I.

INTRODUCTION

Pre-eclampsia, formerly called toxemia of pregnancy is an abnormal condition of

pregnancy characterized by the onset of an acute hypertension after the 24 th week of gestation.
The classic triad of preeclampsia is proteinuria and edema. The cause of the disease remains
unknown despite 100 years of research by thousands of investigators. Pre-eclampsia commonly
causes abnormal metabolic function, including negative nitrogen balance, increase central
nervous system irritability, hyperactive reflexes, compromised renal function,
hemoconncentration, and alteration of the fluids and electrolytes balance. It occurs in 5-7% of
pregnancies. Most often in primigravida and is more common in some areas of the world than
others, the incidence is particularly high in the southern part of the U.S. The incidence increases
with increasing gestational age and it is more common in cases of multiple gestation, H. Mole or
hydramnios. A typical lesion in the kidney, glomerulo endotheliosis is pathognomonic
termination of the pregnancy results in the resolution of the signs and symptoms of the disease
and in healing of the renal lesion. Preeclampsia is classified as mild or severe. Mild eclampsia is
diagnosed if one or more of the following signs develop after 24 th week of gestation. Systolic BP
of140 mmHg or more or an increase of 30 mmHg of more above the woman’s systolic BP;
proteinuria and edema. Severe preeclampsia is diagnosed if one or more of the following signs is
present.; systolic BP 160 mmHg and above, diastolic Bp of 110 mmHg above on two occasions 6
hours apart with the woman on bed rest; proteinuria of 5g or more within 24 hours; oliguria of
less than 400cc in 24 hours; ocular or cerebral vascular disorders; and cyanosis or pulmonary
edema. Complications include premature separation of the placenta, hemolysis, cerebral
hemorrhage, ophthalmologic damage, pulmonary edema, hepatocellular changes, fetal
malnutrition and lower birth rate. The most common complication is eclampsia, which can
results to both maternal and fetal death. Healthy living conditions including a diet with high in
proteins, calories and essential nutritional elements, rest and exercise are associated with
decrease incidence of pre-eclampsia. Treatments include rest sedation, magnesium sulfate, and
antihypertensive. Ultimately if eclampsia threatens delivery by induction of labor or CS may be
necessary. (Mosby’s dictionary of Medicine, Nursing and Health Professions,)

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 In developing countries, preeclampsia impact 4.4% of all deliveries. The incidence of
preeclampsia as of 2002 up to present raises to 146, 320 cases annually. It affects 5% of
pregnancies worldwide. In United States, approximately 1 in 1858 cases or 0.05% equivalent to
146,320 people in the U. S have preeclampsia. (cureresearch.com/p/preeclampsia/stats-
country.htm). In the Philippines, cases of preeclampsia exceeds up to 0.05% of pregnancies
annually or 46,392 cases out of 86,241,697 as of 2009. (www.doh.gov.ph). In local setting, 25
cases of preeclampsia were recorded at the Tarlac Provincial Hospital from January-December of
the year 2008. (TPH records).

As of May 18, 2009, there was an article posted about the cure of preeclampsia entitled
“A possible cure for pre-eclampsia”, this article talks about the new trends about preeclampsia
treatment.

Article: “A possible cure for pre-eclampsia”

A condition which affects one in every ten pregnancies and is responsible for 1,000 baby
deaths in Britain each year may have a genetic cause. Scientists in the United States say they
have discovered in studies with mice, a gene which may be linked with pre-eclampsia in some
women. The researchers from Harvard Medical School found mice, genetically-engineered to be
deficient in an enzyme called COMT (catechol-O-methyltransferase), developed pre-eclampsia.
The research team say low levels of COMT are also seen in pregnant women with the condition
which presents dangers for both mother and baby. The discovery could lead in the future to a
diagnostic test for the condition and possibly some form of preventative treatment. Of all
premature deliveries in the UK, pre-eclampsia accounts for 15% of them because the only way to
safely deal with pre-eclampsia is to deliver the baby. It causes rapid rises in blood pressure and if
the condition is untreated it can lead to convulsions, kidney failure, serious liver problems and
death. Pre-eclampsia is triggered by oxygen starvation caused by leaky blood vessels in the
placenta and the researchers examined the proteins possibly involved in pre-eclampsia by
affecting the level of oxygen delivered to the placenta. Dr. Raghu Kalluri, the study leader says if
a gene is responsible for pre-eclampsia in some families then it could be a useful genetic test.
COMT is an enzyme involved in the development of new blood vessels and a compound it
produces called 2-methoxyoestradiol (2-ME), normally increases during the last three months of
human pregnancy. They realised that mice without any COMT also failed to produce 2-ME, but

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when the COMT was restored the pre-eclampsia was cured. The researchers say as well as the
potential for a genetic test to identify women at risk, this has important implications for a
potential treatment. They say it is possible to measure 2-ME in blood or urine, which could
identify those who need more close monitoring, and those at risk can be treated with a
supplementary pill. Dr. Kalluri says this would give the mothers back what is missing. A large
clinical trial to look at the effect of COMT in women is now on the cards and experts say even
though all women are closely monitored for signs of pre-eclampsia a good test would remove
that need and would be very useful.(www.themedicalnews.com)

IMPORTANCE OF THE CASE STUDY

We chose this case because we are aware that pregnancy - related complications or
abnormalities, is not a simple problem, which can even lead to both fetal and maternal death that
is why this case in very significant. Knowing that Mrs. X is experiencing hypertension during
her pregnancy (preeclampsia) and is at risk for complications such as eclampsia (a life
threatening condition), we, as the student nurses in charge of taking care and rendering
healthcare services to her, must know well about the course of her condition and the possible
nursing interventions we can provide to manage her condition. This case is also significant in the
actual practice of our nursing profession.

Nursing research is also important to nursing profession because new researches helps
people especially those who were engaged on the medical field to know new things and update
their knowledge about certain things which they can use in practicing the nursing profession.

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GENERAL OBJECTIVE:

✔ To come up with a detailed clinical case study of pre-eclampsia and to identify as well
as provide an appropriate and accurate nursing measure and different responsibilities to
consider while taking care of the client.

SPECIFIC OBJECTIVES:

This study aims to:

1. Assess properly to determine the contributing factors regarding the client’s disease and
identify any present abnormalities.

a. Personal Data
b. Family history of health and illness
c. History of past illness
d. History of present illness
e. 13 areas of assessment

2. Gather the needed data that can help to understand how and why the disease occurs
f. Diagnostic and Laboratory Procedures
g. Anatomy and Physiology
h. Pathophysiology book base and client centered

3. Develop an individualized plan considering client characteristics or the situation and setting a
specific, measurable, attainable, realistic and time bounded plan that reflect the onset, date of
problem identified
i. Planning (nursing care plan)

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4. Provide appropriate interventions for every problem encountered and monitor the client’s
response to treatment and therapies through means of physical assessment and communication
with the client
j. Medical management
k. Surgical management
l. Nursing management

5. Judge the effectiveness of chosen interventions, nursing care, and the quality of care provided
m. Client’s daily program in the hospital

6. Describe the general condition of the client upon discharge and know the take home
medications, exercise, and treatment for the client, provide health teachings and inform client for
OPD follow-ups
n. Discharge Planning

7. Broaden the knowledge of each member through further research about the latest news articles
and journals regarding to the client disease
a. Related literature

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II. NURSING PROCESS

A. ASSESSMENT

1. Personal Data

A. Demographic data

Date: September 19, 2009

Name: Mrs X Age: 37 y/o

Sex: female Civil status: married

Occupation: no permanent job Religion: Roman Catholic

Role in the family: mother Address: Tarlac City

Date & place of birth: August 17, 1972 Nationality: Filipino

Tarlac City

Source of referral: husband & other relatives

Usual source of care: hospital

Admitting diagnosis or impression: Pregnancy Uterine 40 2/7 week AOG, Preeclampsia with
gestational HTN, G1P0,

Final Diagnosis: Pregnancy Uterine 40 2/7 weeks delivered to term, cephalic live baby boy,
APGAR 8/9 via primary low transverse segment caesarean section dor proploged 2nd stage of
labor, arrest in fetal head descent, G1P1 (1001)

B. Environmental Status

The patient lives in a mixed-type bungalow, it has two doors, one front door and one back
door, has 2 rooms each with two windows. Their house is about 8 kilometres away from the
nearest health center. They have their own water pump located in the kitchen inside their house.
They have chickens and ducks in their backyard, where a vegetable garden is also found. When it
comes to garbage disposal, they use burning system. She also stated that her husband is a chain
smoker and usually smokes even inside their house.

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 C. Lifestyle

Mrs X. Usually wakes up at around 4:00 in the morning. Upon waking up, she takes her
first cup of coffee while preparing their breakfast which usually consists of dried fish and instant
noodles. After breakfast, she goes to the backyard to clean their garden or she will immediately
proceed to washing their dirty clothes. After doing the chores, she prepares their lunch which
also consists of instant noodles and sometimes. Their dinner consists of what is left from their
lunch. According to her she loves eating fatty foods such as chicharon, fried pork and many
more. The patient usually sleeps at around nine - ten o’clock in the evening.

2. Family History of Health and Illness

See genogram – next page

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GENOGRAM

MATERNAL PATERNAL

8 9
7 8 0 8
9 4
AW AW HPN HPN

6 6 4
7 7 9 6 5 6 5 5 9
4 2 5 8 8 3
HPN AW CVA AW HPN AW AW HPN AST

LEGEND:
- POINTS TO THE PATIENT
AW – ALIVE & WELL
HPN – HYPERTENSION
AST – ASTHMA
4 4 3 DM- Diabetes Mellitus
2 0 3 3 9 CVA - STROKE
0 2 P-E - PREECLAMPSIA
DM AW HPN AST HPN -DECEASED FEMALE
- DECEASED MALE
3 AW
3 9
7
P-E
*BASED ON THE DIAGRAM, WE CAN SAY THAT THE PATIENT HAS HISTORY OF
HYPERTENSION, STROKE, ASTHMA AND DIABETES MELLITUS.
AS *BASED ON THE GENOGRAM, WE CAN SAY THAT THE CLIENT’S PRESENT CONDITION IS
Page | 8
GENETICALLY ACQUIRED.
 3. HISTORY OF PAST ILLNESS

According to the patient, she always experiences cough and colds and fever as a child.
Her mother usually treats this illnesses using over-the-counter drugs and with herbal
medicines. She denies any history of allergies and injuries in the past.

4. HISTORY OF PRESENT ILNESS

The client is on her 40th week AOG. Few days before her confinement, the client
experienced blurring of vision and pounding headache while preparing their breakfast. She
stated “Biglang nanlabo ang paningin ko tapos parang pinupukpok ung ulo ko”. According to
her, she just lied down for a few minutes and she took a pain reliever and the headache
alleviated a little but the blurring of vision persisted for the whole day.

The next day, she went to the health center for her weekly pre-natal check-up. It was that
day when she discovered that she has an elevated blood pressure of 140/90 mmhg. According
to her, she ignored that fact, thinking that it will not do any harm to her and her baby so she
just went home and continued her daily chores.

Few hours before her confinement, while cleaning their house, she experiences the same
symptoms but this time, it was more intense. She described the headache as crashing
headache. She also felt light to moderate uterine contractions. She immediately called her
husband who was inside the house at that time and she was rushed to the emergency
department of the Tarlac Provincial Hospital on the16th day of September two thousand and
nine.

5. 13 AREAS OF ASSESSMENT

Date assessed:

Pre – op: September 19, 2009

Post – op: September 21, 2009
1. Social Status

The 37 year old patient was nine months pregnant at the time of her confinement. She is
happily married to her husband of two years. According to her, she has a good working
relationship with her in-laws as well as with their other relatives. Her husband works as a
jeepney driver. The patient also denies any conflicts among their neighbours.

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 Norms:

Family members should perform their roles. Good communication within the family must
be maintained to obtain a healthy relationship with one another. Social support is a perception
that one has an emotional and tangible resource to call on when needed; perceived social support
is being followed by the family to express the love and care to the family. Financial aspect is one
of the normal constraints in the family.(Kozier, Copyright 2004)

Analysis:

The patient has a harmonious relationship among the people around her. She is well-
supported by her relatives.

2. Mental Status

Level of consciousness

Pre – op:

The patient responds appropriately to the questions asked. She can also recall the names
of her family members. She is also oriented to the date, time, and place she is in.

Post – op:

The patient refused to answer some of our questions, but still she knows the date, place,
and time where she is in.

NORMS:

Level of Consciousness determines whether a person is oriented to the things that are happening.
Response to verbal stimuli indicates that the patient is oriented to the place he or she is in.
(Kozier, Copyright 2004)

ANALYSIS:

Pre – op:

The client is alert and well oriented as she responds appropriately with the questions that
were asked to her.

Post – op:

The patient was hesitant to answer some of our questions, but she is well oriented.

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Mood

Pre – op:

During the interview, the patient appears attentive but there are times that she appears
irritable but she still manages to answer our questions appropriately. A tinge of anxiety was also
noted.

Post – op:

Upon interview to the client, the patient appears to be attentive but sometimes she seems
to be not interested to answer our questions.

NORMS:

Moods are dependent on a person’s view of what is happening around him for example
person who is lacking of sleep may not be approachable. (Kozier, Copyright 2004)

ANALYSIS:

Pre – op:

The client can still manage her emotions despite her condition.

Post – op:

The patient was a little bit hesitant to answer our questions because of the pain she
experiences caused by her operation.

Thought processes and perception

Pre – op:

The client freely expresses her feelings about her condition. She can identify the reality
from not as she states the possible outcomes of her pregnancy,”sabi ng doctor puwedeng
malagay sa peligro ang buhay namin ng anak kaya lagi talaga akong nagdadasal” as verbalized
by the patient.

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Pre – op:

The client seems to be quiet about what she feels. She can still identify reality from not
by stating that she will be fine after few days.

NORMS:

Thought processes is the person’s ability to identify the reality from not. Feelings need to
be explored to determine whether they are based on reality or interpretations memories or fears.
(Kozier, Copyright 2004)

ANALYSIS:

Pre – op:

The client knows what is reality from not, as she talked to as about things that really
happens in reality.

Post – op:

The client still knows what is reality from not.

Cognitive Abilities

Pre – op:

The client is well oriented on the place, time, and date. She also knows about her
condition. She responded normally to the neurological test performed but because she is on bed
rest, the Romberg’s test was not performed.

Post – op:

The client is still well oriented on the date, time and place. She also knows her present
condition. Romberg’s test was not performed because she is still on bed rest.

NORMS:

Clients undertaking a Romberg’s test should be able to stand upright while the eyes
closed then with eyes open. It is a negative Romberg if the client sways slightly but is able to
maintain upright posture. It is positive if the client cannot maintain an upright position. (Kozier,
Copyright 2004)

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ANALYSIS:

Pre – op:

The client has normal cognitive abilities as the outcomes of the neurological tests shown.

Post – op:

The client has normal cognitive abilities.

3. Emotional Status

Pre – op:

The client remains calm even though she knows about what will happen to her child if her
condition was not given enough attention. Despite that, she exhibits poor eye contact during the
interview. Her voice pitch is slightly increased and shaky. She also shows a strong faith in God
as she stated that whatever happens to is within the will and accordance of God.

Post – op:

The client remains calm in spite of her present condition. She still shows strong faith in
God as she stated that God will help her to be strong again.

NORMS:

A person’s emotional status depends much on his ability to cope up with the happenings
in his/her life. He or she may not be in the right mood if some unnecessary things had happened.
(Nursing CEU.com: The process of human development)

ANALYSIS:

Pre – op:

The client is emotionally stable. The poor eye contact is a manifestation of the anxiety
that she gets because of too much worrying.

Post – op:

The client is emotionally stable.

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4. SENSORY PERCEPTION

Sense of taste

Pre – op:

The patient can determine taste. As she verbalized “matamis yung mangga na kinain ko
kanina”. No lesions or abnormalities were found in the tongue and oral cavities and it is
symmetrical.

Post – op:

The patient sense of taste was not assessed because she is on NPO status.

NORMS:

Normal sensation would be accurate perceptions of sweet, sour, salty, and bitter taste.
(Estes, Third edition, Copyright 2006)

ANALYSIS:

Pre – op:

The client has a normal sense of taste.

Post – op:

The client sense of taste was not able to assess.

Auditory Acuity

Pre – op:

Hearing test was performed in the patient to check if he has a good auditory acuity. We
whispered words 3 inches away from her, she was able to repeat the words correctly and clearly
as we asked her to repeat it; we call her name and claimed if she clearly heard us under 10 and
20 feet away. She was able to answer our question correctly. No bleeding, wounds found on his
external ear.

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Post – op:

Hearing test was performed in the patient to check if he has a good auditory acuity. We
whispered words 3 inches away from her; she was able to repeat the words correctly and clearly
as we asked her to repeat it. No bleeding, wounds found on his external ear.

NORMS:

Patient should hear whispered words or watch tick test and ear must free from lesions and
masses. (Estes, Third edition, Copyright 2006)

ANALYSIS:

Pre – op:

The patient’s auditory sense is intact and has no problem.

Post – op:

The patient’s auditory acuity was normal.

Sense of Smell

Pre – op:

She can distinguish different odors. She was able to differentiate the smell of a cologne,
and alcohol that we provided. She told to us that she is irritated in deleterious odor in the hospital
especially in the comfort room. Her nose lies on the midline of her face and it is symmetrical and
nostrils are intact, no bleeding and wounds found.

Post – op:

The patient can distinguish different odors. She can smell the alcohol we asked her to
smell. Her nose lies on the midline of her face and it is symmetrical and nostrils are intact, no
bleeding and wounds found.

NORMS:

Patient must able to identify different smell; nose should be at the midline position of the
face, free from lesions and intact nostrils. (Estes, Third edition, Copyright 2006)

ANALYSIS:
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Pre – op:

The patient’s sense of smell has no problem.

Post – op

The patient’s sense of smell has no problem.

Sense of Sight

Pre – op:

The client can read well through the reading materials provided by the examiners even
without the use of corrective lenses/glasses. Visual Acuity test was not performed due to the
patient’s condition; she was always on bed rest. She also reported that blurring of vision occurs
during episodes or increased blood pressure.

Post – op:

The client can read well through the materials we asked her to read without the use of eye
glasses. Visual acuity test was not performed because the patient is on bed rest. No blurring of
vision reported.

NORMS:

The patient who has a visual acuity of 20/20 in a Snellen chart test is considered to have a
normal visual acuity. (Estes, Third edition, Copyright 2006)

ANALYSIS:

Pre – op:

The patient’s vision has no problem except for the blurring during increased blood
pressure.

Post – op:

The patient’s visual acuity was normal.

Pain Sensation

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Pre – op:

The patient rated her uterine contraction as 7/10 while the headache she felt before was
rated as 9/10.

Post – op:

The patient complains pain on her incision site and rated it as 7/10.

NORMS:

Reacting with a stimulus is a sign of good sensation. (Estes, Third edition, Copyright
2006)

ANALYSIS:

Pre – op:

The patient’s pain sensation has no problem.

Post – op:

The patient’s pain sensation is normal.

5. MOTOR STABILITY

Pre – op:

The patient was not able to walk due to imposed bed rest but she can still move or flex
and extend her hands, elbows, joints and foot.

Post – op:

The patient was not able to walk due to imposed bed rest. She can move her hands,
elbows, joints and foot but she complains difficulty when moving her legs.

NORMS:

Normal motor stability includes the ability to perform the different steps in doing range
of motion. It should be firm with smooth and coordinated movements (Estes, Third edition,
Copyright 2006)

ANALYSIS:

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 Pre – op:

The patient motor stability is impaired but she can still perform range of motion even
though she was on bed rest.

Post – op:

The patient motor stability is impaired due to imposed bed rest.

6. BODY TEMPERATURE

Pre – op:

The patient has cold and clammy skin upon assessment on the first few hours of assessment.

The following body temperatures were obtained:

Date Time Temperature (°C)

PRE – OP:
September 19, 2009 10:00am 36.7
12:00pm 37
2:00pm 37
September 20, 2009 10:00am 37.2
12:00pm 37.2
2:00pm 37.4
POST – OP:
September 21, 2009 10:00am 37.5
12:00pm 37.3
2:00pm 37.5
September 22, 2009 10:00am 37.2
12:00pm 37.3
2:00pm 37.1
September 23, 2009 10:00am 37.3
12:00pm 37.1
NORMS:

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 36.5 C to 37.5 ◦C is the normal body temperature (Kozier, Seventh edition, Copyright
2004)

ANALYSIS:

Pre – op:
The patient has normal body temperature.
Post – op:
The patient has normal body temperature.

7. RESPIRATORY STATUS

Pre – op:

⮚ On the first day of our assessment on the patient, she has a slightly elevated respiratory
rate. She was on Oxygen Therapy via nasal cannula regulated at 3L/min.\

Table below shows the respiratory rate of the patient.

Date Time Respiratory Rate (cpm)

PRE – OP:
September 19, 2009 10:00am 22
12:00pm 20
2:00pm 21

September 20, 2009 10:00am 18

12:00pm 18
2:00pm 17
POST – OP:
September 21, 2009 10:00am 20
12:00pm 19
2:00pm 18
September 22, 2009 10:00am 18
12:00pm 15

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 2:00pm 17
September 23, 2009 10:00am 16
12:00pm 17

NORMS:

Normal respiratory rate for adults is 12-20 cpm. Average is 18. In terms of pattern,
normal respiration must be regular and even in rhythm. The normal depth of respirations is none
exaggerated and effortless (Health Assessment and Physical Examination 3 rd Edition Mary Ellen
Zator Estes).

ANALYSIS:

Pre – op:

The patient has a deviation from normal respiratory status during first few days of stay in
the hospital but achieved a normal respiratory condition as day’s progresses.

Post - op:

The patient has normal respiratory status.

8.) CIRCULATORY STATUS

Pre – op:

The patient nail color turns back within 4 seconds and she has +2edema on face, hands,
and feet. Her pulse is weak and thready upon assessment with regular interval.

The following pulse rate and blood pressure were obtained:

Date Time Pulse Rate(bpm) Blood

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 Pressure(mmHg)
PRE – OP:
September 19, 2009 10:00am 102 bpm 140/90
12:00pm 98bpm 130/90
2:00pm 91 bpm 130/80
September 20, 2009 10:00am 93 bpm 130/90
12:00pm 96 bpm 120/80
2:00pm 90 bpm 120/90
POST –OP:
September 21, 2009 10:00am 98 bpm 130/90
12:00pm 95 bpm 120/80
2:00pm 91 bpm 120/80
September 22, 2009 10:00am 89 bpm 120/90
12:00pm 90 bpm 120/80
2:00pm 92 bpm 120/90
September 23, 2009 10:00am 90 bpm 120/80
12:00pm 86 bpm 120/80

NORMS:

The average heart rate and blood pressure of an adult are 60-120bpm and 120/90mmHg.
No edema should be observed on the extremities because it indicates venous insufficiency, the
pulse is regular in interval, not weak and thread, not bounding.(Kozier, Seventh edition,
Copyright 2004). The normal range of capillary refill test is within 2-3 sec.(Estes, Third edition,
Copyright 2006)

ANALYSIS:

Pre – op:

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 With regard to his circulatory status, it shows that his pulse rate is normal and her blood
pressure was elevated. She also has insufficient venous return and abnormal capillary refill. Her
pulse characteristics did not meet normal findings for weak and thread assessment.

Post –op:

The client’s circulatory status is within normal limits.

9.) NUTRITIONAL STATUS

The client claimed to as that her weight is 63 kg and 5”2’. She also told us that she eat 4
times a day. She prefers eating fatty foods than vegetables. Her family has the ability to provide
her nutritional needs. She has no food and drug allergies and her body mass index (BMI) was
25.56.

NORMS:

BMI is a measurement that indicated body composition. The degree of overweight or

obesity as well as the degree of underweight can be determined. A balanced diet consist of
variety of foods from meat, fish, vegetables and fruits.(Estes, Third edition, Copyright 2006)

Standard Body Mass Index for Adults

● Underweight = <18.5
● Normal weight = 18.5-24.9
● Overweight = 25-29.9
● Obesity = BMI of 30 or greater

ANALYSIS:

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 The patient has an above than normal BMI related to her present maternal condition. Her
diet put her on a greater risk for developing ailment.

10. ELIMINATION STATUS

Upon assessment diaphoresis was noted to the client due to the humid and crowded
environment in the ward she is in. The patient usually defecates one to two times a day, brown in
color, and soft but formed. The patient has yellow-colored urine with turbid appearance. Her
urine output is 20-25cc/hr. For urinalysis results, please see: Laboratory Results.

NORMS:

Normal bowel movement is usually 2-3 times a week which help in elimination of
unnecessary waste material in the body in the GI tract. It should be soft but formed and brown in
color. Urine output of an adult is usually 1200-1500mL per day. The color is pale yellow or
yellow and has turbid appearance.(Kozier Seventh edition, Copyright 2004)

ANALYSIS:

The patient has a normal bowel movement. Her urine characteristics were normal but her
urinary output is decreased.

11.) REPRODUCTIVE STATUS

The patient has a recorded LMP of December 7, 2008. She said her menstrual cycle was
regular and stated have interval of 24-26 days that lasts for 6-7days. She consumed
approximately 2 pads per day. Her recorded menarche was on 1983 at age 11. She got married at
the age of 27 in the year 1999.

September 19, 2009 = G1 P0 T0 P0 A0 L0

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September 20, 2009 = G1 P1 T1 P0 A0 L1

NORMS:

Sexual activity/status can be determined through the presence or absence of sexual urge.
Age is also one of the factors that affect one’s reproductive status because of the hormonal
changes. Length of duration vary from 2-7 days depending on the duration of the cycle.(Outline
in Obstetrics, 3rd edition)

ANALYSIS:

The patient has a normal reproductive status.

12.) STATE OF PHYSICAL REST AND COMFORT

Before admission, the patient usually slept at 10:00 pm and woke up at around 6:00am to
do the house chores and cook breakfast for her family. But upon admission in the hospital she
could not sleep properly because of the environmental stimulus. She also appears irritable upon
assessment.

NORMS:

A normal sleep hour of an adult per day is 6 - 8 hours without being disturbed and
normally is not irritable, restless and other feature indicating uncomfortable situation. (Kozier,
Seventh edition, Copyright 2004)

ANALYSIS:

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 The patient has adequate rest and sleep. But this was aggravated when she was admitted
in the hospital. This indicates that she has an abnormal sleep and rest upon her admission. She
also appears irritable which one of the features signifying uncomfortable.

13. STATE OF SKIN APPENDAGES

Pre – op:

The patient skin was light brown and uniform in color. The scalp has no flakes and free
from lesions. The hair was properly distributed, black and free from infestations. Nails are in
normal angle of 160o characterized as intact but pale in color and no lesions found. No bleeding
or wounds found in the extremities which are cold and clammy especially on hands. Pitting
edema on extremities and face +2.

Post –op:

The patient skin was light brown and uniform in color. The scalp has no flakes and free
from lesions. The hair was properly distributed, black and free from infestations. Nails are in
normal angle of 160o characterized as intact but pale in color and no lesions found. No bleeding
or wounds found in the extremities. No edema was noted.

NORMS:

Skin varies from light to brown from ruddy pink to light pink. Generally, uniform except
in areas exposed to the sun, areas of lighter pigmentation in palms, nail beds, and lips. The hair
should be evenly distributed, thick, shiny and free from infestation. The nails should be 160◦ and
smooth in texture. Edema in any part in the body could not be considered normal. The skin is
slightly warm but not flushed.(Kozier, Seventh edition, Copyright 2004)

ANALYSIS:

Page | 25
Pre – op:

The patient indicates that she has normal skin and appendages except for edema found on
her extremities and face, and a cold clammy skin especially on hands.

Post –op:

The patient has normal state of skin and appendages.

ANATOMY AND PHYSIOLOGY

THE PLACENTA

The placenta is an organ unique to mammals that connects the developing fetus to the
uterine wall. The placenta supplies the fetus with oxygen and food, and allows fetal waste to be
disposed of via the maternal kidneys. Protherial (egg-laying) and metatherial (marsupial)
mammals produce a choriovitelline placenta that, while connected to the uterine wall, provides
nutrients mainly derived from the egg sac. The placenta develops from the same sperm and egg
cells that form the fetus, and functions as a fetomaternal organ with two components, the fetal
part (Chorion frondosum), and the maternal part (Decidua basalis). In humans, the placenta

Page | 26
averages 22 cm (9 inch) in length and 2–2.5 cm (0.8–1 inch) in thickness (greatest thickness at
the center and become thinner peripherally). It typically weighs approximately 500 grams (1 lb).
It has a dark reddish-blue or maroon color. It connects to the fetus by an umbilical cord of
approximately 55–60 cm (22–24 inch) in length that contains two arteries and one vein. The
umbilical cord inserts into the chorionic plate (has an eccentiric attachment). Vessels branch out
over the surface of the placenta and further divide to form a network 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 cotelydons. In humans the placenta usually has a
disc shape but different mammalian species have widely varying shapes. 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 multinucleate continuous cell layer which
covers the surface of the placenta. It forms as a result of differentiation and fusion of the
underlying cytotrophoblast cells, a process which 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 suggested to be complete by the end of the first trimester
of pregnancy (approximately 12–13 weeks). The placenta functions in two purposes. 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 mother. Nutrient transfer to the fetus is both actively and
passively mediated by proteins called nutrient transporters that are expressed within placental
cells. In addition to the transfer of gases and nutrients, the placenta also has metabolic and
endocrine activity. It produces, among other hormones, progesterone, which is important in
maintaining the pregnancy; somatomammotropin (also known as placental lactogen), which acts
to increase the amount of glucose and lipids in the maternal blood; estrogen; relaxin, and beta
human chorionic gonadotrophin (beta-hCG).

PLACENTAL CIRCULATION

Page | 27
Maternal placental circulation

In preparation for implantation, the uterine endometrium undergoes 'decidualisation'.

Spiral arteries in the decidua are remodelled so that they become less convoluted and their
diameter is increased. This increases maternal blood flow to the placenta and also decreases
resistance so that shear stress is reduced. The relatively high pressure as the maternal blood
enters the intervillous space through these spiral arteries bathes the villi in blood. An exchange of
gases takes place. As the pressure decreases, the deoxygenated blood flows back through the
endometrial veins. Maternal blood flow is approx 600–700 ml/min at term.

Fetoplacental circulation

Deoxygenated fetal blood passes through umbilical arteries to the placenta. At the
junction of umbilical cord and placenta, the umbilical arteries branch radially to form chorionic
arteries. Chorionic arteries also branch before they enter into the villi. In the villi, they form an
extensive arteriocapillary venous system, bringing the fetal blood extremely close to the maternal
blood; but no intermingling of fetal and maternal blood occurs ("placental barrier").

PATHOPHYSIOLOGY (Book-Based)

Page | 28
 RISK AND PREDISPOSING FACTORS

MODIFIABLE NON - MODIFIABLE

↑ Sodium intake, Poor Nutrition, Age (<20,>35 years old), family history of
Hypercholesterolemia, lack of activities Hypertension, primipara, Diabetes Mellitus,
during pregnancy, inadequate prenatal Chronic Renal Disease, heart diseases, multi –
care gestation (twins)

Damage to the endothelium cells

(cells that line in the blood vessels)

Endothelium cells releases

endothelin (a potent
vasoconstrictor)

Injury to uterine vessels ↓ Renal perfusion

Placental ischemia Impaired kidney function

↑renin, ↓ prostaglandin
production Activation of renin- ↓ Glomerular
angiotensin system Filtration Rate
↑ Sensitivity of arterioles to
angiotensin
↑ Na retention & ↓ Permeability of
↑ BLOOD PRESSURE water reabsorption renal tubules

EDEMA PROTEINURIA

Headache Visual
disturbances Cold-clammy skin

Weak thready pulse Delayed capillary refill

Page | 29
PATHOPHYSIOLOGY (Client-Based)

RISK AND PREDISPOSING FACTORS

MODIFIABLE NON - MODIFIABLE

↑ Sodium intake, Poor Nutrition, Age (<20,>35 years old), family history of
Hypercholesterolemia, lack of activities Hypertension, primipara
during pregnancy

Damage to the endothelium cells (cells that line in

the blood vessels)

Endothelium cells releases endothelin (a potent

vasoconstrictor)

Injury to uterine vessels ↓ Renal perfusion

Placental ischemia Impaired kidney function

↑renin, ↓ prostaglandin
production Activation of renin- ↓ Glomerular
angiotensin system Filtration Rate
↑ Sensitivity of arterioles to
angiotensin
↑ Na retention & ↓ Permeability of
↑ BLOOD PRESSURE water reabsorption renal tubules

EDEMA PROTEINURIA

Headache Visual
disturbances
Cold-clammy skin

Page | 30
Weak thready pulse Delayed capillary refill
DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/ Date Indication/s Result/s Normal Analysis and

Laboratory Ordered and or Purposes Values Interpretation
Procedures date Result/s (Units used of results
In in the
Hospital)
CBC Sept. 16, 2009 CBC is used as
abroad
Result:
screening test
Sept. 17, 2009 to determine
the values of
formed
elements of the
blood.
>WBC 9.6 4.1 – 10.9 g/dL Normal
>No indicative
abnormalities
noted.

>LYM
1.7 0.6 – 4.1 Normal
> No indicative
abnormalities
noted

>MID
0.3 0.0 – 1.8 Normal
> No indicative
abnormalities
noted

>GRAN
7.6 2.0– 7.8 Normal
> No indicative
abnormalities
noted

>RBC 4.24 4.20 – 6.30 Normal

T/L > No indicative
abnormalities
noted

Page | 31
>HGB 112 120 – 180 g/dL Decreased
>There is a
marked
decreased in
HGB.

>HCT 0.372 0.370 – 0.510 Normal

L/L > No indicative
abnormalities
noted

>MCV 87.8 80.0 – 97.0 fl Normal

> No indicative
abnormalities
noted

>MCH 26.4 26.0 – 32.0 pg Normal

> No indicative
abnormalities
noted

>MCHC 301 310 – 360 g/dL Decreased

>There is a
marked
decreased in
MCHC.

>PLT 231 140 -440 g/L Normal

> No indicative
abnormalities
noted

Page | 32
NURSING RESPONSIBILITIES:

Before:

⮚ Determine the clients understanding of the procedure

⮚ Determine the clients response to previous testing

During:

⮚ Ensure client’s comfort until the procedure will be done

After:

⮚ Document the method of testing and results on the clients record

⮚ Immediately reached the blood sample on the laboratory.
⮚ Follow-up result from laboratory

Diagnostic/ Date Indication/s Result/s Normal Analysis and

Laboratory Ordered and or Purposes Values Interpretation
Procedures date Result/s (Units used of results
In in the
Hospital)

BLOOD Blood tests are FBS: FBS: Normal

Sept. 16, 2009
CHEMISTRY used to 4.84 3.9-6.1
Result: determine mmol/L
physiological
Sept. 17, 2009
and BUN: BUN: Normal
biochemical 8.0 2.9-8.2
states such as mmol/L
disease,
mineral Creatinine: Creatinine: Normal
content, drug 105.6 53-106 mmol/
effectiveness, l
and organ
function Enzymes Enzymes Not normal
SGOT/ AST 8-33 U/L Decrease
4.2 amount of
SGOT/AST
SGPT/ALT
1.9 4-36 U/L Not normal
Decrease
amount of
SGPT/ALT

Page | 33
NURSING RESPONSIBILITIES:

Before:

1. Explain the purpose of the test and the procedure for collection of blood. Client mat
experience anxiety about the procedure, especially if it is perceived as being intrusive or
if they fear unknown to the result. A clear explanation will facilitate cooperation on the
part of the client.
2. Inform the client of the time period before the results will be available.
During:

1. Use the correct procedure for obtaining the blood.

2. Aseptic technique should be use in collection to prevent contamination that can cause
inaccurate results.
3. Ensure correct labelling, storage and transportation of the specimen to avoid invalid test
results.
After:

1. Report results to the appropriate health team members.

2. Compare the previous and current test results and modifies nursing interventions as needed

Diagnostic/ Date Indication/s Result/s Normal Analysis and

Laboratory Ordered and or Purposes Values Interpretation
Procedures date Result/s (Units used of results
In in the
Hospital)

Urinalysis > To determine Color: yellow Color: Normal

Sept. 16, 2009
the presence of
Result: micro straw amber
Sept. 17, 2009 organism, the transparent
type of Appearance:
organism, and

Page | 34
 the antibiotics Turbid Normal
to which the
organism are Appearance:
sensitive. Amber
Pus cells: transparent
> Assess the
color, odor, 3-4 Pus cells:
and Not Normal,
consistency of 0/HPF pus cells are
the urine and RBC: present.
the presence of
0-1 RBC:
clinical signs
of UTI. Red blood Normal
( frequency, cells: 0–2/HPF
urgency,
dysuria, Epithelial
hematuria, cells:
flank pain, Not Normal,
moderate Epithelial moderate
cloudy urine
cells: epithelial cells
with foul odor.
are present.
None to few
Mucus threads:

many
Not Normal,
None mucus threads
are present.

Specific
gravity: Specific
gravity:
1.015 Normal
1.010-1.020
Albumin:
Albumin: Abnormal,
++ albumin is
Negative present
Glucose:

negative Glucose:
Normal
Negative

NURSING RESPONSIBILITIES:

Page | 35
Before:

1. Explain the purpose of the specimen collection and the procedure for collection of the
specimen. Client mat experience anxiety about the procedure, especially if it is perceived
as being intrusive or if they fear unknown to the result. A clear explanation will facilitate
cooperation on the part of the client.
2. Provide proper instruction if client will be the one to collect the specimen.

During:

1. Provide client comfort, privacy and safety. Client may experienced embarrassment or
discomfort when providing a specimen.
2. The nurse needs to be judgemental and sensitive to possible socio cultural beliefs that
might affect client’s condition.
3. Use the correct procedure for obtaining the specimen.
4. Aseptic technique should be use in collection to prevent contamination that can cause
inaccurate results.
5. Note relevant information on the laboratory requisition slip like medications the client is
taking that can affect the result of the specimen.
6. As much as possible collect the specimen at the first void in the morning.

After:

1. Make sure that the specimen label and the laboratory requisition carry the correct
information.
2. Attach the label securely.
3. Transport the specimen to the laboratory promptly. Fresh specimens provide more
accurate results.
4. Report abnormal laboratory findings.
VI. PLANNING.

Page | 36
NURSING CARE PLANS

See next page. . .

Page | 37
September 19, 2009

Assessment Diagnosis Planning Intervention Rationale Expected

Outcome
S> O Decreased cardiac Within 5hrs of > Monitor maternal vital signs > Alteration in vital signs may After 5hrs of
O> with an ongoing output related to nursing and fetal heart rate closely. signify the client risk for nursing
IVF of 1L D5LR, decreased venous intervention, the eclampsia and the high risk intervention, the
received @ the level return. client will > Assess changes in mental newborn. client will
of 750cc @ right hand demonstrate status. demonstrate
regulated 30-31 Scientific adequate cardiac > Changes in mental status adequate cardiac
gtts/min, infusing Explanation: output. may indicate decrease cerebral output as
well Prolonged vascular > Position client in left lateral perfusion or hypoxia. evidenced by:
> pale in appearance constriction position. >blood pressure,
> cold and clammy increases hemo > To increase renal and pulse rate and
skin concentration and placental perfusion. rhythm are within
> noted pitting edema fluid shifts decrease > Institute bed rest. normal
on extremities and cardiac output. > To decrease oxygen demand parameters
face (+2) and increase cardiac output. > Capillary refill
> weak pulse > Provide quiet environment and of 2 seconds.
> with delayed limit visitors. > To decrease stimuli or
capillary refill of 4 stressors.
seconds > Elevate edematous extremities
> FHT of 162 bpm @ and avoid restrictive clothing. > To promote venous return.
10:00 am
> blood pressure of > The following should be > Sodium intake increases the
140/90 mmHg @ encouraged to pt: risks in forming edema.
10:00 am a. Eat foods that are low in Protein intake replaces the loss
> pulse rate of sodium and fats but high in of proteins.
102bpm @ 10:00 am protein and carbohydrate. > Larger meals increases
> respiratory rate of b. Eat small meals and rest after myocardial workload
22cpm @ 10:00 am wards. > It signify signs and
> temperature of 36.7 symptoms of impending
C @ 10:00 am c. Report any visual disturbances, eclampsia
severe headache, nausea and
vomiting, epigastric pain and
abdominal pain. > To reduce anxiety
d. relaxation such as deep
breathing exercise.
> Administer supplemental > To increase oxygen available
oxygen as indicated. to tissues.
Page | 8
Page l 38
September 19, 2009

Assessment Diagnosis Planning Intervention Rationale Expected

Outcome
S>O Ineffective tissue After 6 hrs of > Monitor maternal vital signs > Alteration in vital signs may After 6 hrs of
O> with an ongoing perfusion related to nursing and fetal heart rate closely. signify the client risk for nursing
IVF of 1L D5LR, vasoconstriction of intervention, the eclampsia and the high risk intervention, the
received @ the level blood vessels. client will newborn. client will
of 750cc @ right hand demonstrate > Monitor urine output > Further decreased in urine demonstrate
regulated 30-31 Scientific adequate tissue output can indicate kidney adequate tissue
gtts/min, infusing Explanation: perfusion. damage and eclampsia. perfusion as
well Vasoconstriction is > Assess changes in mental > Changes in mental status may evidenced by:
> pale in appearance due to the presence status. indicate decrease cerebral > capillary refill
> cold and clammy of endothelin in the perfusion or hypoxia. of 2 seconds
skin blood vessels which > Position client in left lateral > To increase renal and > Adequate urine
> noted pitting edema is a potent position. placental perfusion. output.
on extremities and vasoconstrictor.
face (+2) Blood vessels > Institute bed rest. > To decrease oxygen demand
> weak pulse lumens are and increase cardiac output.
> with delayed constricted thus > Provide quiet environment and > To decrease stimuli or
capillary refill of 4 small amount of limit visitors. stressors.
seconds blood can pass > Elevate edematous extremities
> FHT of 162 bpm @ through. and avoid restrictive clothing. > To promote venous return.
10:00 am
> blood pressure of > The following should be
140/90 mmHg @ encouraged to pt: > Sodium intake increases the
10:00 am a. Eat foods that are low in risks in forming edema. Protein
> pulse rate of sodium and fats but high in intake replaces the loss of
102bpm @ 10:00 am protein and carbohydrate. proteins.
> respiratory rate of b. Eat small meals and rest after > Larger meals increases
22cpm @ 10:00 am wards. myocardial workload
> temperature of 36.7 > It signify signs and symptoms
C @ 10:00 am c. Report any visual of impending eclampsia
> urine output of disturbances, severe headache,
170cc from 7:00 am nausea and vomiting, epigastric > To reduce anxiety
to 3:00 pm pain and abdominal pain.
d. relaxation such as deep
breathing exercise. > To increase oxygen available
> Administer supplemental to tissues. Page l 39
oxygen as indicated.
Page | 9
September 19, 2009

Assessment Diagnosis Planning Intervention Rationale Expected

Outcome
S>”Nag-aalala ako sa Anxiety related to Within 1 hour of ⮚ Establish a therapeutic ⮚ To gain the trust of the After 1 hour of
magiging kalagayan actual threats to self/ nursing relationship, conveying patient nursing
ng anak ko” fetus. intervention, the empathy and unconditional intervention, the
patient will be patient would be
positive regard.
O> > with an ongoing Scientific able to identify able to identify
IVF of 1L D5LR, Explanation: healthy ways to healthy ways to
received @ the level During extreme deal with and ⮚ Provide information about pre ⮚ To give patient knowledge deal with and
of 750cc @ right hand emotion, the body express anxiety. eclampsia about pre eclampsia express anxiety
regulated 30-31 tends to compensate as evidenced by
gtts/min, infusing and in the feeling of verbalization of
well anxiety, the body ⮚ Explain the need for stress ⮚ To reduce stress. feelings about
> poor eye contact tends to affect all of management to prevent her anxiety.
> voice changes in the system
further problems by
pitch
> fetal heart rate: 162 encouraging patient to pray
bpm for the safety of the baby and
> irritable herself.
> blood pressure of
140/90 mmHg @ ⮚ Encourage patient to ⮚ Acknowledging and
10:00 am acknowledge and to express expressing feelings help to
> pulse rate of reduce anxiety.
feelings.
102bpm @ 10:00 am

⮚ Provide comfort measures ⮚ Relieves muscle tension and

such as back rub and fatigue.
therapeutic touch.

⮚ Instruct and encourage to do ⮚ Increase oxygen supply, thus

deep breathing exercises help the patient relax.

Page | 10
September 21, 2009

Assessment Diagnosis Planning Intervention Rationale Expected

Outcome

S> “Masakit and tahi Pain related to Within 30 > Monitor vital signs. > Clients who experience pain After 30 minutes
ko.” incision. minutes of may have an alteration in vital of nursing
> Pain scale of 7 out nursing signs. intervention, the
of 10. Scientific intervention, the client pain scale
O> with an ongoing Explanation: client pain scale > Provide comfort measures > To provide non of 7/10 will
IVF of 1L D5LR, After the tissue of 7/10 will such as touch therapy and pharmacological pain decrease to 3/10
received @ the level damage done on the decrease. straightening linens. management. as evidenced by
of 800 cc @ right incision site, absence of
hand, regulated 30-31 inflammation is > Identify ways of > To minimize pain. grimace and
gtts/min, infusing commonly seen, one avoiding/minimizing pain by irritability.
well. of the signs of splinting incision during
> with IFC, patent inflammation is coughing.
> with grimace pain.
> with guarding > The following should be > To lessen anxiety.
behaviour encouraged to the client:
> irritable a. Verbalization of feelings > To reduce muscle tension.
> wound dressing dry about pain.
and intact b. the use of relaxation exercises
> Respiratory rate of such as deep breathing and
20 cpm @ 10:00 am coughing exercise.
> Pulse rate of 98bpm > Administer medications as > To lessen the pain.
@ 10:00am ordered
> BP of 130/90
mmHg @ 10:00 am

Page l 40

Page | 11
 Page l 41
September 21, 2009

Assessment Diagnosis Planning Intervention Rationale Expected

Outcome

S> O Risk for infection Within 8hrs of > Monitor vital signs especially > Elevated body temperature After 8hrs of
O> with an ongoing related to nursing temperature. may indicate infection nursing
IVF of 1L D5LR, postoperative site. intervention, the intervention, the
received @ the level client will be free >Observe and report signs of > Fever of unknown origin is client will be
of 800 cc @ right Scientific from signs of infection such as redness, the most common sign of free from signs
hand, regulated 30-31 Explanation: infection. warmth and increased body nosocomial infection. of infection as
gtts/min, infusing Improper care in the temperature. evidenced by
well. postoperative site absence of
> with IFC, patent will lead to infection >Use appropriate hand hygiene. >To reduce transmission of redness,
> presence of suture because of the antimicrobial resistant swelling and
> wound dressing dry breakage in the skin. microorganism and reduced other signs of
and intact infection rate. infection.
> Respiratory rate of
20 cpm @ 10:00 am > The following should be
> Pulse rate of 98bpm instructed to the client:
@ 10:00am
> BP of 130/90 a.Complete any course of > Prophylactic antibiotic
mmHg @ 10:00 am prophylactic antibiotic unless therapy decreases the risk of
> Temperature of 37 experiencing adverse reaction. infection.
C @ 10:00am
b. Promptly reported signs and > 2/3 of wound infection occur
symptoms of infection such as after discharge.
redness, warmth, swelling,
tenderness or pain and increased
body temperature.
> To prevent and check for
> Change dressing as ordered. signs of infection.

> To prevent infection.

>Administer medications as
prescribed.
Page | 12
Page l 42

Page | 13
C. IMPLEMENTATION

1. Medical Management

i. IVF Therapy

Name/s Date Ordered/ Date Route of General Indication/s, Client’s

of Drug/s taken/Given, Date Admin. Action, Purpose/s Response to
(generic Changed/Discontinue And Mechanism Med with
and Dosage and of Action actual S/E
Brand Frequency
name) of Admin.

D5LR Sept. 16, 2009 Intravenous >contains >used to The patient

Date change: sodium, restore felt better
Sept. 18, 2009 chloride, vascular after the
Sept. 20, 2009 potassium volume and administration
and calcium to replace of the I.V
that can fluid and meds.
maintain electrolytes
balanced that were
fluid and loss in the
electrolytes. patient

D5NM+ Intravenous >provides > used to The patient

100 mg the major replace fluid felt better
tramadol Sept. 23, 2009 intracellular loss from the after the
electrolytes large administration
(potassium, intestine. of the I.V
magnesium, meds.
and
phosphorus)
as well as
sodium and
chloride.
Nursing Responsibilities:

Before:

> Assess patient’s patency for insertion

>Observe sterile technique upon insertion

Page | 43
After:

>Assess for patient’s a reaction.

> Assess for pain, redness, swelling in the insertion site

ii. Drugs

Name/s of Date Ordered/ Date Route of General Indication/s, Client’s

Drug/s taken/Given, Date Admin. And Action, Purpose/s Response to
(generic and Changed/Discontinu Dosage and Mechanism Med with
Brand name) e Frequency of Action actual S/E
of Admin.

Generic Sept. 16, 2009 10 units, 10- >thought >to induce or >nausea and
Name: Started at 6:50 am 15 gtts/ min directly stimulate vomiting.
oxytocin stimulate labor.
uterine
Brand Name: muscle
Oxytocin contractions.

Classification:
Uterine-active
agent

NURSING RESPONSIBILITIES:

BEFORE:

>Explain the action and scientific explanation of drugs to the patient and family members

>Assess pt’s condition at starting therapy & regularly thereafter to monitor the drug’s effectiveness.

Page | 44
>Monitor patient closely for toxicity such as tremor, palpitations, increased heart rate, decreased BP,
seizures, hypokalemia, muscle cramps, headache, and hyperglycemia.

AFTER:

>Proper disposal of syringe and other waste materials

>Check for infiltrations and thrombophlebitis

Name/s of Date Ordered/ Date Route of General Indication/s, Client’s

Drug/s taken/Given, Date Admin. Action, Purpose/s Response to
(generic and Changed/Discontinue And Mechanism Med with
Brand name) Dosage and of Action actual S/E
Frequency
of Admin.

Generic Name: Sept. 16, 2009 750 mg IVP Interferes Gynaecologic >hyperactivity
Cefuroxime q 8 hr. with Infections >headache
bacterial cell >nausea and
Brand name: wall, causing vomiting
Zinacef cell to die.

Classsification:
Antibiotic

NURSING RESPONSIBILITIES:

BEFORE:

>Explain the action and scientific explanation of drugs to the patient and family members

>Assess pt’s condition at starting therapy & regularly thereafter to monitor the drug’s effectiveness.

>Monitor patient closely for toxicity such as tremor, palpitations, increased heart rate, decreased BP,
seizures, hypokalemia, muscle cramps, headache, and hyperglycemia.

AFTER:

>Proper disposal of syringe and other waste materials

>Check for infiltrations and thrombophlebitis

Page | 45
 Name/s of Date Ordered/ Date Route of General Indication/s, Client’s
Drug/s taken/Given, Date Admin. And Action, Purpose/s Response to
(generic and Changed/Discontinue Dosage and Mechanism Med with
Brand name) Frequency of Action actual S/E
of Admin.

Generic Sept. 16, 2009 30 mg IVP q >Interferes >Moderately >the patient

Name: 6 hr. times 6 with severe pain experience
Ketorolac doses prostaglandin drowsiness
biosynthesis headache.
Brand Name: by inhibiting
Toradol cyclogenase
pathway
Classification: arachidonic
Analgesic acid
metabolism.

Before:

>Explain the action and scientific explanation of drugs to the patient and family members

> Assess patient’s infection before therapy

After:

>Assess patient’s condition after therapy.

iii. Diet
>Be alert for adverse reactions & drug interactions
Type of Diet Date Ordered General Indications or Specific Foods Client’s
Date Started Description Purposes taken response
Date Changed and/or
reaction to the
diet.

SODIUM- Sept. 16, 2009 Mildly Diet can be Foods allowed >The patient
RESTRICTED restrictive 2 g prescribed for are fresh fruits was able to eat
DIET sodium diet to patients with and vegetables well.
extremely heart failure, such as banana >the patient

Page | 46
 restricted 200 hypertension, and cabbage. consumed 1
mg sodium renal disease, fresh fruits
diet. cirrhosis,
toxemia of
pregnancy, and
cortisone
therapy.

LOW-FAT, Sept. 16, 2009 Low in fat Diet can be Such as: >the patient
CHOLESTEROL- foods prescribed for gained appetite
RESTRICTED patients with nonfat milk; after the diet
DIET hyperlipedimia, low- was ordered.
carbohydrate, >the patient
atherosclerosis,
low-fat was able to
pancreatitis, consume given
cystic fibrosis, vegetables;
foods.
sprue (disease most fruits;
of breads; pastas;

intestinal tract cornmeal; lean

meats;
characterized
by nsaturated fats
malabsorption),
gastrectomy,
massive
resection of
small

intestine, and
cholecystitis.

iii. Diet

Nursing Responsibilities:

Before:

> Assess patient’s appetite

After:

>Assess patient’s reaction after eating her meals

> Document any difficulty of eating

Page | 47
iv. Activity / Exercise

The patient is strictly on a bed rest thus restriction of work is implemented. The client has
limited activity and performed ROM exercise such as shoulder and elbow exercises, hand and
finger exercises, hip and knee exercises, , and ankle and foot exercises.

2. SURGICAL MANAGEMENT

The pt. undergone Low transverse segment Cesarian Section.

3. NURSING MANAGEMENT (SOAPIE)

See next page . . .

Page | 48
 SOAPIES

September 19, 2009

Subjective Objective Assessment Planning Intervention Evaluation

S> O > pale in appearance Decreased cardiac Within 5hrs of nursing > Monitored maternal vital signs and After 5hrs of
fetal heart rate closely.
> cold and clammy skin output related to intervention, the client nursing
> noted pitting edema on decreased venous will demonstrate > Assessed changes in mental status. intervention, the
extremities and face (+2) return adequate cardiac output. client
> Positioned client in left lateral
> weak pulse position. demonstrated
> with delayed capillary adequate cardiac
> Instituted bed rest.
refill of 4 seconds output as
> Provided quiet environment and
> FHT of 162 bpm @ evidenced by:
limit visitors.
10:00 am >blood pressure,
> Elevated edematous extremities
> blood pressure of pulse rate and
and avoid restrictive clothing.
140/90 mmHg @ 10:00 rhythm are within
> The following were encouraged to
am normal
pt:
> pulse rate of 102bpm @ a. Eat foods that are low in sodium parameters
and fats but high in protein and
10:00 am > Capillary refill
carbohydrate.
> respiratory rate of b. Eat small meals and rest after of 2 seconds.
wards.
22cpm @ 10:00 am
> temperature of 36.7 C c. Report any visual disturbances,
severe headache, nausea and
@ 10:00 am
vomiting, epigastric pain and
abdominal pain.
d. relaxation such as deep breathing
exercise.

> Administered supplemental oxygen

as indicated.

Page | 49
September 19, 2009

Subjective Objective Assessment Planning Intervention Evaluation

S> O > pale in appearance Ineffective tissue After 6 hrs of nursing > Monitored maternal vital signs and
After 6 hrs of
fetal heart rate closely.
> cold and clammy skin perfusion related to intervention, the client
nursing
> noted pitting edema on vasoconstriction of will demonstrate > Monitored urine output
intervention, the
extremities and face (+2) blood vessels. adequate tissue
> Assessed changes in mental status. client
> weak pulse perfusion.
demonstrated
> Positioned client in left lateral
> with delayed capillary
position. adequate tissue
refill of 4 seconds
perfusion as
> Instituted bed rest.
> FHT of 162 bpm @
evidenced by:
10:00 am > Provided quiet environment and
> capillary refill
limit visitors.
> blood pressure of
of 2 seconds
140/90 mmHg @ 10:00 > Elevated edematous extremities
> Adequate urine
and avoid restrictive clothing.
am
output.
> pulse rate of 102bpm @ > The following were encouraged to
pt:
10:00 am
a. Eat foods that are low in sodium
> respiratory rate of and fats but high in protein and
carbohydrate.
22cpm @ 10:00 am
b. Eat small meals and rest after
> temperature of 36.7 C wards.
c. Report any visual disturbances,
@ 10:00 am
severe headache, nausea and
> urine output of 170cc vomiting, epigastric pain and
abdominal pain.
from 7:00 am to 3:00 pm
d. relaxation such as deep breathing
exercise.

> Administered supplemental oxygen

as indicated.
Page | 50
September 19, 2009
SUBJECTIVE Objective
S>”Nag-aalala O> > with an ongoing IVF Anxiety related to
ako sa magiging of 1L D5LR, received @
kalagayan ng the level of 750cc @ right
anak ko” hand regulated 30-31
gtts/min, infusing well
> poor eye contact
> voice changes in pitch
> fetal heart rate: 162 bpm
> irritable
> blood pressure of
140/90 mmHg @ 10:00
am
> pulse rate of 102bpm @
10:00 am
September 21, 2009
Subjective Objective
Assessment Planning Intervention Evaluation
> Established a therapeutic After 1 hour of
Within 1 hour of nursing
relationship, conveying empathy and
nursing
actual threats to intervention, the patient unconditional positive regard.
intervention, the
self/ fetus. will be able to identify
> Provided information about pre
patient would be
healthy ways to deal with eclampsia
able to identify
and express anxiety.
healthy ways to
>Explained the need for stress
management to prevent further deal with and
problems by encouraging patient to
express anxiety
pray for the safety of the baby and
herself. as evidenced by
verbalization of
> Encouraged patient to acknowledge
and to express feelings. feelings about her
anxiety.
> Provided comfort measures such as
back rub and therapeutic touch.
>Instructed and encourage to do deep
breathing exercises
Assessment Planning Intervention Evaluation
Page | 51
 > with an ongoing IVF of Pain related to Within 30 minutes of > Monitored vital signs. After 30 minutes
> “Masakit and
1L D5LR, received @ the
incision. nursing intervention, the of nursing
tahi ko.” level of 800 cc @ right > Provided comfort measures such as
hand, regulated 30-31 client pain scale of 7/10 touch therapy and straightening intervention, the
gtts/min, infusing well. linens.
will decrease. client pain scale
> Pain scale of 7
> with IFC, patent > Identified ways of of 7/10 decreased
out of 10.
avoiding/minimizing pain by
to 3/10 as
> with grimace splinting incision during coughing.
evidenced by
> with guarding behaviour > The following were encouraged to
absence of
the client:
> irritable grimace and
a. Verbalization of feelings about
irritability.
> wound dressing dry and pain.
intact
b. the used of relaxation exercises
> Respiratory rate of 20 such as deep breathing and coughing
cpm @ 10:00 am exercise.

> Pulse rate of 98bpm @ > Administered medications as

10:00am ordered

> BP of 130/90 mmHg @

10:00 am

September 21, 2009

Subjective Objective Assessment Planning Intervention Evaluation

S> O > with an ongoing IVF of Risk for infection Within 8hrs of nursing > Monitored vital signs especially After 8hrs of
temperature.
1L D5LR, received @ the related to intervention, the client nursing
level of 800 cc @ right postoperative site. will be free from signs of >Observed and reported signs of intervention, the
Page | 52
hand, regulated 30-31 infection.
gtts/min, infusing well.
> with IFC, patent
> presence of suture
> wound dressing dry and
intact
> Respiratory rate of 20
cpm @ 10:00 am
> Pulse rate of 98bpm @
10:00am
> BP of 130/90 mmHg @
10:00 am
> Temperature of 37 C @
10:00am
infection such as redness, warmth client manifested
and increased body temperature.
free from signs of
>Used appropriate hand hygiene. infection as
evidenced by
> The following were instructed to
the client: absence of
redness, swelling
a.Complete any course of
prophylactic antibiotic unless and other signs of
experiencing adverse reaction.
infection.
b. Promptly reported signs and
Symptoms of infection such as
redness, warmth, swelling, tenderness
or pain and increased body
temperature.
> Changed dressing as ordered.
>Administered medications as
prescribed.
Page | 53
D. EVALUATION

1. Discharge Planning

Daily Program Saturday Sunday Monday

Sept. 19,2009 Sept. 20, 2009 Sept. 21, 2009

Nursing Problems

1. Decreased cardiac Identified Resolved Resolved

output related to
decreased venous
return.

2. Ineffective tissue Identified Resolved Resolved

perfusion related to
vasoconstriction of
blood vessels.

3. Anxiety related to
actual threats to self/ Identified Resolved Resolved
fetus.

4. Pain related to
Identified/Resolved
incision site.

5. Risk for infection

related to postoperative Identified/Resolved
site

Vital signs T: 36.7 C T: 37.2 C T: 37 C

PR:102bpm PR:93bpm PR:98bpm
RR:22cpm RR:18cpm RR:21cpm
BP:140/90 mmHg BP:130/90 mmHg BP:130/90mmHg

Diagnostic & Lab.

Procedures
Medical and Surgical N/A Cesarian Section N/A
Mgt.
Drugs - Cefuroxime750 mg - Cefuroxime 750 mg
IVP q 8 hr. IVP q 8 hr.

Page | 55
 -Methyldopa Ketorolac 30 mg IVP q
6 hr. times 6 doses
-HNBB

Diet Low fat and low NPO Low fat and low
sodium diet sodium diet

Activity / Exercise Passive ROM Flat on bed for 8 May turn side to side
hours

2. METHOD

The following is a discharge plan that is needed to be implemented by the client with the
help of her significant others.

MEDICATIONS EXERCISE TREATMENT HEALTH OPD DIET

TEACHINGS FOLLOW-UP

>Continue >Perform > N/A >Instructed the >Instructed >Diet as

taking Activities of - The patient patient to eat a the client to tolerated.
maintenance Daily has no further well-balanced go on follow- >foods
medications w/c Living prescribed diet, low in fat up check- low in fat
includes the ff: (ADL’s) as treatments. and sodium to ups. and salt.
- Cefalexin tolerated provide proper
nourishment.
- Mefenamic
acid
- Ferrous Sulfate
-Ascorbic Acid

III. CONCLUSION
Page | 56
 Choosing this case made the group more familiar about the things related to Pre-
eclampsia. The group met the goal of this case. Now the group fully understand what Pre-
eclmapsia is, its signs and symptoms, and the treatments for this condition. The group was able
to apply the appropriate interventions needed by the patient. With our proper explanations, Mrs.
X now understands what her condition is and how it is so crucial that it needs strict monitoring.
In addition, the group, together with our patient, now increased our level of awareness and
gained lots of knowledge with regard to Pre-eclampsia.

IV. RECOMMENDATION

As the patient was about to be discharged, our group recommended the following
health teachings to our client:

✔ Adequate rest

✔ Advise patient to have adequate sleep (6-8 hours).

✔ Refrain doing strenuous activities like lifting heavy objects such as fetching water.

✔ Advise client to take her medications regularly.

✔ Implement ROM exercises

✔ Avoid getting angry because it may trigger hypertension.

✔ Eat nutritious foods especially those low in fat and sodium such as fruits, milk and
vegetables.

For the future researchers, the group recommends the following to:

✔ Use appropriate assessment techniques to come up with a good assessment

✔ Formulate a comprehensive health history

✔ Make a comprehensive Pathophysiology of the condition

✔ Develop good nursing care plans that are patient – oriented

V. BIBLIOGRAPHY

Page | 57
� Carroll SG, Ville Y, Greenough A, Gamsu H, Patel B, Philpott-Howard J, Nicolaides
KH. Preterm prelabour amniorrhexis: intrauterine infection and interval between
membrane rupture and delivery. Arch Dis Child 1995

� COPAR by Untalan book

� cureresearch.com/p/preeclampsia/stats-country.htm
� Fundamentals of Anatomy and Physiology by Donald Rizzo
� Fundamentals of Nursing by Barbara Kozier
� Health Assessment and Physical Examination 3rd Edition Mary Ellen Zator Estes
� Maternal and Child Health Nursing, Fourth Edition by Piliterri
� Medical and Surgical Nursing by Brunner and Suddarth’s book
� Medical and Surgical Nursing by Hawk and Black
� Mosby medical, nursing and allied health dictionary, sixth edition
� Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions
� NANDA Book
� Nutrition and Diet therapy, 9th edition, Ruth Roth
� Wigglesworth JS, Desai R. Female reproductive system. Early Hum Dev 1979; 3:51–65
� www.doh.gov.ph
� www.themedicalnews.com
� www.who.int
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