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I. INTRODUCTION
Preeclampsia, also referred to as toxemia, is a condition that pregnant women can get. It is marked
by high blood pressure accompanied with a high level of protein in the urine. Women with
preeclampsia will often also have swelling in the feet, legs, and hands. Preeclampsia, when present,
usually appears during the second half of pregnancy, generally in the latter part of the second or in
the third trimesters, although it can occur earlier.
In addition symptoms of preeclampsia can include:
• Abdominal pain
• Severe headaches
• A change in reflexes
• Dizziness
The exact causes of preeclampsia are not known, although some researchers suspect poor
nutrition, high body fat, or insufficient blood flow to the uterus as possible causes.
The only real cure for preeclampsia and eclampsia is the birth of the baby. Mild
preeclampsia (blood pressure greater than 140/90) that occurs after 20 weeks of gestation in a
woman who did not have hypertension before; and/or having a small amount of protein in the urine
can be managed with careful hospital or in-home observation along with activity restriction.
The group chose the case for the reason that they wanted to show the readers the process on
how pre-eclampsia occurs and for them to fully understand and be reminded on one of the
be as high as 18% in some settings in Africa (2) If the rate of life threatening eclamptic convulsions
(0.1% of all deliveries) is applied to all deliveries from countries considered to be the least
developed, 50,000 cases of women experiencing this serious complication can be expected each
year. According to Safe Motherhood.org of the 585,000 maternal annually (3), 13%, or 76,050, are
due to eclampsia.
Nurse-Centered Objectives
Upon completion of this case study, the student nurse should be able to:
2. Formulate significant nursing diagnosis, with the significantly related nursing care plan.
3. Identify the different medications administered for this disease their indications,
4. Identify the laboratory and diagnostic procedure done with the pre-eclamptic patient, their
Client-Centered Objectives
Upon completion of this case study, the client should be able to:
3. Learn and understand why such laboratory examinations are being done.
Mrs. Ob, a 39 years old housewife and first time mother, who currently resides at
Guagua Pampanga with her husband Mr. Gyne. She was born a Filipina on November 9,
1969 in Sta. Rita Guagua Pampanga. The patient was admitted at City Hospital with a chief
Mrs. Ob is plain housewife and her husband is an extra laborer on a construction site.
She graduated at a Public High School. And she didn’t continue her college level due to
financial problem.
Mrs. Ob was raised as a Roman Catholic, were she learned about religious values but
she still believes in super natural forces and superstitious beliefs. When it comes in health
matters, she seeks the help of a albularyo and uses herbal medicines to treat any member of
the family who has an ailment. But when serious matters arise she still refers to medical
Ms. Ob resides at Guagua Pampanga and occupies the ancestry house of her family.
The location of their house is not easily accessible to hospitals, health centers and other
government institutions. Mrs. Ob did not report any problems regarding her environment
Mrs. Ob was married to Mrs. Gyne at the age of 33 years old. She has a record of
T1P0A0L1M0 at her 39th week of gestation. She underwent low transverse ceasarian section
under a certain obstetrician at the regional hospital last November 18, 2008 at around 10:00
in the evening, she delivered her 1st child who is term baby with hyperbilirubinemia.
When Mrs. Ob was still pregnant, she only consulted once in a district hospital all
throughout.
linea nigra, and melasma. She also experienced nausea and vomiting, dizziness, and
headache.
Family Health Illness History
Father
Mother
Patient
Legend:
hypertension
died of old age
pneumonia
asthma
deceased
π pre eclampsia
grandmother died from Hypertension and the father was died from Pneumonia. The mother is not
experiencing any health problems but the father has hypertension and asthma. The patient, upon
admission has elevated blood pressure and is suffering from aggravating factors like anxiety,
SKIN
• brown skin generally uniform in color except in areas exposed to the sun
HEAD
• no infestations
EYES
• white sclera
• when looking straight ahead, the client can see objects in the periphery
EARS
• symmetrically aligned
• no lesions or discoloration
NOSE
• symmetric and straight
• no discharge or flaring
• outer lips uniform pink color with symmetric contour, soft and moist
NECK
• head centered
BREAST
• firm
CARDIOVASCULAR
• BP 180/100 mmHg
• PR 114
• reported palpitations
RESPIRATORY/CHEST
• chest symmetric
GASTROINTESTINAL/ABDOMEN
• no tenderness
URINARY
REPRODUCTIVE
MUSCULOSKELETAL/EXTREMITIES
• no bone deformities
• no tenderness
NEUROLOGIC
• oriented
• conscious
• displayed anxiety
PHYSICAL ASSESSMENT
SKIN
• brown skin generally uniform in color except in areas exposed to the sun
HEAD
• rounded
HAIR
• evenly distributed
• no infestations
EYES
• white sclera
• no discharge
EARS
• symmetrically aligned
• no lesions or discoloration
• no discharge
• symmetric contour
NECK
• head centered
• milk letdown
CARDIOVASCULAR
• BP 160/100 mmHg
• PR 106
RESPIRATORY/CHEST
• chest symmetric
GASTROINTESTINAL/ABDOMEN
URINARY
• yellowish urine
REPRODUCTIVE
MUSCULOSKELETAL/EXTREMITIES
• equal strength
• no bone deformities
• no tenderness
NEUROLOGIC
• oriented
• conscious
PHYSICAL ASSESSMENT
SKIN
• brown skin generally uniform in color except in areas exposed to the sun
HEAD
• rounded
• no infestations
EYES
• anicteric sclera
• no discharge
EARS
• symmetrically aligned
• no lesions or discoloration
• no discharge or flaring
• symmetric contour
NECK
• milk letdown
CARDIOVASCULAR
• BP 150/100 mmHg
• PR 96
• chest symmetric
• right and left shoulders and right and left hips are at the same height
GASTROINTESTINAL/ABDOMEN
• rounded contour
URINARY
• yellowish urine
REPRODUCTIVE
• G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
• muscle equal size on both sides of the body
• equal strength
• no tenderness
NEUROLOGIC
• oriented
• conscious
DIAGNOSTIC AND LABORATORY PROCEDURES
Date
Ordered and
Diagnostic or Analysis and
Indication or Date Normal
Laboratory Results Interpretation
Purpose Results Values
Procedure of Results
were
released
WBC Count To determine November 8.0 5-10 x No infection or
inflammation is present.
Pre-operation
assessment of
the patient.
normal
because of the
increase in
plasma volume
during
pregnancy.
Hemoglobin Pre-operation November 96 120- The result
sample of
blood contains
96 g of
hemoglobin.
Decreased
hemoglobin on
pregnant is
normal
because of
their increase
in plasma
volume.
Hematocrit Pre-operation November 0.29 0.37-0.47 The result
sample of
blood
contains .29 g
of hemoglobin.
Decreased
hematocrit on
pregnant is
normal
because of
their increase
in plasma
volume.
Nursing Responsibilities During Different Laboratory Procedures
Before
• Explain to the patient that the WBC test is used to detect an infection or inflammation.
• Tell the patient that the test requires a blood sample. Explain who will perform the
• Explain to the patient that he may experience slight discomfort from the needle puncture
• Inform the patient that he should avoid strenuous exercise for 24 hours before the test.
Also tell him that he should avoid eating a heavy meal before the test.
• If the patient is being treated for an infection, advise him that this test will be repeated
• Notify the laboratory and physician of medications the patient is taking that may affect
During
After
• If a hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is
• Inform the patient that he may resume his usual diet, activity and medications
discontinued before the test, as ordered.
• A patient with severe leucopenia, they have little or no resistance to infection and
Before
• Explain to the patient that RBC count is used to evaluate the number of RBCs and to
• Tell the patient that the test requires a blood sample. Explain who will perform the
• Explain to the patient that he may experience slight discomfort from the needle puncture
• Inform the patients that he need not restrict foods and fluids
During
After
Hemoglobin
Before
• Explain to the patient that the hbg test is used to detect anemia or polycythemia or to
• Tell the patient that the test requires a blood sample. Explain who will perform the
venipuncture and when.
• Explain to the patient that he may experience slight discomfort from the needle puncture
After
Hematocrit
Before
• Explain to the patient that hct is tested to detect anemia and other abnormal conditions
• Tell the patient that the test requires a blood sample. Explain who will perform the
• Explain to the patient that he may experience slight discomfort from the needle puncture
• Inform the patients that he need not restrict foods and fluids
During
After
Efforts to unravel the pathogenesis of pre-eclampsia have been hampered by the lack of
clear diagnostic criteria for the disease and its subtypes. Consequently, several studies have
included a variety of other conditions that do not necessarily reflect an adverse pregnancy outcome.
Abnormal placentation (stage 1), particularly lack of dilatation of the uterine spiral
arterioles, is the common starting point in the genesis of pre-eclampsia, which compromises blood
flow to the maternal–fetal interface. Reduced placental perfusion activates placental factors and
induces systemic hemodynamic changes. The maternal syndrome (stage 2) is a function of the
vascular reactivity, activation of coagulation cascade and loss of vascular integrity. Pre-eclampsia
has effects on most maternal organ systems, but predominantly on the vasculature of the kidneys,
1. Medical Management
electrolytes. minimal
the cesarean
operation.
Nursing Responsibilities:
• Tell the patient that she might feel a discomfort from the tourniquet and the IV insertion
• Check and monitor IVF regulation and level of fluid
b. Pharmacotherapy
Brand name and Date ordered/ Route of General action Client response
Frequency of
Administration
Mefenamic 11-19-08 P.O., 500mg, Inhibits Patient was
synthesis by pain.
decreasing the
activity of the
enzyme,
cyclooxygenase,
which results in
decreased
formation of
prostaglandin
precursors
Cephalosporin 11-19-08 I.V., 750mg, q8 Inhibits bacterial The patient did
Cefuroxime cell wall not acquire
penicillin- adverse
(PBPs) which in
final
transpeptidation
step of
peptidoglycan
synthesis in
bacterial cell
walls, thus
inhibiting cell
wall
biosynthesis.
Bacteria
eventually lyse
due to ongoing
activity of cell
wall autolytic
enzymes
(autolysins and
murein
hydrolases)
assembly is
arrested.
hemoglobin, to treatment
transportation of reaction.
oxygen via
hemoglobin.
Nifedipine 11-19-08 P.O., 10mg, BID Inhibits calcium The patient
voltage-sensitive adverse
smooth muscle
and myocardium
during
depolarization,
producing a
relaxation of
coronary
vascular smooth
muscle and
coronary
vasodilation;
increases
myocardial
oxygen delivery
in patients with
vasospastic
angina
c. Diet
fasting blood
sugar.bcs intake
of food can
increase
glucose level
Clear Liquid 11-19-08 A diet of clear This diet reduce The patient
Diet 11-20-08 liquids maintains stimulation of complied with
d. Exercise
Activity General Purpose Date Order Client Response
Description
pregnancy complaints.
VI. NURSING CARE PLAN
nga daw ung related to sensory nursing environment management. met AEB pt
sumusigaw siya” arising from post pt rate the pain -Encouraged to -to reduce tension from 8 to 5 in a
section. 10 exercise
upon movement
muna dapat image related to abdominal nursing client to looked/ incorporate patient
mabuntis kc pregnancy AEB wound due to intervention, the touch the changes into recognized and
papangit ung changes in surgery, a new patient will able affected body body image. verbalized
tsaka bat ang develops that change of body -to bring back body changes.
-presence of to the pt
emotional
recovery.
-Assist pt to
identify positive
behavior
Cues Nursing Scientific Objective Nursing Rationale Expected
diagnoses Explanation intervention outcomes
S: “bumibilis Decreased Pregnancy After 4 hrs of -Keep client on - decreases Goal Met AEB
nga tibok ng cardiac output Induced nursing bed and in oxygen within 4 hrs. of
puso ko” related to altered Hypertension is a intervention, the position of consumption nursing
verbalized by heart rate (111 condition in patient will comfort intervention the
report of occur. It is caused stability (heart stimuli; provide adequate rest 111 bpm to 100
O: -with the
palpations; by altered cardiac rate will decrease quiet env’t bpm, BP from
tenderness of
(r/t) decreased output that injures from 111 bpm to -to reduce 140/100 to
abdominal are
venous return endothelial cells 100 bpm, BP -Encouraged anxiety 120/80 (Normal
-facial grimaces AEB edema of the arteries. from 140/100 to deep breathing BP)
improvement changes in
cardiac pressures
activities that
may stimulate
valsalva
response (rectal
stimulation,
bearing down
B.M)
O- decreased related to post to disturbance of intervention, the about safe and make beneficial verbalized
ambulation of CS delivery. normal bowel patient will risky practices choices when understanding
the patient bcs movements verbalize for managing need arises. about
through colon.
- Promote
limits of constrictions of
ability.
surgery Integrity related from the nursing hand hygiene. spread of the patient was
to surgery cesarean section intervention, the infection. able to knew the
moisture.
-Apply
dressing healing
VIII. Discharge Plan
comfortable pair of white shirt and white pajama and a pair of flat slip-ons while being
sealed on a chair cuddling her baby boy. Her hair was untidy and up in a ponytail with
visible infestations. She was oriented enough to follow instructions and answers
Methods
M- Instructed the patient to take the following home medication as ordered by the
physician:
Ferrous Sulfate OD
breathing exercise.
T- n/a
breast feeding.
Nurses can help the nation achieve National Health Goals. These goals speak
directly to both fetus and the mother because pregnancy is a high risk factor for them.
Close monitoring in pregnant women and health teaching as much as possible about
Studies shows that there is no certain facts that will give us the idea where
pre-eclampsia arise. But there so many factors that could prevent this complication such
as diet modifications, proper compliance with the health care providers, proper exercise.
And if the complication is already present, proper monitoring, proper diet and drug
With this study, the student nurses were able to gain more knowledge and
Thus, the student nurses would like recommend and share some pointers on how to deal
and provide better facilities. They must be responsible enough to create awareness
program for care and management for all the Filipino people.
To the health care team, they should righteously implementing basic and ideal
procedures regardless of the health care facilities where they belong. They must observe
and always remember to keep in line with their duties towards both the mother and the
To the community and the family, that they must be insufficient coordination
with the government and the health care team regarding promotion of health before,