Angeles University Foundation

College of Nursing
Academic Year 2019 - 2020

MacArthur Highway, Lourdes Sur East, Angeles City 2009

POST NORMAL SPONTANEOUS

DELIVERY; PRE-ECLAMPSIA
WITH SEVERE FEATURES
(Pre-eclampsia)

A Case Study presented by:

BSN II – D | Group 13

Badilla, Rafaela Marejka R.

Buenafe, Zion Merbel D.
Caraan, Zedrake C.
Pineda, Jhaymee M.

Ma. Teresa S. Cabanayan, RN, MN

Clinical Instructor

JBLMRH OB WARD
I. INTRODUCTION

According to a recent study conducted last February of 2018, Pre-eclampsia is a leading

cause of maternal mortality, responsible annually for over 60,000 maternal deaths around the
globe and complicate 5% of all pregnancies. Pre-eclampsia is a multisystem disease featuring
hypertension, proteinuria, and renal, hepatic, and neurological involvement. Diagnosis is often
elusive, as clinical presentation is highly variable. Even those with severe disease can remain
asymptomatic. Angiogenic factors are emerging as having a role in the diagnosis of pre-
eclampsia and in prognostication of established disease.

To diagnose preeclampsia, you have to have high blood pressure and one or more of the
following complications after the 20th week of pregnancy and these are having protein in your
urine (proteinuria), a low platelet count, an impaired liver function, signs of kidney problems
other than protein in the urine, fluid in the lungs (pulmonary edema) and new-onset headaches
or visual disturbances. Previously, preeclampsia was only diagnosed if high blood pressure and
protein in the urine were present. However, experts now know that it's possible to have
preeclampsia, yet never have protein in the urine. A blood pressure reading in excess of 140/90
mm Hg is abnormal in pregnancy. However, a single high blood pressure reading doesn't mean
you have preeclampsia. If you have one reading in the abnormal range — or a reading that's
substantially higher than your usual blood pressure — your doctor will closely observe your
numbers. Having a second abnormal blood pressure reading four hours after the first may
confirm your doctor's suspicion of preeclampsia. Your doctor may have you come in for
additional blood pressure readings and blood and urine tests.

If the doctor suspects preeclampsia, you may need certain tests, including blood tests in
which your doctor will order liver function tests, kidney function tests and also measure your
platelets — the cells that help blood clot, a urine analysis in which your doctor will ask you to
collect your urine for 24 hours, for measurement of the amount of protein in your urine. A single
urine sample that measures the ratio of protein to creatinine — a chemical that's always present
in the urine — also may be used to make the diagnosis, a fetal ultrasound in which your doctor
may also recommend close monitoring of your baby's growth, typically through ultrasound. The
images of your baby created during the ultrasound exam allow your doctor to estimate fetal
weight and the amount of fluid in the uterus (amniotic fluid) and a nonstress test or biophysical
profile in which a nonstress test is a simple procedure that checks how your baby's heart rate
reacts when your baby moves. A biophysical profile uses an ultrasound to measure your baby's
breathing, muscle tone, movement and the volume of amniotic fluid in your uterus.

Treatments are available for the said condition, the most effective treatment for
preeclampsia is delivery. You're at increased risk of seizures, placental abruption, stroke and
possibly severe bleeding until your blood pressure decreases. Of course, if it's too early in your
pregnancy, delivery may not be the best thing for your baby.

If you're diagnosed with preeclampsia, your doctor will let you know how often you'll
need to come in for prenatal visits — likely more frequently than what's typically recommended
for pregnancy. You'll also need more frequent blood tests, ultrasounds and nonstress tests than
would be expected in an uncomplicated pregnancy.

Possible treatment for preeclampsia may include, medications to lower blood pressure. These
medications, called antihypertensives, are used to lower your blood pressure if it's dangerously
high. Blood pressure in the 140/90 millimeters of mercury (mm Hg) range generally isn't
treated. Although there are many different types of antihypertensive medications, a number of
them aren't safe to use during pregnancy. Discuss with your doctor whether you need to use an
antihypertensive medicine in your situation to control your blood pressure. Corticosteroids, if
you have severe preeclampsia or HELLP syndrome, corticosteroid medications can temporarily
improve liver and platelet function to help prolong your pregnancy. Corticosteroids can also
help your baby's lungs become more mature in as little as 48 hours — an important step in
preparing a premature baby for life outside the womb and anticonvulsant medications, if your
preeclampsia is severe, your doctor may prescribe an anticonvulsant medication, such as
magnesium sulfate, to prevent a first seizure.

Also, bed rest used to be routinely recommended for women with preeclampsia. But
research hasn't shown a benefit from this practice, and it can increase your risk of blood clots, as
well as impact your economic and social lives. For most women, bed rest is no longer
recommended.

However, severe preeclampsia may require that you be hospitalized. In the hospital, your
doctor may perform regular nonstress tests or biophysical profiles to monitor your baby's well-
being and measure the volume of amniotic fluid. A lack of amniotic fluid is a sign of poor blood
supply to the baby and if you're diagnosed with preeclampsia near the end of your pregnancy,
your doctor may recommend inducing labor right away. The readiness of your cervix —
whether it's beginning to open (dilate), thin (efface) and soften (ripen) — also may be a factor in
determining whether or when labor will be induced.

In severe cases, it may not be possible to consider your baby's gestational age or the
readiness of your cervix. If it's not possible to wait, your doctor may induce labor or schedule a
C-section right away. During delivery, you may be given magnesium sulfate intravenously to
prevent seizures. If you need pain-relieving medication after your delivery, ask your doctor what
you should take. NSAIDs, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium
(Aleve), can increase your blood pressure. After delivery, it can take some time before high
blood pressure and other preeclampsia symptoms resolve.

With the complexity of the said condition we have chosen the client’s case for us to
come up with a wider perception of pre-eclampsia and what to expect during the postpartal
period. Through focusing on our client’s condition, we are letting ourselves be educated on this
kind ofcondition, manifestations, and proper management. Establishing this clinical case study
will enable us to view the different current trends pertaining to obstetrics and gynecology, most
especially about pre-eclampsia with severe features. Upon administrating this case study, we
will be able to implement the most satisfying and accurate nursing care actions because of the
comprehensive plans the student nurses have come up. This clinical case will aid us, as student
nurses, to further point out essential information regarding pre-eclampsia, and in case
complications might occur.

II. NURSING PROCESS

A. Assessment
 1. PERSONAL DATA

a. demographic data

b. socio-economic and cultural factors

c. environment factors

2. PERSONAL HISTORY

a. Maternal-Obstetric record

b. Antepartal/ Prenatal preparation

c. significant trimestral changes

3. Family health illness history (up to 3rd degree relationship, genorgram)

 DIABETES DIABETES HYPERTENSION

Grandfather Grandmother Grandfather Grandmother

1936 1935 1939 1940

Uncle Auntie Auntie Uncle Auntie Uncle Mother Uncle Auntie Uncle Auntie Father Uncle
1953 1954 1955 1956 1958 1959 1960 1958 1959 1960 1961 1962 1963

Brother Patient
1980 1984

The genogram indicates that the patient’s family from her mother side experienced having
diabetes, in both of her grandfather and grandmother while on her father side her grandfather
experienced having hypertension and her grandmother experienced death due to her old age.

4. History of past illness (disease/ ailments not relevant to patient’s present condition)
According to Patient, if she can recall during her childhood years she would always get sick; the
usual and non-severe childhood illnesses such as common colds, cough, abdominal pain, fever
and these illnesses would last for about a how many days and not to exceed a week, while
during her adolescent age she would experience again common diseases and illnesses; common
colds, cough, fever, dysmenorrhea and diarrhea and because Patient grew up in Samar, wherein
according to her medicines aren’t much available for them, they wouldn’t just buy from any
drugstores and buy those that were prescribed by their physician, they would rarely take
vitamins and but they practice drinking a lots of fluid especially water.

5. History of present illness (disease/ ailments relevant to patient’s condition)

6. Physical examination (Cephalocaudal approach)

(initial assessment upon admission and on every NPI, specific dates should also be
included)

7. DIAGNOSTICS AND LABORATORY PROCEDURES

Diagnostics/ Date ordered date Indications or Results (1st, 2nd, Normal values Analysis and Nursing
laboratory results IN purposes 3rd) (unit used in the interpretation Responsibiliti
procedures hospital) of results es
(CLIENT-
CENTERED)

Creatinine Date Ordered: To monitor or 47.60 umol/L 50.4 – 56.1 The results are Prior:
December 15, to know if the umol/L normal. -Review the
2019 kidneys are Normal patient’s chart.
functioning creatinine level -Prepare all the
normally or are indicates that materials to be
Date of Result: effectively the kidneys are used.
December 15, filtering functioning -Position
2019 creatinine and normally and patients
disposing it in creatinine is properly
the urine. If effectively
Lactate elevated, the 278.00 IU/L 125 – 229 IU/L cleared from During:
Dehydrogenas Date Ordered: kidneys are the body in the - Monitor the
e (LDH) December 15, impaired. urine. patient’s
2019 status.
-Check
Date of Result: The results are patient's vital
December 15, To know if above normal. signs, assess
2019 there are forms This indicates physical
of any tissue that there are condition and
damage or cell injuries in the keep an eye on
damage in the cells. When any monitors
 body. High cells are that the patient
LDH levels in damaged, LDH needs to
pregnancy is a are released remain hooked
marker of into the up to during
severe bloodstream the tests.
preeclampsia. 39 IU/L 5-34 IU/L causing the
SGOT level of LDH After:
(Aspartate Date Ordered: to rise in the - Notify the
aminotransfer December 15, blood. In patient's
ase) 2019 pregnancy, physician
high levels of when
Date of Result: LDH are abnormal or
December 15, associated with critical results
2019 increased that require an
incidence of immediate
To evaluate or maternal response.
to determine complications
how much <6.00 IU/L 5-34 IU/L such as
liver enzyme is abruption
SGPT in the blood. A placenta and
(Alanine Date Ordered: high AST level renal failure.
aminotransfer December 15, indicates that
ase) 2019 the liver is The results are
damaged. above normal.
Date of Result: This means
December 15, that AST or the
2019 enzyme that is
produced by
the liver is
elevated in the
To evaluate or 3.03 mmol/L 3.5-5.1 mmol/L bloodstream. A
to measure high AST level
ALT in the is a sign of
bloodstream. A liver damage Prior:
Potassium Date Ordered: high ALT or it can also -Review the
December 15, indicates that mean having patient’s chart.
2019 the liver is damage to -Prepare all the
damaged. another organ materials to be
Date of Result: such as the used.
December 15, heart or -Position
2019 kidneys. patients
properly
The results are
Hemoglobin: 120-160 g/L within normal During:
109 g/L range. ALT is - Monitor the
more accurate patient’s
than AST at status.
Hematology To measure the Hematocrit: 0.37-0.47 detecting liver -Check
Date Ordered: amount of 0.33 disease. Some patient's vital
December 15, potassium in diseases can signs, assess
2019 the blood. cause a false physical
positive result condition and
Date of Result: on the AST test keep an eye on
December 15, such as having any monitors
2019 diabetic that the patient
 ketoacidosis. needs to
remain hooked
up to during
RBC Count: 4.0-5.4 x 109/L the tests.
3.5 x 109/L
After:
To aid in The results are - Notify the
diagnosing below normal. patient's
anemia, certain During physician
cancers of the pregnancy, when
blood, blood volume abnormal or
inflammatory expands by critical results
diseases, and 50%. More that require an
to monitor electrolytes immediate
blood loss and such as response.
infection. This potassium is
test is needed to keep
important the extra fluid
during in the right
pregnancy to chemical
check for balance. Low
complications potassium
that may affect level is not an
the mother and indicator of
the infant. having
preeclampsia.
4.0-10.0 x 109/L
WBC Count: The results are
11.0 x 109/L below normal.
This signifies
anemia or iron
deficiency.

55.0 - 65.0%
Neutrophils:
78.5%

The results are

below Normal.
25.0 – 35.0% There is an
Lymphocytes insufficient
: supply of RBC
13.9% and may also
signify iron-
deficiency
an automated anemia. RBC
method to mass increases
quantify during
bacterial and pregnancy and
white blood plasma volume
cell (WBC) increases more Prior:
counts. It is resulting in a -Review the
also used in relative anemia patient’s chart.
diagnosing which results - Instruct the
urinary tract in a patient that
infections. physiologically there are no
lowered food, fluid,
hematocrit activity, or
count. medication
restrictions
unless by
The results are medical
below normal. direction.
It also signifies -Provide the
3.0 – 6.0% anemia. High required urine
blood pressure collection
Monocytes: can cause container and
6.1% destruction of specimen
RBCs collection
instructions.

During:
-Wait for the
The results are specimen.
above normal. -Instruct the
The total white patient to wait
blood cell for the results.
count will -Discuss the
2.0%-4.0% frequently be normal values
elevated in of each test.
Eosinophils: pregnancy due
1.0% to increased After:
numbers of Notify the
neutrophils. patient's
However, physician
neutrophilia is
when
not usually
associated with abnormal or
infection or critical results
inflammation. that require an
1.0 – 1.0% The results are immediate
above normal. response.
Basophils: Leukocytosis
0.5% occurs during
normal
150-450 x 109/L pregnancy.
However,
Platelet: reports on
164 x 109/L leukocyte
count and
differentials
associated with
the severity of
 preeclampsia
Color: are scarce.
Yellow
Urine Flow The results are
Cytometry Transparenc below normal.
Date Ordered: y:Clear Negative The reduction
December 15, of lymphocyte
2019 Sugar: levels in a
Negative pregnant
Date of Result: Protein: woman is a
December 15, Positive natural
2019 consequence of
pH: conception and
8.0 is a totally
normal body
Specific process. When
Gravity: conception
1.012 occurs and the
embryo is
awaiting
implantation
into the uterus,
the body
makes
adjustments
within itself to
allow this to
happen without
any hurdles.
The body ends
up suppressing
the immune
system’s
response by
cutting down
the lymphocyte
count, which
allows the
embryo to
implant
successfully
and grow into
a fetus. This is
only
temporary.

The results are

above normal.
During
pregnancy, the
female
immune
system has to
adapt to the
presence of the
fetus. This has
most often
been shown by
increased
numbers of
circulating
monocytes and
granulocytes,
resulting in
increased
number of total
leukocytes
during
pregnancy.

Eosinophil
counts are low
during
pregnancy,
reaching
around
delivery. Thus,
pregnant
women may
have falsely
low numbers
of eosinophils
in response to
parasitic
infection.

The results are

normal. This
may signify
that there is no
presence of
infection.

The results are

normal.
Platelets are
tiny blood cells
that help the
body form
clots to stop
bleeding.

An amount of
protein found
in urine may
indicate
preeclampsia.
Previously,
preeclampsia
was only
diagnosed if
high blood
pressure and
protein in the
urine were
present.
However,
experts now
know that it's
possible to
have
preeclampsia,
yet never have
protein in the
urine.
III. ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY (Human Anatomy & Physiolog,11th Edition, McGraw-Hill)

Female Reproductive system

Ovaries
The two ovaries (ō′var-ēz) are small organs about 2–3.5 cm long and 1–1.5 cm wide. A
peritoneal fold called the mesovarium (mez′ō-vā′rē-ŭm; mesentery of the ovary) attaches each
ovary to the posterior surface of the broad ligament. Two other ligaments are associated with the
ovary: the suspensory ligament, which extends from the mesovarium to the body wall, and the
ovarian ligament, which attaches the ovary to the superior margin of the uterus. The ovarian
arteries, veins, and nerves traverse the suspensory ligament and enter the ovary through the
mesovarium.

Ovarian Histology
The visceral peritoneum, made up of simple cuboidal epithelium, covers the surface of
the ovary, where it is called the ovarian epithelium, or germinal epithelium. Immediately below
the epithe- lium is a capsule of dense fibrous connective tissue, the tunica albuginea (al-bū-jin′ē-
ă). The cortex is the denser, outer part of the ovary, and the medulla is the looser, inner part of
the ovary. The connective tissue of the ovary is called the stroma. Blood vessels, lymphatic
vessels, and nerves from the mesovarium enter the medulla. Numerous ovarian follicles, each of
which contains an oocyte (ō′ō-sīt), are distributed throughout the stroma of the cortex.

Oogenesis and Fertilization

The formation of female gametes begins in the fetus. By the fourth month of
development, the ovaries contain 5 million oogonia (ō-ō-gō′nē-ă; oon, egg + gone, generation),
the cells from which oocytes develop. By the time of birth, many of the oogonia have
degenerated, and the remaining ones have begun meiosis. Also, oogonia can form after birth
from stem cells, but the extent to which this occurs, and how long it occurs, is not clear. Meiosis
stops, however, during the first meiotic division at a stage called prophase I. The cell at this
stage is called a primary oocyte, and at birth there are about 2 million of them. From birth to
puberty, the number of primary oocytes decreases to around 300,000–400,000. Only about 400
primary oocytes will complete development and give rise to the secondary oocytes that are
eventually released from the ovaries.

Ovulation
Is the release of a secondary oocyte from an ovary. Just before ovulation, the primary
oocyte completes the first meiotic division to produce a secondary oocyte and a polar body.
Unlike meiosis in males, cytoplasm is not split evenly between the two cells. Most of the
cytoplasm of the primary oocyte remains with the secondary oocyte. The cytoplasm contains
organelles, such as mitochondria, and nutrients that increase the viability of the secondary
oocyte. The polar body either degenerates or divides to form two polar bodies. Eventually, the
polar bodies degenerate. The secondary oocyte begins the second meiotic division, but it stops
in metaphase II.

After ovulation, the secondary oocyte may be fertilized by a sperm cell. Fertilization (fer
′til-i-zā-shŭn) begins when a sperm cell binds to the plasma membrane and pen- etrates the
plasma membrane of a secondary oocyte. Subsequently, the secondary oocyte completes the
second meiotic division to form two cells, each containing 23 chromosomes. One of these cells
has very little cytoplasm and is another polar body that degenerates. In the other, larger cell, the
23 chromosomes from the sperm cell nucleus join with the 23 chromosomes from the oocyte to
form a zygote (zī′gōt) and complete fertilization. The zygote has 23 pairs of chromosomes (a
total of 46 chromosomes). All cells of the human body contain 23 pairs of chromosomes, except
for the male and female gametes. The zygote divides by mitosis to form two cells, which divide
to form four cells, and so on. Seven days after ovulation, the mass of cells may implant in or
attach to the uterine wall. The implanted mass of cells continues to develop for approximately 9
months to form a new individual.
Follicle Development
As discussed earlier, oogenesis begins when a female is in her mother’s uterus. The
primary oocytes present at birth are located in primordial follicles. A primordial follicle is a
primary oocyte surrounded by a single layer of flat cells, called granulosa cells.

Once puberty begins, some of the primordial follicles become primary follicles as the
oocyte enlarges and the single layer of granulosa cells becomes enlarged and cuboidal.
Subsequently, several layers of granulosa cells form, and a layer of clear material called the
zona pellucida (zō′nă pellū′sid-dă; girdle + pellucidus, passage of light) is deposited around the
primary oocyte.

Approximately every 28 days, hormonal changes stimulate some of the primary follicles
to continue to develop. The primary follicle becomes a secondary follicle as fluid-filled spaces
called vesicles form among the granulosa cells, and a cap- sule called the theca (thē′kă; a box)
forms around the follicle. Cells of the theca interna surround the granulosa cells, where they
participate in the synthesis of ovarian hormones. The theca externa is primarily connective
tissue that merges with the stroma of the ovary.

The secondary follicle continues to enlarge; when the fluid- filled vesicles fuse to form a
single, fluid-filled chamber called the antrum (an′trŭm), the follicle is called a mature follicle, or
Graafian (graf′ē-ăn) follicle. The oocyte is pushed off to one side and lies in a mass of granulosa
cells called the cumulus cells, or cumulus oophorus (kū′mū-lŭs ō-of′ōr-ŭs).

The mature follicle forms a lump on the surface of the ovary. During ovulation, the
mature follicle ruptures, forcing a small amount of blood, follicular fluid, and the oocyte,
surrounded by the cumulus cells, into the peritoneal cavity. The cumulus cells resemble a crown
radiating from the oocyte and are thus called the corona radiata. Usually, only one mature
follicle reaches the most advanced stages of development and is ovulated. The other follicles
degenerate, a process called atresia.

Fate of the Follicle

After ovulation, the follicle still has an important function. It is transformed into a
glandular structure called the corpus luteum (kōr′pŭs loo′tē-ŭm; yellow body), which has a
convoluted appear- ance as a result of its collapse after ovulation.The granulosa cells and the
theca interna, now called luteal cells, enlarge and begin to secrete hormones—progesterone and
smaller amounts of estrogen.

If pregnancy occurs, the corpus luteum enlarges and remains throughout pregnancy as
the corpus luteum of pregnancy. If pregnancy does not occur, the corpus luteum remains
functional for about 10–12 days and then begins to degenerate.

Progesterone and estrogen secretion decreases, and connective tissue cells become
enlarged and clear, giving the whole structure a whitish color; it is therefore called the corpus
albicans (al′bī-kanz; white body). The corpus albicans continues to shrink and eventually
disappears after several months or even years.

Uterine Tubes
A uterine tube, also called a fallopian (fa-lō′pē-an) tube or oviduct (ō′vi-dŭkt), is
associated with each ovary and extends from the area of the ovary to the uterus. Each tube is
located along the superior margin of the broad ligament. The part of the broad ligament most
directly associated with the uterine tube is called the mesosalpinx (mez′ō-sal′pinks).

The uterine tube opens directly into the peritoneal cavity to receive the oocyte from the
ovary. It expands to form the infundibu- lum (in-fŭn-dib′ū-lŭm; funnel), and long, thin processes
called fimbriae (fim′brē-ē; fringe) surround the opening of the infun- dibulum. The inner
surfaces of the fimbriae consist of a ciliated mucous membrane.
 The part of the uterine tube that is nearest the infundibulum is called the ampulla. It is
the widest and longest part of the tube and accounts for about 7.5–8 cm of the total 10 cm length
of the tube. Fertilization usually occurs in the ampulla. The part of the uterine tube nearest the
uterus, the isthmus, is much narrower and has thicker walls than the ampulla. The uterine part,
or intramural part, of the tube passes through the uterine wall and ends in a very small uterine
opening.

The wall of each uterine tube consists of three layers. The outer serosa is formed by the
peritoneum, the middle muscular layer consists of longitudinal and circular smooth muscle
cells, and the inner mucosa consists of a mucous membrane of simple ciliated columnar
epithelium. The mucosa is arranged into numerous longitudinal folds.

The mucosa of the uterine tubes provides nutrients for the oocyte or, if fertilization has
occurred, for the developing embry- onic mass as it passes through the uterine tube. The ciliated
epithelium helps move the small amount of fluid and the oocyte, or the developing embryonic
mass, through the uterine tubes.

Uterus
The uterus (ū′ter-ŭs) is the size and shape of a medium-sized pear— about 7.5 cm long
and 5 cm width. It is slightly flattened anteroposteriorly and is oriented in the pelvic cavity with
the larger, rounded part, the fundus (fŭn′dŭs), directed supe- riorly and the narrower part, the
cervix (ser′viks), directed inferiorly. The main part of the uterus, the body, is between the fundus
and the cervix. A slight constriction called the isthmus marks the junction of the cervix and the
body. Internally, the uterine cavity continues as the cervical canal, which opens through the
ostium into the vagina.

The uterus is supported by the broad ligament, the round ligaments and the uterosacral
ligaments. The broad ligament is a peritoneal fold extending from the lateral margins of the
uterus to the wall of the pelvis on either side. It also ensheathes the ovaries and the uterine
tubes. The round ligaments extend from the uterus through the inguinal canals to the labia
majora of the external genitalia, and the uterosacral ligaments attach the lateral wall of the
uterus to the sacrum. Normally, the uterus is anteverted, mean- ing that the body of the uterus is
tipped slightly anteriorly.

However, in some women, the uterus is retroverted, or tipped posteriorly.

In addition to the ligaments, skeletal muscles of the pelvic floor support the uterus inferiorly. If
these muscles are weakened (e.g., in childbirth), the uterus can extend inferiorly into the vagina,
a condition called a prolapsed uterus.
The uterine wall is composed of three layers: the perimetrium, the myometrium, and the
endometrium.

The perimetrium (per-i-mē′trē-ŭm), or serous layer, is the peritoneum that covers the
uterus. The next layer, just deep to the perimetrium, is the myometrium (mī′ō-mē′trē-ŭm), or
muscular layer, composed of a thick layer of smooth muscle. The myometrium accounts for the
bulk of the uterine wall and is the thickest layer of smooth muscle in the body. In the cervix, the
muscular layer contains less muscle and more dense connective tissue. The cervix is therefore
more rigid and less contractile than the rest of the uterus.

The innermost layer of the uterus is the endometrium (en′dō-mē′trē-ŭm), or mucous

membrane, which consists of a simple columnar epithelial lining and a connective tissue layer
called the lamina propria. Simple tubular glands, called spiral glands, are scattered about the
lamina propria and open through the epithelium into the uterine cavity. The endometrium
consists of two layers: A thin, deep basal layer is the deepest part of the lamina propria and is
continuous with the myometrium, and a thicker, superficial functional layer, con- sisting of most
of the lamina propria and the endothelium, lines the cavity itself. The functional layer is so
named because it under- goes changes and sloughing during the female menstrual cycle. Small
spiral arteries of the lamina propria supply blood to the functional layer of the endometrium.
These blood vessels play an important role in the cyclic changes of the endometrium.

Columnar epithelial cells line the cervical canal, which contains cervical mucous glands.
The mucus fills the cervical canal and acts as a barrier to substances that could pass from the
vagina into the uterus. Near ovulation, the consistency of the mucus changes, easing the passage
of sperm cells from the vagina into the uterus.

Vagina
The vagina (vă-jī′nă) is the female organ of copulation, receiving the penis during
intercourse. It also allows menstrual flow and childbirth. The vagina is a tube about 10 cm long
that extends from the uterus to the outside of the body. Longitudinal ridges called columns
extend the length of the anterior and posterior vaginal walls, and several transverse ridges called
rugae (roo′gē) extend between the anterior and posterior columns. The superior, domed part of
the vagina, the fornix (fōr′niks), is attached to the sides of the cervix, so that a part of the cervix
extends into the vagina.

The wall of the vagina consists of an outer muscular layer and an inner mucous
membrane. The muscular layer is smooth muscle that allows the vagina to increase in size to
accommodate the penis during intercourse and to stretch greatly during childbirth. The mucous
membrane is moist stratified squamous epithelium that forms a pro- tective surface layer. The
vaginal mucous membrane releases most of the lubricating secretions produced by the female
during intercourse.

A thin mucous membrane called the hymen (hī′men) covers the vaginal opening, or
orifice. Sometimes, the hymen completely closes the vaginal opening (a condition called
imperforate hymen), and it must be removed to allow menstrual flow. More commonly, the
hymen is perforated by one or several holes. The openings in the hymen are usually greatly
enlarged during the first sexual intercourse. In addition, the hymen can be perforated earlier in a
young woman’s life, such as during strenuous physical exercise. Thus, the absence of an intact
hymen does not necessarily indicate that a woman has had sexual intercourse, as was once
thought.
External genitalia
The external female genitalia, also referred to as the vulva (vŭl′vă), or pudendum (pū-
den′dŭm), consist of the vestibule and its sur- rounding structures. The vestibule (ves′ti-bool) is
the space into which the vagina opens posteriorly and the urethra opens anteriorly. A pair of
thin, longitudinal skin folds called the labia (lā′bē-ă; lips) minora (sing. labium minus) form a
border on each side of the vestibule. A small, erectile structure called the clitoris (klit′ō-ris) is
located in the anterior margin of the vestibule. Anteriorly, the two labia minora unite over the
clitoris to form a fold of skin called the prepuce.

The clitoris is usually less than 2 cm in length and consists of a shaft and a distal glans.
Well supplied with sensory receptors, it initiates and intensifies levels of sexual tension. The
clitoris contains two erectile structures, the corpora cavernosa, each of which expands at the
base end of the clitoris to form the crus of the clitoris and attaches the clitoris to the pelvic
bones. The corpora cavernosa of the clitoris are comparable to the corpora cavernosa of the
penis, and they become engorged with blood as a result of sexual excite- ment. In most women,
this engorgement results in an increase in the diameter, but not the length, of the clitoris. With
increased diameter, the clitoris makes better contact with the prepuce and surrounding tissues
and is more easily stimulated.

Erectile tissue that corresponds to the corpus spongiosum of the male lies deep to and on
the lateral margins of the vestibular floor on each side of the vaginal orifice. Each erectile body
is called a bulb of the vestibule. Like other erectile tissue, it becomes engorged with blood and
is more sensitive during sexual arousal. Expansion of the bulbs causes narrowing of the vaginal
orifice and allows better contact of the vagina with the penis during intercourse.

On each side of the vestibule, between the vaginal opening and the labia minora, is an
opening of the duct of the greater vestibular gland. Additional small mucous glands, the lesser
vestibular glands, or paraurethral glands, are located near the clitoris and urethral opening. They
produce a lubricating fluid that helps maintain the moistness of the vestibule.

Lateral to the labia minora are two prominent, rounded folds of skin called the labia
majora. Subcutaneous adipose tissue is primar- ily responsible for the prominence of the labia
majora. The two labia majora unite anteriorly in an elevation over the symphysis pubis called
the mons pubis (monz pū′bis). The lateral surfaces of the labia majora and the surface of the
mons pubis are covered with coarse hair. The medial surfaces are covered with numerous seba-
ceous and sweat glands. The space between the labia majora is called the pudendal cleft. Most
of the time, the labia majora are in contact with each other across the midline, closing the
pudendal cleft and concealing the deeper structures within the vestibule.

Perineum
The female perineum is divided into two triangles by the superficial and deep transverse
perineal muscles. The anterior urogenital triangle contains the external genitalia, and the
posterior anal triangle contains the anal opening. The region between the vagina and the anus is
the clinical perineum. The skin and muscle of this region can tear during childbirth. To prevent
such tearing, an incision called an episiotomy (e-piz-ē-ot′ō-mē, e-pis-ē-ot′ō-mē) is sometimes
made in the clinical perineum. This clean, straight incision is easier to repair than a tear would
be. Alternatively, allowing the perineum to stretch slowly during delivery may prevent tearing,
thereby making an episiotomy unnecessary.

Menstrual Cycle
The term menstrual (men′stroo-ăl) cycle technically refers to the cyclic changes in
sexually mature, nonpregnant females that culminate in menses. Typically, the menstrual cycle
is about 28 days long, although it can be as short as 18 days in some women and as long as 40
days in others. Menses (men′sēz) is a period of mild hemorrhage that occurs approximately once
each month, during which the uterine epithelium is sloughed and expelled from the uterus.
Menstruation (men-stroo-ā′shŭn) is the discharge of the blood and other elements of the uterine
mucous membrane. Although the term menstrual cycle refers specifically to changes in the
uterus, the term is often used to refer to all the cyclic events in the female reproductive system,
including alterations in hormone secretion and changes in the ovaries.

The first day of menses is considered day 1 of the menstrual cycle, and menses typically
lasts 4–5 days. Ovulation occurs on about day 14 of a 28-day menstrual cycle; however, the
timing of ovulation varies from individual to individual and even within a single individual
from one menstrual cycle to the next. The time between ovulation, on day 14, and the next
menses is typically 14 days. The time between the first day of menses and the day of ovulation
is more variable than the time between ovulation and the next menses. The time between the
ending of menses and ovulation is called the proliferative phase, because of the rapid
proliferation of the uterine mucosa, or the follicular phase, because of the rapid development of
ovarian follicles. The period after ovulation and before the next menses is called the secretory
phase, because of the maturation of and secretion by uterine glands, or the luteal phase, because
of the existence of the corpus luteum.

Ovarian Cycle
The term ovarian cycle refers to the regular events that occur in the ovaries of sexually
mature, nonpregnant women during the menstrual cycle. The hypothalamus and anterior
pituitary release hormones that control these events. FSH from the anterior pituitary is primarily
responsible for initiating the development of primary follicles, and as many as 25 follicles begin
to mature during each menstrual cycle. However, normally only 1 is ovulated. The follicles that
start to develop in response to FSH may not ovulate during the same menstrual cycle in which
they begin to mature, but they may ovulate one or two cycles later. The remaining follicles
degenerate. Larger, more mature follicles appear to secrete estrogen and other substances that
have an inhibitory effect on other, less mature follicles.
 Early in the menstrual cycle, the release of GnRH from the hypothalamus increases, as
does the sensitivity of the anterior pituitary to GnRH. These changes stimulate the anterior
pituitary to produce and release small amounts of FSH and LH. FSH and LH 1044 stimulate
follicular growth and maturation. They also cause an increase in estrogen secretion by the
developing follicles. FSH exerts its main effect on the granulosa cells, whereas LH exerts its
initial effect on the theca interna cells and later on the granulosa cells. LH stimulates the theca
interna cells to produce androgens, which diffuse from these cells to the granulosa cells. FSH
stimulates the granulosa cells to convert androgens to estrogen. In addition, FSH gradually
increases LH receptors in the granulosa cells. Estrogen produced by the granulosa cells
increases LH receptors in the theca interna cells. Consequently, theca interna cells and granulosa
cells cooperate to produce estrogen. Estrogen, in turn, increases receptors for LH in both theca
interna cells and granulosa cells.

After LH receptors in the granulosa cells have increased, LH stimulates the granulosa
cells to produce progesterone, which diffuses from the granulosa cells to the theca interna cells,
where it is converted to androgens. These androgens are also converted to estrogen by the
granulosa cells. Thus, the production of androgens by the theca interna cells increases, resulting
in a gradual increase in estrogen secre- tion by granulosa cells throughout the follicular phase,
even though only a small increase in LH secretion occurs. FSH levels actually decrease during
the follicular phase because developing follicles pro- duce inhibin, which has a negative-
feedback effect on FSH secretion. The gradual increase in estrogen levels, especially late in the
follicular phase, begins to have a positive-feedback effect on LH and FSH release from the
anterior pituitary.

Consequently, as the estrogen level in the blood increases, it stimulates greater LH and
FSH secretion. The sustained increase in estrogen is necessary for this positive- feedback effect.
In response, LH and FSH secretion increases rapidly and in large amounts just before ovulation
(figure 28.18). The increase in blood levels of both LH and FSH is called the LH surge, and the
increase in FSH is called the FSH surge. The LH surge occurs several hours earlier and to a
greater degree than the FSH surge, and the LH surge can last up to 24 hours. The LH surge
initiates ovulation and causes the ovulated follicle to become the corpus luteum. FSH can make
the follicle more sensitive to the influence of LH by stimulating the synthesis of additional LH
receptors in the follicles and by stimulating the development of follicles that may ovulate during
later ovarian cycles.

The LH surge causes the primary oocyte to complete the first meiotic division just
before or during the process of ovulation. Also, the LH surge triggers several events that are
very much like inflammation in a mature follicle. These events result in ovulation. The follicle
enlarges due to edema. Proteolytic enzymes break down the ovarian tissue around the follicle,
causing the follicle to rupture, and the oocyte and some surrounding follicle cells are slowly
extruded from the ovary.

Shortly after ovulation, the follicle’s production of estrogen decreases. The remaining
granulosa cells of the ovulated follicle are converted to corpus luteum cells and begin to secrete
proges- terone. After the corpus luteum forms, progesterone levels become much higher than
before ovulation, and some estrogen is produced. The increased progesterone and estrogen have
a negative-feedback effect on GnRH release from the hypothalamus. As a result, LH and FSH
release from the anterior pituitary decreases. Estrogen and progesterone also cause the down-
regulation of GnRH receptors in the anterior pituitary, and the anterior pituitary cells become
less sensitive to GnRH.

Because of the decreased secretion of GnRH and decreased sensitivity of the anterior
pituitary to GnRH, the rate of LH and FSH secretion declines to very low levels after ovu-
lation. If the ovulated oocyte is fertilized, the outer layer of the devel- oping embryo begins to
secrete the LH-like substance human chorionic gonadotropin (hCG), which keeps the corpus
luteum from degenerating. As a result, blood levels of estrogen and pro- gesterone do not
decrease, and menses does not occur. If fertilization does not occur, hCG is not produced. The
cells of the corpus luteum begin to atrophy after day 25 or 26, and the blood levels of estrogen
and progesterone decrease rapidly, resulting in menses.
Uterine Cycle

The term uterine cycle refers to changes that occur primarily in the endometrium of the
uterus during the menstrual cycle. Other, more subtle changes also take place in the vagina and
other structures during the menstrual cycle. Cyclic secretions of estrogen and progesterone are
the primary cause of these changes.

The endometrium of the uterus begins to proliferate after men- ses. The remaining
epithelial cells rapidly divide and replace the cells of the functional layer that were sloughed
during the last menses. A relatively uniform layer of low cuboidal endometrial cells is pro-
duced. The cells later become columnar, and the layer of cells folds to form tubular spiral
glands. Blood vessels called spiral arteries proj- ect through the delicate connective tissue that
separates the individ- ual spiral glands to supply nutrients to the endometrial cells. After
ovulation, the endometrium becomes thicker, and the spiral glands develop to a greater extent
and begin to secrete small amounts of a fluid rich in glycogen. Approximately 7 days after
ovulation, or about day 21 of the menstrual cycle, the endometrium is prepared to receive a
developing embryonic mass, if fertilization has occurred. If the developing embryonic mass
arrives in the uterus too early or too late, the endometrium does not provide a suitable
environment for it.

Estrogen causes the endometrial cells and, to a lesser degree, the myometrial cells to
proliferate. It also makes the uterine tissue more sensitive to progesterone by stimulating the
synthesis of progesterone receptor molecules within the uterine cells. After ovulation, progester-
one from the corpus luteum binds to the progesterone receptors, resulting in cellular
hypertrophy in the endometrium and myometri- um and causing the endometrial cells to
become secretory. Estrogen increases the tendency of the smooth muscle cells of the uterus to
con- tract in response to stimuli, but progesterone inhibits smooth muscle contractions. When
progesterone levels increase while estrogen levels are low, contractions of the uterine smooth
muscle are reduced.
 In menstrual cycles in which pregnancy does not occur, pro- gesterone and estrogen
levels decline to low levels as the corpus luteum degenerates. As a consequence, the uterine
lining also begins to degenerate. The spiral arteries constrict in a rhythmic pattern for longer and
longer periods as progesterone levels fall. As a result, all but the basal parts of the spiral glands
become ischemic and then necrotic. As the cells become necrotic, they slough into the uterine
lumen. The necrotic endometrium, mucous secretions, and a small amount of blood released
from the spiral arteries make up the menstrual fluid. Decreases in progesterone levels and
increases in inflammatory substances that stimulate myometrial smooth muscle cells cause
uterine contractions, which expel the menstrual fluid from the uterus through the cervix and into
the vagina.
IV. THE PATIENT’S ILLNESS

9. PATHOPHYSIOLOGY (Book Based and Client Centered)

Synthesis of the Disease (Book-Based)

1. Definition of the Disease

Preeclampsia or severe preeclampsia is a disorder of pregnancy characterized by
high blood pressure and significant proteinuria after 20 weeks gestation. It is also
characterized by signs of damage to another organ system most often the liver and
kidneys. If left untreated, it may lead to serious or even fatal complications for both
the mother and the baby. Rarely, preeclampsia develops after delivery of a baby, a
condition known as postpartum preeclampsia.

2. Predisposing/Precipitating Factors
The most significant risk factors for preeclampsia are:
 previous history of preeclampsia;
 multiple gestation;
 history of chronic high blood pressure, diabetes, kidney disease or organ
transplant;
 first pregnancy;
 obesity, particularly with Body Mass Index (BMI) of 30 or greater;
 over 35 or under 20 years of age
 family history of preeclampsia;
 polycystic ovarian syndrome, lupus or other autoimmune disorders,
including rheumatoid arthritis, sarcoidosis and multiple sclerosis;
 in-vitro fertilization and;
 sickle cell disease.

3. Signs and Symptoms

Preeclampsia sometimes develops without any symptoms. High blood pressure
may develop slowly, or it may have a sudden onset. Monitoring blood pressure is an
important part of prenatal care because the first sign of preeclampsia is commonly a
rise in blood pressure. Blood pressure that exceeds 140/90 millimeters of mercury
(mm Hg) or greater documented on two occasions, at least four hours apart is
abnormal.
Other signs of Preeclampsia may include:
 excess protein in the urine (proteinuria) or additional signs of kidney
problems;
  severe headaches;
 changes in vision, including temporary loss of vision, blurred vision or
light sensitivity;
 upper abdominal pain, usually under your ribs on the right side;
 Nausea or vomiting;
 decreased urine output;
 decreased levels of platelets in your blood (thrombocytopenia);
 impaired liver function and;
 shortness of breath, caused by fluid in your lungs

4. Health Promotion and preventive Aspects of the Disease

Pregnant women should make sure to attend prenatal visits so their
healthcare provider can monitor their blood pressure and other laboratory tests
such as urinalysis, blood tests, fetal ultrasound and nonstress test or biophysical
profile. Currently, there is no accurate way to prevent preeclampsia. Some
contributing factors to high blood pressure can be controlled and some can’t. The
best way for a pregnant woman to stay healthy is to follow the doctor’s diet and
exercise such as using little or no salt in meals, drinking 6-8 glasses of water,
getting enough rest, exercise regularly, elevate feet several times during the day,
avoid drinking alcohol and beverages containing caffeine and make sure to drink
the prescribed medicines and supplements.

Synthesis of the Disease (Patient-Centered)

1. Predisposing/Precipitating Factors (with dates)

According to the patient, she did not had preeclampsia from her previous
pregnancies. There is also no history of preeclampsia on her family.

2. Signs and Symptoms (with dates)

As seen from the nurse’s chart, on the 15th of December 2019, patient’s
chief complain was an elevated blood pressure of 170/160. On the same day, she
also experienced headache and nausea and vomiting. She was also undergone
laboratory tests such as urinalysis and blood tests. Based from the results, she was
positive for proteinuria, a common sign for having preeclampsia.
V. THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT

a. IVFs, OT, NGT Feeding, Nebulization, TPN, Oxygen Therapy, etc.

Medical Date ordered, General description Medication(s) or Client’s Response

Management Date(s) performed, Purpose(s) to the Treatment
Treatment Date changed
#3 D5 LRS x 1L DO: Lactated Ringer’s It was given to the Patient manifested
20gtts/min Oct. 13, 2019 Solution and 5% client to maintain no signs of edema in
DP: Dextrose is an IV adequate fluids and the intravenous site
Oct 13, 2019 fluid for daily usage serves as a site for
DC: to keep maintenance administration of
Oct 13, 2019 of body fluids, some drugs.
nutrition, and for
dehydration. It
contains electrolytes,
sodium, potassium,
calcium, chloride,
lactate, and
osmolality. This
solution is a
parenteral fluid,
hypertonic Solution,
non-pyrogenic
solution, electrolyte
replenisher, and a
nutrient replenisher.

#5 PNSS 20gms DO: Sodium is a major It was given to the Patient manifested
MgS04 x 1L 100 Dec. 16-17, 2019 cation in client it was given no signs of
cc/hr DP: extracellular fluid to the client since it symptoms and
Dec. 16-17, 2019 and helps maintain helps to neutralizes absence of pain in
DC: water distribution, the gastric area by the gastric area was
Dec. 16-17, 2019 fluid and electrolyte reducing acid noted
balance, acid-base secretions thus
equilibrium, and preventing peptic
osmotic pressure. ulcer and other
Chloride is the major gastrointestinal
anion in disorder.
extracellular fluid
and is involved in
maintaining acid-
base bal- ance.
Solutions of NaCl
resemble
extracellular fluid.
Reduces corneal
edema by an osmotic
 effect. Therapeutic
Effects: IV, PO:
Replacement in
deficiency states and
maintenance of
homeostasis.

Nursing Responsibilities

BEFORE:

● Check the doctor’s order.

● Assure rate and amount of flow.

● Prepare the equipment needed.

● Obtain IV solution and check for sediments and any crack or leak from the container.

● Check for the expiration date.

DURING:

● Explain the importance of the purpose of IVF to client.

● Place the patient in a comfortable position.

● Maintain aseptic technique throughout the procedure.

● Watch out for fluid overload.

● Secure needle and proper infusion.

AFTER:

● Check for swelling around the site for IV infiltration. Assess for any signs of edema or
bulging of the vein.

● Regulate IVF as ordered.

● Observe for the reaction of patient to the solution given.

● Document related data.

● Chart the procedure including time, name, dosage and patient response.
 ● Properly dispose used material after insertion.

B. Drugs

Name of Date Route of Indication(s) or Client’s

drugs Ordered Admin. Purpose(s) response to the
Generic Date taken/ Dosage and Medication with
name given frequency of actual side
Brand name Date adm. effects
changed
Magnesium RA: It was given to the client since it Patient manifested
Sulfate Intravenously helps to neutralizes the gastric no signs of
DO: (IV) area by reducing acid secretions symptoms and
12-12-19 D: 50g thus preventing peptic ulcer and absence of pain in
DP: FA: q8 other gastrointestinal disorder. the gastric area was
10-12-19 noted
DC:
10-12-19

Furosemide RA: It was given to the client to Patient manifested a

DO: Intravenously manage hypertension. The drug decrease of blood
12-12-19 (IV) intended to inhibit reabsorption pressure from
DP: D: 20mg of sodium chloride primarily in 130/80 to 90/60
12-12-19 FA: q8 loop of Henle and also in the
DC: proximal tubules, which lowers
12-12-19 blood pressure and manages
hypertension.
Amlodipine RA: It was given since the client is Patient manifested
Intravenously complaining of chest pain and the no signs of
DO: (IV) purpose of the drug is to reduce symptoms and
10-13-19 D: 10mg systolic, diastolic, and mean verbalized decrease
DP: FA: OD @ 6am arterial blood pressure. in pain from 7 to 3
10-13-19
DC:
10-13-19

Losartan RA: It was given since the client is Patient manifested

Intravenously still having hypertension and this no signs of
DO: (IV) medication is intended symptoms and
12-12-19 D: 50mg Selectively blocks the binding of manifested a
DP: FA: OD @6am angiotensin II to the decrease in blood
12-12-19 AT1 receptors found in many pressure from
DC: tissues (e.g., vascular smooth 130/80 to 90:60
12-12-19 muscle, adrenal glands).
Antihypertensive effect results
from blocking the
vasoconstricting and aldosterone-
secreting effects of angiotensin
II.
Cefuroxime It was given to the client to Patient manifested
DO: prevent Preferentially binds to no signs of infection
12-12-19 one or more of the penicillin-
DP: RA: Orally binding proteins (PBP) located
 12-12-19 taken on cell walls of susceptible
DC: D: 500mg/tab organisms. This inhibits third and
12-12-19 FA: 1 tab OD final stage of bacterial cell wall
@6am synthesis, thus killing the
DO: bacterium. Partial cross-
12-12-19 allergenicity between other beta-
DP: lactam antibiotics and
12-12-19 cephalosporins has been
DC: reported.
12-12-19

BEFORE:

● Check for the patient identification on the chart

● Check the medication if it is the right drug to be administered to the patient

● Check the right dose and route needed

DURING:

● Confirm the patient’s identification

● Explain the medication to be given.

● Confirm again if it is the right drug.

● Clean the IV port with cotton ball with alcohol

● Insert the syringe on the IV port, and slowly push the medication.

AFTER:

● Confirm again if the right drug was administered

● Check for any reactions

● Document the time that the drug has been administered

C. Diet

Type of diet Date ordered General Indications Specific Client’s

date started description or pusposes foods taken response and
date ended or reaction to
the diet
DAT (Diet As 12/17/19 In this type of A DAT diet Patient ate Patient complied
Tolerated) diet, the patient indicates that the mixed fruits with the diet
can now eat gastrointestinal and vegetables. prescribed.
anything that tracts is
they can manage tolerating food
which and is ready for
progresses to advancement to
solid foods in the next stage.
the form of
purees, chunks
and finally a
regular diet.

BEFORE:

● Check the doctor’s order for specification.

● Inform patient and their S/O that the client has a DAT/regular diet.

● Explain the purpose of the diet.

● Provide the S/O of what to expect during this diet and what the client can and cannot eat.

DURING:

● Assess patient’s condition.

● Assure that the patient and S/O are following the order and answering their questions as
needed.

● Instruct patient and their S/O that they can use a wet cotton ball to keep oral cavity and
lips moist to prevent cracking of lips.

AFTER:

● Observe patient’s response on the diet.

● Monitor patient’s condition

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

 1. Client’s Daily Progress Chart (from admission to discharge)

10/13 10/14 10/15 10/16 10/17 10/18

Number problems:
1. Imbalanced ✓ ✓ ✓ ✓ ✓
nutrition: More
than body
requirements as
evidenced by
reports of excessive
intake of salt
2. Deficient ✓ ✓ ✓ ✓ ✓
knowledge r/t
unfamiliarity with
information
resources as
evidenced by
request for
information
3. ✓ ✓ ✓ ✓ ✓

4. ✓ ✓ ✓ ✓ ✓

5. ✓ ✓ ✓ ✓ ✓

Vital signs (6-12 shift):

 Temperature (C) 36.5 36.2 36.5 36 36.4 36
 Pulse rate(bpm) 80 75 80 74 75 72
 Respiratory 20 19 19 20 19 20
rate(cpm)
 Blood 9/60 90/60 100//70 90/60 90/60 90/60
pressure(mmHg)

Diagnostics/Laboratory
procedures:

CBC

 Platelet 345,000 313,000

 HCT 33 41
 MCU 86.9 fL 93 fL
 MCHC 345 328 g/dL
 Hemoglobin 109 102 g/L
 Erythrocytes 4.9 4.9
 WBC 5.5 g/L 5.5 g/L
 Neutrophils 78.5 73
 Lymphocytes 13.9 14
  Monocytes 5.9 6.0
 Eosinophils 1.0 1.0
 Basophils 0.2 0.5

IVFs

1. D5LRS ✓

2.

Drugs Administered

MgS04 ✓ ✓
Amlodipine 10mg 1 tab ✓ ✓ ✓
Cefuroxime 500mg 1 cap ✓ ✓ ✓
Losartan 50mg 1cap ✓ ✓ ✓

Diet

• DAT ✓ ✓ ✓ ✓ ✓ ✓

2. DISCHARGE PLANNING

A. General Condition of Client upon Discharge

The patient showed no signs of fever or difficulty of breathing. However, the patient still
expressed slight fatigue. The patient’s vital signs are as follows:

 Temperature: 36.5ºC / axilla

 Pulse rate: 75 bpm

 Respiratory Rate: 20 bpm

 Blood Pressure: 90/60

B. Discharge Planning:
Medication:

For completion of MgS04 up to 24 hrs

Amlodipine 10mg 1 tab OD 6am
Cefuroxime 500mg 1 cap q12
Losartan 50mg 1cap 6pm

Exercise:

- Promote rest to conserve energy

- To stop further bleeding

Treatment:

Instructed patient to follow strict compliance to treatment regimen.

Health Teachings:

Emphasized the importance of proper hygiene

Explained the importance of treatment regimen

Explained the importance of early ambulation with minimal movements to prevent dizziness

Explained the importance of rest

Explained the important of maintaining hydration

Out Patient Department (OPD):

Instructed the patient to return after one week.

Diet:

Diet which can enhance iron production and speedy recovery. DAT, eat food rich in iron and
increase oral fluid intake.

VII. CONCLUSION AND RECOMMENDATIONS

Therefore, we conclude that in line with our Student Nurse-Centered Objectives that after
1 day of student-nurse-patient interaction, the student-nurses were able to established rapport to
accurately gather information in a systematic manner in order to determine the health-related
needs of the patient, defined what Pre-eclampsia is, gathered information to further assess the
patient which includes the demographic data, family health and history, and history of past and
present disease condition, assessed patient status/condition, namely: presence of signs and
symptoms, and other abnormal changes that are manifested by the patient through physical
examination, observation, or direct interview, reviewed, obtained and identified the requisition of
different laboratory and diagnostic procedures done to the patient, as well as the medications
administered to the patient, understood the anatomy and physiology, synthesis of disease and
pathophysiology of Pre-eclampsia, and understand Medical and Surgical management as to
disease condition.

After the completion of this study, the student-nurses were able to perform therapeutic
nursing interventions and communicated in order to implement the nursing care plan effectively,
utilized critical thinking in order to learn new skills and knowledge that are vital in the
management of a patient with Pre-eclampsia, planned holistic care to enhance, modify, and
support the health patterns of the client's system in various health factors/determinants, learned
the indications of the different diagnostic exam and test done to the patient, as well as the drugs
administered to the patient and will be able to discuss their corresponding side effects, became
more familiar of the structure and the function of the affected system or organ and relate the
alterations in the anatomy and physiology with the manifestations of the patient, and raised the
level of awareness of the patient about the other health problems she might encounter.

Further recommendations are made available by the student nurses regarding this clinical
case study.

1. To fellow student nurses and to the future ones. This clinical case study can aid them in
understanding more about pre-eclampsia: its whole process, the manifestations a woman
undergo during the process, the proper assessment that must be done in attaining the
patient’s situation leading to the execution of nursing diagnoses and intervening care.
This study highlights important points in the provision of medical, drug, diet, and surgical
care. In a way, students can as well do the same but with thorough understanding of the
patient’s situation.
2. To women undergoing the childbearing process. This clinical study may help them better
understand the mechanisms they are going through within their condition as soon-to-be
mothers. With this case study, they will be encouraged to know the steps in achieving
proper maternal care.
 3. To the Philippine government: that it may focus on recognizing the importance of
maternal and child health care through establishing beneficial programs and activities for
both the pre- and postpartal women.

VIII. BIBLIOGRAPHY

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5832913/

https://www.ncbi.nlm.nih.gov/pubmed/24165327

https://www.mayoclinic.org/diseases-conditions/preeclampsia/diagnosis-treatment/drc-20355751
NURSING CARE PLAN 1: Imbalanced nutrition: More than body requirements as evidenced by reports of excessive intake of salt

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
SUBJECTIVE: Imbalanced Eating salt raises the SHORT TERM: 1. Monitor vital signs 1. To track changes in SHORT TERM:
Patient verbalize nutrition: More amount of sodium in After 8 hours of patient’s condition The patient shall
excessive intake of than body your bloodstream nursing verbalize and
salt in her diet requirements as and wrecks the interventions, 2. Discuss necessity 2. Excessive salt intake demonstrate
evidenced by delicate balance, the patient will for decreased caloric expands the intravascular understanding of
OBJECTIVE: reports of reducing the ability verbalize and intake and limited fluid volume and may health teachings
Patient may excessive intake of your kidneys to demonstrate intake of fats, salt, and damage kidneys, which regarding her
manifest: of salt remove the water. understanding of sugar as indicated. can further diet.
 Blood The result is a health teachings aggravate hypertension.
pressure higher blood regarding her die.t
of 160/100 pressure due to the 3. Review usual daily 3. Identifies current LONG TERM:
extra fluid and extra LONG TERM: caloric intake and strengths and weaknesse The patient shall
strain on the After 2-3 days of dietary choices. s in dietary program. report and
delicate blood vessel nursing Aids in determining demonstrate
s leading to the interventions, individual need for change of her
kidneys. the patient will adjustment and teaching. diet and manifest
report and a normal blood
demonstrate 4. Instruct and assist in 4. Avoiding foods high in pressure.
change of her diet appropriate food saturated fat and
and manifest a selections, such as a cholesterol is important
normal blood diet rich in fruits, in preventing
pressure. vegetables, and low- progressing
fat dairy foods atherogenesis.
referred to as the Moderation and use of
DASH Dietary low-fat products in place
Approaches to Stop of total abstinence from
Hypertension) diet and certain food items may
avoiding foods high in prevent sense of
saturated fat (butter, deprivation and enhance
cheese, eggs, ice cooperation with dietary
cream, meat) and regimen. The DASH
cholesterol (fatty diet, in conjunction with
meat, egg yolks, exercise, weight loss,
whole dairy products, and limits on salt intake,
shrimp, organ meats). may reduce or even
eliminate the need for
drug therapy.
NURSING CARE PLAN 2: Deficient knowledge r/t unfamiliarity with information resources as evidenced by request for information

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS EXPLANATION INTERVENTIONS OUTCOME
Subjective: Deficient A lack of After 2 hours Independent: After 2 hours
“Hindi ko knowledge r/t cognitive of nursing of nursing
masyado alam unfamiliarity information or intervention, 1. Provide an 1. Conveying intervention,
yung sakit ko. with psychomotor the patient will atmosphere of respect is the patient
Bakit po ba information ability needed for be able to: respect, especially shall have:
naging ganon?” resources as health restoration, openness, important when
As verbalized evidenced by preservation, or 1. Identify trust, and providing 1. Identified
by the patient request for health promotion signs and collaboration education to signs and
information is identified as symptoms patients with symptoms
Knowledge of different values of
Deficit or preeclampsi and beliefs about preeclamp
Deficient a health and sia
Knowledge. illness.
Knowledge plays 2. Verbalize 2. Verbalized
an influential and awareness 2. Include the 2. Goal setting awareness
significant part of and patient in allows the and
a patient’s life understandi creating the learner to know understand
and recovery. It ng of the teaching plan, what will be ing of the
may include any disease beginning with discussed and disease
of the three process and establishing expected during process
domains: appropriate objectives and the session. and
cognitive domain term plan goals for appropriat
(intellectual learning at the e term
activities, 3. Initiate beginning of plan
problem-solving, lifestyle the session.
and others); changes for 3. Initiated
affective domain better 3. Assess 3. Establishes data lifestyle
(feelings, health patient’s/coupl base and provides changes
attitudes, belief); outcomes e’s knowledge information. Provide for better
and psychomotor of the disease information about health
domain (physical process. areas in which outcomes
skills or Provide learning is needed.
procedures). information Taking information
about can improve
pathophysiolog understanding and
y of reduce fear, helping
preeclampsia to facilitate the
and its treatment plan for
implications the client
for mother and
fetus

4. Provide 4. Helps ensure that

information patient seeks
about timely treatment
signs/symptom and may prevent
s indicating worsening of
worsening of preeclamptic
condition, and state or
instruct patient additional
when to notify complications.
healthcare
provider

5. Review
5. Strengthens
techniques for
importance of
stress
patient’s
management
responsibility in
and diet
treatment.
restriction such
 as avoiding
drinking
alcohols or
beverages
containing
caffeine

6. Have patient 6. Fears and

informed of health anxieties can be
status, results of compounded
when tests, and when
fetal well-being patient/couple
does not have
adequate
information
about the state of
the disease
process or its
impact on patient
and fetus.
FDAR 1: (paki-specify nalang dito yung nursing diagnosis)

DATE TIME FOCUS NURSING PROGRESS NOTES