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Case Study On Pre Eclampsia
Case Study On Pre Eclampsia
On
Pre-
eclampsia
Patient is hospitalized in S GRD 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 –
FAMILY HISTORY
FAMILY HISTORY
Shiv Ramdai
60yrs 57 yrs
Avinash Savita
30yrs 27 yrs
FEMALE
Rakhi
3yrs
PATIENT
MALE.
HEALTH FACILTY NEAR HOME :
PERSONAL HISTORY
PERSONAL HYGIENE:
Menstrual history-
Age of menarche: 12 years
Duration of menstruation: 4-5 days
Amount of menstruation: normal flow
Dymenorrhea: Present
LMP - 25-05- 2017 EDOD -3-3-18 , POG 36 wks
Marital History :
Spouse health - Good
Spouse occupation - Self-employed
Substance use - No H/o substance abuse
Addiction use - No addiction
Sexual history
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
Temperature – 98.20 F
Pulse - 110/ min
Blood Pressure – 176/110 mm Hg
Anthropometric Measurement
Height 5’ 3”
Daily fluid requirement 3 liters at least 2.4 liters
Abdominal girth 14 inches 14-15 inches
Fundal height 38 cm 38 cm
Involution of uterus ------------- ----------
INVESTIGATION: on 1/03/18
SPECIAL INVESTIGATION:
ULTRASOUND :
Impression: Alive fetus corresponding 36weeks in cephalic presentation.
DOPPLER STUDY: FHS is heard, 148bpm.
NST : Not performed
ENDOSCOPY : Not performed
PLAN OF TREATMENT
MEDICAL MANAGEMENT
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.
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.
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.
Impaired skin To promote Assess the The condition of It provides The chances
integrity related proper healing. condition of skin skin and of surgical baseline of infection
to cesarean and surgical incision is assessed information. is less and
section as incision. for infection. healing is
evidenced by good.
redness.
DISEASE STUDY
Pre-eclampsia
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 Absent
Family history Present. History of hypertension from
maternal side.
Placental facors Absent
Genetic factors Absent
Immunological phenomenon Absent
New paternity 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.
Sedative Done. Diazepam 5mg is given to patient.
Diuretics Done. Frusemide 40 mg is given.
Antihypertensives Done. Hydralazine hydrochloride 5 mg is
given to patient.
Termination of pregnancy Cesarean section is done.
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 and then
cesarean section is performed on her. The patient delivered alive male. The baby cried
immediately after 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 of patient is normal.
5th day- Patient is 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 – 176/110mmHg B.P – 140/100mmHg B.P – 110/90mmHg
MEDICATIONS:
1) Injection Genta Continued Continued
2) Injection Taxim Continued Continued
3) Inj. diclofenac Continued ----------
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 the surgical incision 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
Dutta D.C. “Textbook of obstetrics” 6th edition. Central publisher. Pg- 221-231.
Internet source-
www.medscape.com