I.

Introduction

It was the fourth (4th) day of our hospital exposure at Tarlac Provincial
Hospital-Delivery Room when we found our prospect patient for our case study.
For the purpose of confidentiality we will call our prospect, Mrs. Rosalinda. She
39 years of age and presently residing at San Miguel, Tarlac with her husband
Carlos Miguel.
Mrs. Rosalinda was admitted on June 29, 2009 complaining of epigastric
and labor pains. On admission, she was diagnosed with preeclampsia at 38
weeks AOG and a BP of 160/100

Definition
Preeclampsia is a complication of pregnancy. In preeclampsia, the woman
has dangerously high blood pressure, swelling (edema) and protein in the urine
(proteinuria). Blood pressure rises from 140/90 mm Hg to 160/110 mm Hg. High
blood pressure is first noted sometime after week 20 of pregnancy and is
accompanied by protein in the urine (2g of protein in 24 hour urine or 2+ to 3+ on
qualitative examination)

Risk Factors
Preeclampsia is most common among women who have never given birth
to a baby (called nulliparas). About 7% of all nulliparas develop preeclampsia.
The disease is most common in mothers under the age of 20 or over the age of
35. Other risk factors include poverty, multiple pregnancies (twins, triplets, etc.),
pre-existing chronic hypertension or kidney disease, diabetes, excess amniotic
fluid, and a condition of the fetus called nonimmune hydrops. The tendency to
develop preeclampsia appears to run in families.The daughters and sisters of
women who have had preeclampsia are more likely to develop the condition.

Causes and symptoms

Experts are still trying to understand the exact causes of preeclampsia
and eclampsia. It is generally accepted that preeclampsia and eclampsia in
general are problematic because these conditions cause blood vessels to leak.
The effects are seen throughout the body.

• General body tissues.

When blood vessels leak, they allow fluid to flow out into the tissues of the
body. The result is swelling in the hands, feet, legs, arms, and face. While
many pregnant women experience swelling in their feet, and sometimes in
their hands, swelling of the upper limbs and face is a sign of a more
serious problem. As fluid is retained in these tissues, the woman may
experience significant weight gain (two or more pounds per week).
• Brain. Leaky vessels can cause damage within the brain, resulting in
seizures or coma.

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 • Eyes. The woman may experience problems seeing, and may have
blurry vision or may see spots. The retina may become detached.
• Lungs. Fluid may leak into the tissues of the lungs, resulting in
shortness of breath.
• Liver. Leaky vessels within the liver may cause it to swell. The liver may
be involved in a serious complication of preeclampsia, called the HELLP
syndrome. In this syndrome, red blood cells are abnormally destroyed,
chemicals called liver enzymes are abnormally high, and cells involved in
the clotting of blood (platelets) are low.
• Kidneys. The small capillaries within the kidneys can leak. Normally, the
filtration system within the kidney is too fine to allow protein (which is
relatively large) to leave the bloodstream and enter the urine. In
preeclampsia, however, the leaky capillaries allow protein to be dumped
into the urine. The development of protein in the urine is very serious, and
often results in a low birth weight baby. These babies have a higher risk of
complications, including death.
• Blood pressure. In preeclampsia, the volume of circulating blood is
lower than normal because fluid is leaking into other parts of the body. The
heart tries to make up for this by pumping a larger quantity of blood with
each contraction. Blood vessels usually expand in diameter (dilate) in this
situation to decrease the work load on the heart. In preeclampsia,
however, the blood vessels are abnormally constricted, causing the heart
to work even harder to pump against the small diameters of the vessels.
This causes an increase in blood pressure.

The most serious consequences of preeclampsia and eclampsia include

brain damage in the mother due to brain swelling and oxygen deprivation during
seizures. Mothers can also experience blindness, kidney failure, liver rupture,
and placental abruption. Babies born to preeclamptic mothers are often smaller
than normal, which makes them more susceptible to complications during labor,
delivery, and in early infancy. Babies of preeclamptic mothers are also at risk of
being born prematurely, and can suffer the complications associated with
prematurity.

Prognosis
The prognosis in preeeclampsia (and eclampsia) depends on how
carefully a patient is monitored. Very careful, consistent monitoring allows quick
decisions to be made, and improves the woman’s prognosis. Still, the most
common causes of death in pregnant women are related to high blood pressure.
About 33% of all patients with preeclampsia will have the condition again with
later pregnancies. Eclampsia occurs in about 1 out of every 200 women with
preeclampsia. If not treated, eclampsia is almost always fatal.

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II. Objectives

a. Establish rapport and gain the trust and cooperation of the patient and
immediate family members.

b. Perform and obtain thorough and complete physical assessment using the
assessment techniques following the cephalocaudal approach; obtain
complete medical, socio-cultural, and family history related to the patient’s
current health condition.

c. Analyze and prioritize problems based from the gathered pertinent data to
come up with the correct nursing diagnoses.

d. Plan the appropriate nursing interventions to address the patient’s health

needs. The interventions should address not only the physical well being
of the patient but also her emotional, social, and mental welfare.

e. Implement the planned nursing interventions to meet the desired

outcomes and help improve patient’s condition.

f. Impart useful health teachings to the patient and immediate family

members to prevent further development of the patient’s condition and
other related complications, and for the patient to be able to adjust well
and continue with her normal life after being discharged from the hospital.

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III. Nursing health history

a. Biographical information
Surname: X First name: Rosalinda Middle name: Z
Age: 39
Nationality: Filipino
Address: Brgy. San Miguel Tarlac City
b. Reasons For seeking Health Care

Mrs. X seeks for health care because of the chief complains of labor pain

c. Client Expectation

Mrs. X has expectation in the following areas:

 Information needed about his disease process and involvement in

decision making.

 Caring and compassion expressed by care providers.

 Timelines of caregiver’s response to client request.

 Relief of pain and symptoms.

 Deliver the neonate safely.

d. Present Illness

Mrs. X came to the emergency room last Tuesday, June 30, 2009 after her
client meeting and subsequently complaining of severe epigastric and labor
pain.

e. Past Health History

Mrs. X has only been hospitalized on her first born delivery.

f. Family History

Mrs. X has verbalized that the only heredo-familial disease that they have
was hypertension on her mother side.

g. Immunization

She verbalized that she had a complete vaccination.

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h. Nutrition

She verbalized that she primarily eats vegetable and meat.

i. Environment History

Mrs. X leaves at San Miguel, Tarlac City. Their concrete type of house is
located in a residential area with good ventilation. Their water source was
on water pump but they buy drinking water and their garbage was being
burn.

j. Psychosocial History

Mrs. X stated that she has a lot of support system coming from her family
and relatives.

k. Spiritual Health

Mrs. X is a Roman Catholic and makes it a point to visit and attened a

mass every Sunday with her husband. Their beliefs about life. Their
source for guidance in acting their beliefs, and the relationship they have
in exercising their faith is truly God centered manner.

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IV. Assessment

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V. Anatomy and physiology

Renal system

The excretory system consists of the kidneys, the ureters, the urinary bladders,
and the urethra. The kidneys are the major excretory organs of the body. The
skin, liver, lungs, and intestines eliminate some waste products, but if the kidneys
fail to function, these other excretory organs cannot adequately compensate.
The Urinary system eliminates waste, regulates blood volume, ion concentration
and pH; and it is involve with red blood cell production.

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1. Approximately 180 L of filtrate enters the nephrons each day; of that volume 65% is
reabsorbed in the proximal tubule. In the proximal tubule, solute molecules move by
active transport and cotransport from the lumen of the tubule into the interstitial fluid.
Water moves by osmosis because the cells of the tubule wall are permeable to water.

2. Approximately 15% of the filtrate volume is reabsorbed in this segment of the

descending limb of the loop of Henle. The concentrated interstitial fluid of the medulla.
Because the wall of the descending limb is permeable to water, water moves by
osmosis from the tubule into the more concentrated interstitial fluid. By the time the
filtrate reaches the tip of the renal pyramid, the concentration of the filtrate is equal to
the concentration of the interstitial fluid.
3. The descending limb into the loop of Henle is not permeable to water. Solutes diffuse
out of the thin segment.

4. Na+, K+, and Cl- are cotransported across the apical membrane of the thick
segment. Na+ is actively transported and K+ and Cl- diffuse across the basal
membrane of the epithelial cells of the thick segment into the interstitial fluid.

5. The volume of the filtrate doesn’t change as it passes through the ascending limb, but
the concentration is greatly reduced. By the time the filtrate reaches the cortex of the
kidney, the concentration is approximately 100 mOsm/L, which less concentrated than
interstitial fluid of the cortex.

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6. The distal tubule and collecting are permeable to water if ADH is present. If ADH is
present, water moves by osmosis from the less concentrated filtrate into the more
concentrated fluid. By the time the filtrate reaches the tip of the renal pyramid an
additional 19% of the filtrate is reabsorbed.

7. One percent or less remains as urine.

Vascular system

The heart provides the major force that causes blood to circulate, and the
peripheral circulation functions to carry blood, exchange nutrients, waste
products, and gases, transport hormones, components of the immune system,
molecules required for coagulation, enzymes, nutrients, gases, waste products,
and other substances are transported in the blood to all areas of the body,
regulate blood pressure, and direct blood flow. Blood flows from the heart
through elastic arteries, muscular arteries, and arterioles to the capillaries. Blood
returns to the heart from the capillaries through venules, small veins, and large
vein. Layers of blood vessels The tunica intima consists of endothelium, a
delicate connective tissue basement membrane, a thin layer of connective tissue
called the lamina propia, and a fenestrated layer of elastic fibers call the internal
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 elastic membrane. The internal elastic membrane separates the tunica intima
from the next layer, the tunica media. The tunica media, or middle layer,
consists of smooth muscle cells arranged circularly around the blood vessel. The
amount of blood flowing through a blood vessel can be regulated by contraction
or relaxation of the smooth muscle in the tunica media. A decrease in blood flow
results from vasoconstriction, an increase in blood vessel diameter because of
smooth muscle relaxation. The tunica adventitia is composed of connective
tissue, which varies from the dense connective tissue near the tunica media to
loose connective tissue that merges with the connective tissue surrounding the
blood vessels.

Female Reproductive System

The vagina is a muscular, hollow tube that extends from the vaginal opening to
the uterus. The vagina is about 3 to 5 inches (8 to 12 centimeters) long in a grown
woman. Because it has muscular walls it can expand and contract. This ability to
become wider or narrower allows the vagina to accommodate something as slim as a
tampon and as wide as a baby. The vagina's muscular walls are lined with mucous
membranes, which keep it protected and moist. The vagina has several functions: for
sexual intercourse, as the pathway that a baby takes out of a woman's body during
childbirth, and as the route for the menstrual blood (the period) to leave the body from
the uterus.

The vagina connects with the uterus, or womb, at the cervix. The cervix has
strong, thick walls. The opening of the cervix is very small (no wider than a straw),
which is why a tampon can never get lost inside a girl's body. During childbirth, the
cervix can expand to allow a baby to pass.

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 The uterus is shaped like an upside-down pear, with a thick lining and muscular
walls - in fact, the uterus contains some of the strongest muscles in the female body.
These muscles are able to expand and contract to accommodate a growing fetus and
then help push the baby out during labor. When a woman isn't pregnant, the uterus is
only about 3 inches (7.5 centimeters) long and 2 inches (5 centimeters) wide.

At the upper corners of the uterus, the fallopian tubes connect the uterus to the
ovaries. The ovaries are two oval-shaped organs that lie to the upper right and left of
the uterus. They produce, store, and release eggs into the fallopian tubes in the process
called ovulation .Each ovary measures about 1 1/2 to 2 inches (4 to 5 centimeters) in a
grown woman.

There are two fallopian tubes, each attached to a side of the uterus. The fallopian
tubes are about 4 inches (10 centimeters) long and about as wide as a piece of
spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the
other end of each fallopian tube is a fringed area that looks like a funnel. This fringed
area wraps around the ovary but doesn't completely attach to it. When an egg pops out
of an ovary, it enters the fallopian tube. Once the egg is in the fallopian tube, tiny hairs
in the tube's lining help push it down the narrow passageway toward the uterus.

The ovaries are also part of the endocrine system because they produce female
sex hormones such as estrogen and progesterone.

Placenta

The placenta or afterbirth is a highly vascularized ephemeral organ present in

placental vertebrates that connects the developing fetal tissues to the uterine wall. The
placenta supplies the fetus with maternal nutrients, and allows fetal waste to be
disposed of via the maternal kidneys.

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In humans, the placenta averages 22 cm (9 in.) in length and 2-2.5 cm (0.8-1 in.) in
thickness. It typically weighs approximately 500 grams (1 lb). It has a dark reddish/blue
or maroon color. It connects to the fetus by an umbilical cord of approximately 55-60 cm
(22-24 in.) in length that contains two arteries and one vein. The umbilical cord inserts
into the chorionic plate. Vessels branch out over the surface of the placenta and further
divide to form a network covered by a thin layer of cells. This results in the formation of
villous tree structures. On the maternal side, these villous tree structures are grouped
into lobules called cotelydons. In humans the placenta usually has a disc shape but
different mammalian species have widely varying shapes..

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VI. Pathophysiology

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VII. Medical management

Doctor’s orders

Post partum order

On June 29, 2009 at 7:00 pm the doctor ordered to ward and IVF to consume
DAT. He also ordered to follow up lab results. Medications prescribed are
cefalexin TID, FeSO4 OD, Mefinamic Acid TID. Also ordered is to put ice pack
over fundus, massage uterus as needed, perineal hygiene and to watch out for
profuse vaginal bleeding, refer.

On june 30, 2009 at 3:50pm the doctor ordered to admit patient to OB service
charity ward and to secure consent. He also ordered to monitor and record TPR
every shift. The patient is also under a DAT diet. The patient is for diagnostic for
CBC, U/A, blood typing, and HBsAg, with IVF of D5LRS 1L for 8 hours.
Medications prescribed are HNBB 1 amp, for IVP every 4 hours, MgSO4 5g deep
IM in each buttocks and Hydralazine 5mg IVP. To Labor Room, for perenial prep,
monitor Vital signs FHT POL and record, to refer accordingly.

Last july 01, 2009 the doctor ordered NPO at 10pm, for blood chem. tomorrow.

July 02, 2009, the doctor ordered to continue medications, start nefedipine 30g
stat then OD, carry out blood chem. then refer. With BP of 150/90, negative fever,
negative haldz, negative profuse vaginal bleeding, negative pain C/L CBS

July 03, 2009 the doctor ordered continue meds with low, salt low fat diet. Follow
up blood chem.

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Drug study

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 Laboratory

Analyzed: 06/30/09 19:04

Blood type “A”

Test Result Reference Range (LIMIT 2) Findings

WBC 14.2 G/L 4.1-10.9 G/L Above normal

values

LYM 1.5 10.3%L 0.6-4.1 10.0-58.5%L Normal

Increase MID 0.4 2.7%M 0.0-1.8 0.1-24.0%M Normal

GRAN 12.4 87.0%G 2.0-7.8 37.0-92.0%L Above normal

values

RBC 3.87 T/L 4.20-6.30 T/L Below normal

values

HGB 117. g/L 120.-180. g/L Below normal

values

HCT .348 L/L .370-.510 L/L Below normal

values

MCV 89.9 f/L 80.0-97.0 f/L Normal

MCH 30.2 pg 26.0-32.0 pg Normal

MCHC 336. g/L 310.-360 g/L Normal

PLT 289. G/L 140.-440. G/L Normal

MID cells may include less frequently occurring and rare cells correlating to monocytes,
eosinophils, basophils, blasts and other precursor white cells

HBsAg – NON REACTIVE

VIII. Nursing Management

a. NCP

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b. NURSE’S NOTES

On june 30, 2009, patient was admitted to ER, with the chief complaint
of labor pain @ 3:3OPM. Patient’s vital signs were taken and recorded and with

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 IVF of D5lr L @ 3Ogtts/min, afebrile, on NPO, with uterine contraction, IE done,
cervix fully dilate, and medications are given. At 4:50pm, patient delivered
spontaneously alive baby boy attended by Dr.Valdoz, placenta out completely,
BP recorded at 170/110, oxytocin incorporated to IVF,and massage uterus till firm
& contracted. At 5:30pm administered MgS04 5g deep IM on each buttock,placed
ice pack over fundus,latest BP 150/110 At 6:30pm patient y transfered,afebrile,(-)
DOB,with ongoing IVF of D5LR 1L infusing well,withminimal vaginal bleedin,DAT
instructed.

IX. METHODS

M-Cefalexin, Mefenamic acid, Ferrous sulphate

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 E- Early ambulation to promote peristalsis, and circulation

T-CBC, BT, Hepa-B screening, UA, B-HCG, CXR-PAT

H-Deep breathing exercises- to promote lung expansion

Pursed-Lip breathing- to prevent lung collapse

Coughing exercise- to remove excess secretion and help prevent air tripping.

Educate on avoiding pregnancy for 1yr. or Birth spacing

O- Return to TPH-OPD after 1 week from discharge (07-07-09)

D- DAT

S- Continue activities of daily living

X. Recommendation

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 As a recommendation, the patient is adviced to monitor her blood pressure by
having regular visits / check up to her doctor. She is also encouraged to improve
her daily diet for her body to obtain the needed nutrients so she could quickly
recuperate.
Since the patient has verbalized desire to have another baby, she was also
adviced to take extra precaution and watch for signs of preeclampsia. She is now
aware of her condition and thereby encouraged to maintain a clean healthy
lifestyle.

XI. Evaluation.
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Nurse centered
The student-nurses from group 11 section C were able to obtain complete
knowledge on the patient’s condition; analyse and prioritize problems; plan the
appropriate nursing interventions and were able to implement the nursing care
plans.
The student-nurses were also able to impart useful health teachings to the
patient and her family to be able to perform self-care.

Patient centered
There was a significant change to the patient’s condition from the time she
was admitted up to the present: her blood pressure has decreased from 180/120
mmHg to 130/90 mmHg.

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