) room 231 bed 1 Time requested:
1:35:36
Test Name SI Units Conventional Units

Result Reference Result Reference


Range Range

Blood Urea Nitrogen 5.21 mmol/L 2.14-7.14 14.59 mg/dL 6-20

Total Cholesterol 5.11 mmol/L Upto 5.2 197.30 mg/dL Upto 200

Triglycerides 1.19 mmol/L Upto 2.3 105.31 mg/dL Upto 200

HDL Cholesterol 1.30 mmol/L (L) > 1.68 50.19 mg/dL >65.0

LDL Cholesterol 3.27 mmol/L (H) < 2.59 126.25 mg/dL <100

SGOT/AST 21.46 U/L Upto 32 21.46 U/L Upto32

SGPT/ALT 21.79 U/L Upto 33 21.79 U/L Upto33

Analysis:
All results are normal except for the HDL cholesterol is low and the LDL cholesterol is high which results to
increase blood pressure.

34
Complete Blood Count (CBC)
Description: The complete blood count (CBC) is one of the most commonly ordered blood tests. The
complete blood count is the calculation of the cellular (formed elements) of blood.
Purpose:
1. To determine the values of blood components.
2. Evaluate the composition and concentration of the cellular components of the blood.
3. Necessary to determine infection, anemia, thrombocytopenia, etc.
4. For early detection of early bleeding tendencies.

Nursing Responsibilities Rationale

Before the Procedure

1. Explain the purpose for the laboratory tests is to To inform the client the importance of the
identify the cause of the infection and hematologic procedure.
disorder.

2. Inform the client for any food, fluid, or drug To prepare the client prior to procedure.
restrictions. Each test should be checked for specific
restrictions.

3.Remember to monitor the clients vital signs before


To obtain a baseline data.
and after the procedure.

During the Procedure

1. Be supportive of the client and family members To alleviate anxiety.


during the procedure.

After the Procedure

1. Check laboratory results and report any abnormal For documentation.


test results.

2. Validate clients reaction and feeling.


For the continuity of care and for the compliance
of the patient.

35
Name: DGI Patient ID: 0000000001196193 Date requested: 04/29/2018 1
Age/Gender: 27/F Pavilion/Bed #: ADULT DEPT..(Pav 2) room 231 bed 1 Time requested: 11:41:23

Exam Name Result Unit Reference Range

White Blood Cell 13.15 (H) 10^9/L 4.0-10.0

Red Blood Cell 4.16 10^12/L 4.0-5.4

Hematocrit 0.39 9/L 0.37-0.43

Hemoglobin 130 9/L 120-160

MCV 94.0 fL 82-98

MCH 31.5 % 28-33

MCHC 33.5 % 33-36

Platelet Count 373 % 150-400

RDW 14 % 11.4-14.0

Neutrophil 67.7 (H) % 55-65

Lympocytes 21.3 (L) % 23-25

Eosinophils 4.0 % 2.0-4.0

Monocytes 6.2 % 3.0-8.0

Basophils 0.8 % 0-1.0

Analysis:
All results are normal except for the neutrophil is high and the lymphocytes are low due to altered
thermoregulation.
URINALYSIS
Description:A urinalysis involves checking the appearance, concentration and content of urine. Abnormal
urinalysis results may point to a disease or illness.

Purpose
1. To check your overall health
2. To diagnose a medical condition.
3. To monitor a medical condition.
NURSING RESPONSIBILITY:
Pretest Phase
1. Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are
recommended.
2. Cover all specimens tightly, label properly and send immediately to the laboratory.

36
Post Test Phase
3. Observe standard precautions when handling urine specimens.
Name: DGI Patient ID: 0000000001196193 Date requested: 04/29/2018
Age/Gender: 27/F Pavilion/Bed #: ADULT DEPT..(Pav 2) room 231 bed 1 Time requested: 15:56:44

Routine Result Reference


Physical

Exam

Color Light Yellow Light Yellow-Amber

Transparency Turbid Clear


(Clarity)

Chemical Result Reference Chemical Result Reference


Analysis Analysis

Glucose Negative < 5.5 mmol/L pH 6.0 5.00-8.00

Bilirubin Negative < 5 umol/L Protein > 4.0 g/L (+4) 0.1 g/L

Ketone 0.5 mmol/L < 0.4 mmol/L Urobilinogen Negative < 4umol/L
trace

Specific 1.035 1.005-1.035 Nitrite Positive +4 Negative


Gravity

Blood >280/uL (+4) < 9/uL Leukocytes > 625/uL (+4) < 14u/L

Ascorbic Acid Negative < 0.5 mmol/L Micro Albumin 150mg/dL < 11mg/L
(+3)

Creatinine 8.8 mmol/L < 0.9 mmol/L Calcium > 12.5 mmol/L < 2.4 mmol/L
(+2) H

Analysis:
All result are normal except for blood +4, creatinine +2, protein +4, nitrite +4, micro albumin +3, calcium
high due to altered functioning of the kidneys caused by high blood pressure.

37
Random Blood Sugar
Description: A random blood glucose test is used to diagnose diabetes. The test measures the level of
glucose (a type of sugar) in your blood.

Purpose: To determine or monitor blood glucose levels of clients at risk for hyperglycemia or hypoglycemia
To promote blood glucose regulation the client
Nursing Responsibilities
Instruct patient to not to eat and drink 2 hours prior to procedure.

Name: DGI Hospital No: 643850 Date extracted : 10:20 am


Age/Gender: 27/F Ward: ER Time released: 4/27/18
Test Normal Values Unit Result

Random Blood Sugar 6.1-8.02 Mmol/L 6.17

Analysis:
The result is within normal ranges.

Test for Treponema Pallidum


Purpose: To screen for or diagnose an infection with the bacterium Treponema pallidum, which causes
syphilis, a sexually transmitted disease (STD)

Treponema Pallidum/Syphilis Result: Nonreactive

Analysis:
Test for Treponema Pallidum was non reactive.

Test for Hepa B Surface Antigen


To screen for or diagnose a hepatitis B virus (HBV) infection or to determine if the vaccine against hepatitis
B has produced the desired level of immunity; may also be used to guide treatment and assess its
effectiveness.

HBsAg (Screening) Result: Nonreactive

Analysis:
Test for Hepa B surface antigen was nonreactive.

38
IV. MEDICAL AND SURGICAL MANAGEMENT

ECG
Electrocardiography is the most commonly used test for evaluating cardiac status, graphically records the
electrical current (electrical potential) generated by the heart. This current radiates from the heart in all
directions and, on reaching the skin, is measured by electrodes connected to an amplier and strip chart
recorder. The standard resting ECG uses five electrodes to measure the electrical potential from 12 different
leads; the standard limb leads (I,II,III), the augmented limb leads (aVf, aVL, and aVr), and the precordial, or
chest, leads(V1throughV6).

PURPOSE
To help identify primary conduction abnormalities, cardiac arrhythmias, cardiac hypertrophy, pericarditis,
electrolyte imbalances, myocardial ischemia, and the site and extent of myocardial infarction.

1. To monitor recovery from an MI.


2. To evaluate the effectiveness of cardiac medication.
3. To assess pacemaker performance
4. To determine effectiveness of thrombolytic therapy and the resolution of ST-segment depression or
elevation and T-wave changes.

PROCEDURE
Patient Preparation for Electrocardiography (ECG)

1. Explain to the patient the need to lie still, relax, and breathe normally during the procedure.
2. Note current cardiac drug therapy on the test request form as well as any other pertinent clinical
information, such as chest pain or pacemaker.
3. Explain that the test is painless and takes 5 to 10 minutes.

Implementation

1. Place the patient in a supine or semi-Fowler’s position.


2. Expose the chest, ankles, and wrists.
3. Place electrodes on the inner aspect of the wrists, on the medical aspect of the lower legs, and on
the chest.
4. After all electrodes are in place, connect the lead wires.
5. Press the START button and input any required information.
6. Make sure that all leads are represented in the tracing. If not, determine which electrode has come
loose, reattach it, and restart the tracing.
7. All recording and other nearby electrical equipment should be properly grounded.
8. Make sure that the electrodes are firmly attached.

39
NURSING RESPONSIBILITIES

1. Disconnect the equipment, remove the electrodes, and remove the gel with a moist cloth towel.
2. If the patient is having recurrent chest pain or if serial ECG’s are ordered, leave the electrode
patches in place.

Computerized Tomography Scan

CT scan delineates the bony anatomy/architecture like cortical integrity more clearly and picks up
pathological fracture and is helpful in assessing ossification and calcification (chondroid component) more
accurately. However, the soft tissue component and medullary extent is best defined by an MRI.

PURPOSES

1. Diagnose muscle and bone disorders, such as bone tumors and fractures
2. Pinpoint the location of a tumor, infection or blood clot
3. Guide procedures such as surgery, biopsy and radiation therapy
4. Detect and monitor diseases and conditions such as cancer, heart disease, lung nodules and liver
masses
5. Monitor the effectiveness of certain treatments, such as cancer treatment
6. Detect internal injuries and internal bleeding

NURSING MANAGEMENT

Preparation for a CT scan typically depends of which part of the body is to be scanned. Usually, the patient
will be asked to:

1. Take off some or all of the clothing and wear a hospital gown.
2. Remove any metal objects, such as a belt or jewelry, which might interfere with image results.
3. Stop eating for a few hours before the scan.
4. If a patient is going to have a contrast injection, he or she should not have anything to eat or drink
for a few hours before the CT scan because the injection may cause stomach upset.
5. To receive the contrast injection, an IV is inserted into the arm just prior to the scan. The contrast
then enters the body through the IV.
6. Prior to most CT scans of the abdomen and pelvis, it is important to drink an oral contrast agent
that contains dilute barium. This contrast agent helps the radiologist identify the gastrointestinal
tract (stomach, small and large bowel), detect abnormalities of these organs, and to separate these
structures from other structures within the abdomen.
7. If the patient has a history of allergy to contrast material (such as iodine), the requesting physician
and radiology staff should be notified.
8. The patient will be asked to drink slightly less than a quart spread out over 1.5 to 2 hours.
9. If an infant or toddler is having the CT scan, the doctor may recommend a sedative to keep the
child calm and still. Movement blurs the images and may lead to inaccurate results.

40
VITAL SIGNS MONITORING

Nursing intervention for the collection and analysis of blood pressure, temperature, pulse rate, respiratory
rate, and O2 saturation were done to determine and prevent the possible complications. It was routine the
monitoring ordered for the client to evaluate progress of her recuperation based on the accepted standards
of client’s current health status.

Nursing Responsibilities

Strictoring of the vital signs is one of the most important nursing responsibilities for any abnormal change in
the client’s vital sign means that there is a problem in the client homeostasis.

1. Take Vital signs accurately. Report any abnormalities to the physician.


2. Ask the patient or relatives about previous activity 30 minutes before taking the vital signs.
3. Inform the patient about the procedure to gain cooperation.
4. Get the pulse, cardiac rate, and respiratory rate in one full minute.
5. Get the temperature in 5-10 minutes for axilla, oral 2-3 minutes, and 1-2 minutes for
rectal.
6. Check the tightness or looses of BP cuff.

Intravenous Fluid

Is therapy that delivers liquid substances directly into a vein. The intravenous (IV) route of
administration can be used for injections (with a syringe at higher pressures) or infusions (typically using
only the pressure supplied by gravity). Intravenous infusions are commonly referred to as drips. The
intravenous route is the fastest way to deliver medications and fluid replacement throughout the body,
because the circulation carries them. Intravenous therapy may be used for fluid replacement (such as
correcting dehydration), to correct electrolyte imbalances, to deliver medications, and for blood transfusions.

Purposes of Intravenous (IV) Therapy

1. To supply fluid when clients are unable to take in an adequate volume of fluids by mouth.
2. To provide salts and other electrolytes needed to maintain electrolyte imbalance.
3. To provide glucose (dextrose), the main fuel for metabolism.
4. To provide water-soluble vitamins and medications.
5. To establish a lifeline for rapidly needed medications.

NURSING CONSIDERATION

1. Verify the doctor’s order


2. Know the type, amount and indication of IV therapy.
3. Practice strict asepsis.
4. Inform client and explain purpose of therapy.
5. PRIME IV tubing to expel air. This will prevent air embolism.
6. Clean the insertion site of IV needle from center to the periphery with alcoholized cotton swab.
7. Shave area of needle insertion if hairy.
8. Change IV tubing every 72 hours to prevent contamination.

41
9. Change/alter needle insertion site every 72 hours to prevent thrombophlebitis.
10. Regulate IV every 15-20 minutes to ensure administration of proper volume of IV fluid as ordered.
11. Observe for potential complications.

***Lactated Ringer’s Solution with 5% Dextrose (D5LR)

Lactated Ringer's and 5% Dextrose Injection, USP administered intravenously has value as a source of
water, electrolytes, and calories. One liter has an ionic concentration of 130 mEq sodium, 4 mEq potassium,
2.7 mEq calcium, 109 mEq chloride and 28 mEq lactate. The osmolarity is 525 mOsmol/L (calc).
Normal physiologic range is approximately 280 to 310 mOsmol/L. Administration of substantially hypertonic
solutions may cause vein damage. The caloric content is 180 kcal/L.

NURSING RESPONSIBILITIES

1. Monitor I & O accurately.


2. Explain rules of I & O monitoring. All fluids taken must be recorded.
3. Follow the prescribed fluid intake limit. Regulate well the IV hourly.
4. Monitor electrolytes to determine any imbalances.

DIET

Dietary regulation depends on the severity of the disease. Therapeutic diets involve modification of food
intake to supplement the needs of the client’s body. The eating pattern of the client is prepared by the
nutritional components necessitated by a client’s disease state or nutritional status or to prepare a client for
a procedure.

LOW SALT LOW FAT DIET

PURPOSE

The purpose of a low-salt, low-fat and low-cholesterol diet, often referred to as a heart-healthy diet, is to
reduce the amount of cholesterol in your blood and also to prevent fluid retention. Most often called the
silent killer; hypertension is a consistent blood pressure that never goes below 140/90 mmHg, only higher.
Inability to control or maintain a normal blood pressure risks the patient to increase chances of heart failure
and MI.

NURSING RESPONSIBILITIES

One of the factors that increase the risk of developing hypertension is a high sodium diet. For people who
had already existing hypertension, here are tips to reduce the sodium you consume:

1. Read the labels on your food containers.


2. Only use products with reduced sodium or no salt added.
3. To enhance the flavors when cooking, use spices, herbs, oils, and lemon to add food flavor.
4. Rinse canned foods to remove more sodium.
5. Eat fresh foods because processed foods contain a high amount of sodium.
6. Adhere to the DASH (Dietary Approaches to Stop Hypertension) of the National Heart, Lung,
and Blood Institute. DASH recommends to have a daily 2, 000 calorie diet of:

42
DRUG STUDY

Name of Drug Route. Dosage & Indication Mechanism of Action Contraindication Adverse Effects Nursing Consideration
Frequency
Generic Name: Route: a pain reliever and Pain relief may result Hypersensitivity to drug Hepatic: Observe for acute toxicity
Paracetamol Oral Route a fever reducer from inhibition of and overdose.
Hepatotoxicity
Brand Name: prostaglandin synthesis in
Dosage:
Biogesic Metabolic:
300mg CNS
Classification:
Frequency: Hypoglycemic Coma
Analgesic
Q4
Skin:

Rash, Uricaria

Generic Name: Route: treat high blood pressure Inhibits influx of Hypersensitivity to drug CNS: Monitor heart rate and
Amlodipine Besylate Oral Route (hypertension) extracellular calcium ions, Headache, Dizziness, rhythm and blood
Brand Name: Dosage: thereby decreasing Drowsiness pressure
Norvasc L 1 tab
myocardial contractility, CV:
Classification: Frequency: relaxing coronary and Palpitation
Calcium Channel Blocker OD
vascular muscles and GI:
decreasing peripheral Nausea, Abdominal
resistance Discomfort

43
Name of Drug Route. Dosage & Indication Mechanism of Action Contraindication Adverse Effects Nursing Consideration
Frequency
Generic: Route: treat high blood pressure Blocks stimulation of Heart rate below 45 CNS: Measure blood pressure
Metoprolol tartrate Oral Route and prevent angina beta1(myocardial) beats/minute. Fatigue, weakness, closely when starting
(chest pain) adrenergic receptors, dizziness therapy.
Brand: Dosage: usually without affecting CV:
Apo-Metoprolol 50mg/tab beta2 (pulmonary, Pulmonary edema
vascular, uterine) EENT:
Classification: Frequency adrenergic receptor sites Blurred vision, stuffy
Beta adrenergic blockers TID Nose
Generic: Route: used to treat partial Prevent seizures by Hypersensitivity to drug CNS: Measure temperature and
Levetiracetam Oral Route onset seizures in adults inhibiting nerve impulses or its components Aggression, Irritability watch for signs and
in hippocampus of brain. EENT symptoms of infection
Brand: Dosage: Rhinitis, Sinusitis
Keppra 500mg GI:
Nausea, Vomiting,
Classification: Frequency Respiratory:
Anticonvulsant OD Cough

44
Name of Drug Route. Dosage & Indication Mechanism of Action Contraindication Adverse Effects Nursing Consideration
Frequency
Generic: Route: an iron supplement used Replaces iron stores Hypersensitivity to drug CNS Watch for signs and
Ferrous Sulfate Oral Route to treat or prevent low found in hemoglobin in or its components Drowsiness, headache symptoms of
blood levels of iron red blood cells, GI hypersensitivity reaction
Brand Name: Dosage: myoglobin and other Upset stomach, nausea,
1 tab heme enzymes in the diarrhea
Fersulfate Iron
body.
Frequency

Classification: OD

Anti-Anemic

Generic: Route: help lower "bad" Reduces concentration of Hypersensitivity to drugs CNS: Monitor blood lipid levls
Atorvastatin Calcium Oral Route cholesterol and fats (such serum cholesterol and or its components Amnesia, Abnormal results.
as LDL, triglycerides) and low density lipoprotein dreams
Brand: Dosage: raise "good" cholesterol CV:
Lipitor 20mg/tab (HDL) in the blood. Orthostatic hypotension
Metabolic:
Classification: Frequency Hypoglycemia
HMG-CoA reductase OD
Inhibitor

45
Top 10 Prioritized Nursing Diagnosis

1. Ineffective Tissue Perfusion


2. Ineffective Thermoregulation
3. Alteration in Comfort (Headache)
4. Activity Intolerance
5. Impaired Skin Integrity
6. Anxiety
7. Disturbed Sleeping Pattern
8. Risk for Injury
9. Ineffective Coping
10. Alteration In Urinary Elimination

46
Ineffective Tissue Perfusion

CUES Nursing Diagnosis Rationale Goals Nursing Interventions Rationale Evaluation

Objectives: Ineffective tissue The presence of partial Short Term Independent: Short Term
perfusion related to blockage of the blood  Establish rapport  To promote
After 15-30 minutes of After 15-30 minutes of
interruption of blood flow vessel can be cooperation
nursing interventions, the nursing interventions, the
Lipid Profile results: as manifested by: multifactorial. These can  Monitor vital and
client will be able to:  To provide baseline client:
cognitive signs, data and monitor
be due to watching for changes
 HDL cholesterol  Headache changes.
vasoconstriction, fat  BP reduces from in blood pressure,  Reduced BP to
(1.30mmol/L [L]) Lipid Profile results: heart and respiratory
accumulation and 130/90 to 120/80 120/90
 LDL cholesterol rate.
 HDL cholesterol therefore decreases mmHg GOAL PARTIALLY MET
(3.27mmol/L [H])  Check for capillary  To determine blood
(1.30mmol/L [L]) elasticity of vessel wall  Demonstrate stable circulation
refill Long Term
 LDL cholesterol leader to alteration of vital sign
Urinalysis results: (3.27mmol/L [H]) Long Term  Elevate head of bed  To promote After 8 hours of combined
blood perfusion.
to 45 degrees circulation
Urinalysis results: independent, dependent
 Blood (>280/uL [+4]) After 8 hours of combined
 Enough rest is nursing interventions, the
 Creatinine (8.8 independent, dependent,  Advise patient to
 Blood (>280/uL [+4]) needed to conserve
Reference: Medical have enough rest client:
mmol/L [+2])  Creatinine (8.8 and collaborative nursing energy
Surgical 13th Edition p.
 Calcium (>12.5 mmol/L [+2]) interventions, the client  Have not maintained
1472  Instruct patient to
mmol/L [H]) will be able to have: avoid neck flexion  To avoid obstruction normal laboratory
 Calcium (>12.5 of arterial and
and extreme results
V/S as follows: mmol/L [H]) venous blood flow
 Maintained normal hip/knee extension
GOAL PARTIALLY MET
BP- 130/90 mmHg laboratory results

47
V/S as follows:  Breathing and  To promote
relaxation exercises circulation
BP- 130/90 mmHg
 Emphasize need for  To enhance
regular exercise circulation and
program promote general
well-being.

 Discourage sitting,
standing, crossing  These restricts
legs for extended circulation and leads
period of time to venous stasis and
edema

Dependent:
Administer medications  To help alleviate
as prescribed. Symptoms

Amlodipine 1tab OD  Treats high blood


given pressure

-Metoprolol tartrate  Used for treating


50mg/tab TID given OD high blood pressure

 Helps lower bad


Atoravastatin 20mg/tab cholesterol and fats
and raise good
cholesterol

48
Ineffective Thermoregulation

CUES Nursing Diagnosis Rationale Goals Nursing Interventions Rationale Evaluation

Subjective: Ineffective Hyperthermia is caused Short Term Independent: Short Term


“Oo, mainit nga yung thermoregulation by the tissue trauma. This  Monitor vital and  To provide baseline After 20-30 minutes of
After 10-20 minutes of
pakiramdam ko ngayon, (hyperthermia) related to is a normal response of cognitive signs, data and monitor nursing interventions, the
nursing interventions, the watching for changes changes.
eh.” as verbalized by viral infection as the body to fight for a temperature client
client will be able to:
the patient. manifested by: persistent infection that is
 Reduced
caused by a certain virus  Reduce temperature  Note
Objectives:  Skin warm to touch presence/absence of  Heat loss decreased temperature from
which may have entered from 37.8*C to by environmental
 Flushed skin sweating as body 37.8*C to 37.5*C
 Skin warm to touch the body of the patient. 37.5*C attempt to increase factors that causes
heat loss inability to sweat GOAL MET
 Flushed skin
CBC results:
CBC results: Long Term Long Term
 Maintain ambient  To prevent for
 White blood cell Reference: Medical temperature in client’s heat After 3 hours of combined
 White blood cell After 2-3 hours of production or heat
(13.15 [H]) Surgical 13th Edition p. comfortable range independent, dependent,
(13.15 [H]) combined independent, loss
 Neutrophil (67.7 [H]) 873 and collaborative nursing
 Neutrophil (67.7 [H]) dependent, and
 Lymphocytes  Render tepid sponge  To restore or interventions, the client:
 Lymphocytes collaborative nursing
bath maintain body
(21.3[L]) interventions, the client
(21.3[L]) temperature of  Maintain temperature
will be able to: cooling
V/S as follows: from 37.5 *C to 36.5
V/S as follows:  To promote skin *C
Temp: 37.8 C*  Maintain temperature  Increase fluid intake
circulation
GOAL PARTIALLY MET
Temp: 37.8 C* from 37.5 *C to 36.5 *C

49
 Instruct to wear loose  To enhance skin
clothes circulation and
ventilation
 Continuous  To restore or
rendering of tepid maintain body
sponge bath temperature of
cooling

 Health education  Body’s normal


response to infection
Dependent:
 Administer  To help alleviate
medications as Symptoms
prescribed.

-Paracetamo 300mg Q4  A fever reducer

50
Alteration in Comfort

CUES Nursing Diagnosis Rationale Goals Nursing Interventions Rationale Evaluation

Subjective: Alteration in comfort Blood pressure is the vital Short Term Independent: Short Term
(headache) related to force that propels After 15-30 minutes of  Monitor vital and  To provide baseline
“Kagabi sobrang sakit ng After 30 minutes of
increased intravascular oxygen-rich blood to all nursing interventions, the cognitive signs, data and monitor
ulo ko, kahit hanggang watching for changes changes. nursing interventions, the
pressure as manifested parts of your body. When client will be able to: in blood pressure,
ngayon masakit pa rin.” client will be able to:
by: an elevated Blood heart and respiratory
as verbalized by the  Reduce pain scale rate.
pressure occurs, an  Reduce pain scale
patient. from moderate 7/10
increased in vascular  Assist client with  Dizziness and from moderate 7/10
to mild at least 3/10 ambulation as
Objectives:  Guarding behavior pressure may cause blurred vision to mild at least 5/10
needed frequently are
 Decrease blood
 Facial Grimace constriction of blood flow associated with
 Guarding behavior pressure to
 Headache that may lead to different vascular headache GOAL PARTIALLY MET
 Facial Grimace 120/80mmHg
 Pain scale of 7/10 symptoms like headache.  Limit visitors inside  To provide relaxation
 Headache Long Term the room and quiet
 Pain scale of 7/10 After 3-4 hours of environment Long Term
combined independent,
Reference: Medical  Enhances the body’s
V/S as follows:  Breathing and After 3-4 hours of
dependent nursing circulation that
V/S as follows: Surgical 13th Edition p. relaxation exercises
reduces pain combined independent,
interventions, the client
BP- 130/90 mmHg 1097
BP- 130/90 mmHg dependent, and
will be able to:  Assist in comfortable
 To relieve comfort collaborative nursing
position
and ease pain
 Express no pain interventions, the client:

51
 Emphasize need for  To enhance  Expressed light pain
regular exercise circulation and
 Maintain normal
program promote general
well-being. laboratory results
 Discourage sitting,  These restricts
standing, crossing circulation and leads
legs for extended to venous stasis and GOAL PARTIALLY MET
period of time edema

52
Activity intolerance

CUES Nursing Diagnosis Rationale Goals Nursing Interventions Rationale Evaluation

Subjective: Activity intolerance Activity intolerance is Short-term goal: Independent: Short Term
related to generalized characterized as an After 30 minutes to 1 hour  -Provide a quiet  -To promote adequate
Patient: “Oo nanghihina After 1 hour of nursing
body weakness as of nursing intervention, environment rest
ako ng konti tapos medyo insufficient physiological interventions, the client
evidenced by: the patient will be able to:
ngalay." or psychological energy  -Encourage  -To reduce muscle
 Body weakness to endure or complete  Identify negative relaxation tension
techniques
Objective: required or desired daily factors affecting Identified negative factors
activities due to activity intolerance affecting activity intolerance
 Body weakness  -Maintain heavy
accommodation of body activity  -Reduces physical and reduced their effects by
and reduce their
restrictions stress and oxygen
malaise, weakness and effects by participate demand participate willingly in mild
usually fatigue. willingly in mild desired activities.

desired activities.  -To minimize sob if


Reference:  -Position the happens
client in
Medical-Surgical by Long –term goal: Goal partially met!
comfortable
position as
Brunners and Suddarths After 2 days of nursing he/she preferred.
10th edition intervention, the patient
Long Term
Page. 679 will be able to:  -Plan care to
carefully balance
After 2 days of nursing
rest periods with
 -to reduce fatigue interventions, the client
activities

53
 Report measurable reported measurable
increase in activity increased in activity
tolerance as evidence tolerance as evidenced by
by the patient will the patient was moving
move freely and freely and without any
without any problems problems

Goal met!

54
Impaired skin integrity
CUES Nursing Diagnosis Rationale Goals Nursing Interventions Rationale Evaluation

Short term: Independent: Short term:


 Determine age  Elderly patients’
Subjective: Impaired skin integrity Impaired skin integrity is After 30 mins. To 1 hour After 1 hour of nursing
of patient. skin is normally
related to varicella as an accommodation of an of nursing intervention the intervention, the patient
Patient " Nung mga less elastic and
manifested by: infection on caused by patient will be able to: was able to participate in
nakaraang araw, oo pero has less
varicella-zoster virus, a prevention measures and
ngayon, wala naman. moisture,
member of a group of treatment program about
Nung mga nakaraang Participate in prevention making for
DNA viruses. The virus the chicken pox.
linggo lang siya makati." measures and treatment higher risk of
causing chicken pox is
 Skin scabs due program about the skin impairment
indistinguishable, hence,
to varicella the name of varicella- chicken pox. Goal met!
Objectives:  Dry lips zoster virus. The disease  Healthy varies
 Assess patients
 wrinkled skin is characterized by from individual
 Skin scabs due general
layer due to post Long term: Long term:
to varicella painful vesicular eruption to individual, but
condition of skin
edema. along the area of should have
 Dry lips After 2 days of nursing
distribution of the sensory good turgor. intervention, the patient
 wrinkled skin After 2 days of nursing
nerves from one or more was not able to decrease
layer due to post intervention, the patient
posterior ganglia. It is  Skin stretched in skin lesions but able to
edema. will be able to:  Assess for
represent a reactivation tautly over decreased in skin
patients Edema
of latent varicella virus edematous dryness.

55
Reference: infection and reflects Remain intact as tissue is at risk
lowered immunity. evidenced by decrease in for impairment
Nursing Diagnosis 10th  Reassess skin
edition Page.870 skin lesions, dry skin.  The incidence
often and Goal partially met!
and onset of
Reference: whenever
skin breakdown
patient’s
Medical-Surgical Nursing is directly related
condition or
13th edition to the number of
treatment plan
Brunner and Suddarth’s risk factors
result in an
Page 1670 present
increases
number of risk
factors

Dependent:

Administered skin  To treat skin


moisturizer as prescribed
irritability and
by the physician.
skin dryness and
other underlying
cause.

56
Discharge Planning
Medication:

Generic/Brand Name Preparation Dosage Action


Amlodipine Besylate/ Oral before or after 1 tab treat high blood pressure
Norvasc L meal
(hypertension)
Metoprolol tartrate/ Oral before or after 50mg/tab treat high blood pressure
Apo-Metoprolol meal
(hypertension)

Environment:

 Your obstetrician may tell you to rest more often. You may need total bed rest if you have more
severe symptoms of eclampsia after giving birth.
 Well ventilated surroundings may help the client to breathe properly and to minimize other
underlying factors for post-partum eclampsia.

Treatment:

 Client should check her blood pressure each day. Sit and rest for 5 minutes before taking her BP.
Extend the arm and support it on a flat surface. Her arm should be at the same level as her heart.
Follow the directions that came with the BP monitor. Take BP at least 2 times each day with the
help of some relatives or member of the family. Choose the same times each day, such as morning
and evening. Take at least 2 BP readings each time. Keep a record of BP readings and bring it to
the follow-up visits. Ask a healthcare provider what the BP should be.

Health Teaching:

 Uterine Changes, After-pains, or cramping, are normal. This cramping means that the uterus is
contracting to return to its non-pregnant size. The uterus takes five to six weeks to return to its non-
pregnant size.
 Vaginal Discharge Usually lasts about ten days to four weeks. The color will change from bright red
to brownish to tan and will become less in amount and finally disappear.
 Menstruation: your period will resume in approximately six to eight weeks, unless breastfeeding.

Outpatient Referral:

 Follow up 1-2 weeks after delivery to evaluate the patient for BP control and any residual deficits
from the eclamptic seizure. Patients with persistent hypertension past 8 weeks' puerperium or
neurologic changes may need medical referral.

Diet:
• Encourage patient not to skip meals
• Identified foods rich in vitamins and mineral for the patient
• Instruct the client to eat properly and with discipline to prevent possible problem that may causes
the blood pressure to high. Advise the client to avoid fatty foods and high cholesterol enriched
foods.

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