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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.
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.
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.
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
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.
f. Family History
Mrs. X has verbalized that the only heredo-familial disease that they have
was hypertension on her mother side.
g. Immunization
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
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.
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.
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
BSN 3F – Delivery Room Area | Case Study: Preeclampsia 12
Group 24
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.
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.
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
Doctor’s orders
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.
MID cells may include less frequently occurring and rare cells correlating to monocytes,
eosinophils, basophils, blasts and other precursor white cells
a. NCP
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
IX. METHODS
Coughing exercise- to remove excess secretion and help prevent air tripping.
D- DAT
X. Recommendation
XI. Evaluation.
BSN 3F – Delivery Room Area | Case Study: Preeclampsia 34
Group 24
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.