Pre-Eclampsia

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Table of Contents

Chapter 1 – Introduction
Objectives

Chapter 2 – Assessment
Nursing Health History
Personal Data of the Patient
Chief Complaints
History of Present Illness
Past Medical History
Family Health History
Physical Assessment
Diagnostic Procedure
Anatomy and Physiology of the Systems affected
a. Pathophysiology
Chapter 3 – Planning
A. List of Prioritized Nursing Diagnoses
B. NCP
C. Drug Study

Chapter 4 – Discharge Planning

Chapter 1 – Introduction
We, group 1 of JRU BSN A314, would like to thank Sta. Rita de Baclaran Hospital for allowing
us to choose a patient for our case. We also thank our clinical instructor, Mr. Belocura and our
preceptor Ms. Hazel Ann Cruz, for patiently teaching us and making sure we learn the most
from our clinical exposure.
Objectives
General Objectives – We did this case study for us to have a deeper understanding of what
preeclampsia is, thus to give us an idea of how we could give proper nursing care for our
clients with this condition.
Specific Objective - We hope to be able to address the client’s health needs and also to assess
for any health deficit or risks like acute pain, infection, and self-care.

Chapter 2 Assessment

A. Personal Data
Name: A.K.A ‘CHURVA”
Age: 30 yrs old
Sex: Female
Address: Baclaran City

Chief complaint: Labor pains

B. Past Medical History

The patient’s past history was post CS.

C. Present medical History

The patient was admitted Dec 1 2007 at 11: am; chief complaint was severe abdominal
pain and increasing B/P.
She was admitted in Sta. Rita Medical Hospital.

D. Family Health History

There’s a history of hypertension in the client’s family. Her mother had hypertension.

3. Diagnostic Procedures

Common laboratory tests to diagnose Pregnancy-induced hypertension would include

blood test, renal function, creatinine, and BUN. But these tests were not noted on the client’s
chart. What we found out instead is the continual rising of the client’s blood pressure from the
time she got in the hospital at 10am until she was admitted.
 Blood pressure taking is one easy method to monitor the client’s blood pressure. The
client’s blood pressure was at 170/90 at 10am then increased to 170/100 at 12nn and reached
190/100 at 1pm. While the normal blood pressure is below 120/80; blood pressure between
120/80 and 139/89 is called "pre–hypertension", and a blood pressure of 140/90 or above is
considered high.

4. Anatomy & Physiology

The Circulatory (Cardiovascular)

System

The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body and
pick up waste materials and toxins for elimination. This system is made up of the heart, the
veins, the arteries, and the capillaries.

Circulation is achieved by a continuous one-way movement of blood throughout the body. The
network of blood vessels that flow through the body is so extensive that blood flows within
close proximity to almost every cell.

Heart
The heart is a muscular pump that propels blood throughout the body. The heart is located
between the lungs, slightly to the left of center in the chest. The heart is broken down into
four chambers including:

• The right atrium, which is a chamber which receives oxygen- poor blood from the
veins.
• The right ventricle which pumps the oxygen-poor blood from the right atrium to the
lungs.
• The left atrium which receives the now oxygen-rich blood that is returning from the
lungs.
• The left ventricle, which pumps the oxygenated blood through the arteries to the rest
of the body.

Blood Vessels
Blood vessels are broken down into three groups: the arteries which carry blood out of the
heart to the capillaries, the veins which transport oxygen-poor blood back to the heart, and
the capillaries which transfer oxygen and other nutrients into the cells and removes carbon
dioxide and other metabolic waste from these body tissues.

Blood Pressure
Blood pressure is the force exerted by the blood against the walls of the blood vessels. The
output or direct pumping of the heart and the resistance to blood flow in the vessels
determines blood pressure. Resistance is determined by blood viscosity and by friction
between the blood and the wall of the blood vessel.
Blood pressure = blood flow x resistance.

PATHOPHYSIOLOGY OF PREGNANCY-INDUCED HYPERTENSION

Vasopasm

Peripheral Arteriole
Vasoconstriction

BLURRING OF VISON, HEADACHE

INCREASED BLOOD PRESSURE

PREGNANCY-INDUCED
HYPERTENSION
Chapter 3 – Planning
Priority: 1. Acute pain 2. Risk for infection 3. Self-care deficit

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Independent
Subjective Cues: Acute pain related Within 8 hrs nursing > Provide information and > Promotes problem Goals met.
“Masakit ang tahi ko,” to surgical incision intervention the patient anticipatory guidance regarding solving, helps reduce pain
as verbalized by the as evidenced by will: causes of discomfort and associated with anxiety
patient. facial mask of appropriate interventions. and fear of the unknown,
pain. > Identify and use and provides sense of
appropriate interventions control.
to manage
pain/discomfort. > Reposition client, reduce > Relaxes muscles, and
noxious stimuli, and offer comfort redirects attention away
Objective Cues: > Verbalize lessening of measures, e.g., back rubs. from painful sensations.
level of pain. Encourage use of breathing and Promotes comfort, and
(+) Guarding relaxation techniques and reduces unpleasant
behavior > Appear relaxed, able to distraction (stimulation of distractions, enhancing
(+) Facial mask of sleep/rest appropriately. cutaneous tissue). sense of well-being.
pain
> Encourage early ambulation. > Decreases gas formation
and promotes peristalsis to
relieve discomfort of gas
accumulation, which often
peaks on 3rd day after
Collaborative cesarean birth.
> Administer analgesics every 3–4 > Promotes comfort, which
hr prn. Medicate lactating client improves psychological
45–60 min before breastfeeding. status and enhances
mobility. Use of medication
with limited ability to cross
into milk allows lactating
mother to enjoy feeding
without adverse effects on
infant.
ASSESSMENT
Subjective Cues:
“Paano maiiwasan ang
impeksyon sa tahi ko?”
Objective Cues:
[Not applicable; presence of
signs/symptoms establishes an
actual diagnosis]
NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Risk for infection At the end of the 3 days Independent
related to tissue of nursing intervention, > Encourage and use careful > Helps prevent or retard > Goals met.
trauma/broken skin. the client will: handwashing and appropriate spread of infection.
disposal of soiled perineal pads,
> Demonstrate and contaminated linen.
techniques to reduce risks Discuss with client the
and/or promote healing. importance of continuing these
measures after discharge.
> Display wound free of
purulent drainage with > Prevents dehydration;
> Encourage oral fluids and diet
initial signs of healing high in protein, vitamin C, and maximizes circulation and
(i.e., approximation of iron. urine flow. Protein and vitamin
wound edges), uterus C are needed for collagen
soft/nontender, with formation; iron is needed for
normal lochial flow and Hb synthesis.
character.
> Inspect abdominal dressing > A sterile dressing covering
for exudate or oozing. Remove the wound in the first 24 hr
dressing, as indicated. following cesarean birth helps
protect it from injury or
contamination. Oozing may
indicate hematoma, loss of
suture approximation, or
wound dehiscence, requiring
further intervention. Removing
the dressing allows incision to
dry and promotes healing.
> Inspect incision, evaluate > These signs indicate wound
healing process, noting infection. Wound infections
localized redness, edema, pain, are usually clinically apparent
exudate, or loss of 3–8 days after the procedure.
approximation of wound edges.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Self-care deficit related At the end of a two hour Independent

Subjective Cues: to decreased strength nursing intervention, the > Assess client’s > Physical pain experience may Goals met.
“Kailan ko kaya maire- and endurance as client will: psychological status. be compounded by mental pain
resume ang normal na evidenced by inability to that interferes with client’s
gawain ko?” ambulate independently. > Verbalization of desire and motivation to
inability to participate at assume autonomy.
Objective Cues: level desired.
Inability to ambulate > Offer assistance as needed > Improves self-esteem;
independently. > Demonstrate with hygiene (e.g., mouth increases feelings of well-being.
techniques to meet self- care, bathing, back rubs, and
care needs. perineal care).
> Identify/use available
resources. > Offer choices when > Allows some autonomy, even
possible (e.g., selection of though client depends on
juices, scheduling of bath, professional assistance.
destination during
ambulation).

Collaborative
> Administer analgesic agent > Reduces discomfort, which
every 3–4 hr, as needed. could interfere with ability to
engage in self-care.
Chapter III Implementation
Medical Management - Drug Study

Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibilities

Hydralazine is used to Essential Check if the client takes the

Hydralazine treat high blood pressure. hypertension, alone or medication and if it is in the right
(Apresoline) It works by relaxing the as an adjunct.
Hypersensitivity to • flushing (feeling of patient and check also the doctor’s
hydralazine; coronary warmth)
blood vessels so that Management of order. Observe for any reaction to
artery disease; mitral
blood can flow more easily moderate to severe
valvular rheumatic • headache the medication like headache,
through the body. hypertension, flushing, vomiting, etc. If any
heart disease.
congestive heart reaction occurs inform your
failure, hypertension • eye tearing physician.
secondary to pre-
eclampsia/eclampsia; Monitor BP every 5 mins.
treatment of primary
pulmonary
hypertension. Under
indications.

Start with 10 mg four

times daily for the first
2 to 4 days, increase
to 25 mg four times
daily for the balance
of the first week. For
the second and
subsequent weeks,
increase dosage to 50
mg four times daily.
For maintenance,
adjust dosage to the
lowest effective
levels.
Name of Drug Use
Arthrotec (Diclofenac Used for treatmentfor
Na) rheumatoid,
arthritis,dysmenorrheal,
headache, post partum
pain.
Arthrotec contains
dicoflenac sodium and
misoprostol.
Administration of
misoprotol to women who
are pregnant can cause
abortion, premature birth ,
or birth defects. Uterine
rupture has been reported
when misoprostol was
asministered in pregnant
women to induce labor or
to induce abortion beyond
the 8th week of pregnancy.
Indication/ Dosage Contraindication Side effects Nursing responsibilities
Check if the client takes the
ARTHROTEC is ARTHROTEC is • .abdominal pain medication. Check for the doctor’s
indicated for contraindicated in • diarrhea
order and if it is the right patient.
treatment of the signs patients with • GI symptoms
Observe for any effect and if any
and symptoms of hypersensitivity to
side effects occur inform physician.
osteoarthritis or diclofenac or to
rheumatoid arthritis in misoprostol or other
Carefully consider the potential
patients at high risk of prostaglandins.
benefits and risks of ARTHROTEC
developing NSAID-
and other treatment options before
induced gastric and
deciding to use ARTHROTEC. Use
duodenal ulcers and
the lowest effective dose for the
their complications.
shortest duration consistent with
individual patient treatment ...
ARTHROTEC is
administered as
ARTHROTEC 50 (50
mg diclofenac
sodium/200 mcg
misoprostol) or as
ARTHROTEC 75 (75
mg diclofenac
sodium/200 mcg
misoprostol).
Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibiliries

Before you administer penicillin,

Penicillin G Penicillin G is used look at the solution closely. It should
routinely for maternal The early use of
A previous • rash be clear and free of floating
hypersensitivity
infections during
penicillin G was linked reaction to any • fever material. Gently squeeze the bag or
pregnancy. observe the solution container to
penicillin is a • dizziness
make sure there are no leaks. Do
to increased uterine contraindication.
not use the solution if it is
activity and abortion. discolored, if it contains particles, or
It is not known if the bag or container leaks. Use a
new solution, but show the
whether this was damaged one to your health care
related to impurities in provider.

the drug or to
penicillin itself.
Chapter IV Discharge Planning

Medication
Drug to be continued, Hydralazine (Apresoline) oral. For maintenance, adjust dosage to the
lowest effective levels.

Exercise
The client should limit the no. of stairs she climbs to one flight/dayfor the first week at
home. Beginning the second week, if her lochial discharge is normal, she may start to increase
this activity. Limit stair climbing to only when necessary for first two weeks.

Treatment
Advice client to monitor blood pressure, take prescribed medications and perform wound
care as needed.

Health Teaching
Teaching should focus on action to maintain comfort, to promote healing and restore
wellness.
 avoid heavy work (lifting or straining) for at least first 3 weeks after birth.
(it is usually advised that she doesn’t return to an outside for at least 3 weeks (better 6
weeks) not only for her own health but also for enjoyment of the early weeks with her
newborn. Explore with th client what she consider heavy work)
 get lots of sleep. Sleep when baby sleeps.
(Client should at least 1 rest period a day and try to get a good night’s sleep. She can rest
during the day when her newborn is sleeping.)
 take advantage of help from others.
 avoid having sexual intercourse at least a month
 call your health care provider if you have any of the warning signs of sickness:
(fever greater than100F, severe pain, redness or swelling in the incision site, foul smelling
vaginal discharge, increase bleeding, back ache or severe abdominal pain or cramping
(unrelieved by medication).)
 report increasing pain, swelling, or opening or gaping of wound edges.
 teach the client how to change wound dressings and perform wound care.
 instruct client to use pain medication as ordered.
 emphasize the importance of hygiene and hand washing to prevent infection

Out Patient follow-up

The client should return to her physician 2-4 weeks after.

Diet
The client’s diet is high protein and low sodium diet.