Acknowledgement

The researchers would like to reach out our most profound appreciation and
appreciation to those individuals who had made a difference in the completion of this
study. The researchers would like to express their sincerest gratitude and appreciation
towards these individuals who were with them from the start of our journey and to those
individuals who lend their assistance to make this study possible. First and foremost,
praises and thanks to God, the Almighty, for His showers of blessings throughout the
case study and its successful completion. The researchers would also like to express
their deep and sincere gratitude to the RLE advisers, for providing them the invaluable
supervision, support, and tutelage during the course of the study. Gratitude will also be
given to them for their empathy, patience, and knowledge that they imparted. It was a
great privilege and honor to work and study under their guidance. Thanks, and
appreciations also go to the patient who willingly helped with his full cooperation which
has made the research study achieve its smooth completion. Also like to give thanks for
the time and knowledge that you have given to conduct this study. Last but not the
least, to our dearest parents for their deep consideration for the finances and undying
support throughout the making of the case study. As well as for their words of
encouragement to all those nights that we have spent making this case study.

The Researchers,

1
I. Introduction

Severe pre-eclampsia is a serious condition that can occur during pregnancy,

typically after the 20th week. It is characterized by high blood pressure, protein in the
urine, and often involves damage to other organs systems, such as the liver and
kidneys. This condition can lead to complications for both the mother and baby if not
properly managed. It is crucial for health care providers to monitor and treat severe pre-
eclampsia promptly to reduce the risk of serious outcomes.

Pre- eclampsia can be particularly dangerous because many of the signs are
silent while some symptoms resemble " normal" effects of pregnancy on our body.
Many women sufferings from pre- eclampsia don't feel sick and maybe surprised or
become frustrated when they are admitted in hospital. High blood pressure is an
important sign of pre- eclampsia. The disease is sometimes referred to as a silent killer
because most people can't feel their blood pressure going up. As a result, patient
awareness of the warning signs is one of most important tools we must successfully
help women receive the care they need.

According to the World Health Organization (WHO), the incidence of pre-

eclampsia ranges between 2% and 10% of pregnancies worldwide. About 1.8 - 16.7%
of the incidents are reported in developing countries, while in developed countries, the
rate is 0.4%.

In the Philippines, a total of 202 women were included in the analysis where 24
(11.9%), 11(5.4%) and 13 (6.4%) developed pre- eclampsia, early onset pre- eclampsia
and late onset pre- eclampsia.

2
II. Objectives

General Objectives

This case presentation aims to come up with in-depth understanding of severe

pre-eclampsia for us to be able to come up with the best nursing care plan in the care
and for all the aspects that contribute to and affect the condition of patient.

Specific Objectives

• To organize patient’s data to establish good background information.

• To be able to know the pathophysiological basis of severe pre-eclampsia.
• To make and decide on different nursing care plans.
• To determine the signs and symptoms on the current health history and other
manifestations of the patient.
• To discuss the normal functioning of organs which is involved on the case of the
patient.
• To know the laboratory and diagnostic test the patient had undergone.
• To better understand the medication given to the patient.
• To explain to the patient the cause or reason of having severe pre-eclampsia,
laboratory examination and drug administration.
• To formulate a discharge plan and prognosis for the continuous health care even at
home.

3
III. Patient’s Data

Biographical Data

Name: Mrs. A

Age: 25 years old

Sex: Female

Religion: Islam

Nationality: Filipino

Birth Place: Lower Paatan, Kacaban

Birth Date: April 23, 1999

Civil Status: Married

Address: Lower Paatan, Kacaban

Occupation: Street food vendor

Admission History
I. Chief Complaint: Severe abdominal pain

II. Admission Diagnosis: G2 P1 38 weeks AOG. Cephalic in labor. Previous

cesarean section 2021 due to eclampsia

III. Date and Time of Admission: April 21, 2024 @ 12:10 am

IV. Attending Physician: J. Romerde

V. LMP: July 15, 2023
VI. DOD: April 21, 2024

4
IV. Personal/Social/Health History
Ms. A was a G2 P1 pregnancy uterine 38 weeks AOG by last menstrual period.
Cephalic in labor. She was previously undergone cesarean section on her first baby
way back 2021 due to Eclampsia. She had no history of any major illnesses. She
also completed her COVID vaccines which is the Pfizer, she is also a complete
immunize child. Before she went to the hospital, Mrs. A did not take any drugs or
vitamins. Her menarche was on April of 2011 when she was 12 years old. She has a
regular menstruation and she is not using any contraceptives.

5
V. Family Background and Health History

GENOGRAM

GRANDFATHER GRANDMOTHER GRANDFATHER GRANDMOTHER

MOTHER FATHER

PATIENT
SIBLING 1

CHILD 1 FETUS
LEGEND:

NO MAJOR DIABETES FETUS PREGNANT

DIAGNOSIS MELLITUS

6
 The patient is a 25 years old female. Lives in Lower Paatan, Kabacan, North
Cotabato. The health background of the patient, on the paternal side, all members of
the family have no major diagnosis. The maternal side, all members of the family have
no major diagnosis, except for the mother of the patient who is diagnosed with diabetes
mellitus. Finally, Mrs. A is pregnant and has a fetus inside her womb at 38 weeks age of
gestation.

7
VI. Developmental Data

Theorist Application to the Problem

According to ERIKSON, individuals continue to go through

ERIK ERIKSON
psychosocial stages throughout their lifespan. At the age of

28, the individual would be in stage of “Ego integrity vs

Despair”. This stage focuses on reflecting on one’s life,

evaluating achievements, and finding a sense of fulfillment.

With severe preeclampsia, the individual may be facing

physical limitations and the possibility of mortality, which can

influence their overall sense of integrity or lead to feelings of

(Psychosocial Development despair.

Theory)

Abraham Maslow is known for his hierarchy of needs

theory, which outlines human motivation. By age 25,

ABRAHAM MASLOW
individuals are usually focused on fulfilling their psychological

and esteem needs according to Malow’s framework. This

includes need such as belongingness, achievement, and self-

esteem. At this age, people often strive for personal growth,

career advancement, and building relationships that provide a

sense of belonging and recognition.

8
 (Hierarchy of Needs)

JEAN PIAGET Jean Piaget, a renowned developmental psychologist,

emphasized the stages of cognitive development in children.

By age 2, children typically exhibit simple problem-solving

skills, object permanence, and basic symbolic thought. At 25,

individuals are well beyond Piaget’s stages of childhood

development and are typically in the stage of formal

operational thought, characterized by abstract thinking,

hypothetical reasoning, and the ability to systematically solve

problems.

(Cognitive Development)

9
VII. Definition of Complete Diagnosis

A diagnosis of preeclampsia happens if you have high blood pressure after 20

weeks of pregnancy and at least one of the following findings: Protein in your urine

(proteinuria), indicating an impaired kidney. Other signs of kidney problems. A low blood

platelet count.

Severe preeclampsia occurs when a pregnant woman has any of the following:

Systolic blood pressure of 160 mmHg or higher or diastolic blood pressure of 110

mmHg or higher on two occasions at least 4 hours apart while the patient is on bed rest.

10
VIII. Physical Assessment

System Findings
General Appearance  Patient is conscious and anxious.
 Patient is oriented to time, place and people.
 Patient able to answer questions directly.
 Patient appears in significant discomfort.
 Height: 152 cm
 Weight: 78 kg
 BMI: 33.76 - Obese
Vital Signs  Blood Pressure: 160/100 mmHg
 Pulse Rate: 89 bpm
 Respiratory Rate: 21 cpm
 Temperature: 36.5 oC
 Oxygen Saturation: 98%
Skin, Hair and Nails  Skin is smooth and moistened, skin color is light
brown.
 Hair color is black.
 Nails are neatly trimmed and clean
 Capillary refill test resulted with <3 seconds normal
return of color.
HEENT  Patient complain headache and reported slight
(Head, Ears, Eyes, Nose disturbance in vision.
and Throat)  Skull is symmetrical, round and erect on midline with
no tenderness and any deformities.
 Swelled face.
 Peri-orbital edema present around the eyes.
 Good eye movement and coordination.
 Pupils are equal and round, reactive to light and
accommodation.

11
  Ears are bilaterally symmetrical and sound heard
equally on both ears.
 No discharges, redness, or masses, small amount of
cerumen is present.
 Nose is located midline, symmetrical with no
discharge.
 Lip is light pink in color, moist, no discoloration or
cracks.
 Pink gums with no inflammation, swelling or
redness.
 Throat has no inflammation or swelling, and no
difficulty of swelling.
Thorax and Lungs  Bilateral chest appears symmetrical with sternum
located at midline.
 Equal expansion of both lungs.
 Breathing sounds are clear.
Breast  Bilateral breast appears symmetrical without visible
deformities.
 Nipples are appointed in same direction.
 No swelling or discharge seen.
Abdomen  Round shape, no distention or lesions, previous
incisional scar is present.
 Linea nigra and striae gravidarum present.
 Fundal height at 38 cm.
Genital Area  No discoloration, swelling, or redness,
 No abnormal vaginal discharge or any abnormalities.
Lower Extremities  Bilaterally symmetrical, no visible deformity.
 Skin is warm to touch.
 Edema is present on both feet.
 No extra digits.

12
Fetal Assessment

Systems Findings
Fetal Heart Rate 154 bpm
Fetal Presentation Cephalic presentation
Fetal Movement Active fetal movement and cardiac
activity
Fetal Weight Estimated fetal weight of 1409 grams
Fetal Length Approximately 46 cm

13
VIII. Anatomy and Physiology

Preeclampsia is a complex disorder that involves dysfunction in multiple organ

systems, primarily due to impaired blood vessel function.

Blood Vessels: Part of the circulatory system, they

transport blood throughout the body. Preeclampsia
causes the blood vessels to constrict or narrow, leading
to increased blood pressure. This constriction reduces
blood flow to various organs, contributing to their

dysfunction.

Heart: Pumps blood throughout the body, providing

oxygen and nutrients to tissues. The increased blood
pressure and reduced blood flow can strain the heart,
leading to symptoms such as chest pain, palpitations,
and shortness of breath. In severe cases, it can result in
heart failure.

Kidneys: Filter blood, removing waste and excess fluid

to produce urine. The reduced blood flow to the kidneys
can impair their ability to filter waste products from the
blood, leading to proteinuria (protein in the urine) and
decreased urine output. This can result in kidney
damage and compromise their function.

Lungs: Responsible for exchanging oxygen and carbon

dioxide during breathing. Preeclampsia can cause

14
pulmonary edema, a condition where fluid accumulates in the lungs. This fluid buildup
makes it difficult for oxygen to

reach the bloodstream, leading to shortness of breath and

respiratory distress.

Liver: Performs numerous functions including

detoxification, metabolism, and production of
biochemicals necessary for digestion. Preeclampsia
may impair liver function, leading to elevated liver
enzymes and other signs of liver damage. In severe
cases, it can result in a condition called HELLP
syndrome (hemolysis, elevated liver enzymes, and low
platelet count), which can be life-threatening for both the
mother and the baby.

Brain: Controls most bodily functions and processes

sensory information. Preeclampsia can cause cerebral
edema (swelling in the brain) and impaired blood flow to
the brain, leading to symptoms such as headaches,
seizures (eclampsia), confusion, and visual
disturbances. In severe cases, it can result in stroke.

Eyes: Responsible for vision, converting light into

electrical signals that the brain interprets. Preeclampsia
can affect the blood vessels in the eyes, leading to

15
visual disturbances such as blurred vision, sensitivity to light, or temporary vision loss.
This is known as hypertensive retinopathy.

Placenta: An organ that develops during pregnancy,

providing oxygen and nutrients to the fetus and
removing waste products. Preeclampsia affects the
blood vessels in the placenta, leading to inadequate
blood flow to the fetus. This can result in fetal growth
restriction, preterm birth, and other complications for
the baby. Overall, preeclampsia is a serious condition
that requires close monitoring and medical
management to prevent complications for both the
mother and the baby.

16
IX. Etiology and Symptomatology

ETIOLOGY

Ideas S/Sx Actual Rationale Significance

Placental  Abnormal placental The placenta doesn't get
Dysfunction development can lead to enough blood. This could be
inadequate perfusion and because the placenta didn't
oxygenation of the placenta, develop properly as it was
triggering a cascade of events forming during the first half of
such as oxidative stress, the pregnancy. The problem
release of vasoactive with the placenta means the
substances, and inflammation. blood supply between mother
and baby is disrupted.
Genetic Genetic predisposition plays a Identifying genetic markers
Factors role in pre-eclampsia aids risk assessment and
susceptibility, with variations in personalized interventions.
genes related to vascular
function, immune response,
and angiogenesis influencing
the risk of developing the
condition.
Immunological The immune system needs to Understanding the
Dysregulation strike a delicate balance to immunological basis of
support a healthy pregnancy. preeclampsia is crucial for
When this balance is improving diagnosis and
disrupted, it can cause developing targeted therapies.
inflammation and abnormal It highlights the importance of
immune responses. This immune monitoring during
disruption can affect the cells pregnancy to identify at-risk
lining blood vessels individuals early and
(endothelial cells), making implement interventions to

17
 them not work as they should. mitigate the severity of
As a result, this can lead to a preeclampsia.
condition called preeclampsia,
which can cause high blood
pressure and other
complications during
pregnancy.
Placental Reduced placental perfusion Induces maternal endothelial
Ischemia/ due to impaired spiral artery dysfunction, hypertension, and
Hypoxia remodeling leads to placental proteinuria, highlighting
ischemia and hypoxia, potential therapeutic avenues.
triggering the release of
factors like soluble fms-like
tyrosine kinase-1 (sFlt-1) and
soluble endoglin (sEng).
Diabetes Diabetes induces systemic Poorly controlled diabetes
Mellitus endothelial dysfunction, escalates pre-eclampsia
heightening susceptibility to severity, necessitating vigilant
pre-eclampsia's vascular monitoring and early
complications. intervention to reduce maternal
and fetal risks.
Hypertension  High blood pressure triggers Hypertension, especially when
vascular remodeling, combined with other risk
inflammation, and oxidative factors like diabetes, amplifies
stress, predisposing to pre- the likelihood of severe pre-
eclampsia development. eclampsia, leading to serious
maternal and fetal
complications. Effective
hypertension management in
pregnancy is vital to mitigate
pre-eclampsia risks.

18
Kidney Pre-existing kidney disease is Managing and optimizing renal
Diesease a significant risk factor for function before and during
developing preeclampsia due pregnancy in women with
to altered renal function, kidney disease are essential
increased systemic for reducing the risk and
inflammation, and endothelial severity of preeclampsia.
dysfunction. Kidney disease Close collaboration between
can also lead to hypertension nephrologists and obstetricians
and proteinuria, which are is crucial in providing
cardinal features of comprehensive care to these
preeclampsia. high-risk individuals.
Advanced Advanced maternal age (e.g. As more women delay
Maternal Age over 35 years old) is childbearing, understanding
associated with changes in the unique challenges and
vascular function, oxidative risks associated with advanced
stress, and decreased maternal age becomes critical.
uteroplacental perfusion, all of Prenatal care strategies
which are factors that can tailored to older mothers,
contribute to preeclampsia. including close monitoring of
blood pressure and early
detection of preeclampsia, can
help mitigate its severity and
complications.
Obesity  Obesity is associated with The rising prevalence of
chronic low-grade obesity underscores the
inflammation, insulin increased risk of preeclampsia
resistance, and endothelial in obese pregnant individuals.
dysfunction, all of which are Managing weight and
factors implicated in the addressing metabolic health
pathogenesis of preeclampsia. before and during pregnancy
are essential strategies for

19
reducing the incidence and
severity of preeclampsia in this
population.

20
SYMPTOMATOLOGY

Ideas S/Sx Actual Rationale Significance

Hypertension  Vascular dysfunction Monitoring and managing
and vasoconstriction hypertension are critical in
lead to elevated preventing maternal and
systemic blood pressure, fetal complications,
contributing to end- highlighting the need for
organ damage and antihypertensive therapy
complications such as and close blood pressure
eclampsia and stroke. monitoring.
Proteinuria  Endothelial injury and Proteinuria is a hallmark of
increased vascular pre-eclampsia and HELLP
permeability result in syndrome, serving as a
leakage of proteins, diagnostic criterion and
particularly albumin, into indicator of disease
the urine, reflecting renal severity. It underscores
dysfunction. the importance of renal
function monitoring and
early intervention to
prevent renal failure.
Visual  Vascular changes in Visual symptoms are
Disturbances retinal blood vessels, concerning for impending
cerebral vasospasm, or eclampsia or neurological
neurological involvement complications,
can lead to visual necessitating urgent
disturbances. evaluation and potential
delivery to prevent vision
loss and seizures.
Headaches  Cerebral vasospasm, Headaches can be a
increased intracranial warning sign of worsening
pressure, and pre-eclampsia, impending

21
 neurovascular changes eclampsia, or neurological
contribute to headaches complications such as
in pre-eclampsia. posterior reversible
encephalopathy syndrome
(PRES). Prompt
evaluation and
management are crucial to
prevent serious
neurological sequelae.
Decreased Urine Reduced renal perfusion Monitoring urine output is
Output due to vasoconstriction essential to assess renal
and decreased function and fluid status.
glomerular filtration rate Oliguria or anuria may
contribute to decreased indicate severe pre-
urine output. eclampsia, renal failure, or
impending eclampsia,
requiring prompt
intervention.
Epigastric or  Hepatic involvement, Epigastric pain may
Upper Abdominal hepatic capsular indicate HELLP syndrome
Pain distension, or or liver dysfunction,
subcapsular hematoma necessitating assessment
can cause epigastric of liver enzymes, platelet
pain. count, and consideration
of delivery to prevent
hepatic rupture or
infarction.
Edema  Increased capillary While edema is common
permeability and fluid in pregnancy, excessive or
retention due to vascular sudden-onset edema in
changes and renal combination with other

22
 dysfunction lead to symptoms may indicate
edema. severe pre-eclampsia or
complications such as
pulmonary edema.
Monitoring for signs of
volume overload and
respiratory distress is
crucial.
Thrombocytopenia Preeclampsia can lead Thrombocytopenia is a
to decreased platelet significant marker of
levels, a condition severe preeclampsia and
known as indicates a higher risk of
thrombocytopenia. This bleeding complications,
occurs due to the such as hemorrhage
activation of platelets during childbirth.
and their consumption in Monitoring platelet levels
response to vascular is crucial in managing
damage and clot preeclampsia and guiding
formation. decisions regarding
delivery timing and mode.
Nausea and Nausea and vomiting Persistent or severe
vomiting are common symptoms nausea and vomiting in
in pregnancy, but when preeclampsia can lead to
they occur or worsen in dehydration, electrolyte
the context of imbalances, and nutritional
preeclampsia, they can deficiencies, impacting
indicate more severe both maternal and fetal
disease. The exact health. Close monitoring
cause of these and management of these
symptoms in symptoms are essential to
preeclampsia is not fully prevent complications.

23
 understood but may
relate to altered liver
function and increased
sensitivity to metabolic
changes.
Tachycardia Tachycardia is a Tachycardia in the context
common response to of severe preeclampsia
stress, pain, or can indicate
physiological changes. cardiovascular stress and
In severe preeclampsia, compromised cardiac
tachycardia can result function. It may also be a
from increased sign of impending
sympathetic activity, eclampsia. Monitoring
reduced blood volume heart rate and addressing
due to fluid shifts, or underlying causes are
cardiac strain from crucial in managing severe
hypertension and preeclampsia and
vascular changes. preventing further
complications.

24
 X. Pathophysiology

PRE-CLAMPSIA

Predisposing Factors Precipitating Factors

Age, Gender Obesity High Sodium,

History of High Fat Diet
and Economic
Eclampsia Obesity can lead
Status
to reduced nitric During
Women with pregnancy
The majority of oxide and
history of excess intake of
pre-eclamptic endothelial
eclampsia are at sodium leads to
women were dysfunction that
higher risk of increased water
patient with less places additional
developing of retention in the
than 24 years of stress on blood
pre-eclampsia body, raising the
age at 33.3%, vessels
and potentially blood volume
and belonged to contributing to
develop to and putting
lower socio- low elasticity of
eclampsia, pre- pressure on
economic class. blood vessels
existent of blood vessels
National Library and higher
endothelial wall. High fat diet
of Medicine vascular
impairment can can contribute to
2022. resistance.
increase the risk obesity.
of recurrence of
preeclampsia.

Vasoconstriction occurs leading to

vasospasm and blood pressure increase
dramatically.

Endothelial dysfunction and

Cardiovascular Increased
increased vasoconstriction
System blood pressure
and poor organ perfusion.

Decreased glomeruli filtration Increased blood

rate and increased serum urea,
permeability of glomeruli nitrogen, uric acid
Renal System
membranes, allowing the and creatinine,
serum proteins albumin decreased25 urine
excrete into the urine. output, and
proteinuria
 Liver cell damage and hepatic
inflammation. Endothelial cell
Right upper
Hepatic lining in liver blood cell
quadrant or
System become damaged leading to
epigastric pain
decreased blood flow and
localized ischemia.

Swelling brain tissue altered Nausea, vomiting,

the cerebral blood flow, severe headaches,
Neurological
allowing fluid to leak in brain visual disturbances,
System
tissue, creating pressure to hyperflexia,
cranial muscle. irritability

Fluid diffusion from vascular

Interstitial space into in the interstitial Edema
Tissue space that leads to increased
extracellular volume

Decreased fetal
Placental Reduced blood flow to the growth and fetal
Circulation placenta movement

Diagnostic Test
TVS, CBC with PLT Count, UA

PRE-ECLAMPSIA

26
 Blood Pressure: 160/100 mmHg or 40
mmHg higher in systolic and 20 mmHg
SEVERE higher in diastolic
PRE-ECLAMPSIA Proteinuria: 5g/2hours
Other symptoms: Severe edema with
rapid weight gain, blurred vision, severe
headache, retinal edema, pulmonary
edema, epigastric pain, nausea and
vomiting

If Treated If Not Treated

- Eclampsia
Medical Management - HELLP Syndrome
- Magnesium Sulfate (MgSO4) - Organ Damage
Loading dose of 4-6g IVTT and - Abruptio Placenta
maintenance dose of 1-2g/hour IV or IM - FDIU
as ordered - Maternal Stroke
- Hydralazine
50mg PO every 4-6 hours

The patient has poor compliance

Nursing Management with medical regimen.
- Monitor vital signs, fetal heart tones,
The patient has no financial and
urine output, maternal daily weights, and
emotional support
results for laboratory tests.
- Check patient for hyperflexia as warning
sign of seizures.
- Encourage high protein, moderate
sodium diet.
- Promote complete bed rest, position
Poor Prognosis
patient in side lying.
- Minimize all stimuli.
- Continue to monitor 24-48 hours post
delivery.

Good Prognosis
27
XI. Doctor’s Order

DATE/TIME PROGRESS ORDERS

4/20/24 G2P0 - Pls admit to delivery room
11:50 PM LMP-B7/27/23 - Secure consent
AOG- 38WKS - VS q hourly
PREV. CS 2021 - NPO
DT ECLAMPSIA - D5LR 1L @ 120cc per hour
- Labs:
- CBC with Platelet Count
- U/A
- Syphillis
- Hbsag
- RAT
- Meds:
- Ampicillin 2g IVTT, q6 ANST
- Metocloperamide 1 amp IVTT prior to or
- Ranitidine 1 amp IVTT prior to or
- For stat CS with BTL
- Secure consent
- Pls. Secure 1unit PRBC screening and
crossmatching
- Insert foley catheter attatch to urobag
- FHT monitoring
- For abdominal prep
- Refer

4/21/24 - Inform Anesthesiologist on duty and NOD

12AM - Refer
4/21/24 160/110mmHG - Hydralazine 5mg IVTT Now

28
6AM - Mgso4 loading dose 4gms slow IVTT Now
- 5gms deep IM on each buttocks MD 5gms
Deep IM on each alternate buttocks q4 x 6
doses with toxicity precautions
- Deep Tendon Reflex <+2
- Respiratory Rate <16 Cycle/Min
- U/O <30cc per hour
4/21/24 S/P STAT CS - Post Op
- To PACU x2 hours then ward once stable
- NPO
- VS q15 x2 Hours, q30mins x2 hours, q hourly
x4 hrs then q shift
- IVF: D5LR 1L + Oxytocin 20 IU at 120cc per
hour
- TF: D5LR 1L +OXYTOCIN 20 IU at 120cc per
hour
- Meds:
- Ampicillin 1g IVTT q6
- Hydralazine 5mg IVTT q6 for BP >150 mmHg
systolic
- Ranitidine 50mg IVTT q8 x3 doses
- Tranexamic 500mg IVTT q 8hrs next dose
12nn x2 more doses
- Celecoxib 200mg 1 cap BID
- Flat on bed x6 hours
- O2 @ 2 LPM until awake
- Keep uterus contracted
4/21/24 - Addenum:
10AM - Ketorolac 30mg IVTT q6 x3 doses next dose
at 2pm then shift to Celecoxib PO once on
Soft Diet

29
 - Paracetamol 600mg IVTT q6 x3 doses next
dose at 12 pm
- Trammadol 50mg + PNSS 4cc Slow IVTT q6
hours PRN for severe pain
- Refer Accordingly
4/21/24 140/80mmHg - Hydralazine 5mg IVTT x diastolic BP
1:20PM >100mmHg
- May have general liquid diet once with flatus
at 7pm today {4/21/24}
- C/D IVTT meds due
- Start PO meds
- Cefuroxime 500mg 1 cap BID x7 days
- Mefenamic Acid 500mg 1 cap TID for pain
- Mtv+Iron 1 cap once a day
- Amlodipine 10mg 1 tab once a day
- Metorolol 100mg 1 tab BID
- Refer
4/22/24 130/80 mmHg - DAT
8AM - C/D IVF
- Continue Meds
- Start Spironolactone 50mg / tab once a day at
bedtime x7 days
- For wound dressing today
- Apply abdominal binder
- Encourage ambulation
- Remove FC, should void after 6 hours
- I And O q shift
- Increase Oral Fluid Intake
- Daily hygiene and perineal care
- Refer
4/22/24 Hgb 114 - Hold BT

30
3:15PM
4/23/24 BP 120/90 mmHg - May Go Home
8AM TEMP 37.6 - Home Meds:
Hgb 114 - Cefuroxime 500mg 1 tab BID x7 days
WBC 12 - Mtv+Iron 1 tab OD
PLT 261 - Mefenamic Acid 500mg 1 cap TID
- Amlodipine 10mg 1 tab OD
- Follow up check up after 1 week
- advised

31
XII. Diagnostic Tests

DIAGNOSTIC EXAM SIGNIFICANT NORMAL VALUES RESULTS

They are used to Uterine The uterus is

evaluate various Measurements: anteverted measuring
organs and Length: Typically 6.51×4.58 cm. The
systems, including ranges from 7 to 9 cervix measures
the abdomen, cm. 4.07×3.38cm within the
pelvis, heart, blood cervical cavity is single
Width: Usually
ULTRASOUND vessels, and fetal pole measuring
around 4 to 5 cm.
musculoskeletal 1.66cm. Compatible
system. Ultrasounds Thickness: with 8 week's & 1day
can help diagnose Thickness of
the AOG. Real time scan

conditions such as uterine wall can vary reveals somatic

gallstones, kidney but is generally movement nor cardiac

stones, tumors, and between 2 to 4 mm. activity.

vascular Cervical Amniotic fluid is still
abnormalities. Measurements: prominent

Length: Generally, The right ovary

measures around 3 measures
to 4 cm. 1.36×0.95cm cystic

Width: Normal width structure noted within.

varies but is typically The left ovary was not
around 2.5 to 3 cm. demonstrated in the
scan made.
Thickness:
Thickness of the
cervical canal is
usually around 2 to 3
mm.

32
 Fetal Pole:

Crown-Rump Length
(CRL): At around 8
weeks, the CRL of
the fetal pole is
typically between 7
to 13 mm.

Head Diameter:
Measures around 9
to 11 mm.

Abdominal Diameter:
Usually around 4 to
6 mm.

Amniotic fluid: There

should be some
amount of amniotic
fluid visible around
the embryo within
the gestational sac.

A high hematocrit Hemoglobin:120- Hemoglobin: 128 g/L

value can be a sign 160g/L
Hematocrit: 35.1%
of preeclampsia.
Hematocrit: 37 –
Hematocrit tells the Red Blood Cells: 4.49
54%
percentage of red x 1012/L

blood cells in the Red blood cells:4.5-

White Blood Cells:
CBC blood-a hematocrit 5.4×10¹²/L
12.24 x 109/L
value of 42 means White blood cells:
Platelet Count: 261 x
that red blood cells 5.0-10.0×10⁹/L

33
 make up 42% of the Platelet count:150- 109/L
blood volume. A 400×10⁹/L
normal hematocrit
value for a
nonpregnant woman
is between 36% and
44%.

Blood typing is Types (A, B, AB, or Type B+

crucial in O)
determining
Rh: Positive or
compatibility
Negative (+, -)
between the donor's
blood and the
recipient's blood
during blood
transfusions.
Blood Typing
Matching the blood
types (A, B, AB, or
O) and the Rh factor
(positive or
negative) helps
prevent adverse
reactions, such as
hemolysis
(destruction of red
blood cells) or
immune responses.

The serum and Proteinuria level Color: light yellow

salivary UA levels above 300 mg/24
Transparency: Hazy
showed an hours.
Sugar: Acidic
34
UA increasing trend Urine dipstick over Albumin:+1
from healthy 1+
Specific Gravity: 1.010
controls (group 1) to
Protein/creatinine
non-severe pre- Rbc: 0-2/HPF
ratio greater than
eclampsia (group 2) Pus cells: 5-10/HPF
0.3.
with the highest
values in severe Serum uric acid level .

pre-eclampsia above 5.6 mg/dL.

(group 3). Serum creatinine

Oligohydramnios level over 1.1 mg/dL.
was present in
10(20%) cases in
group 1 whereas
24(48%) cases in
group 3.

35
Complete Blood Count
EXAMINATION RESULTS NORMAL VALUES
HEMOGLOBIN 121 g/L 135-175g/L
HEMATOCRIT 35.1% 36.00-42.00
RBC 4.49 10^12/L 4.50-5.00 mmol/I
MCV 78.3 f/L 80.00-100.00fL
MCH 26.9 pg 27.00-31.00 pg/cell
MCHC 343 g/L 320.00-360.00 g/L
LEUCOCYTES NO. 12.24 10^9/L 5.00-10.00x10^9/L
CONC (WBC COUNT)
NEUTROPHILS 81.4% 55.00-65.00
LYMPHOCYTES 12.3% 25.00-40.00
MONOCYTES 4.3% 2.00-6.00
EOSINOPHILS 2.0% 1.00-5.00
BASOPHILS 0.0% 0.00-1.00
PLATELET 261 10^9/L 140-440

Urinalysis

EXAMINATION RESULT NORMAL VALUE

COLOR LIGHT YELLOW LIGHT YELLOW
TRANSPARENCY HAZY CLEAR
REACTION ACIDIC NEGATIVE
SUGAR NEGATIVE NEGATIVE
ALBUMIN 1+ 4+
SPECIFIC GRAVITY 1.010 1.005-1.030
RBC 0-2/HPF ≤2 RBC’s/HPF
PUS CELLS 5-10/HPF 0-2/HPF

36
XIII. Drug Study

Name of Classification Mechanism Indication Contraindicatio Adverse Nursing

Drug of Action n Effect Responsibilities
Generic Therapeutic Binds For the Patients with a Antibiotics- Before Administration:
Name: Classification bacteria cell treatment of known associated  Obtain CBC, renal
: membranes, many hypersensitivity colitis, other function tests.
Cefuroxime Antibiotic inhibits cell different to drug. super-  Question for
wall types of infections history of
Brand Pharmacologi synthesis. bacterial (abdominal allergies,
Name: cal Therapeutic infections cramps, particularly
Classification Effect: severe cephalosporins,
Ceftin : Bactericidal watery penicillin.
Second Pharmacoki diarrhea,
Actual/ generation netics: fever0 may During Administration:
Dosage/ cephalosporin Rapidly result from  Explain the
Route/ absorbed altered importance of
Frequency
from GI tract. bacterial continuous
Protein balance in antibiotic therapy
500 mg BID
binding: GI tract. for full length of
for 7days
33%-50%. Nephrotoxic treatment.
Widely ity may  Inform patient that
distributed, occur, esp. discomfort may

37
including to in pts with occur.
CSF. preexisting
Primarily renal After Administration:
excreted disease. Pts  Assess oral cavity
unchanged with history for white patches
in urine. of penicillin on mucus
Moderately allergy is at membranes,
removed by increased tongue.
hemodialysis risk for  Monitor daily
. developing pattern of bowel
a severe activity and stool
hypersensiti consistency.
vity reaction  Monitor intake
(severe and output and
pruritus, renal function test
angioedem for nephrotoxicity.
a,  Be alert for
bronchospa superinfection.
sm
anaphylaxis
).

38
 Name of Classification Mechanis Indication Contraindicatio Adverse Effect Nursing
Drug m of n Responsibilities
Action
Generic Therapeutic Hydralazin Treatment of
 Coronary  Hypotension Before
Name: Classification: e is used to hypertension
artery  Tachycardia Administration:
Antihypertensiv treat high , including
disease  Headache
Hydralazin e blood hypertension  Assess
 Mitral  Flushing
e pressure. It associated patient’s vital
valvular  Nausea/
works by with signs and any
rheumatic vomiting
Brand relaxing the preeclampsi signs/symptom
heart  Palpitation
Name: blood a and s of
disease.
vessels so eclampsia  Peripheral preeclampsia.
that blood during edema  Check doctor’s
Apresoline
can flow pregnancy. order.
Dosage: more easily  Review the
5mg through the patient’s
body. medical history
Route:
for any
IVTT
contraindicatio
Frequency n or previous
: every 4-6 adverse
hours reaction to

39
 hydralazine.
 Ensure proper
dosage
calculation.

During
Administration:

 Monitor patient
vital signs.
 Watch for
signs of
adverse
reactions.

After
Administration:

 Continue
monitoring
patient’s vital
signs
especially the

40
 blood pressure
and heart rate.
 Assess the
patient for any
signs of
improvement
or worsening
of symptoms.

41
 Name of Classification Mechanism of Indication Contraindicatio Adverse Effect Nursing
Drug Action n Responsibilities
Generic >Pre- To prevent Parenteral CNS: drowsiness Before:Take an
Name: eclampsia Magnesium control administration depress reflexes, appropriate
Magnesiu woman: 4g IV Sulfate is seizure in contraindicated placid paralysis. seizure
m Sulfate in 250 ml. essential pre- in patient with hypothermia CV: precaution.
D5W with element for eclampsia heart block hypotension,
Brand normal saline muscle and To manage myocardial lushing During:
Name: and 4-5 g. nerve preterm damage. bradycardia, Check
Magnesiu deep IM into transmission labor Use cautiously in circulatory Magnesiumlevel
m Sulfate buttock Extracellular patients with collapse, repeatd doses.
alternate in fluid levels: impaired renal Disappearance of
 depress
every 4 hrs. 1.5-2.5 mg/L. function Use knee. Jerl and
cardiacfunction
P.R.N 4g IV. Mg depresses cautiously in patellar reflexes
Skin:
Lodding dose the CNS is a sign of
 pregnant diaphoresis
then 1 2 qhr. andcontrols impeding
woman
as LV infusion convulsion by magnesium
during labor
Dose should blocking toxicity.
notexceed 30- release of Monitor urine
40 g. daily acetycholine at intake and output.
the myoneutral
junction Also, After:

42
mg decrease  Observe
sensitivity of neonates for
motor end for signs of
plate to magnesium
acytycholine toxicity.
and decreases
the excitability
of the mother ,
membrane as
a laxative it
acts in the
small and
target intestine
to attract and
retain water in
the intestinal
lumen,
increasing
intraluminal
pressure, also
releases
cholycystokini

43
n.

44
 Name of Classification Mechanism Indication Contraindication Adverse Nursing
Drug of Action Effect Responsibilities
Antiemetic, Metoclopram Metoclopra
Generic  Hypersensitivi  Extrapyrami Before
Prokinetic ide works mide is
Name: ty to dal administration:
agent primarily by indicated for
Metoclopra metocloprami symptoms
antagonizing the  Assess the
mide de or any (e.g.,
dopamine treatment of patient's medical
component of dystonia,
Brand receptors in gastroesop history, allergies,
the dyskinesia)
Name: the hageal and current
formulation.  Sedation
Reglan chemorecept reflux medications.
 Gastrointestin  Diarrhea
or trigger disease  Check for
Dosage: al obstruction,  Tardive
zone (CTZ) (GERD), contraindications
perforation, or dyskinesia
of the brain. diabetic and potential
1 AMP
hemorrhage. (a
It also gastropares drug interactions.
Route: Per  Pheochromoc potentially
sensitizes is, nausea  Monitor vital
Orem ytoma irreversible
tissues to and signs, especially
the effects of vomiting  Seizure movement
Frequency: blood pressure,
acetylcholine associated disorders disorder)
STAT as
, which with  Hyperprolac
metoclopramide
enhances chemothera tinemi
can cause
gastric py, and  Neuroleptic
hypotension.
motility and postoperativ malignant
syndrome During
45
accelerates e nausea
(rare but administration:
gastric and
serious)
emptying. vomiting.  Administer the
medication as
prescribed,
ensuring the
correct dosage
and route.
 Monitor the
patient for any
signs of adverse
reactions, such
as extrapyramidal
symptoms or
sedation.
 Educate the
patient about the
medication,
including its
purpose, dosage,
potential side
effects, and any

46
 necessary
precautions.

After
administration:

 Monitor the
patient's
response to the
medication,
assessing for
improvements in
symptoms or the
development of
adverse effects.
 Document the
administration
and the patient's
response in the
medical record.
 Provide
appropriate
supportive care
47
as needed, such
as managing
adverse effects
or addressing
any concerns the
patient may have.

48
 Name of Classification Mechanism Indication Contraindicatio Adverse Nursing
Drug of Action n Effect Responsibilities
Generic Therapeutic Ketorolac, Ketorolac is This drug is Headache, 1. Check doctor’s
Name: Classification like other a Non- contraindicated drowsiness, order to avoid
: NSAIDs, steroidal to dizziness, mistake.
Ketorolac Non-steroidal blocks anti- pregnant patient pallor, 2. Observe the 10
anti- cyclooxygen inflammator who are sweating, RIGHTs in
Brand inflammatory ases (COX), y drug hypersensitive to dry mouth, administering the
Name: drug (NSAID) which are (NSAID) Ketorolac drugs. diarrhea, drug.
enzymes and has And patients with edema, 3. Assess and
Toradol Pregnancy that convert antipyretic, cross – sensitive vasodilation accurately record
category: C arachidonic analgesic with and maternal vital
Actual/ acid into and anti- other NSAIDs injection signs.
Dosage/ prostaglandi inflammator and site pain. 4. Assess the
Route/ ns, y during pre or client’s history of
Frequency
prostacyclin, properties.2 perioperative allergy to the drug
and It is use. to avoid
30mg IVTT
thromboxane indicated for complications.
q6 X 3
. The short term 5. Encourage client
DOSES
inhibition of manageme to report severe
these nt of acute pain for prompt
substances pain that intervention.

49
decreases requires the 6. Tell patient to
pain, fever, calibre of avoid activities
and pain requiring
inflammation manageme alertness because
.[4] nt offered this drug can
Ketorolac by opioids. cause headache,
does so by dizziness and
inhibiting drowsiness.
both 7. Instruct client to
cyclooxygen call the attention
ase-1 and of any health care
cyclooxygen professional when
ase-2. It has difficulty of
higher breathing is
demonstrate experienced to
d potency give prompt
than most intervention.
other 8. Terminate or
NSAIDs discontinue
infusion if uterine
hypersensitivity
occurs.

50
51
XIV. Surgical Procedure

EMERGENCY CESAREAN SECTION

Indication:

Emergency cesarean section is indicated in cases of severe pre-eclampsia when

vaginal delivery is contraindicated due to the risk of complications related to
hypertension, organ dysfunction, and fetal distress.

Prior to the procedure: consent form is being signed by the patient

Patient Preparation:

 Mrs. A is placed in the supine position on the operating table.

 Continuous fetal heart rate monitoring is initiated.
 Anesthesia consultation is obtained for regional or general anesthesia
administration.

Procedure Steps:

1. Skin Preparation and Draping: The abdomen is cleansed with an antiseptic

solution. Sterile drapes are applied to expose the abdomen while maintaining
aseptic technique.
2. Incision: A low transverse incision (Pfannenstiel incision) is made just above the
pubic symphysis to access the uterus. Care is taken to avoid the placental site to
minimize bleeding.
3. Uterine Entry: The rectus muscles are dissected, and the peritoneum is incised.
Blunt dissection is performed to enter the abdominal cavity. The bladder is dissected
downwards and retracted to expose the lower uterine segment.
4. Exploration and Delivery: Upon entry into the uterus, the surgical team carefully
assesses the location of the placenta to avoid excessive bleeding. If the placenta
partially or completely covers the cervix (placenta previa), it is gently separated from

52
 the uterine wall to access the baby. The baby is delivered through the uterine
incision, ensuring proper handling to prevent neonatal injury.
5. Cord Clamping and Placental Delivery: After the baby is delivered, the umbilical
cord is clamped and cut. The placenta is then carefully removed from the uterine
cavity to minimize the risk of retained placenta and postpartum hemorrhage.
6. Uterine Repair and Closure: The uterine incision is closed in layers using
absorbable sutures to achieve hemostasis and prevent uterine rupture. The
peritoneum and rectus muscles are approximated, and the skin incision is closed
with sutures or staples.
7. Postoperative Care: Mrs. A is transferred to the recovery area for close monitoring
of vital signs, bleeding, and pain control. Ongoing assessment of uterine tone and
lochia is performed to detect any signs of complications such as uterine atony or
retained placenta. Maternal-fetal bonding and breastfeeding support are provided as
appropriate.

Outcome:

Emergency cesarean section for severe pre-eclampsia aims to safely deliver the
baby while minimizing maternal and fetal risks associated with prolonged labor and
vaginal delivery in the presence of hypertensive emergencies. This surgical intervention
helps prevent life-threatening conditions and ensures optimal outcomes for both mother
and baby.

53
XV. Nursing Theories

Theory of Interpersonal Relations

Hildegard Peplau's theory focuses on the nurse-patient relationship, emphasizing

phases of the relationship: orientation, working, and termination. In caring for a patient
with severe pre-eclampsia, nurses using Peplau's theory would establish a clear
communication pathway, developing a therapeutic relationship. The orientation phase
involves assessing the patient's understanding of her condition and establishing trust.
The working phase focuses on interventions, education, and emotional support. Finally,
the termination phase would prepare the patient for discharge and transition to other
care providers, ensuring continuity of care.

Theory of Human Caring

Jean Watson's theory emphasizes the caring relationship between the nurse and
the patient, focusing on the humanistic aspects of nursing. In severe pre-eclampsia, this
theory underscores the importance of a compassionate and empathetic approach.
Nurses can build a therapeutic relationship with the patient, offering emotional support,
active listening, and reassurance. This caring approach can help alleviate anxiety and
stress, which are common in patients with severe pre-eclampsia.

Roy's Adaptation Model

Sister Callista Roy's model focuses on how individuals adapt to changes in their
environment. It emphasizes the role of nursing in promoting successful adaptation to
health challenges. Severe pre-eclampsia can significantly disrupt a woman's normal
physiological and psychological balance. Nurses using Roy's model would assess how
the patient is adapting to the stress of the condition, including physiological responses
(e.g., blood pressure, edema), self-concept, and social roles (e.g., family relationships).
Nursing interventions aim to support adaptation, providing care and education to help
the patient and her family to adjust to the condition and treatment.

54
Self-Care Deficit Theory

This theory, developed by Dorothea Orem, is based on the idea that individuals
can care for themselves, but may require nursing intervention when they cannot meet
their own care needs. Patients with severe pre-eclampsia often require substantial
assistance due to their condition's risks and limitations on activity. Nurses can assess
self-care deficits in areas such as medication management, monitoring symptoms, and
mobility, providing necessary support and education. The goal is to help the patient
regain as much independence as possible while ensuring safety and stability.

55
XVI. Nursing Care Plan

Date/ Cues Nursing Patient Nursing Rationale Evaluation

Time Diagnosis Outcome Interventions
Subjective: Anxiety related to After 8 hours 1. Listening
April 21, actively and
severe pre- of nursing focus on the
2024 “Mahadlok ko kay
eclampsia intervention, patient
basin mag discussed her
4:00 pm personal
convulsion na feelings.
pod ko parehas 2. Provide
education
sa una nako na about
pagbuntis” 3. Encourage
open
verbalized by the communication
and address
patient. any specific
concerns or
questions the
patient may
Objective: have.
4. Encourage the
- Facial Grimace involvement of
the patient's
noted. family
- Weakness. members or
support
systems in the
care process.
Vital Signs:

- Blood

56
 Pressure:
160/100
mmHg
- Pulse
Rate :89 bpm
- Respiratory
Rate: 21 cpm
- Temperaure:
36.5OC
- SpO2: 98%

57
Date/ Cues Nursing Patient Nursing Rationale Evaluation
Time Diagnosis Outcome Interventions
Subjective: Risk for fall After 8  Assessment  Regular After 8
April
“Ga blur akong related to hours of and assessment and hours of
22,
panan-aw kauban sa visual nursing monitoring monitoring of vital nursing
2024
gasakit nako na ulo” disturbance intervention, vital signs signs, including intervention,

5:00 as verbalized by the related AEB the patient and also the blood pressure, the patient

pm patient. elevated will be able health heart rate, and can

blood to condition of oxygen saturation, demonstrate
pressure demonstrate the patient are essential to be able to
Objective: secondary to and demonstrate
 Place the detect any
- (+) facial grimace preeclampsia establish patient in a worsening of and
safety semi-Fowler's preeclampsia or establish
Vital Signs: measures. position. development of safety

- Blood Pressure:  Ensure a eclampsia measures

160/100 mmHg calm and promptly. regarding

- Pulse Rate: quiet  This position her

89bpm environment promotes optimal condition.

- Respiratory Rate: for the oxygenation and

21 cpm patient. reduces - Goal met

- Temperature:  Have seizure intracranial

36.6oC precautions pressure, which

58
- Oxygen in place, can help manage
Saturation: 98% including visual
padded side disturbances and
rails and prevent
suction complications
equipment at  : Excessive
the bedside. stimulation can
 Provide increase anxiety
education on and blood
signs and pressure,
symptoms of exacerbating
worsening visual
preeclampsia disturbances and
and the other
importance of preeclampsia
reporting any symptoms.
changes  Visual
promptly. disturbances can
be a precursor to
eclampsia, which
is characterized
by seizures.

59
 Precautions help
ensure the safety
of the patient
during a seizure
episode.
 Empowering the
patient with
knowledge helps
in early detection
of complications,
including visual
disturbances, and
promotes timely
intervention.

60
 Date/ Cues Nursing Patient Nursing Rationale Evaluation
Time Diagnosis Outcome Interventions
Subjective: Acute pain After 8 hrs  Provided  Regular After 8hrs of
April
related to of nursing regular assessment nursing
22, “Sakit kayo and
surgical intervention assessment ensures intervention
2024 tinahian” verbalized
incision. patient will and timely patient
by the patient.
5:00 pm verbalize management intervention to verbalized
reduce of of pain. alleviate reduce of pain

Objective: pain.  Monitored vital discomfort from the pain

signs, incision and promote skill of 8/10 to
- Facial Grimace
site, and recovery. 6/10.
- Body Malaise
uterine fundus  Monitoring
- Pain Scale 8 out of regularly. vital signs
10  Encouraged helps in early
early detection of
ambulation any primary
Vital Signs:
and deep complications
Blood Pressure: 140/90 mmHg breathing  Monitoring the
exercise. incision site is
Respiratory Rate :21 cpm  Administered essential for
medication as identifying
prescribed. signs of

61
 infection or
improper
healing.
 Regular
assessment
of the uterine
fundus aids in
detecting
abnormal
bleeding.
Helps prevent
complications
such as deep
vein
thrombosis
(DVT) and
aids in the
recovery
process.
 Deep
breathing
exercises

62
 promote lung
expansion
and prevent
respiratory
complications.
 To manage
postoperative
discomfort.

63
Date/ Cues Nursing Patient Nursing Rationale Evaluation
Time Diagnosis Outcome Interventions
April 22, Subjective: Impaired skin After 8hours - Evaluate - For Goal was met
2024 "Gapang hupong integrity related of nursing mentation. confusion after 8hours of
5:00 pm akong mga tiil" as to as interventions - Restrict or nursing
verbalized by the evidenced by patient will be sodium and personality interventions
patient. edema. able to fluid intake. changes. patient was
verbalize - Advised to - To able verbalized
Objective: understanding elevate the emphasize understanding
(+) Edema of individual edematous dietary/fluid of individual
dietary/fluid extremities, restriction dietary/fluid
Vital Signs: restrictions. change - To reduce restriction.
- Temperature: position tissue .
36.5⁰C frequently. pressure
- Pulse Rate: - Stress the and risk for
89bpm need for skin
- Respiratory mobility and breakdown.
Rate: 21cpm frequent - To prevent
- Blood Pressure: position stasis and
160/100 mmHg changes. risk of
- Oxygen - Identify signs tissue
Saturation: 96% requiring injury.

64
notification of - To ensure
healthcare timely
provider. evaluation/
intervention

65
Date/ Cues Nursing Patient Nursing Rationale Evaluation
Time Diagnosis Outcome Interventions
April Subjective: Risk for  After a series  Monitor  To measure  Patient
22, “Medyo gapula infection of nursing patient’s vital body basic demonstrated
2024 akonng tahi ug related to interventions signs, functions, understanding
5:00 medyo hapdi siya postoperative the patient will including elevated body about the risk
pm ilihok” of cesarean demonstrate temperature temperature factors and
section. understanding and blood are one the signs of
Objective: about the risk pressure. sign of infection.
- Discomfort to factors and  Position the infection, it is  Patient
site of incision what to look patient in also important remained
- Weakness for signs of comfortable to monitor afebrile as
- Facial grimace infection. position that blood evidenced by
noted.  After 8 hours could relieve pressure temperature
of nursing discomfort, since client of 36.5 C, and
Vital Signs: interventions  Educate the has pre- the patient
- Blood the patient will patient about eclampsia. remained free
Pressure: remain the possible  To relieve from infection.
90/70 mmHg afebrile and signs of feeling of
- Pulse Rate: free from infection. discomfort, so  Goal met.
78bpm infection  Teach the that client

66
- Respiratory patient about would comply
Rate: 22 cpm proper to the
- Temperature: perineal interventions.
37OC care,  To improve
- SpO2: 98% especially proper
before and healing
after renal or without the
bowel invasion of
activity. infection.
 Encourage  Adequate
the patient to hydration can
increase oral help improve
fluid intake. immune
 Encourage system
the patient to function to
increase promote
intake of proper
Protein and healing.
Vitamin C –  Protein is
rich food. essential for
 Emphasize repairing and
the necessity building

67
 of taking tissues during
antibiotics as wound
prescribed healing and
by the Vitamin C has
physician, antioxidant
especially properties,
the dosage, protecting
time and cells from
length of damage and
therapy. supporting the
 Emphasize immune
to the patient system.
to report any  To ensure
signs of successful
infection and treatment and
problems reduce the
encountered. risk of
antibiotic
resistance,
follow your
physician’s
instructions

68
 for dosage,
timing, and
length of
therapy
precisely.
 - To ensure
immediate
response for
possible
complications.

69
 XVII. Discharge Plan

METHOD HEALTH TEACHING RATIONALE

Medication  Instruct the patient to take all the  To prevent complication and
prescribed medicine at the right time as to stabilize the patient's
directed by the physician. condition.
 Ensure that the patient is capable of  To achieve the medication's
following medication instructions. therapeutic impact and avoid
further problems and
Medications: dangers
 Cefuroxime 500 Mg 1 tablet 2x a day (6am
and 6pm) 7days After meal
 Multivitamins+Fes O4 1 tablet once a day
(6am) 1 Month
 Mefenamic Acid 500 Mg 1 tablet 3x a day
(6am-12nn-6pm) as needed for pain
 Amlodipine 1o Mg 1 tablet once a day
(6am)
Activities  Avoid sexual intercourse and any activities  To minimize any potential
such as heavy lifting or strenuous exercise. risks or complications and
allow for proper healing and
recovery.
Treatment  Continued medical follow-up including  To helps manage grief,
blood pressure monitoring every day and detect potential health
address any complication. issues, and ensure recovery.
Hygiene  Maintain good hygiene practice includes  To prevent infection.
regular bathing or showering, changing
sanitary pads frequently, and keeping the
genital area clean.
Out-  Follow the physician’s order or  To ensure physical and
Patient recommendation before returning to emotional healing.

70
Referral normal activities.
Diet  Balanced Nutrition: Emphasize a well-  To support her physical
balanced diet that includes a variety of recovery and nutrients can
fruits, vegetables, whole grains, lean help optimize healing and
proteins, and healthy fats. support overall health as the
 Hydration: Encourage adequate hydration body goes through this
by drinking plenty of water throughout the challenging period.
day.  Staying hydrated can
support normal bodily
functions and help the body
cope with physical and
emotional demands of the
situation.
Spiritual  Encourage the client to continue to seek  Positive beliefs, comfort, and
God’s guidance and enlightenment. strength gained from religion,
meditation, and prayer can
contribute to well-being.
(Rich, 2020)
 Share spiritual thoughts that can  Scripture has an amazing
encourage the patient. way of uplifting spirit and
encouraging people.
(Nouran, 2018)

71
XVIII. Prognosis

This chapter deals with the notion about the phasing of a patient’s recovery as
anticipated by the usual process and idiosyncrasy of the disease state. Accordingly,
prognosis relatively amends patient charted implications (Selim et. al., 2020)

CRITERIA POOR FAIR GOOD JUSTIFICATION

Onset of Illness  Prior to admission patient experienced 1
day of dizziness.
Duration of  Symptoms felt by the patient had
Illness happened for about 1 day prior to
admission.
Precipitating  The patient has a history of eclampsia
Factor to her previous delivery.
Age  At the age of 24, patient experiences a
preeclampsia. However, a fair notion
suggests that she is still managing
reasonably well.
Socioeconomic  There is no socioeconomic status
Factor indicated on patient’s data. However,
the patient was able to comply with the
necessary medications and treatment
needed with the collective help from
relatives and family.
Attitude and  The patient is taking an active role in
willingness to her health by willingly cooperating with
take all the health-care providers’ efforts.
medications The patient is well oriented about the
compliance to medications and treatment she
treatment receives. With the help of family,
regimen. relatives, and significant others, the

72
 patient was able to comply with the
necessary medications and treatment
that the patient needs to undergo

Final Prognosis

CRITERIA INDICATION SCORE

Onset of Illness Good 3
Duration of Illness Good 3
Precipitating Factor Fair 3
Age Fair 2
Socioeconomic Factor Fair 2
Attitude and willingness to take Good 3
medications compliance to
treatment regimen.
INDICATION
TOTAL POOR FAIR GOOD GDENERAL
1 2 3 PROGNOSIS
COMPUTATION (0*1)6 (3*2)6 (4*3)6 1-1.6: POOR
1.7-2.3: FAIR
2.4-3: GOOD
0 1 2 3

Patient A has a good prognosis which means good chance of recovery.

73
XIX. Recommendation

To the Patient:

For the patient diagnosed with severe pre-eclampsia, nursing recommendations focus
on close monitoring of blood pressure, urine output, and fetal well-being. Patients
should be educated about signs and symptoms of worsening pre-eclampsia, such as
severe headaches, visual disturbances, and abdominal pain, and instructed to seek
immediate medical attention if these occur. Additionally, strict bed rest and medication
compliance, often including antihypertensive drugs like labetalol or hydralazine, are
crucial in managing pre-eclampsia to prevent further complications like eclampsia or
HELLP syndrome.

To the Family/Watcher:

Family or watchers of the patient with severe pre-eclampsia should be informed about
the condition's seriousness and potential risks to both the mother and the baby. They
should be encouraged to provide emotional support and assist with daily activities as
needed, promoting a calm and stress-free environment for the patient.

To the Student Nurses:

Student nurses involved in the care of a patient with severe pre-eclampsia should focus
on enhancing their knowledge about the condition, its pathophysiology, and evidence-
based nursing interventions. They should actively participate in monitoring vital signs,
administering medications under supervision, and assisting with patient education to
improve outcomes and develop their clinical skills.

To the Health care providers:

Health care providers managing patients with severe pre-eclampsia should ensure
timely and comprehensive assessment, including regular blood pressure monitoring,

74
urine analysis for proteinuria, and fetal monitoring through non-stress tests or
biophysical profiles. Collaboration with obstetricians, neonatologists, and other
specialists is essential to provide optimal care, considering potential complications like
preterm birth, placental abruption, or fetal distress.

To the community:

Awareness programs about pre-eclampsia's signs, risk factors, and preventive

measures can significantly contribute to early detection and management. Encouraging
pregnant individuals to attend regular prenatal check-ups, maintain a healthy lifestyle
with balanced nutrition and adequate physical activity, and seek prompt medical
attention for any concerning symptoms can help reduce the incidence and severity of
pre-eclampsia, promoting maternal and fetal well-being.

75
X. Reference

76