Case Presentation

On
Pre-
eclampsia

Submitted To: Respected mam Karuna

sharma
Professor, OBG Nursing
SGRDCollege Of Nursing, vallah,
Asr
Submitted By:
Rajdawinder Kaur
M.Sc. Nsg 2nd year
 PATIENT’S DATA

 NAME OF THE PATIENT : Sukhwinder kaur

 AGE : 32 yrs
 RELIGION : sikh
 MARITAL STATUS : Married
 ADDRESS : Amritsar
 ADMISSION / IN- PATIENT NO. : 1667738/329579
 NAME OF WARD : Postnatal ward
 DATE OF ADMISSION : 1/12/16
 DATE OF DISCHARGE : 7/09/17
 EDUCATIONAL STATUS : Matric
 OCCUPATION : Housewife
 CONSULTANT DOCTOR : Dr. madhu nagpal
 PROVISIONAL DIGNOSIS : Pre-eclampsia
 CHIEF COMPLAINTS:

At the time of admission

¤ High blood pressure x 8 month (190/100)

¤ Labour pain x 2 hour

 HISTORY OF PRESENT ILLNESS :

Patient is hospitalized in SGRD HOSPITAL due to labour pain. The patient noted on and
off hypogastric intermittent pain radiating to the lower sacral area. On examination the
high blood pressure is noted with pitting edema of about 2mm.

PAST HISTORY –

 MEDICAL : No H/o Hypertension prior to pregnancy.

No H/o Diabetes Mellitus.
No H/o Tuberclosis.
No H/o Renal Failure.

 SURGICAL : Not significant

 GYNECOLOGICAL : Not Significant

 OBSTETRICS: G2P1L1

FAMILY HISTORY

Name of the Relationship Age/ Marital Occupation Health Educational

family with patient Sex status Status Background
member
Surta singh Father-in-law 68yrs/M Married -------------- Good Illiterate
Beant kaur Mother-in-law 65yrs/F Married ------ Good Illiterate
Hardeep Husband 38yrs/M Married Labourer Good Matric
singh
Harkirat Son 11yrs/M Unmarried --------- Good 4th
singh

FAMILY HISTORY

Surta singh Beant

68yrs 65 yrs

Hardeep singh sukhwinder kaur

38yrs 32 yrs

FEMALE
Harkirat singh
11yrs

PATIENT

MALE.
HEALTH FACILTY NEAR HOME :

Health Center – SGRD Hospital

Transport Facility – Bike
Socio-economic Status – middle class
Housing – Pakka
Number of rooms – 2
Water supply –Tap
Sanitation – Adequate
Family Income per month- Rs 12,000/ month

PERSONAL HISTORY

 Hobbies : watching TV, Cooking

 Dietary habits : Vegetarian
 Addictions : No H/o Drug Addiction

PERSONAL HYGIENE:

Oral hygiene : Toothpaste

 Mode: brush
 2 time a day
 Bath per day frequency - 1
 Diet : Vegetarian
 No. of meals - 3 meals per day
 Food preferences- Home made food
 Type of food - Punjabi Food
 Fluid - 4-5 glasses per day
 Tea& coffee – Tea 1 cups/ day
Sleep & rest - 1 hr in afternoon/ day
7 hrs in night/ day
Elimination

Bowel per day – regular

Urine frequency- 3-4 times a day

Color- pale yellow

Mobility & exercise

Exercise /activity- Moderate
Joints- no pain in joint
Menstrual history-
Age of menarche: 12 years
Duration of menstruation: 4-5 days
Amount of menstruation: normal flow
Dymenorrhea: Present
LMP - 01-12- 2016
Marital History :
Spouse health - Good
Spouse occupation - Self-employed
Substance use - No H/o substance abuse
Addiction use - No addiction

OBSTETRICAL HISTORY: Not-Significant

Sexual history

 Any IUD being used/ method of contraception - No H/O IUD insertion/

Other method - condoms
 Dyspareunia : Mild level
 Relationship : Satisfactory

PHYSICAL ASSESSMENT

General appearance & behavior: Moderate appearance with normal height/ good
behavior
Patient is comfortable, cooperative, well oriented
to TPP .i.e. Time place and person

Vital signs on :

Temperature – 98.20 F
Pulse - 110/ min
Blood Pressure – 190/100 mm Hg
 Anthropometric Measurement

Anthropometric Measurement Actual Expected

Weight Gain during 68 kg( pregnancy) 66-68kg

pregnancy 57 kg ( before 3rd Trimester
pregnancy)

Height 5’ 3”
Daily fluid requirement 3 liters at least 2.4 liters
Abdominal girth 80cm 80 cm
Fundal height 30 cm 30 cm
Involution of uterus ------------- ----------

Immunization status TT1 – At 2nd Month / Dose- 0.5 ml, I/M

TT2 – At 6th Month / Dose- 0.5 ml, I/M
Physical assessment
SUBJECTIVE DATA OBJECTIVE DATA
HEAD: Inspection:
Hair colour- Black
Texture – Normal
Dandruff - Absent
Palpation: Leisons- Absent
VISION: Normal 20/20
HEARING: Normal
SPEECH & ORIENTATION: Normal speech/ well oriented to TPP
( Time, Place, Person)
RESPIRATORY SYSTEM: On inspection:
Chest Expansion – B/L Expansion
Respiratory Rate – 28/ min
On palpation: No mass formation
On percussion: No fluid accumulation,

CIRCULATORY SYSTEM:
LYMPHATIC SYSTEM:
GASTROINTESTINAL SYSTEM AND
NUTRITION/ HYDRATION:
URINARY SYSTEM:
REPRODUCTIVE SYSTEM:
INTEGUMENTARY SYSTEM:
PSYCHO-SOCIAL ASPECT:
MUSCULO SKELTAL SYSTEM:
NEUROLOGICAL ASSESSMENT:
On auscultation: Normal breath sounds
Pulse : 110/min
Blood pressure: 190/ 100 mm of Hg
On inspection: Jugular Vein - present
On palpation: No cardiomegaly
On auscultation: murmur heard
On palpation:
Lymph nodes – No lymphadenopathy
Inflammation- Absent
Per Abdomen:
On inspection: Shiny
On auscultation: Normal bowel sounds
On palpation: No hepatomegaly,
spleenomegaly
On percussion: No fluid accumulation
Constipation : often
Urine analysis:
Colour – Yellow
No Pus cells, casts and crystals
Culture Test – No growth
Lochia - Not significant
Postnatal day- N/S
Colour – N/S
No. of pad used/ day- N/S
Average blood loss /day- N/S
Spotting-present
Skin Texture – Edema in ankle
Polydactyl/ Syndactyl y– Absent
Cyanosis – Absent
Capillary Refill Time – 2.5 sec
Family support – available
Sound mind body interaction
Specific- No Psychiatric illness
Joint mobility – adequate
Fatigue- present
Level of consciousness : Fully conscious
Memory: Intact ( long term memory)
Orientation: well oriented to TPP

ABDOMINAL ASSESSMENT:
PER VAGINAL ASSESSMENT:
NEONATAL ASSESSMENT:
Insight: Present
Judgment: present
General intelligence: adequate
Speech: adequate, no speech and
articulation disorder
Behavior: adequate and good coping
Skills
INSPECTION:
Skin: shiny
Shape – Ovoid shaped
Linea Nigra – present
Striae Gravidarum – present
PALPATION:
Tenderness – No
FHS is heard
Distension - No
Abdominal girth – 86cm
Fundal height – 30cm
Leakage per Examination: vaginal
discharges present
Normal

VITAL SIGNS & PROGRESS NOTES:

SR VITALS DAY 1 DAY 2 DAY 3
NO.
1. TEMPERATURE 98.60 F 98.6O F 98.60 F
2. PULSE 110/ MIN 90/MIN 80/MIN
3. RESPIRATION 26/MIN 22/MIN 20/MIN
4. BLOOD 190/100 140/100 130/90
PRESSURE mmHg mmHg mmHg

INVESTIGATION:

Lab test Patient ‘s lab test value Normal Value

Hb 11.5 gm% 12-17 gm%
B.T. 1-5’’ min 1’’-5’’ min
CT 4’-9’’ 4’’-9’’
TLC 8,600/cumm 4000-11000/cumm
RBS 89 mgm% 80-140 mgm%
VDRL test NR NR
SGOT 34 unit/liter 5 to 43 unit/liter
SGPT 45 unit/liter 7 to 56 unit/liter
Albumin in urine 3+ Nil
Blood urea 21mg/dl 10-50 mg/dl
Blood creatinine 1.2 mg/dl 0.5-1.4 mg/dl
Bleeding time 2 minutes 1-3 minutes

SPECIAL INVESTIGATION:

 ULTRASOUND :
Impression: Alive fetus corresponding 30weeks in cephalic presentation.
 DOPPLER STUDY: FHS is heard, 148bpm.
 NST : Not performed
 ENDOSCOPY : Not performed

PLAN OF TREATMENT

MEDICAL MANAGEMENT

Sr.no. Name of drug Route/ dose/ Action

time
1. Inj. ceftraixone I/V/1 gm/ BD Antibiotics

2. Inj. genta I/V / 80 mg / BD Antibiotics

Salt-
Gentamiacin
3. Inj. Diclofenac I/M/3ml/T.D.S Analgesic
Salt- Diclofenac
Sodium
4. Ringer lactate I/V/BD/500ml Parentally fluid

Nursing management

NURSING ASSESSMENT
1. Monitor vital signs and FHR.
2. Minimize external stimuli; promote rest and relaxation
3. Measure and record urine output, protein level, and specific gravity.
4. Assess for edema of face, arms, hands, legs, ankles, and feet. Also assess for
pulmonary edema.
5. Weigh the client daily.
6. Assess deep tendon reflexes every 4 hours.
7. Assess for placental separation, headache and visual disturbance, epigastric pain, and
altered level of consciousness.

SHORT TERM GOALS

1. To maintain adequate tissue perfusion.
2. To increase activity tolerance.
3. To maintain normal skin integrity.
4. To increase knowledge level of the client.

LONG TERM GOALS

1. To educate the patient about follow up.
2. To prevent complications in the patient.
3. To provide psychosocial support to patient.
4. To rehabilitate the patient.

NURSING DIAGNOSIS
 Ineffective tissue perfusion related to decrease in RBC, hemoglobin and
hematocrit as evidenced by weak and pale in appearance.
 Activity intolerance related to body weakness secondary to low RBC level as evidenced
by intolerance for long standing and walking independently.
 Impaired skin integrity related to cesarean section as evidenced by surgical incision.
 Knowledge deficit related to pre-eclampsia, treatment and self-care as evidenced by
asking statement of concern.

NURSING CARE PLAN

Nsg diagnosis Objectives Planning Implementation Rationale Evaluation

Ineffective To maintain Monitor the vital The vital signs are It provides The
tissue adequate tissue signs, assess monitored, urinary baseline adequate
perfusion perfusion. urine output and output and weight information. tissue
related to weigh client. of the client is perfusion is
decrease in checked daily. maintained.
RBC,
hemoglobin
and
hematocrit as
evidenced by
weak and pale
in
appearance.
Place the client The client is placed This avoid
on left in left recumbent uterine
recumbent position and pressure on
position. maternal well- vena cava and
being is checked prevent supine
periodically. hypotension.
Maintain Adequate This promotes
adequate ventilation is oxygenation
ventilation. maintained. and good
blood
circulation.
Administer fluid I/V fluids are Replacement
as prescribed. administered as of fluid
prescribed by maintains
doctor. circulatory
volume and
tissue
perfusion.
Insert catheter as Foley’s catheter is It detects early
indicated by inserted to note signs of fluid
doctor and urinary output. overload.
monitor urine
output.
Administer Oxygen is It ensures
oxygen as administered as supply of
prescribed. prescribed by oxygen to both
doctor. mother &
fetus.
 Nsg diagnosis Objectives Planning Implementation Rationale Evaluation

Activity To able client Assist the client Assistance is It ensures The client is
intolerance to perform during moving provided to the safety and able to
related to ADL with and on going in client whenever she additional perform
body minimum the room. needs it. support for the ADL with
weakness assistance. client. minimum
secondary to assistance.
low RBC level
as evidenced
by less
tolerance for
long standing
and walking
independently
Assist the client The client is It improves
in comfortable assisted in a comfort.
position. comfortable
position.
Assist with ADL The client is It increases
as indicated to assisted in daily client
reduce activity only when independence.
expenditure. and where she
needs assistance.
Let the client do Opportunity is It increases
much of provided to client self-reliance.
activities. so that she that she
can do much of
activities.
Proper Proper ventilation It gives enough
ventilation and and oxygen is oxygen supply.
oxygen should provided to client.
be provided.

Nsg diagnosis Objectives Planning Implementation Rationale Evaluation

Impaired skin To promote Assess the The condition of It provides The chances
integrity proper healing. condition of skin skin and of baseline of infection
and Episiotomy Episiotomy information. is less and
incision. incision is assessed healing is
for infection. good.
Stress on proper Proper hand It controls the
hand washing. hygiene is spread of
maintained before infection.
and after touching
client.
Encouraged to Client is instructed It aids in tissue
eat foods that to take sprouted repair.
are rich in pulses, and animal
protein. products.
Claen the Episiotomy is It helps in
episiotomy cleaned.. wound healing.
stitches with
betadine
Change the Pad Pad is changed at a It decreases the
at regular regular interval. chances of
intervals. infection.
The necessary & The pamphlets with With hand of
important necessary pamphlet the
information information is important
regarding given to the patient. information
hygiene should regarding
be given to hygiene is with
patient. the hand of the
patient.
Nsg diagnosis Objectives Planning Implementation Rationale Evaluation

Knowledge To increase Assess the The knowledge It provides The

deficit related to knowledge knowledge level level of the client baseline knowledge
pre-eclampsia, level of the of the client and and family information. of client is
treatment and client. family members. members are increased.
self care as assessed.
evidenced by
asking statement
of concern.

Identify family’s Family’s priorities It helps in

priorities when while providing meeting needs
providing information are of family.
information. identified.
Identify Client/couple’s Inaccurate
client/couple’s perception of perception
perceptions of events are needs to be
events and identified and assessed on
correct misunderstanding continual
misunderstandin are corrected. basis.
g.
Necessary Pamphlet having Client can
information needed information access the
should be given is given to the information
in hand of client. client. whenever
needed.
All doubts of the All doubts of the It increases
client and family client and family knowledge of
members should members are the client and
be cleared out. cleared out. eliminate
wrong
information.
The necessary & The pamphlets with With hand of
important necessary pamphlet the
information information is important
regarding given to the patient. information
disorder should regarding
be given to condition is
patient. with the hand
of the patient.
 DISEASE STUDY
Pre-eclampsia

Definition– It is a multi-system disorder of unknown etiology characterized by

development of hypertension to the extent of 140/90mm Hg or more with proteinuria
after the 20th week in a previously normotensive and non-proteinuric patient.

Classification:
 Primary (70%)
 Pre-eclampsia
 Eclampsia (with convulsion)
 Secondary (30%)
 Pre-eclampsia-eclampsia superimposed on chronic hypertension (25%)
 Pre-eclampsia-eclampsia superimposed on chronic renal disease (5%)

Risk Factors-

In Book In Patient
Primigravida, age Absent, patient is 32 year
Family history Present. History of hypertension from
maternal side.
Placental facors Absent
Genetic factors Absent
Immunological phenomenon Absent
Obesity, smoking Absent
Pre-existing vascular or renal disease. Present
Thrombophilias Not present

clinical Features

In Book In Patient
 Mild symptoms
Slight swelling on ankles on rising in
morning or tightness of the ring on the Present
fingers.
In Book In Patient
 Alarming Symptoms
Headache
Disturbed sleep
Diminished urine output Present
Epigastric pain
Eye symptoms

Signs of Pre-eclampsia

In Book In Patient
Abnormal weight gain Present
Rise of blood pressure Present
Edema Ankle Oedema present
Pulmonary edema Absent

Investigation:

In Book In Patient
Urine examination Done. Monitoring show 176/110 mmHg
Opthalmoscopic examination Done
Blood values Done
Antenatal fetal monitoring Done

Management
Medical Management

In Book In Patient
Rest. Done. Rest in left lateral position is given
to patient.
Diet. Done. Diet with adequate protein and less
salt is given.
Anticonvulsant drug Done. Mgso4 ( acc to Pritchard method)
Diuretics Done. Frusemide 40 mg is given.
Antihypertensives Done. labetalol 200 mg is given to patient.
Tab nifidipine 10 mg is given to patient
Termination of pregnancy Normal vaginal delivery
Management during labor

In Book In Patient
Patient should be in bed. Done.
Liberal sedatives Not done.
Antihypertensive drug Done.
Blood pressure and urine output monitoring Done.

Puerperium Management

In Book In Patient
Close monitoring for atleast 48 hours. Done
Sedative Done
Blood pressure monitoring Done
 PROGRESS REPORT
1st day – Patient is admitted with mild labour pain and complaint of pre-eclampsia. The
first blood pressure of client is noted and antihypertensive is given to her. The patient
delivered normal vaginal delivery (still birth).
2nd day – The patient is closely monitor for first 48 hours of puerperium period. The
blood pressure and urine output is checked periodically.
3rd day – The normal tissue perfusion and skin integrity is maintained. the assistance
during activity is provided to the client. The antibiotics was given. The patient was
monitored periodically for sign of infection. With adequate nursing interventions the
chances of infection get reduced.
4th day- The patient is normal and they are discharged.
1st day 2nd day 3rd day
Vital signs-
stable stable stable
Temp.-98.60 F Temp.-98.60 F Temp.- 98.60 F
Pulse- 110/min Pulse- 100/min Pulse- 90/min
Respiration – 26/min Respiration – 20/min Respiration – 20/min
B.P – 190/100mmHg B.P – 140/100mmHg B.P – 110/90mmHg

MEDICATIONS:
1) Injection Genta Continued Continued
2) Injection ceftriaxone Continued Continued
3) Tab BCforte Continued ----------

Sign & symptoms:

1) pain Relieved relieved

2) restlessness Relieved relieved

General condition:
Not stable Stable stable

INTAKE OUTPUT:
Positive balance Positive balance Positive balance

PHYSICAL
MOBILITY:
Bed rest Bed rest Bed rest
 HEALTH EDUCATION
 Patient is instructed to check Lochia daily and to contact with obstetrician if
redness and discharge occurs.
 Advise her to take proper rest on left side and in quiet environment.
 Patient is advised to avoid high salt diet.
 Maintain adequate fluid intake.
 Ensure intake of protein about 1gm/kg/day.
 Mother is advised to give breastfeeding to her newborn and encourage about
rooming-in-practice.
 Instruct the patient to resume activities of daily living gradually.
 Raised her both legs slightly to reduce oedema.
 The patient is reminded about follow-up care and to take her medications.
 The mother is advised to visit the paediatrician once a month, for neonatal check-
up.
 Advice the patient to have nutritious diet.
 Patient was encouraged for postnatal exercises and proper rest to avoid fatigue
and discomfort.
 Use sanitory pads in puerperium.
 Maintain perineal hygiene.
 Report to doctor in case of abnormal lochial discharge.
 Advice the patient to come for follow-up checkup after 10 days.
 BIBLIOGRAPHY

• Annamma Jacob.Textbook of Midwifery & Gynaecology Nursing’.Published

by Jaypee Brothers. 3rd edition :Page 284-290 .
• DC Dutta , ‘‘Textbook of Obstretrics’’, Edition 6th , Published by Heera Lal
Kaur ,Page 598-604.
• Sharma JB, ‘ textbook of obsteteric, ‘published by avichal, 1st editio, page 312-
315.
• National Collaborating Centre for Women’s and Children’s Health, Intrapartum
care of healthy women and their babies dur ing childbirth
• www.niceguidelines.com/normal labour
• www.pubmed.com