I.

Introduction
Pregnancy induced hypertension is a condition which effects many women
in the world. This is true even for those expecting mothers in the Philippines. Studies of
preeclampsia report about 5 percent of nulliparous women develop preeclampsia and
40 to 50 percent of these women develop severe disease worldwide. In the Philippines,
according to Department of Health, Maternal Mortality Rate (MMR) is 162 out of 10,000
live births (Family Planning Survey 2006). Maternal deaths account for 14% of deaths
among women. For the past five years all of the causes of maternal deaths exhibited an
upward trend. Preeclampsia showed an increasing trend of 6.89%; 20%; 40%; and
100%. Ten women die every day in the Philippines from pregnancy and childbirth
related causes but for every mother who dies, roughly 20 more suffer serious disease
and disability. The UNFPA office in the Philippines declared that family planning can
help prevent maternal deaths by 35%.

II. Statement of Objectives
General Objectives
After 2 weeks of providing effective and efficient care and nurse-patient
interaction, the patient will be able to cite specific ways to reach optimum level of
wellness appropriate for patient's individualized situation and perform necessary lifestyle
modifications to accomplish optimum level of wellness.
Specific Objectives
Nurse
After 2 weeks of providing holistic care, the nurse will be able to:
1. Establish rapport and interact with the patient,
2. Obtain nursing history important to patient's case,
3. Perform a thorough physical assessment of the patients present
condition,
4. Identify subjective and objective problems of the patient,
5. Detected abnormalities from the assessment and results of diagnostic
examinations and reported.
6. Identify nursing diagnoses pertinent to patient's situation
7. Implement a comprehensive plan of care needed for a post-operative
patient, and
8. Evaluate the interventions provided in the given span of time for efficiency
and effectiveness.
9. Improve and modify nursing care plan according to patients needs after
evaluation

Patient and SO
After 2 days of receiving holistic care and participating in nurses-patient
interaction, the patient and significant others will be able to:
1. Establish trust towards the nurse,
2. Cooperate in procedures performed by the nurses to the patient for
management and treatment, such as wound dressing, vital signs
monitoring and taking in of medications,
3. Participate with the nurse in activities aimed at the patients holistic well
being, such as in a health teaching
4. Demonstrate proper wound care,
5. Demonstrate proper ROM exercises,
6. Comply with the physicians recommendations on his course of treatment

III. Patient's Profile
General Data
A case of A.R., 47 years old, Filipino, catholic, a resident of Inayagan, City
of Naga, Cebu who was admitted last 06/03/2013 with a final diagnosis of G8P8
Pregnancy uterine delivered cephalic, term livebirth via NSD, severe preeclampsia,
grand multiparity.
Name of Patient : A.R.
Age : 47 years old
Sex : Female
Address : Inayagan, City of Naga, Cebu
Civil Status : Married
Nationality : Filipino
Religion : Catholic
Occupation : Housekeeper
Weight : 60 kg
Height : 50
Date of Admission : 06/03/13
Date of Discharge : 06/08/13

Vital Signs
Date Taken : 06/04/13
Time Taken : 1:50 P.M.
Temperature : 36.7 C
Pulse Rate : 96 bpm
Respiratory Rate : 35 cpm
Blood Pressure : 150/100 mm/Hg

Gordon's Functional Health Pattern
Health Perception and Health Maintenance

Client described her general state of health to be excellent before she had been
hospitalized. She described health as an important aspect of life so that we can go on
living. If she would experience minor illnesses, she would immediately rest and sleep.
She claimed that she is takes medications during her pregnancy.

Client claimed that she had no heredo-familial disease. She is non-asthmatic,
non-diabetic and not a known hypertensive. She had no food allergy. She doesn't
smoke cigarrettes and doesn't drink caffeinated or alcoholic beverages. She seeks
prenatal check-up and does take the prescribe vitamin supplements.

Client explained that she is living in a non-congested and quiet, calm
neighborhood. Her place is a rural area with lots of neighbors. Her house is made up of
mixed materials.
She stated that she likes his house because it is clean and well-kept.

Nutrition and Metabolism

Client 51 tall and weighs 128 lbs. She claimed that she does not feel good
about her weight. She said, Dako ra jud kaayo ko pag buntis nako.

Client eats 3-4 times of full meal a day. She occasionally takes her snacks mid-
afternoon. Her usual diet would consist of rice with meat (pork or beef), fish, egg,
vegetables. She said that she prefers to eat meat and fish, vegetables and eggs. She
can consume about kilo of meat and about 2 pieces of fish a day. She said, Lami
man gud naa utan, isda ug itlog kay pakapagana sa kaon. She is not fond of eating
sweets and vegetables and fruits. Client drinks about 6-8 glasses of water a day. She
added that she does not have any discomfort in eating or swallowing.
Upon hospitalization, the client is placed on diet as tolerated.

Elimination

Client voids 8-9 times a day with clear, amber-yellow-colored urine amounting
about 40-60 cc per void. She claimed that she has no difficulty or discomfort in
urinating. She had no experienced urination at nighttime.

Client defecates 1-2 times a day usually in the morning after breakfast and in the
afternoon. She defecates brown- to dark brown-colored, well-formed stools. She
claimed that when she feels the urge to defecate, she would go to the toilet right away.
She added that she has no problem with defecation.

Upon hospitalization, the client was advised to urinate or defecate at the comfort
room with assistance. She said, Dili ayo ko ka tarong og libang kay wala ko na anad
malibang dili sa amoa Client defecates once a day since the time of admission.

Activity and Exercise

Client had been a housewife for years. Her usual daily routine would include
bathing, toileting, washing clothes, and cleaning the house. She verbalized that she had
not experienced any discomfort when performing his activities of daily living. Her
exercise is only walking and doing chores. She spends his wee hours by watching
television or listening to the radio. She consumes his time talking with his friends.

Cognition and Perception

Clients highest educational attainment is high school level. She graduated as an
ordinary student. She said that she had not continued her education because of
financial reason. Her parents cannot afford to continue her education. She can
communicate and understand well. She knows and understands Cebuano and Tagalog.
She admitted that she has a hard time comprehending English. She can read
newspaper. She knows how to follow simple instructions and has a good memory.

Client verbalized that she has no problems in hearing and seeing. She said,
Nindot pa akong pang dungog og panan-aw. Dili pa ko hap-hap. She added that she
has a good sense of taste.

Sleep and Rest

Client sleeps 7-9 hours everyday including nap time. She sleeps at around 10
PM and wakes up at around 5 AM. She takes her nap in the afternoon, usually from 2
PM to 4 PM. She claimed that she had no problem in sleeping and does not practice
bedtime ritual. She claimed that she can achieve an adequate sleep.

In the hospital, the client complaint of having a hard time sleeping because of the
noise, the congested and dirty environment and the frequent monitoring of the hospital
staff and personnel. She claimed that she can hardly sleep. She said, Dili jud ayo ko
katarong og katulog diri sa hospital.

Sexuality and Reproduction

Client had her menarche at the age of 12. . Client had her first sexual contact
with a boyfriend at age 18. She claimed that she is sexually active. Her last sexual
contact was with her husband. She claimed that she does not experience any
discomfort during sexual activity.





Self-Perception and Self-Concept

Client described herself to be independent, optimistic, friendly, caring, thoughtful
and patient. According to her, she used to be a supportive and understanding daughter,
a responsible and loving mother of her child. To her neighbor, the client claimed that
she is an accommodating host in every occasion in her house. She enjoys hanging out
with her neighbors.

Roles and Relationship

Client is the fifth child among the 8 children. She has 3 brother and 4 sisters. Her
siblings are living with their own family. She claimed that she has remained in contact
with her siblings. She often gets to see them especially during a celebration.

Stress Tolerance and Coping

Client mentioned that, in order to ease his stressful situations, she prays, watch
television and talks with her friends. Client stated that she had not experienced any
major problems recently. She always views her family as her strength when she is faced
with a problem. She resolves stressors immediately by talking to her parents or siblings.
She seldom talks to his friends for any concerns. She stated, Mas maayo jud ma storya
nako akong gibati.

Values and Belief

Client does not believe in superstitions. She explained she rarely goes to church
because it is far from his place. She prays in a nearby chapel every Sunday. She
verbalized that she has a strong faith in God.




IV. Pathophysiology
Anatomy and Physiology
The female reproductive
system consists of the
ovaries, uterine tubes (or
fallopian tubes), uterus,
vagina, external genitalia,
and mammary glands. The
internal reproductive organs
of the female are located
within the pelvis, between the
urinary bladder and the
rectum. The uterus and the
vagina are in the midline ,
with an ovary to each side of
the organ. The internal
reproductive organs are held
in place within the pelvis with
ligaments. The most conspicuous is the brad ligament, which spreads out on both sides
of the uterus and to which the ovaries and the uterine tubes attach.
Ovaries
The two ovaries are small organs suspended in the pelvic cavity by ligaments. The
suspensory ligament extends from each ovary to the
lateral body wall, and the ovarian ligament attaches
the ovary to the superior margin of the uterus.
A layer of visceral peritoneum covers the
surface of the ovary. The outer part of the ovary is
made up of dense connective tissue and contains
the ovarian follicles. Each of the ovarian follicles
contains an oocyte, the female sex cell. Loose
connective tissue makes up the inner part of the ovary, where blood vessels, lymphatic
vessels, and nerves are located.

Uterine Tubes
A uterine tube, fallopian tube, or oviduct (named after the italian anatomist, Gabriele
Fallopio) is associated with each ovary. The uterine tubes extend from the area of the
ovaries to the uterus. The open directly into the peritoneal cavity near each ovary and
receive an oocyte. The opening of each uterine tube is surrounded by long, thin
processes called fimbriae.
The fimbriae nearly surround the surface of the ovary. As a result, as soon as the
oocyte is ovulated, it comes into contact with the surface of the fimbriae. Cilia on the
fimbriae surface sweep the oocyte into the uterine tube. Fertilization usually occurs in
the part of the uterine tube near the ovary known as the ampulla.
Uterus
The uterus is as big as the size of a medium-sized pear. It is oriented in the pelvic cavity
with the larger, rounded portion directed superiorly. The part of the uterus superior to
the entrance of the fallopian tubes is called the fundus. The main part of the uterus is
called the body, and the narrower part is termed the cervix and is directed inferiorly.
Internally, the uterine cavity in the fundus and uterine body continues through the cervix
as the cervical canal, which opens into the vagina. The cervical canal is lined by
mucous glands.
The uterus is supported by the broad ligament and the round ligament. In addition to
these ligaments that support the uterus, much support is provided inferiorly to the uterus
by skeletal muscles of the pelvic floor. If ligaments that support the uterus or the
muscles of the pelvic floor are weakened such as in childbirth, the uterus can extend
inferiorly into the vagina, a condition termed as a prolapsed uterus. Severe cases
require surgical correction.
Vagina
The vagina is the female organ of copulation and functions to receive the penis during
intercourse. It also allows menstrual flow and childbirth. The vagina extends from the
uterus to outside the body. The superior portion of the vagina is attached to the sides of
the cervix so that a part of the cervix extends into the vagina.
The mucous membrane is moist stratified squamous epithelium that forms a protective
surface layer. Lubricating fluid passes through the vaginal epithelium into the vagina.
In young females, the vaginal opening is covered by a thin mucous membrane known
as the hymen. The hymen can completely close the vaginal orifice in which case it must
be removed to allow menstrual flow. More commonly, the hymen is perforated by one or
several holes. The openings of the hymen are usually greatly enlarged during the first
sexual intercourse. The hymen can also be perforated during a variety of activities
including strenuous exercise. The condition of the hymen is therefore not a reliable
indicator of virginity.
The External Genitalia
The external female genitalia, also called the vulva, or pudendum, consists of the
vestibule and its surrounding structures. The vestibule is the space into which the
vagina and urethra open. The urethra opens just anterior to the vagina. The vestibule is
bordered by a pair of thin, longitudinal skin folds called the labia minora. A small erectile
structure called the clitoris is located in the anterior margin of the vestibule. The two
labia minora unite over the clitoris to form a fold of skin known as the prepuce.
The clitoris consists of a shaft and a distal glans. Like the glans penis, the clitoris is well
supplied with sensory receptors, and it is made up of erectile tissue. An additional
erectile tissue is located on either side of the vaginal opening.
On each side of the vestibule, between the vaginal opening and the labia minora, are
openings of the greater vestibular glands. These glands produce a lubricating fluid that
helps maintin the moistness of the vestibule.
Lateral to the labia minor are two prominent rounded folds of skin called the labia
majora. The two labia majora unite anteriorly at the elevation of tissue over thepubic
symphysis calle dthe mons pubis. The lateral surfaces of the labia majora and the
surface of the mons pubis are covered with coarse hair. The medial
surfaces of the labia minora are covered with numerous sebaceous and sweat glands.
The space between the labia minor is called the pudendal cleft. Most of the time, the
labia minora are in contact with each other across the midline , closing the pudendal
cleft and covering the deeper structures within the vestibule.
The region between the vagina and the anus is the clinical perineum. The skin and
muscle of this region can tear during childbirth. To preven such tearing, an incision
called an episiotomy is sometimes made in the clinical perineum. Traditionally, this
clean, straight incision is thought to result in less injury, and less trouble in healing, and
less pain. However, many studies indicate that there is less injury and pain when no
episiotomy is performed.
Mammary Glands
Mammary glands are located inside the breasts of sexually mature female body. They
are in actuality modified sweat glands which are in fact comprised of secretory
mammary alveoli and the appropriate ducts. Mammary glands are considered to be part
of the integumentary system rather than the reproductive system. The glands are
associated with the female reproductive system in part due to their assistance in
attracting a mate as well as their role in nourishing a baby. Size and shape of the
female breast are different for every human body and factors such as race, age, body
fat, and pregnancy can make a large difference in these variations.
The release of estrogen during puberty releases hormones that stimulate the growth of
the breasts and the functions of the mammary glands. Pregnant women as well as
nursing women experience hypotrophy of the breasts while it is not uncommon for
atrophy of the breasts to occur after menopause.
Adipose tissue in varying amounts segregates each lobe. While this tissue controls the
size and shape that the breast takes, there is no determination by this tissue when it
comes to the womans ability to suckle her young. Lobules are subdivisions of each
lobe. These subdivisions contain mammary alveoli. The milk of a lactating female are
produced within the mammary alveoli. Suspensory ligaments support the breasts which
are attached between the lobules and run deep into the fascia which overlap the
pectoral muscles. Breast milk is secreted into a network of mammary ducts which
receive the milk from the clusters of mammary alveoli. These mammary ducts converge
to form lactiferous ducts. Near the nipple, each lactiferous duct expands into the lumen
to allow for outward flow of milk. The lactiferous sinuses store the milk before the
suckling action, or additional pressure, releases it from the body. The milk leaves the
body from the tip of the nipple.
The nipple contains some erectile tissue that protrudes into a cylindrical projection. The
circular area around the nipple that contrasts in color is the areola. Sebaceous areola
glands create a bumpy surface around the areola which resides just under the surface
of the areolas skin. These glands secrete fluids during lactation as well as when a
woman is not lactating, which keep the nipple supple. The complexion of the areola is
based on the complexion of the skin that covers the rest of the body, varying in
pigments and tints. During gestation most areola surfaces darken. It also becomes
larger in most cases. This is thought to be more obvious for a nursing infant to find.
Branches of the internal thoracic artery are responsible for supplying blood flow to the
nipple as well as the rest of the breast and mammary glands. Between the second,
third, and forth intercoastal spaces these braches of the thoracic artery enter the
mammary glands. These spaces are positioned laterally to the sternum and offer entry
to the mammary artery, which only supplies supportive blood. The return veins run
alongside the initial arteries which supply the blood. During pregnancy and lactation,
and sometimes during other periods, a superficial venous plexus can be seen through
the surface of the skin.
The fourth, fifth, and sixth thoracic nerves innervate the breast principally through
sensory somatic neurons. These neurons are derivative of the anterior and lateral
branches of the thoracic nerves. The release of milk is dependant upon the sensory
innervations as stimulus is the only natural release an infant can provide to be
nourished.
Fertilization and Pregnancy
If a female and male have sex within several days of the female's ovulation (egg
release), fertilization can occur. When the male ejaculates (which is when semen leaves
a man's penis), between 0.05 and 0.2 fluid ounces (1.5 to 6.0 milliliters) of semen is
deposited into the vagina. Between 75 and 900 million sperm are in this small amount of
semen, and they "swim" up from the vagina through the cervix and uterus to meet the
egg in the fallopian tube. It takes only one sperm to fertilize the egg.
About a week after the sperm fertilizes the egg, the fertilized egg (zygote) has become a
multi-celled blastocyst (pronounced: blas-tuh-sist). A blastocyst is about the size of a
pinhead, and it's a hollow ball of cells with fluid inside. The blastocyst burrows itself into
the lining of the uterus, called the endometrium (pronounced: en-doh-mee-tree-um).
The hormone estrogen causes the endometrium to become thick and rich with blood.
Progesterone, another hormone released by the ovaries, keeps the endometrium thick
with blood so that the blastocyst can attach to the uterus and absorb nutrients from it.
This process is called implantation (pronounced: im-plan-tay-shun).
As cells from the blastocyst take in nourishment, another stage of development, the
embryonic stage, begins. The inner cells form a flattened circular shape called the
embryonic disk, which will develop into a baby. The outer cells become thin membranes
that form around the baby. The cells multiply thousands of times and move to new
positions to eventually become the embryo (pronounced: em-bree-o). After
approximately 8 weeks, the embryo is about the size of an adult's thumb, but almost all
of its parts the brain and nerves, the heart and blood, the stomach and intestines,
and the muscles and skin have formed.
During the fetal stage, which lasts from 9 weeks after fertilization to birth, development
continues as cells multiply, move, and change. The fetus (pronounced: fee-tus) floats in
amniotic (pronounced: am-nee-ah-tik) fluid inside the amniotic sac. The fetus receives
oxygen and nourishment from the mother's blood via the placenta (pronounced: pluh-
sen-tuh), a disk-like structure that sticks to the inner lining of the uterus and
connects to the fetus via the umbilical (pronounced: um-bih-lih-kul) cord. The amniotic
fluid and membrane cushion the fetus against bumps and jolts to the mother's body.
Pregnancy lasts an average of 280 days about 9 months. When the baby is ready for
birth, its head presses on the cervix, which begins to relax and widen to get ready for
the baby to pass into and through the vagina. The mucus that has formed a plug in the
cervix loosens, and with amniotic fluid, comes out through the vagina when the mother's
water breaks.
When the contractions of labor begin, the walls of the uterus contract as they are
stimulated by the pituitary hormone oxytocin (pronounced: ahk-see-toh-sin). The
contractions cause the cervix to widen and begin to open. After several hours of this
widening, the cervix is dilated (opened) enough for the baby to come through. The baby
is pushed out of the uterus, through the cervix, and along the birth canal. The baby's
head usually comes first; the umbilical cord comes out with the baby and is cut after the
baby is delivered.
The last stage of the birth process involves the delivery of the placenta, which is now
called the afterbirth. After it has separated from the inner lining of the uterus,
contractions of the uterus push it out, along with its membranes and fluids.
Pathophysiology
Women with preeclampsia have abnormal blood vessels feeding the placenta,
although the exact cause of this abnormality is not known. There are no tests that can
reliably predict who will get preeclampsia, and there is no way to prevent it.
Predisposing Factors:
- Age
- Race
- Primipara
- Family history of pre-eclampsia
Precipitating factors:
- Diet and nutrition
- Multiple gestation
- Previous pre-eclampsia
- H-mole
- Pre-existing history to hypertension
- Renal disease
- Diabetes
- Connective tissue diseases
- Obesity v
Theories concerning the causes of PIH
- Uterine Stretch Theory- Uterine stretch causing vasoconstriction and producing
ischemia
- Altered Vascular Activity due to pregnancy- decreased glomerular filtration rate
with retention of salt and water
- Natural Hypertensive Process- diet and/or presence of co-morbid pre-existing
conditions






vasospasm vasocontriction
Predisposing Factors Precipitating Factors Etiology: UNKNOWN
vasocontriction vasospasm Endothelial damage
Predisposing Factors Precipitating Factors Etiology: UNKNOWN
vasocontriction vasospasm Endothelial damage
Precipitating Factors
Endothelial damage
Predisposing Factors Etiology: UNKNOWN Precipitating Factors
vasocontriction vasospasm Endothelial damage
Predisposing Factors Etiology: UNKNOWN Precipitating Factors
vasocontriction vasospasm Endothelial damage
Predisposing Factors Etiology: UNKNOWN


























Decreased placental
perfusion
Uteroplacental
areteriole lesions
- Intrauterine growth
restriction
- Abruption placenta
- Increased uterine
contractility

























Retinal arteriole damage
Platelet aggregation thrombocytopenia
Blurred vision
Disseminated
intravascular
coagulation













Legend:







Classification of PIH
Type of PIH Symptoms
Gestational hpn - Blood pressure 140/90 or systolic
pressure elevated 30 mmHg or
diastolic pressure elevated 15
mmHg above prepregnancy level
Complication
Signs and symptoms
Disease process
- No proteinuria
- No edema
- Prepregnant BP returns to normal
after birth
Mild - Blood pressure 140/90 or systolic
pressure elevated 30 mmHg or
diastolic pressure elevated 15
mmHg above prepregnancy level
- Proteinuria of 1-2+ on a random
sample (loss of 1 g/L)
- Weight gain over 2 lbs per week in
second trimester and 1 lbs per
week in 3
rd
trimester
- Mild edema in upper extremities or
face
Severe - Blood pressure of 160/110
- Proteinuria 3-4+ on a random
sample and 5 g on a 245-hour
sample
- Oliguria (500 ml or less in 24 hours)
- Altered renal function test
- Creatinine more than 1.2 mg/ dL
- Cerebral or visual disturbances
- Extensive peripheral edema
- Pulmonary or cardiac involvement
- Hepatic dysfunction
- Thrombocytopenia
- Right epigastric pain (abdominal
edema or ischemia to the pancreas
and liver)
eclampsia - Convulsion
- Coma
- Accompanied by signs and
symptoms of preeclamsia


V. Course in the Ward
Diagnostics/ Examinations
Medications
Surgical Management
VI. Theoretical Framework
VII. NCP
VIII. Discharge Care Plan
IX. Conclusion
X. Recommendation