St.

Paul University Philippines

Tuguegarao City, Cagayan 3500 SCHOOL OF HEALTH SCIENCES College of Nursing

A Case Presentation In Mild Pre-Eclampsia

Case Presentors: Berbano, Anna Dominique D. Burga, Abigail S. Cabauatan, Karel Joy A. Calimag, Dianne Joselle C. Cario, Lorren Leigh R. Mallillin, Hans Russel D. Panelist Mr. Melanie Reboldera Adolfo, MSN Ms. Jana Angela Flores, RN Mrs. Jenniffer Masirag, MSN Mr. Ryan Michael Padua, MSN Mrs. Miriam Pattugalan, MSN Mr. Robert Umoso, MSN

INTRODUCTION
Mild Pre-eclampsia is a condition in which hypertension arises in pregnancy (pregnancyinduced hypertension). Mild pre-eclampsia is any status above gestational hypertension and below the point of seizures. It may develop from 20 weeks gestation (it is considered early onset before 32 weeks). Its progress differs among patients; most cases are diagnosed pre-term. Signs and symptoms: Proteinuria (+1 - +2) Blood pressure rises to 140/90(taken on two occasions at least 6 hours apart) Mild edema in upper extremities or face Weight gain of more than 2 lb/wk in the second trimester or 1 lb/wk in the third trimester Risk Factors for Pre-eclampsia The incidence of preeclampsia is higher in women with a history of preeclampsia, multiple gestations, and chronic hypertension or underlying renal disease. In addition, pre-eclampsia, spontaneous preterm delivery, or fetal growth deviation in a first singleton pregnancy predisposes women to those complications in their second pregnancy, especially if the complications were severe. Gestational Age Preeclampsia in a first pregnancy, with delivery between 32 and 36 weeks' gestation, increased the risk of preeclampsia in a second pregnancy from 14.1% to 25.3%. Fetal growth 2-3 standard deviations below the mean in a first pregnancy increased the risk of preeclampsia from 1.1% to 1.8% in the second pregnancy. Primigravid patients in particular seem to be predisposed to preeclampsia. Maternal Age Women aged 35 years and older have a markedly increased risk of preeclampsia. Race

Additional Risk Factor Some risk factors contribute to poor placentation, whereas others contribute to increased placental mass and poor placental perfusion secondary to vascular abnormalities. Preeclampsia risk factors also include the following: Hydatidiform mole Obesity Thrombophilia Oocyte donation or donor insemination Urinary tract infection Diabetes Collagen vascular disease Periodontal disease Nursing Interventions Clients with mild pre-eclampsia can be managed at home with frequent follow-up care. Regardless of setting of the, the care is similar. Monitor Antiplatelet Therapy. Monitor increase of platelet because of the increased tendency for platelets to cluster along arterial walls, a mild antiplatelet agent, such as low-dose aspirin, may prevent or delay the development of pre-eclampsia. Promote Bed Rest Recumbent position is advice to avoid uterine pressure on the vena cava and prevent supine hypotension syndrome. Promote Good Nutrition

A pregnant women need to continue her usual pregnancy nutrition. Sodium restriction of salt is no longer true because sodium restriction may activate the renin angiotensin-aldosteron system and may result in increased blood pressure. Provide Emotional Support Providing emotional support can help the mother to verbalized her feeling about her current condition.

PATIENTS PROFILE:
Name: SAP Address: Lallo, Cagayan Age: 20 y/o Birth day: 0ctober 13, 1990 Religion: Roman Catholic Civil status: Married Age of gestation: 29 weeks and 5 days Last Menstrual Period: December 20, 2010 Expected Date of Confinement: September 27, 2011 OB Score: 2110010 FHR: 124 bpm Fundal Height: 38.1 cm Menarche: 12 y/o Coitarche: 18 y/o Admitting Diagnosis: Gestational Hypertension vs. Pre-eclampsia Final Diagnosis: Mild Pre-eclampsia Date of admission: July 17, 2011 Date handled: July 18, 2011 Attending Physician: Dr. Baggay Initial vital signs: BP: 110/70 mmHg Temp.: 36.1o C PR: 60 bpm RR: 17 cpm

PHYSICAL ASSESSMENT

Date of Assessment

July 18, 2011 @9:00 AM T=36.1o PR=60 bpm RR= 17cpm BP:110/70 mmHg Patient is relaxed, coordinated movements, clean, no body odor, no breath odor, oriented, cooperative, and smiles sometimes Received pt. sitting on bed with ongoing IVF of #2 D5LRS 300cc x KVO patent and infusing well @ left metacarpal vein.

Vital Signs

General Appearance

SKIN Area Assessed Skin Color Technique used Inspection Normal Findings Varies from light to Deep Brown/tan; Rudd pink to light pink; Generally uniform except in areas exposed to the sun Actual Findings Analysis

Tan Uniform except in areas exposed to sun like arms and legs

Normal

Uniformity of skin color

Inspection

Normal Edema in lower extremities is normal due to pregnancy physiology, edema on upper extremities is not normal due to increase fluid retention Normal Normal

Edema

Inspection and Palpation

No edema

Edema in lower and upper extremities

Skin moisture Skin temperature

Palpation and observation Palpation

Moisture in skin folds and axillae Within normal range (36.5-37.5)

Moisture in skin folds and axillae 36.1o C (upon endorsement) Skin springs back to previous state when pinched (1 second)

Skin turgor

Palpation

When pinched, skin springs back to previous state

Normal

NAILS Area Assessed Technique used Normal Findings Convex curvature; angle b/n nail and nail bed of about 160o Smooth Texture Highly vascular and pink=light skinned clients; Dark skinned= brown or black pigmentation Intact epidermis Prompt return of pink or usual color within 4 seconds HAIR Technique used Inspection Inspection Inspection Inspection Inspection Actual Findings Analysis

Nail Plate shape

Inspection

Convex curvature

Normal

Nail Texture

Inspection and Palpation

Smooth

Normal

Nail Bed color

Inspection

Pink

Normal

Tissue surrounding nails

Inspection

Intact epidermis

Normal

Capillary refill time

Blanch test

Prompt return of pink color within 2 seconds

Normal

Area Assessed Evenness of hair growth Hair thickness or thinness Hair texture and oiliness Presence of Infestations Amount of body hair

Normal Findings Evenly distributed hair Thick hair Silky resilient hair No infestation or infection Variable

Actual Findings Evenly distributed hair Thick hair Silky and Resilient No infestations or infection present Moderate deal of body and scalp hair

Analysis Normal Normal Normal Normal Normal

HEAD Area Assessed Skull size, shape and symmetry Nodules and masses Technique used Inspection Normal Findings Rounded(normocephalic and symmetric), smooth skull contour Absence of nodules and masses Actual Findings Normocephalic and symmetric, smooth skull contour Absence of nodules and masses Analysis

Normal

Palpation

Normal

Facial features Edema and Hollowness in eyes Symmetry of facial movements

Inspection

Symmetric or slightly assymetric facial features, palpebral fissures equal in size No edema and hollowness

Symmetric; Palpebral fissures equal in size

Normal

Inspection and palpation Inspection

No edema and Hollowness

Normal

Symmetric facial movements

Symmetric facial movements

Normal

EYES Technique used

Area Assessed EXTERNAL EYE STRUCTURE Eyebrows for hair distribution, alignment, skin quality and movement) Eyelashes for evenness and distribution and direction of curl Eyelids for surface charac., position in relation to the cornea, ability to blink, frequency of blinking Bulbar conjunctiva for color, texture and presence of lesions Palpebral conjunctiva (color, texture, presence of lesions) Lacrimal gland

Normal Findings

Actual Findings

Analysis

Inspection

Hair evenly distributed; skin intact; Eyebrows symmetrically aligned; equal movement

Hair evenly distributed; skin intact; Eyebrows symmetrically aligned; equal movement

Normal

Inspection

Equally distributed; curled slightly outward

Equally distributed; curled slightly outward

Normal

Inspection

Skin intact; no discharge & discoloration; lips closed symmetrically; 15-20 involuntary blinks per minute; bilateral blinking

Skin intact; no discharge & discoloration; lips closed symmetrically; bilateral blinking

Normal

Inspection

Transparent; capillaries sometimes evident; sclera appears white

Transparent; capillaries sometimes evident; sclera appears white

Normal

Inspection

Shiny, smooth and pink/red; Absence of lesions

Shiny, smooth and pink/red; Absence of lesions

Normal

Inspection and palpation

No edema or tenderness over lacrimal gland

No edema or tenderness over lacrimal gland

Normal

Lacrimal sac &Nasolacrimal duct Cornea for clarity and texture Anterior chamber for transparency and depth Pupils for color, shape and symmetry of size

Inspection and Palpation Inspection

No edema or tearing Transparent, shiny and smooth, Details of the eyelids are visible Transparent, no shadows of light on iris, depth of about 3mm Illuminated pupil constricts, non-illuminated pupils constricts

No edema or tearing Transparent, shiny and smooth, Details of the eyelids are visible Transparent, no shadows of light on iris Illuminated pupil constricts, nonilluminated pupils constricts

Normal

Normal

Inspection

Normal

Inspection

Normal

EARS and HEARING Area Assessed Auricles for color, symmetry of size and position Auricles for texture, elasticity and areas of tenderness Response to normal voice tones Technique used Inspection Normal Findings Color same the as facial skin; symmetric position Firm; mobile and not tender; pina recoils after it is folded Normal voice tones audible >Able to hear ticking in both ears Actual Findings Color the same as facial skin; symmetric position Firm; mobile and not tender; pina recoils after it is folded Normal voice tones audible >Able to hear ticking in both ears Analysis

Normal

Palpation

Normal

Gross hearing acquity test > Watch tick test

Normal

NOSE and SINUSES Technique used

Area Assessed External nose for deviations in shape, size or color and flaring or discharge from the nares External nose for areas of tenderness, masses or displacements of bones and cartilage

Normal Findings

Actual Findings

Analysis

Inspection

Symmetric and straight, no discharge or flaring, uniform in color

Symmetric and straight, no discharge or flaring, uniform in color

Normal

Palpation

Not tender, no lesions

Not tender, no lesions

Normal

Patency of Nasal cavities

Inspection

Airs moves freely as the client breathes through the nares MOUTH and OROPHARYNX

Airs moves freely as the client breathes through the nares

Normal

Area Assessed Outer lips for symmetry of contour and color Inner lips and Buccal mucosa for color and presence of lesions

Technique used

Normal Findings

Actual Findings

Analysis

Inspect

Uniform pink color

Uniform pink color

Normal

Inspect

Uniform pink color; absence of lesions

Uniform pink color; absence of lesions

Normal

Teeth and gums

Inspect

Pink gums; no retraction of gums

Pink gums; no retraction of gums teeth=upper-12 Lower-14 Pink and smooth posterior wall Pink and smooth; no discharge; normal size=Grade 1 (tonsils are behind tonsillar pillars

Not Normal due to improper hygiene Normal

Oropharynx for color and texture Tonsils for color, discharge and size

Inspection

Pink and smooth posterior wall Pink and smooth; no discharge; normal size=Grade 1 (tonsils are behind tonsillar pillars)

Inspection

Normal

Gag Reflex

Pressing posterior tongue with a tongue depressor

Present

Present

Normal

TONGUE

Area Assessed Surface of tongue for position, color, lesions Tongue movement

Technique used

Normal Findings Central position; pink color; absence of lesions Moves Freely

Actual Findings

Analysis

Inspection

Central position; pink color; absence of lesions Moves Freely

Normal

Inspection

Normal

Base of the tongue, mouth floor and frenulum Salivary duct opening for any swelling or redness

Inspection

Smooth tongue base with prominent veins

Smooth tongue base with prominent veins

Normal

Inspection

Same as color of buccal mucosa and floor of mouth

Same as color of buccal mucosa and floor of mouth

Normal

PALATES and UVULA Technique used

Area Assessed Hard and soft palate for color, shape and the presence of bony prominences Uvula for position and mobility

Normal Findings

Actual Findings

Analysis

Inspection

Soft palate=Light pink Hard Palate=Lighter pink Positioned in midline of soft palate NECK

Soft palate=Light pink Hard Palate=Lighter pink

Normal

Inspection

Positioned in midline of soft palate

Normal

Area Assessed Neck muscles for swelling or masses Head movement Lymph nodes Trachea for lateral deviation

Technique used Inspection

Normal Findings

Actual Findings

Analysis

Muscles equal in size Coordinated, smooth movement with no discomforts Not palpable Central placement in midline of neck; spaces are equal in both sides Not visible on inspection Lobes may not e palpated, if palpated, lobed are small, smooth, centrally located, painless and rise freely with swallowing

Muscles equal in size Coordinated, smooth movement with no discomforts Not palpable Central placement in midline of neck; spaces are equal in both sides Not visible on inspection Lobes may not e palpated, if palpated, lobed are small, smooth, centrally located, painless and rise freely with swallowing

Normal

Observation Palpation

Normal Normal

Palpation

Normal

Thyroid Gland

Inspection

Normal

Thyroid gland for smoothness

Palpation

Normal

POSTERIOR THORAX Technique used Inspection

Area Assessed Shape and symmetry of thorax Spinal Alignment for deformities Posterior Thorax Respiratory excursion

Normal Findings 1:2 Anteroposterior to Transverse Spine vertically aligned Skin intact, uniform temperature Full and symmetric chest excursion ANTERIOR THORAX

Actual Findings 1:2 Anteroposterior to Transverse Spine vertically Aligned Skin intact, uniform temperature Full and symmetric chest excursion

Analysis

Normal

Inspection Palpation Palpation

Normal Normal Normal

Area Assessed Breathing Pattern Costal Angle Respiratory Excursion Anterior Chest

Technique used Inspection Inspection Palpation

Normal Findings Quiet, rhythmic and effortless Less than 90o Full, symmetric excursion Bronchovesicular and vesicular breath sounds

Actual Findings Quiet, rhythmic and effortless Less than 90o Full, symmetric excursion Bronchovesicular and vesicular breath sounds

Analysis Normal Normal Normal

Auscultation

Normal

PERIPHERAL VASCULAR SYSTEM Technique used Palpation

Area Assessed Carotid Arteries Peripheral Perfusion (Skin of hands and feet for color, tempt, edema and skin changes) Capillary Refill

Normal Findings Symmetric pulse volume, full pulsations Skin color=pink Skin Tempt=Normal(Not excessively warm or cold) No edema Immediate return of color less than 4 secs

Actual Findings Symmetric pulse volume, full pulsations Skin color=pink Skin Tempt=Normal(Not excessively warm or cold) No edema Immediate return of color less than 2 secs

Analysis Normal

Inspection Palpation

Normal

Blanch Test

Normal

ABDOMEN Technique used Inspection

Area Assessed Symmetry of contour

Normal Findings Symmetric contour

Actual Findings Symmetric contour

Analysis Normal

Skin appearance Abdominal Movements Abdomen for areas of tenderness

Inspection

Smooth, color is the same with color of the body, No spots Symmetric movements caused by respiration No tenderness

Smooth with straie gravidarum and linea nigra; color=tan Symmetric movements caused by respiration No tenderness

Normal due to pregnancy Normal

Observation

Palpation

Normal

MUSCULOSKELETAL Technique used Inspection Inspection Inspection

Area Assessed

Normal Findings Equal size on both sides of the body No tremor No deformities

Actual Findings Equal size on both sides of the body No tremor No deformities

Analysis

Muscle for size Tremors Skeleton for normal Structure and deformities Bones to locate areas of Edema and Tenderness Joints for swelling Joint for tenderness, smoothness of movement, swelling and presence of nodules

Normal Normal Normal

Palpation Inspection

No tenderness or swelling No swelling

No tenderness or swelling No swelling

Normal Normal

Palpation

No tenderness, swelling and nodules, Joints move smoothly

No tenderness, swelling and nodules, Joints move smoothly

Normal

NEUROLOGIC Area Assessed Technique used Normal Findings Able to express self, Able to recognize other persons, awareness of when and where, awareness of who they are; Able to concentrate and recite the alphabet; can count; Able to calculate Glasgow Coma Scale totaling 15 points; Client is alert and oriented Actual Findings Analysis

Language, Orientation, Attention span or calculation

Observation

Can speak clearly; Able to express self; knows time and place; knows basic arithmetic

Normal

Level of consciousness

Glasgow Coma Scale

Glasgow Coma Scale totaling 15 points; Client is alert and oriented

Normal

Glossopharyngeal (Gag reflex)

Light touch

Pain Sensation

Pressing posterior tongue with a tongue depressor Asked client to respond oo or hindi whenever the client feels the cotton wisp touching his skin Asked client to close his eyes and say oo or hindi when the sharp end of the ballpen is felt

Present

Present

Normal

Light tickling or touch sensation

Light tickling or touch sensation

Normal

Can recognize sharp and dull sensations

Can recognize sharp and dull sensations

Normal

LABARATORY RESULTS Urinalysis

Examination Requested: U/A Requesting Physician: Dr. Baggay Date Requested: 07/17/11

Physical Color Transparency Ph Specific gravity Characteristics Albumin

Normal findings Straw yellow to Amber Clear 5-8.5 1.003-1.030 (-)

Actual findings Yellow Hazy 6.0 1.030 +2

Analysis Normal Presence of blood in the urine Normal Normal Increased due to decrease in glomerular filtration Positive due to decrease in glomerular filtration Normal Normal Normal Normal Normal Normal Normal Increased due to decrease in glomerular filtration Normal Normal

Blood

(-)

+3
(-) (-) (-) (-) (-) (-) 2-5 / hpf 5-12 / hpf

Sugar Ketone Bilirubin Urobilinogen Nitrites Leukocytes Microscopic Leukocytes Erythrocytes

(-) (-) (-) (-) (-) (-) 0-5 0-2 4 Few

Squamous epithelial cell Crystal amorphous urates

(+)2 Few

Hematology Report #1
Examination Requested: CBC Requesting Physician: Dr. Baggay Date Requested: 07/17/11 Normal Values Hemoglobin concentration Erythrocyte vol. fraction Erythrocyte # concentration WBC Differential Count F=120-160 g/L F=0-38-0.47 4.50 21.84 Exam. Results 134 .38 4.5-6x109 /L 4.5-11x109 /L Analysis Normal Normal Normal Due to infection

Neutrophiles Lymphocytes Monocytes Eosinophiles Basophiles

89.6 5.0 5.2 0.1 0.1

.35-.65 0.20-0.40 0.02-0.08 0-0.5 0-.01

To aid in the work of WBC To aid in the work of WBC To aid in the work of WBC Normal Decreased due to intake of steroid

ANATOMY AND PHYSIOLOGY OF:

a. Cardiovascular System b. Female Reproductive System c. Urinary System

a. Physiology of the Heart Generates blood pressure Routes blood through the systemic and pulmonary circulation Its pumping action and valves ensure a one-way flow of blood through the heart and blood vessels Helps regulate blood supply to tissues Size, form and location of the heart The heart is approximately the size of the fist and is located at the pericardial cavity

Anatomy of the heart - Pericardium - The pericardial sac consists of a fibrous and serous pericardium. The fibrous pericardium is lined by the parietal pericardium - The outer surface of the heart is line by the visceral pericardium(epicardium) - Between the visceral and parietal pericardium is the pericardial cavity, which is filled with pericardial fluid. - External Anatomy - Atria are separated externally from the ventricles by coronary sulcus. The right and left ventricles are separated externally by the interventricular sulci. - The inferior and superior venacava enter the right atrium. The four pulmonary veins enter the left atrium. - The pulmonary trunk exists the right ventricle. The aorta exist the left ventricle. - Heart Chambers and Internal Anatomy - There are four chambers in the heart. The left and right atria receive blood from veins and function mainly as reservoirs. Contraction of the atria completes ventricular filling. - The atria are separated internally from each other by interatrial septum. - The ventricles are the main pumping chambers of the heart. The right ventricle pumps blood into the pulmonary trunk and the left ventricle, which has a thicker wall, and pumps blood into the aorta. - The ventricles are separated internally by the interventricular septum. - Heart Valves - Ensures one-way flow of blood - The tricuspid valve (three cusps) separates the right atrium and right ventricle, and the bicuspid valve (two cusps) separates the left atrium and left ventricle. - The papillary muscles attach by the chordate tendineae to the cusps of the tricuspid and bicuspid valves and adjust tension on the valves. - The aorta and pulmonary trunk are separated from the ventricles by the semilunar valves - The skeleton of the heart is a plate of fibrous connective tissue that separates the atria from the ventricles, acts as an electrical barrier between atria and ventricles, and supports the valves of the heart - Route of blood flow through the heart - The left and right sides of the heart can be considered separate pumps.

- Blood flows from the systemic vessels to the right atrium and from right atrium to the right ventricle. From the right ventricle blood flows to the pulmonary trunk and from the pulmonary trunks to the lungs. From the lungs, blood flows through the pulmonary veins to the left atrium, and from the left atrium, blood flows to the left ventricle. From the left ventricle, blood flows into the aorta and then through the systemic vessels. - Blood Supply to the Heart - The left and right coronary arteries originate from the base of the aorta and supply the heart. - The left coronary artery has three major branches; the anterior interventricular, the circumflex, and the left marginal arteries. - The right coronary artery has two major branches: the posterior interventricular and the right marginal arteries. - Blood returns from the heart tissue through cardiac veins to the coronary sinus and into the right atrium. Small cardiac veins also return blood directly to the right atrium.

Histology of the Heart Heart Wall - It consists of the epicardium, the middle myocardium, and the inner endocarium Cardiac Muscle - It is striated and depends on ATP for energy. It depends on aerobic metabolism. - Its cells are joined by intercalated disks that allow action potentials to be propagated throughout the heart.

- Regulation of Heart Function Cardiac output (volume of blood pumped per ventricle per minute) is equal to the stroke volume (volume of blood ejected per beat) times the heart rate (beats per minute)

b. External Structures: - Mons Veneris/Pubis - Pad of fat which lies over the symphysis pubis where dark and curly hair grow in triangular shape that begins 1-2 years before the onset of menstruation. It protects the surrounding delicate tissues from trauma. - Majora

Two (2) lengthwise fatty folds of skin extending from mons veneris to the perineum that protect the labia minora, urinary meatus and vaginal orifice. Labia Minora - 2 thinner, lenghtwise folds of hairless skin extending from clitoris to fourchette. Glands in the labia minora lubricates the vulva Very sensitive because of rich nerve supply Space between the labia is called the Vestibule Clitoris - Small, erectile structure at the anterior junction of the labia minora that contains more nerve endings. It is very sensitive to temperature and touch, and secretes a fatty substance called Smegma. It is comparable to the penis in its being extremely sensitive. Vestibule - The flattened smooth surface inside the labia. It encloses the openings of the urethra and vagina. Skenes Glands/Paraurethral Gland - Located just lateral to the urinary meatus on both sides. Secretion helps lubricate the external genital during coitus. Bartholins Gland/Vulvovaginal Glands - Located lateral to the vaginal opening on both sides. It lubricates the external vulva during coitus and the alkaline pH of their secretion helps to improve sperm survival in the vagina. Fourchette - Thin fold of tissue formed by the merging of the labia majora and labia minora below the vaginal orifice. Perineum - Muscular, skin-covered space between the vaginal opening and the anus. It is easily stretched during childbirth to allow enlargement of vagina and passage of the fetal head. It contains the muscles (pubococcygeal and levator ani) which support the pelvic organs, the arteries that supply blood and the pudendal nerves which are important during delivery under anesthesia. Urethral meatus - External opening of the urethra. It contains the openings of the Skenes glands which are often involved in the infections of the external genitalia. Vaginal Orifice/Introitus - External opening of the vagina, covered by a thin membrane called Hymen.

Internal Structures: - Fallopian tube/Oviduct - 4 inches long from each side of the uterus (fundus). It transports the mature ova form the ovaries to the uterus and provide a place for fertilization of the ova by the sperm in its outer 3rd or outer half. Parts: Interstitial lies within the uterine wall Isthmus portion that is cut or sealed in a tubal ligation. Ampulla widest, longest portion that spreads into fingerlike projections/fimbriae and it is where fertilization usually occurs. Infundibulum - rim of the funnel covered by fimbriated cells (hair covered fingerlike projections) that help to guide the ova into the fallopian tube. - Ovaries - Oval, almond sized, dull white sex glands on either side of the uterus that measures 4 by 2 cm in diameter and 1.5 cm thick. It is responsible for the production, maturation and discharge of ova and secretion of estrogen and progesterone. - Uterus - Hollow, pear-shaped muscular organ, 3 inches long, 2 inches wide, weighing 50-60 grams held in place by broad and round ligaments and abundant blood supply from

the uterine and ovarian arteries. It is located in the lower pelvis, posterior to the bladder and anterior to the rectum. Organ of menstruation, site of implantation and provide nourishment to the products of conception. Layers: Perimetrium - Outermost layer of the uterus comprised of connective tissue, it offers added strength and support to the structure. Myometrium - Middle layer, comprised of smooth muscles running in 3 directions; expels fetus during birth process then contracts around blood vessels to prevent hemorrhage. Endometrium - Inner layer which is visibly vascular and is shed during menstruation and following delivery.

Divisions of the Uterus: Fundus Upper rounded, dome-shaped portion that can be palpated to determine uterine growth during pregnancy and the force of contractions and for the assessment that the uterus is returning to its non-pregnant state following child birth.

Corpus - Body of the uterus. Isthmus - Area between corpus and cervix which forms part of the lower uterine segment. It enlarges greatly to aid in accommodating the fetus. The portion that is cut when a fetus is delivered by a caesarian section. Cervix - Lower cylindrical portion that represents 1/3 of the total uterus. Half of it lies above the vagina; half of it extends to the vagina. The cavity is termed the cervical canal. It has 2 openings/Os: internal os that open to the uterine cavity and the external os that opens to the vagina. Vagina - A 3-4 inch long dilatable canal located between the bladder and the rectum, it contains reggae which permits considerable stretching without tearing. It acts as an organ of intercourse/copulation and passageway for menstrual discharges and fetus. Doderleins bacillus is the normal flora of the vagina which makes the pH of vagina acidic, detrimental to the growth of pathologic bacteria.

c. Kidneys The kidneys are two brownish, bean shaped organs about the size of a fist, and they weigh about 5 ounces. They are located in the upper right and left back part of the abdominal cavity. Each kidney contains about 1,200,000 microscopic filters called nephrons. Nephrons are smaller than the smaller dots. Its main function to maintain the water balance and to eliminate waste materials from the blood. Ureters The left and the right ureters are long muscular tubes. They are about 12 inches long with a diameter 2 to 3 millimeters.

Connects pelvis of each kidney to urinary bladder. They carry urine from each kidney to the urinary bladder. Urinary Bladder The urinary bladder is a muscular sac that holds urine. It is located in front the pelvis and behind the pubis. As the bladder fills walls stretch signaling the desire to urinate. Urethra The urethra is a muscular tube which carries urine from the bladder to the outside part of the body. In the female, it is a one inch long from the bladder to the cleft of the labia. In the male, it is several inches long from the prostate gland to the penis. When one is about to urinate, a value in the urethra relaxes to allow the urine to flow out.

Mechanism: Glomerulus Each nephron is composed of a glomerulus. The glomerulus is surrounded by hollow capsule known as Bowman s capsule. The capillaries in the glomerulus filter the waste materials of the blood except protein and the cells. Filtered Fluid The filtered fluid enters the Bowman s capsule, where it flow down through its twisted tubes. The walls of the tubes absorb back in to the blood the needed water and blood chemicals. Pathway of Unwanted Chemicals o Unwanted chemicals are discharged. The unwanted chemicals are the waste products. They come out in the form of urine. The urine passes into the ureter and on to the urinary bladder. And the urethra which releases it to the outside of the body. Urine gives valuable clues to the body. Sugar in the urine is an indication of diabetes. Albumin may signify that the kidneys are not functioning properly.

DRUG STUDY
Dexamethasone Dose: 6mg IM Classification: Hormones and synthetic substitutes, adrenal corticosteroid; glucocorticoid; steroid Action: Long acting synthetic acetic adrenocorticoid with intense anti-inflammatory activity and minimal mineralocorticoid activity. Anti-inflammatory action-prevents accumulation of inflammatory cells at site of infection; Immunosuppression-not clearly understood but may be due to prevention or suppression of delayed hypersensitivity immune reaction. Therapeutic effects Drug has anti-inflammatory and immunosuppression properties Uses:

Adrenal insufficiency, concomitantly with mineralocorticoid; inflammatory conditions, allergic states, collagen diseases, hematologic disorders, cerebral edema and Addisonian shock. Also palliative treatment of neoplastic disease, as adjunctive short-term therapy in acute rheumatic disorders and GI diseases, and as a diagnostic test for Cushings syndrome and for differential diagnosis of adrenal hyperplasia and adrenal adenoma.

Containdications: Systemic fungal infection, acute infections, active or resting tuberculosis, varicella, vaccinia, administration of live virus vaccines (to patient, family members), latent or active amebiasis Adverse Effects: Aerosol therapy- nasal irritation, dryness, epistaxis, rebound congestion, bronchial asthma, anosomia, perforation of nasal septum CNS-euphoria, insomnia, convulsions, increase icp, vertigo, headache, psychic disturbances CV-CHF, hypertension, edema Endocrine-menstrual irregularities, hyperglycemia; Cushingoid state; growth suppression in children, hirsutism Musculoskeletal-muscle weakness, loss of muscle mass, vertebral compression fracture, pathologic fracture of long bones, tendon rupture Skin-acne, impaired wound healing, petechiae, ecchymoses, diaphoresis, allergic dermatitis, hypo/hyperpigmentation, SC and cutaneous atrophy, burning and tingling in perineal area (following IV injection) Nursing Implications: Monitor and report signs and symptoms of Cushings syndrome or other systemic adverse effects Monitor neonates born to a mother who has been receiving a corticosteroid during pregnancy for symptoms of hypoadrenocorticism Monitor for signs and symptoms of hypersensitivy reactions Patient and family education Take drug exactly as prescribed Report lack of response to medication or malaise, orthostatic hypotension, muscular weakness and pain, nausea, vomiting, anorexia; hypoglycemic reactions or mental depression to physician. These symptoms may signal hypoadrenocorticism. Report changes in appearance and easy bruising to physician. These symptoms may signal hypoadrenocorticism. Note: hiccups that occur for several hours following each dose may be a complication of high dose oral Dexamethasone

Keep appointments for check-ups; make sure electrolytes and BP are evaluated during therapy at regular intervals Add Potassium-rich foods to diet; report signs of hypokalemia. Concomitant potassiumdepleting diuretic can enhance Dexamethasone-induced potassium loss Note: Dexamethasone doses regimen may need to be altered during stress. Consult physician if change in living or working environment is anticipated. Discontinue drug gradually under the guidance of the physician. Note: it is important to prevent exposure to infection, trauma and sudden changes in environmental factors because drug is an immunosuppresor. Do not breastfeed while taking this drug without consulting physician.

Magnesium Sulfate Dose: 5g deep IM every six hours times 24 hours Classification: Gastrointestinal agent; saline cathartic; replacement agent; anticonvulsant Actions: Orally: acts as a laxative by osmotic retention of fluid, which distends colon, increases water content of feces, and causes mechanical stimulation of bowel activity. Parenterally: acts as a CNS depressant and depressant of smooth, skeletal and cardiac muscle function. Therapeutic Effects: Effective parenterally as a CNS depressant, smooth muscle relaxant and anticonvulsant in labor and delivery, and cardiac disorders. It is a laxative when taken orally. Uses:

Orally to relieve acute constipation and to evacuate bowel in preparation for x-ray of intestines Parenterally to control seizures in toxemia in pregnancy, epilepsy, and acute nephritis and for prophylaxis and treatment of hypomagnesemia. Topically to reduce edema, inflammation, and itching.

Contraindication: Myocardial damage; heart block; cardiac arrest except for certain arrhythmias; IV administration during the 2h preceding the delivery; PO use in patient with abdominal pain, nausea, vomiting, fetal impaction, or intestinal irritation, obstruction, perforation. Adverse effects: Body as a whole: flushing, sweating, extreme thirst, sedation, confusion, depressed or no reflexes, muscle weakness, flaccid paralysis, hypothermia. Cardiovascular: hypotension, depressed cardiac function, complete heart block, circulatory collapse. Respiratory: respiratory paralysis. Metabolic: hypermagnesemia, hypocalcemia, dehydration, electrolyte imbalance including hypocalcemia with reapeated laxative use. Nursing Implications: Observe constantly when given IV. Check BP and pulse every 10 to 15 minutes or more often if indicated. Lab tests: monitor plasma magnesium level in patients receiving drug parenterally. Plasma levels in excess of 4meqs/ L are reflected in depressed deep tendon reflexes and other symptoms of magnesium intoxication. Cardiac arrest occurs at levels in excess of 25 meqs/L. Monitor calcium and phosphorus levels also.

Early indicators of magnesium toxicity (hypermagnesemia) include cathartic effect, profound of thirst, feeling of warmth, sedation, confusion, depressed deep tendon reflexes, and muscle weakness. Monitor respiratory rate closely. Report immediately if rate falls below 12. Test patellar reflex before each repeated parenteral dose. Depression or absence of reflexes is a useful index of magnesium intoxication. Check urinary output, especially in patients with impaired kidney function. Therapy is generally not continued if urinary output is less than 100mL during the 4h preceding each dose. Observe patients receiving drug for hypomagnesemia for improvement in these signs of deficiency. Irritability, choreiform movements, tremors, tetany, twitching, muscle cramps, tachycardia, hypertension, psychotic behavior.

Patient and Family Education Drink sufficient water during the day when the drug is administered orally to prevent net loss of water. Recommended daily allowances of magnesium and obtain in a normal diet period. Rich sources are whole-grain cereals, legumes, nuts, milk, most green leafy vegetables and bananas. Do not breastfeed while taking the drug without consulting the physician.

Methyldopa Dose: 500mg every eight hours Classification: Cardiovascular agent; central-acting antihypertensive; autonomic nervous system agent; alpha-adrenergist antagonist (sympathomimetic).

Actions: Structurally related to catecholamines and their precursors. Has weak neurotransmitter properties; inhibits decarboxylation of Dopa, thereby reducing concentration of Dopamine, a precursor of norepinephrine. It also inhibits the precursor of serotonin.

Therapeutic Effects: Lowers standing and supine BP, and unlike adrenergic blockers, it is not prone to produce orthostatic hypotension, diurnal BP variations, or exercise hyperytension. Reduces renalvascular resistance; maintains cardiac output without acceleration, but may slow heart rate; tends to support sodium and water retention. Uses:

Treatment of sustained moderate to severe hypertension , particularly in patients with kidney dysfunction. Also used in selected patients with carcinoid disease. Parenteral form has been used for treatment of hypertensive crises but is not preferred because of its slow onset of action.

Contraindications: Active liver disease (hepatitis, cirrhosis) ; pheochoromocytoma; blood dyscrasias. Safety during pregnancy (category C) is not established. Cautious Use: History is impaired liver or kidney function or disease; angina pectoris; history of mental depression; lactation; young or older adult patients. Adverse Effect:

Body as a Whole: hypertensive (fever skin eruptions, ulceration of soles of feet , flu like symptoms, lymphadenophaty, eosinophilia) CNS: Sedation, drowsiness, sluggishness, headache, weakness, fatigue, dizziness, vertigo, decrease in mental acuity, inability to concentrate, amnesia like syndrome, parkinsonism, mild psychoses, depression, nightmares. CV: orthostatic hypotension, syncope, bradycardia , myocarditis, edema, weight gain ( sodium and water retention) paradoxic hypertensive reaction (especially in IV administration) GI: diarrhea, constipation, abdominal distension, malabsorption syndrome, nausea, vomiting, dry mouth, sore or black tongue, sialadenitis, abnormal liver function test, jaundice, hepatitis, hepatic necrosis (rare). Hematalogic: Positive direct Coombs test (common especially in African Americans), granulocytopenia. Special senses: nasal stuffiness. Endocrine: gynecomastia, lactation, decreased libido, impotence, hypothermia (large dosesp), positive test for lupus and rheumatoid factors. Skin: granulomatous skin lesions.

NURSING IMPLICATIONS Assessment of Drug Effects Check BP and pulse at least q30minutes until stabilized during IV infusion and observer for adequacy and urinary output. Take BP taken at regular intervals in lying, sitting, and standing positions during period of dosage adjustment if physician requests. Be aware that transient sedation, drowsiness, mental depression, weakness and headaches commonly occur during first 24-72h of therapy or whenever dosage is increased. Symptoms tend to disappear with continuation of therapy or dosage reduction. Supervision of ambulation in older adults and patients with impaired kidney function; both are particularly likely to manifest orthostatic hypothension with dizziness and lightheadedness during period of dosage adjustment. Monitor fluid and electrolyte balance and I and O. report oliguria and changes I and O ratio. Weight patient daily, and check for edema because methyldopa favors sodium and water retention. Lab test: scheduled baseline and periodic blood counts and liver function test especially during first 6-12 weeks of therapy or if patient develops unexplained fever; periodic serum electrolytes. Be alert to and report symptoms of mental depression (e.g., anorexia, insomnia, inattention to personal hygiene, withdrawal). Drug-induced depression may persist after drug is withdrawn. Be alert that rising BP indicating tolerance to drug effect may occur during week 2 or 3 of therapy.

Patient and Family Education Exercise caution with hot baths and shower, prolonged standing in one position , and strenuous exercise that may enhanced orsthostatic hypotension. Make position changes slowly, particularly from lying down to upright posture; dangle legs a few minutes before standing. Avoid potentianally hazardous task such as driving until response to drug is known; drug may affect ability to perform activities required concentrated mental effort, especially during first few days of therapy or whenever dosage is increased. Do not to take OTC medications unless approved by physician. Do not breast feed while taking this drug without consulting a physician.

Multivitamins Dose: 1 capsule Classification: Vitamins

Indications: Tretment and prevention of vitamin deficiencies Actions: Prevention of deficiency or replacement in patients whose nutritional status is questionable Contraindications: Hypersensitivity to preservatives, colorants or additives Adverse effects: Allergic reactions to preservatives, colorants, or additives Nursing considerations: Assess patient for signs of nutrition deficiency prior to and throughout therapy. Instruct to notify side effects of medications to physician. Encourage to comply on medications. Encourage patient to comply with physicians recommendations. Explain the best source of vitamins is a well balanced diet with foods in the four basic food groups.

Ascorbic acid (Vitamin C) Dose: 1 tab Classification: Vitamin Action: Water soluble vitamin essential for synthesis and maintenance of collagen and intercellular ground substance of body tissue cells, blood vessel, cartilages, bones, teeth, skin, and tendons. Unlike most mammals, humans are unable to synthesize ascorbic acid in the body; therefore it must be consumed daily. Therapeutic effect: Increases protection mechanism of the immune system, thus supporting wound healing. Necessary for wound healing and resistance to wound healing Uses:

Prophylaxis and treatment of scurvy and as a dietary supplement.

Contraindication: Use of sodium ascorbate in patients on sodium restriction; use of calcium ascorbate in patient receiving digitalis. Safety during pregnancy (category C) or lactation is not established Adverse effects: GI- nausea, vomiting, heart burn, diarrhea or abdominal cramps Hematologic-acute hemolytic anemia, sickle-cell crisis CNS-headache or insomnia Urogenital-urethritis, dysuria, crystaluria, hyperoxaluria, hyperurecemia Other-mild soreness at the injection site, dizziness and temporary faintness with rapid IV administration

Nursing Implications: Lab Test: Periodic HCT and HGB serum electrolytes Monitor for signs and symptoms of acute hemolytic anemia High doses of Vitamin C are not recommended during pregnancy Take large doses of Vitamin C in divided amounts because the body uses only what is needed at a particular time and excretes the rest in urine Megadoses can interfere with the absorption of Vitamin B12 Note: Vitamin C increases the absorption of Iron when taken at the same time as iron-rich foods Do not breastfeed while taking this drug without consulting physician