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8/13/2019 Case-Study-PreEclampsia 3.doc
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Pre-Eclampsia
Nursingcasestudy.blogspot.com
http://www.nursingcasestudy.blogspot.com/http://www.nursingcasestudy.blogspot.com/8/13/2019 Case-Study-PreEclampsia 3.doc
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I. INTRODUCTION
Description of the Disease
Preeclampsia, also referred to as toxemia, is a condition that pregnant women can
get. It is marked by high blood pressure accompanied with a high level of protein in the
urine. Women with preeclampsia will often also have swelling in the feet, legs, and
hands. Preeclampsia, when present, usually appears during the second half of pregnancy,
generally in the latter part of the second or in the third trimesters, although it can occur
earlier.
In addition symptoms of preeclampsia can include:
apid weight gain caused by a significant increase in bodily fluid
!bdominal pain
"evere headaches
! change in reflexes
educed output of urine or no urine
#i$$iness
%xcessive vomiting and nausea
&he exact causes of preeclampsia are not known, although some researchers
suspect poor nutrition, high body fat, or insufficient blood flow to the uterus as possible
causes.
&he only real cure for preeclampsia and eclampsia is the birth of the baby. 'ild
preeclampsia (blood pressure greater than )*+-+ that occurs after /+ weeks of gestation
in a woman who did not have hypertension before0 andor having a small amount of
protein in the urine can be managed with careful hospital or in1home observation along
with activity restriction.
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&he group chose the case for the reason that they wanted to show the readers the
process on how pre1eclampsia occurs and for them to fully understand and be reminded
on one of the complications associated with pregnancy.
In developing countries: preeclampsiaeclampsia impact *.*2 of all deliveries ()
and may be as high as )32 in some settings in !frica (/ If the rate of life threatening
eclamptic convulsions (+.)2 of all deliveries is applied to all deliveries from countries
considered to be the least developed, 4+,+++ cases of women experiencing this serious
complication can be expected each year. !ccording to "afe 'otherhood.org of the
434,+++ maternal annually (5, )52, or 67,+4+, are due to eclampsia.
Nurse-Centered Objectives
8pon completion of this case study, the student nurse should be able to:
). Identify the risk factor contributing to the occurrence of the disease.
/. 9ormulate significant nursing diagnosis, with the significantly related nursing care
plan.
5. Identify the different medications administered for this disease their indications,
contraindications, side effect, and specific responsibility .
*. Identify the different medications administered for this disease their indications,
contraindications, side effect, and specific responsibility .
Client-Centered Objectives
8pon completion of this case study, the client should be able to:
). 8nderstand awareness of her disease.
/. now the possible causes of the disease.
5. ;earn and understand why such laboratory examinations are being done.
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II. NURSING ISTOR!
a. #emographic #ata
'rs.
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"aternal-child ealth istor#
a. 'aternal B
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$a%il# ealth Illness istor#
Legend:
hypertension
died of old age
pneumonia
asthma
deceased pre eclampsia
*pink border mother side*blue border father side
*
Grandmother
Grandfather
Mother
Grandmother
Grandfather
Father
Patient
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Aoth the grandparents from the mother@s side died from old age. 9rom the father@s
side, the grandmother died from >ypertension and the father was died from Pneumonia.
&he mother is not experiencing any health problems but the father has hypertension and
asthma. &he patient, upon admission has elevated blood pressure and is suffering from
aggravating factors like anxiety, nervousness and fear.
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&!SIC'( 'SS)SS")NT
Nove%ber *+, *
S/IN
brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (56C?
when pinched, skin readily springs back to previous state
moist skin folds
nails with smooth texture
nail beds pink
prompt capillary refill time (/ seconds
bipedal non1pitting edema
)'D
absence of nodules or masses
symmetric facial features and movements
symmetric nasolabial folds
evenly distributed black hair
no infestations
)!)S
eyebrows symmetrically aligned with eDual movement
eyelashes eDually distributed and curled slightly outward
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bilateral blinking exhibited
no discharge, edema or tearing
white sclera
pink palpebral conEunctiva
iris black in color
pupils eDual in si$e with smooth borders
illuminated pupils constricts
pupils converge when near obEect is moved toward the nose
when looking straight ahead, the client can see obEects in the periphery
both eyes coordinated, move in unison with parallel alignment
)'RS
color same as facial skin
symmetrically aligned
pinna immediately recoils after it is folded
pinna is not tender
no lesions or discoloration
dry cerumen, grayish1tan color
normal voice tones audible
able to hear ticking of a watch in both ears
NOS)
symmetric and straight
no discharge or flaring
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"OUT 'ND TRO'T
outer lips uniform pink color with symmetric contour, soft and moist
buccal mucosa is of uniform pink color
gums are pink
tongue pink, moist, at central position
N)C/
head centered
lymph nodes not palpable
0R)'ST
firm
generally symmetric in si$e
C'RDIO1'SCU('R
AP )3+)++ mm>g
P ))*
reported palpitations
symmetric pulse strength
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chest symmetric
chest wall intact, no tenderness, no masses
symmetric chest expansion and excursion
: /- breaths per minute
G'STROINT)STIN'(2'0DO")N
striae present at hypogastric and iliac regions
linea nigra present
no tenderness
presence of surgical incision
URIN'R!
absence of nocturia, dysuria, urgency, hesitancy,
light yellow urine
R)&RODUCTI1)
regular menstrual cycle
=)P)
"USCU(OS/)()T'(2)3TR)"ITI)S
muscle eDual si$e on both sides of the body
no bone deformities
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N)URO(OGIC
can respond to verbal commands
oriented
conscious
displayed anxiety
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&!SIC'( 'SS)SS")NT
Nove%ber *, *
S/IN
brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (56C?
good skin turgor
moist skin folds
nails with smooth texture
nail beds pink
prompt capillary refill time
bipedal non1pitting edema
)'D
rounded
smooth skull contour
symmetric facial features
symmetric nasolabial folds
symmetric facial movements
'IR
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evenly distributed
no infestations
)!)S
eyebrows symmetrically aligned
eyelashes curled slightly outward
exhibited bilateral blinking
both eyes coordinated, move in unison and with parallel alignment
white sclera
pink palpebral conEunctiva
pupils eDually round and reactive to light and accommodation
iris black in color
pupils eDual in si$e with smooth borders
illuminated pupils constricts
no discharge
)'RS
color same as facial skin
symmetrically aligned
pinna immediately recoils after it is folded
pinna is not tender
no lesions or discoloration
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NOS) 'ND SINUS)S
symmetric and straight
no discharge
absence of lesions and tenderness
nasal septum intact and in the midline
sinuses not tender
"OUT 'ND TRO'T
outer lips uniform pink color
symmetric contour
buccal mucosa is of uniform pink color
no abrasions and ulcerations
gums are pink
tongue pink, moist, at central position
tongue moves freely with no tenderness
palate surface intact
uvula positioned in midline
palatine tonsils pink and smooth and not swollen
N)C/
head centered
head movement coordinated and smooth with no discomfort
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0R)'ST 'ND '3I((')
rounded, generally symmetric
areola rounded and the same shape
nipples round, everted and eDual in si$e
milk letdown
C'RDIO1'SCU('R
AP )7+)++ mm>g
P )+7
prompt capillary refill time (less than ) second
symmetric pulse strength
R)S&IR'TOR!2C)ST
chest symmetric
chest wall intact, no tenderness, no masses
full symmetric chest expansion and excursion
respiratory rate of // breaths per minute
G'STROINT)STIN'(2'0DO")N
striae present at hypogastric and iliac regions
symmetric movement caused by respiration
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URIN'R!
yellowish urine
R)&RODUCTI1)
regular menstrual cycle
=)P) ()1+1+1)1+
"USCU(OS/)()T'(2)3TR)"ITI)S
muscle eDual si$e on both sides of the body
eDual strength
no bone deformities
no tenderness
no tenderness on calf muscle when dorsiflexed
N)URO(OGIC
can respond to verbal commands
oriented
conscious
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&!SIC'( 'SS)SS")NT
Nove%ber *4, *
S/IN
brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (56./C?
when pinched, skin readily springs back to previous state
moist skin folds
nails with smooth texture
nail beds pink
nail plate angle about )7+C
prompt capillary refill time
bipedal non1pitting edema
)'D
rounded
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symmetric facial features
symmetric nasolabial folds
symmetric facial movements
'IR
thick, evenly districbuted black hair
no infestations
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)!)S
eyebrows symmetrically aligned
exhibited bilateral blinking
anicteric sclera
pink palpebral conEunctiva
pupils eDually round and reactive to light and accommodation
no discharge
)'RS
symmetrically aligned
pinna not tender and immediately recoils after folded
no lesions or discoloration
dry cerumen, grayish1tan color
normal voice tones audible
able to hear ticking of a watch in both ears
NOS) 'ND SINUS)S
symmetric and straight
no discharge or flaring
absence of lesions and tenderness
nasal septum intact and in the midline
both nares patent
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outer lips uniform pink color
symmetric contour
buccal mucosa is of uniform pink color
gums are pink
tongue pink, moist, at central position
palate surface intact
uvula positioned in midline
palatine tonsils pink and smooth and not swollen
gag reflex present
5+ adult teeth, / molars missing, ) with black discoloration of the enamel
N)C/
neck muscles eDual in si$e, head centered
head movement coordinated and smooth with no discomfort
lymph nodes not palpable
0R)'ST 'ND '3I((')
areola rounded and the same shape
nipples round, everted and eDual in si$e
milk letdown
C'RDIO1'SCU('R
AP )4+)++ mm>g
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prompt capillary refill time (less than ) second
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R)S&IR'TOR!2C)ST
chest symmetric
right and left shoulders and right and left hips are at the same height
chest wall intact, no tenderness, no masses
full symmetric chest expansion and excursion
respiratory rate is /3 breaths per minute
G'STROINT)STIN'(2'0DO")N
striae present at hypogastric and iliac regions
rounded contour
symmetric movement caused by respiration
tender because of suture form cesarean operation
URIN'R!
yellowish urine
R)&RODUCTI1)
regular menstrual cycle
=)P) ()1+1+1)1+
"USCU(OS/)()T'(2)3TR)"ITI)S
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eDual strength
no tenderness
walks aided to maintains balance
no tenderness on calf muscle when dorsiflexed
N)URO(OGIC
can respond to verbal commands
oriented
conscious
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DI'GNOSTIC 'ND ('0OR'TOR! &ROC)DUR)S
#iagnostic or
;aboratoryProcedure
Indication or
Purpose
#ateemoglobin Pre1operation
assessment of
the patient.
November
)7, /++3
-7 )/+1
)7+g;
&he result
indicates that a
)+++ ml
sample of
blood contains
-7 f
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hemoglobin on
pregnant is
normal
because of
their increase
in plasma
volume.
>ematocrit
(2
Pre1operation
assessment of
the patient.
November
)7, /++3
+./- +.561+.*6
g;
&he result
indicates that a
)+++ ml
sample of
blood
contains ./- g
of hemoglobin.
#ecreased
hematocrit on
pregnant is
normal
because of
their increase
in plasma
volume.
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Aefore
%xplain to the patient that the WA? test is used to detect an infection or
inflammation.
&ell the patient that the test reDuires a blood sample. %xplain who will perform
the venipuncture and when.
%xplain to the patient that he may experience slight discomfort from the needle
puncture and the tourniDuet.
Inform the patient that he should avoid strenuous exercise for /* hours before the
test. !lso tell him that he should avoid eating a heavy meal before the test.
If the patient is being treated for an infection, advise him that this test will be
repeated to monitor his progress.
Notify the laboratory and physician of medications the patient is taking that may
affect test results: they may need to be restricted.
#uring
%nsure subdermal bleeding has stopped before removing pressure.
!fter
If a hematoma develops at the venipuncture site, apply warm soaks. If the
hematoma is large, monitor pulses distal the venipuncture site.
Inform the patient that he may resume his usual diet, activity and medications
discontinued before the test, as ordered.
! patient with severe leucopenia, they have little or no resistance to infection and
reDuires protective isolation.
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%xplain to the patient that A? count is used to evaluate the number of A?s and
to detect possible blood disorders.
&ell the patient that the test reDuires a blood sample. %xplain who will perform
the venipuncture and when.
%xplain to the patient that he may experience slight discomfort from the needle
puncture and the tourniDuet.
Inform the patients that he need not restrict foods and fluids
#uring
%nsure subdermal bleeding has stopped before removing pressure.
!fter
If a hematoma develops at the venipuncture site, apply warm soaks.
e%o5lobin
Aefore
%xplain to the patient that the hbg test is used to detect anemia or polycythemia or
to assess his response to treatment.
&ell the patient that the test reDuires a blood sample. %xplain who will perform
the venipuncture and when.
%xplain to the patient that he may experience slight discomfort from the needle
puncture and the tourniDuet.
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#uring
%nsure subdermal bleeding has stopped before removing pressure.
!fter
If a hematoma develops at the venipuncture site, apply warm soaks.
e%atocrit
Aefore
%xplain to the patient that hct is tested to detect anemia and other abnormal
conditions
&ell the patient that the test reDuires a blood sample. %xplain who will perform
the venipuncture and when.
%xplain to the patient that he may experience slight discomfort from the needle
puncture and the tourniDuet.
Inform the patients that he need not restrict foods and fluids
#uring
%nsure subdermal bleeding has stopped before removing pressure.
!fter
If a hematoma develops at the venipuncture site, apply warm soaks.
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III.T) &'TI)NT 'ND IS I((N)SS
%fforts to unravel the pathogenesis of pre1eclampsia have been hampered by the
lack of clear diagnostic criteria for the disease and its subtypes. ?onseDuently, several
studies have included a variety of other conditions that do not necessarily reflect an
adverse pregnancy outcome.
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!bnormal placentation (stage ), particularly lack of dilatation of the uterine
spiral arterioles, is the common starting point in the genesis of pre1eclampsia, which
compromises blood flow to the maternalBfetal interface. educed placental perfusion
activates placental factors and induces systemic hemodynamic changes. &he maternal
syndrome (stage / is a function of the circulatory disturbance caused by systemic
maternal endothelial cell dysfunction resulting in vascular reactivity, activation of
coagulation cascade and loss of vascular integrity. Pre1eclampsia has effects on most
maternal organ systems, but predominantly on the vasculature of the kidneys, liver and
brain.
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1. T) &'TI)NT 'ND IS C'R)
7. "edical "ana5e%ent
a. I1$s, 0T, NGT feedin5, Nebuli8ation, T&N, O9#5en Therap#
'edical
'anagement
#ate
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%xplain the procedure to the patient
&ell the patient that she might feel a discomfort from the tourniDuet and the IF
insertion
?heck and monitor IF9 regulation and level of fluid
?heck if there is a need for removal and replacement of fluid
?heck if the tube is in the vein and signs of edema
?heck if there is a back1flow of blood
?heck if there is bubbles present in the tube
!lways 'onitor F".
b. &har%acotherap#
Arand name and
=eneric name
#ate ordered
#ate started
#ate changed
oute of
!dministration,
#osage and
9reDuency of
!dministration
=eneral action ?lient response
'efenamic
!cid
))1)-1+3 P.
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?efuroxime
sodium
cell wall
synthesis by
binding to one or
more of the
penicillin1
binding proteins
(PAPs which in
turn inhibits the
final
transpeptidation
step of
peptidoglycan
synthesis in
bacterial cell
walls, thus
inhibiting cell
wall
biosynthesis.
Aacteria
eventually lyse
due to ongoing
activity of cell
wall autolytic
en$ymes
(autolysins and
murein
not acDuire
infection and
did not
experience any
adverse
reaction.
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arrested.
9errous "ulfate ))1)-1+3 P.
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myocardial
oxygen delivery
in patients with
vasospastic
angina
c. Diet
&ype of #iet #ate
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interrupted. ?lear
liDuids are easily
absorbed by the
body. by mouth
(NP
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1I. NURSING C'R) &('N
?ues Nursing
diagnoses
"cientific
%xplanation
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=uarding
behavior
support the
affected area
upon movement
affected area
?ues Nursing
diagnoses
"cientific
%xplanation
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?ues Nursing
diagnoses
"cientific
%xplanation
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K /3 cycles
per min.
PK ))) bpm
pressor
substances. &his
results to
vasoconstriction
and increases AP
dramatically
changing
positions slowly
1give
information
about positive
signs of
improvement
1Instruct client to
avoid or limit
activities that
may stimulate
valsalva
response (rectal
stimulation,
hypotension
1to provide
encouragement
1to prevent in
changes in
cardiac pressures
or impede blow
flow
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bearing down
A.'
?ues Nursingdiagnoses
"cientific%xplanation
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1 %ncourage
activity within
limits of
individual
ability.
1&o stimulate
constrictions of
the intestines
?ues Nursing
diagnoses
"cientific
%xplanation
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to surgery cesarean section
altered the skin
integrity making
it more
susceptible to
pathogens and
even the pt@s
normal flora
intervention, the
patient will able
to know the
preventive
measures of
wound healing
1%ncouraged to
increase foods
that are rich in
protein
1%ncouraged
proper clothing
1!pply
appropriate
dressing
infection.
1 to aid in tissue
repair
1to maintained the
proper skin
moisture.
1to help in wound
healing
able to knew
the preventive
measures of
wound healing
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1III. Dischar5e &lan
=eneral ?ondition of client upon discharge
#uring nurse1patient interaction upon discharge, the patient was wearing a
comfortable pair of white shirt and white paEama and a pair of flat slip1ons while being
sealed on a chair cuddling her baby boy. >er hair was untidy and up in a ponytail with
visible infestations. "he was oriented enough to follow instructions and answers
Duestions asked by the student nurse.
"ethods
"1 Instructed the patient to take the following home medication as ordered by the
physician:
'efenamic !cid 4++mg PN
9errous "ulfate
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1 Instructed patient to take a bath everyday. %mphasi$e the importance of breast
feeding.
O1 !dvice to visit or have a follow up check1up with her attending physician.
D1 ;ow fat, ;ow salt diet.
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I3. Conclusion
Nurses can help the nation achieve National >ealth =oals. &hese goals speak
directly to both fetus and the mother because pregnancy is a high risk factor for them.
?lose monitoring in pregnant women and health teaching as much as possible about
pregnancy could definitely reduce life threatening complications.
"tudies shows that there is no certain facts that will give us the idea where pre1
eclampsia arise. Aut there so many factors that could prevent this complication such as
diet modifications, proper compliance with the health care providers, proper exercise.
!nd if the complication is already present, proper monitoring, proper diet and drug
compliance should be ruled in.
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3. Reco%%endations
With this study, the student nurses were able to gain more knowledge and wider
view and perspective of the complication of pregnancy which is pre1eclampsia. &hus, the
student nurses would like recommend and share some pointers on how to deal with
different diseases with pregnancy specifically pre1eclampsia.
&o the government, primarily they should allocate sufficient budget to sustain and
provide better facilities. &hey must be responsible enough to create awareness program
for care and management for all the 9ilipino people.
&o the health care team, they should righteously implementing basic and ideal
procedures regardless of the health care facilities where they belong. &hey must observe
and always remember to keep in line with their duties towards both the mother and the
child during the pregnancy.
&o the community and the family, that they must be insufficient coordination with
the government and the health care team regarding promotion of health before, during,
and after the delivery of the baby.