Case Study Pre-Eclampsia

Holy Angel University
Angeles City
College of Nursing
Pre-Eclampsia
December 05, 2008
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:
Rapid weight gain caused by a significant increase in bodily fluid
Abdominal pain
Severe headaches
A change in reflexes
Reduced output of urine or no urine
Dizziness
Excessive vomiting and nausea

The 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.
The only real cure for preeclampsia and eclampsia is the birth of the baby. Mild
preeclampsia (blood pressure greater than 140/90) that occurs after 20 weeks of gestation
in a woman who did not have hypertension before; and/or having a small amount of
protein in the urine can be managed with careful hospital or in-home observation along
with activity restriction.
The group chose the case for the reason that they wanted to show the readers the
process on how pre-eclampsia occurs and for them to fully understand and be reminded
on one of the complications associated with pregnancy.
In developing countries: preeclampsia/eclampsia impact 4.4% of all deliveries (1)
and may be as high as 18% in some settings in Africa (2) If the rate of life threatening
eclamptic convulsions (0.1% of all deliveries) is applied to all deliveries from countries
considered to be the least developed, 50,000 cases of women experiencing this serious
complication can be expected each year. According to Safe Motherhood.org of the
585,000 maternal annually (3), 13%, or 76,050, are due to eclampsia.
Nurse-Centered Objectives
Upon completion of this case study, the student nurse should be able to:
1. Identify the risk factor contributing to the occurrence of the disease.
2. Formulate significant nursing diagnosis, with the significantly related nursing care
plan.
3. Identify the different medications administered for this disease their indications,
contraindications, side effect, and specific responsibility .
4. Identify the laboratory and diagnostic procedure done with the pre-eclamptic
patient, their indication and purposes, and specific nursing responsibilities.
Client-Centered Objectives
Upon completion of this case study, the client should be able to:
1. Understand awareness of her disease.
2. Know the possible causes of the disease.
3. Learn and understand why such laboratory examinations are being done.
II. NURSING HISTORY

a.) Demographic Data
Mrs. Ob, a 39 years old housewife and first time mother, who currently
resides at Guagua Pampanga with her husband Mr. Gyne. She was born a Filipina
on November 9, 1969 in Sta. Rita Guagua Pampanga. The patient was admitted at
a Regional Hospital with a chief complaint of abdominal pain, last November 15,
2008 at around 3:00 p.m.
b.) Socio-Economic and Cultural Factors
Mrs. Ob is plain housewife and her husband is an extra laborer on a

construction site. She graduated at a Public High School. And she didnt continue
her college level due to financial problem.
Mrs. Ob was raised as a Roman Catholic, were she learned about religious
values but she still believes in super natural forces and superstitious beliefs. When
it comes in health matters, she seeks the help of a albularyo and uses herbal
medicines to treat any member of the family who has an ailment. But when
serious matters arise she still refers to medical professionals for help.
c.) Environmental factors
Ms. Ob resides at Guagua Pampanga and occupies the ancestry house of

her family. The location of their house is not easily accessible to hospitals, health
centers and other government institutions. Mrs. Ob did not report any problems
regarding her environment which interfered to her pregnancy.
Maternal-child Health History
a.) Maternal Obstetric record (for OB cases)
Mrs. Ob was married to Mrs. Gyne at the age of 33 years old. She has a
record of T1P0A0L1M0 at her 39th week of gestation. She underwent low
transverse ceasarian section under a certain obstetrician at the regional hospital
last November 18, 2008 at around 10:00 in the evening, she delivered her 1st child
who is term baby with hyperbilirubinemia.
b.) Antepartal/ Prenatal Preparation
When Mrs. Ob was still pregnant, she only consulted once in a district
hospital all throughout.
c.) Significant Trimestral Changes (1st to 3rd trimester)
Mrs. Ob rxperienced some changes in her pregnancy, such as striae

gravidarum, linea nigra, and melasma. She also experienced nausea and vomiting,
dizziness, and headache.
Family Health Illness History
Grandmother
Grandfather
Grandmother
Grandfather
Mother
Father
Patient
Legend:
hypertension
pneumonia
died of old age
deceased
pre eclampsia
asthma
*pink border mother side

*blue border father side
*violet border - patient
Both the grandparents from the mothers side died from old age. From the fathers
side, the grandmother died from Hypertension and the father was died from Pneumonia.
The mother is not experiencing any health problems but the father has hypertension and
asthma. The patient, upon admission has elevated blood pressure and is suffering from
aggravating factors like anxiety, nervousness and fear.
PHYSICAL ASSESSMENT
November 27, 2008
SKIN
brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (37C)
when pinched, skin readily springs back to previous state
moist skin folds
nails with smooth texture
nail beds pink
prompt capillary refill time (2 seconds)
bipedal non-pitting edema
HEAD
absence of nodules or masses
symmetric facial features and movements
symmetric nasolabial folds
evenly distributed black hair
no infestations
EYES
eyebrows symmetrically aligned with equal movement
eyelashes equally distributed and curled slightly outward
skin of eyelids intact with no discoloration
lids close symmetrically
bilateral blinking exhibited
no discharge, edema or tearing
white sclera
pink palpebral conjunctiva
iris black in color
pupils equal in size with smooth borders
illuminated pupils constricts
pupils converge when near object is moved toward the nose
when looking straight ahead, the client can see objects in the periphery
both eyes coordinated, move in unison with parallel alignment
EARS
color same as facial skin
symmetrically aligned
pinna immediately recoils after it is folded
pinna is not tender
no lesions or discoloration
dry cerumen, grayish-tan color
normal voice tones audible
able to hear ticking of a watch in both ears
NOSE
symmetric and straight
no discharge or flaring
absence of lesions and tenderness
nasal septum intact and in the midline
MOUTH AND THROAT
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
NECK
head centered
lymph nodes not palpable
BREAST
firm
generally symmetric in size
CARDIOVASCULAR
BP 180/100 mmHg
PR 114
reported palpitations
symmetric pulse strength
RESPIRATORY/CHEST
chest symmetric
chest wall intact, no tenderness, no masses
symmetric chest expansion and excursion
RR: 29 breaths per minute
GASTROINTESTINAL/ABDOMEN
striae present at hypogastric and iliac regions
linea nigra present
no tenderness
presence of surgical incision
URINARY
absence of nocturia, dysuria, urgency, hesitancy,
light yellow urine
REPRODUCTIVE
regular menstrual cycle
G1P1
MUSCULOSKELETAL/EXTREMITIES
muscle equal size on both sides of the body
no bone deformities
no tenderness
NEUROLOGIC
can respond to verbal commands
oriented
conscious
displayed anxiety
PHYSICAL ASSESSMENT
November 28, 2008
SKIN
skin temperature uniform and within the normal range (37C)
good skin turgor
moist skin folds
nail beds pink
prompt capillary refill time
HEAD
rounded
smooth skull contour
symmetric facial features
symmetric facial movements
HAIR
thick black hair
evenly distributed
no infestations
EYES
eyebrows symmetrically aligned
eyelashes curled slightly outward
exhibited bilateral blinking
both eyes coordinated, move in unison and with parallel alignment
white sclera
pupils equally round and reactive to light and accommodation
iris black in color
pupils equal in size with smooth borders
illuminated pupils constricts
no discharge
EARS
color same as facial skin
pinna immediately recoils after it is folded
pinna is not tender
NOSE AND SINUSES
no discharge
sinuses not tender
MOUTH AND THROAT
outer lips uniform pink color
symmetric contour
no abrasions and ulcerations
gums are pink
tongue moves freely with no tenderness
palate surface intact
uvula positioned in midline
palatine tonsils pink and smooth and not swollen
NECK
head centered
head movement coordinated and smooth with no discomfort
BREAST AND AXILLAE
rounded, generally symmetric
areola rounded and the same shape
nipples round, everted and equal in size
milk letdown
CARDIOVASCULAR
BP 160/100 mmHg
PR 106
prompt capillary refill time (less than 1 second)
symmetric pulse strength
RESPIRATORY/CHEST
chest symmetric
full symmetric chest expansion and excursion
respiratory rate of 22 breaths per minute
symmetric movement caused by respiration
tender because of suture from cesarean operation
URINARY
yellowish urine
REPRODUCTIVE
G1P1 (1-0-0-1-0)
equal strength
no bone deformities
no tenderness
no tenderness on calf muscle when dorsiflexed
NEUROLOGIC
oriented
conscious
PHYSICAL ASSESSMENT
November 29, 2008
SKIN
skin temperature uniform and within the normal range (37.2C)
when pinched, skin readily springs back to previous state
moist skin folds
nail beds pink
nail plate angle about 160
prompt capillary refill time
HEAD
rounded
smooth skull contour
no masses, tenderness in the scalp
symmetric facial features
symmetric facial movements
HAIR
thick, evenly districbuted black hair
no infestations
EYES
eyebrows symmetrically aligned
exhibited bilateral blinking
anicteric sclera
pupils equally round and reactive to light and accommodation
no discharge
EARS
pinna not tender and immediately recoils after folded
able to hear ticking of a watch in both ears
NOSE AND SINUSES
no discharge or flaring
both nares patent
MOUTH AND THROAT
outer lips uniform pink color
symmetric contour
gums are pink
palate surface intact
uvula positioned in midline
palatine tonsils pink and smooth and not swollen
gag reflex present
30 adult teeth, 2 molars missing, 1 with black discoloration of the enamel
NECK
neck muscles equal in size, head centered
head movement coordinated and smooth with no discomfort
BREAST AND AXILLAE
areola rounded and the same shape
nipples round, everted and equal in size
milk letdown
CARDIOVASCULAR
BP 150/100 mmHg
PR 96
strong, regular rhythm
prompt capillary refill time (less than 1 second)
RESPIRATORY/CHEST
chest symmetric
right and left shoulders and right and left hips are at the same height
full symmetric chest expansion and excursion
respiratory rate is 28 breaths per minute
rounded contour
symmetric movement caused by respiration
tender because of suture form cesarean operation
URINARY
yellowish urine
REPRODUCTIVE
G1P1 (1-0-0-1-0)
smooth coordinated movements
equal strength
no tenderness
walks aided to maintains balance
no tenderness on calf muscle when dorsiflexed
NEUROLOGIC
oriented
conscious
DIAGNOSTIC AND LABORATORY PROCEDURES
Diagnostic or
Laboratory
Procedure
WBC Count
Indication or
Purpose
Date
Ordered and
Date
Results
were
released
To determine
November
infection or
16, 2008
Results
Normal
Values
Analysis and
Interpretation
of Results
8.0
5-10 x
No infection or
109/L
inflammation
inflammation
is present.
Pre-operation
assessment of
the patient.
RBC Count
Pre-operation
November
assessment of
16, 2008
3.3
4.2-5.4 x
1012 /L
the patient.
Decreased
RBC count on
pregnant is
normal
because of the
increase in
plasma volume
during
Hemoglobin
Pre-operation
November
assessment of
16, 2008
the patient.
96
120160g/L
pregnancy.
The result
indicates that a
1000 ml
sample of
blood contains
96 g of
hemoglobin.
Decreased
hemoglobin on
pregnant is
normal
because of
their increase
in plasma
Hematocrit
Pre-operation
November
(%)
assessment of
16, 2008
0.29
0.37-0.47
g/L
the patient.
volume.
The result
indicates that a
1000 ml
sample of
blood
contains .29 g
of hemoglobin.
Decreased
hematocrit on
pregnant is
normal
because of
their increase
in plasma
volume.
Nursing Responsibilities During Different Laboratory Procedures
White Blood Cell Count
Before
Explain to the patient that the WBC test is used to detect an infection or
inflammation.
Tell the patient that the test requires a blood sample. Explain who will perform the
venipuncture and when.
Explain to the patient that he may experience slight discomfort from the needle
puncture and the tourniquet.
Inform the patient that he should avoid strenuous exercise for 24 hours before the
test. Also 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.
During
Ensure subdermal bleeding has stopped before removing pressure.
After
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.
A patient with severe leucopenia, they have little or no resistance to infection and
requires protective isolation.
Red Blood Cell Count

Before
Explain to the patient that RBC count is used to evaluate the number of RBCs and
to detect possible blood disorders.
Inform the patients that he need not restrict foods and fluids
During
After
If a hematoma develops at the venipuncture site, apply warm soaks.
Hemoglobin
Before
Explain to the patient that the hbg test is used to detect anemia or polycythemia or
to assess his response to treatment.
During
After
Hematocrit
Before
Explain to the patient that hct is tested to detect anemia and other abnormal
conditions
Inform the patients that he need not restrict foods and fluids
During
After
III. THE PATIENT AND HIS ILLNESS
Efforts to unravel the pathogenesis of pre-eclampsia have been hampered by the

lack of clear diagnostic criteria for the disease and its subtypes. Consequently, several
studies have included a variety of other conditions that do not necessarily reflect an
adverse pregnancy outcome.
Abnormal placentation (stage 1), particularly lack of dilatation of the uterine

spiral arterioles, is the common starting point in the genesis of pre-eclampsia, which
compromises blood flow to the maternalfetal interface. Reduced placental perfusion
activates placental factors and induces systemic hemodynamic changes. The maternal
syndrome (stage 2) 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. Pre-eclampsia has effects on most
maternal organ systems, but predominantly on the vasculature of the kidneys, liver and
brain.
V. THE PATIENT AND HIS CARE

1. Medical Management
a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy
Medical
Management
IVF
Date Ordered
General
Indication &
Client Response
Date Ordered
Description
5% dextrose in
Purpose
D5NM is
to Treatment
The patient
November 15,
lactated ringers administered by
responded well
2008
solution
with no signs of
D5LRS 1L
intravenous
30gtts/min
(Osmolarity of infusion for
irritation and
527-hyprtonic,
parenteral
adverse reactions.
pH of 4.9)
maintenance of
-provides
routine daily fluid
Date d/c
November 20,
2008
calories and free and electrolyte
water, provides
requirement with
electrolytes.
minimal
Also contains
carbohydrates
sodium lactate
calories and to
which is used in correct or replace

treating mild to fluid losses due to
moderate
change in the
metabolic
patients diet
acidosis.
(NPO) and during

the cesarean
operation.
Nursing Responsibilities:
Check the doctors order
Explain the procedure to the patient
Tell the patient that she might feel a discomfort from the tourniquet and the IV
insertion
Check and monitor IVF regulation and level of fluid
Check if there is a need for removal and replacement of fluid
Check if the tube is in the vein and signs of edema
Check if there is a back-flow of blood
Check if there is bubbles present in the tube
Always Monitor V/S.
b. Pharmacotherapy
Brand name and Date ordered/
Route of
General action
Client response
Generic name
Date started/
Administration,
Date changed/
Dosage and
Administration
P.O., 500mg,
Inhibits
Patient was
TID for pain
prostaglandin
relieved from
synthesis by
pain.
Frequency of
Mefenamic
11-19-08
Acid
decreasing the
activity of the
enzyme,
cyclooxygenase,
which results in
decreased
formation of
prostaglandin
Cephalosporin
11-19-08
I.V., 750mg, q8
precursors
Inhibits bacterial
The patient did
Cefuroxime
cell wall
not acquire
sodium
synthesis by
infection and
binding to one or did not

more of the
experience any
penicillin-
adverse
binding proteins
reaction.
(PBPs) which in
turn inhibits the
final
transpeptidation
step of
peptidoglycan
synthesis in
bacterial cell
walls, thus
inhibiting cell
wall
biosynthesis.
Bacteria
eventually lyse
due to ongoing
activity of cell
wall autolytic
enzymes
(autolysins and
murein
hydrolases)
while cell wall
assembly is
arrested.
Ferrous Sulfate
11-19-08
P.O., O.D.
Replaces iron,
The patient
found in
responded well
hemoglobin,
to treatment
myoglobin, and
and did not
other enzymes;
experience any
allows the
adverse
transportation of
reaction.
oxygen via
Nifedipine
11-19-08
P.O., 10mg, BID
hemoglobin.
Inhibits calcium
The patient
ion from
responded well
entering the
to treatment
"slow channels"
and did not
or select
experience any
voltage-sensitive adverse
areas of vascular
smooth muscle
and myocardium
during
depolarization,
producing a
relaxation of
coronary
vascular smooth
muscle and
coronary
vasodilation;
increases
reaction.
myocardial
oxygen delivery
in patients with
vasospastic
angina
c. Diet
Type of Diet
NPO
Date Ordered,
General
Indication &
Client
Date Performed,
Description
Purpose
Response to
Date Administer
11-17-08
The patient is not
This is done to
Treatment
The patient
11-19-08
allowed to take
prevent
complied with
any oral food or
alteration of the
the prescribed
liquid
result of the
diet.
fasting blood
sugar.bcs intake
of food can
increase
Clear Liquid
11-19-08
A diet of clear
glucose level
This diet reduce
Diet
11-20-08
liquids maintains
stimulation of
complied with
vital body fluids,
the digestive
the prescribed
salts, and
system, and
diet.
minerals; and also
leave no residue
gives some energy
in the intestinal
for patients when
tract. This is
normal food intake why a clear

must be
liquid diet is
The patient
interrupted. Clear
often prescribed
liquids are easily
in preparation
absorbed by the
for surgery, and
body. by mouth
is generally the
(NPO) for a long
first diet given
time. This diet is
by mouth after
also used in
surgery. Clear
preparation for
liquids are
medical tests such
given when a
as sigmoidoscopy,
person has been
colonoscopy, or
without food by
certain x-rays.
mouth (NPO)
for a long time.
d. Exercise
Activity
General
Purpose
Date Order
Description
Complete Bed
Rest
Client
Response
Prescribed
To provide
maternal
adequate rest
11-18-08
The client
adhered to the
complication of
order without
pregnancy
complaints.
VI. NURSING CARE PLAN
Cues
S-sumasakit
Nursing
diagnoses
Acute pain
Scientific
Explanation
Unpleasant
nga daw ung
related to
tahi niya at
postparum
Objective
After 2-4 hr of
Nursing
intervention
- Provide quite
Rationale
-to promote pain
Expected
outcomes
Goal Partially
sensory
nursing
environment
management.
met AEB pt
experience
intervention, the
rated the pain
sumusigaw siya
arising from post pt rate the pain
-Encouraged to
as the SO
surgical incision
from 8 to 3 in a
do deep
pain scale of 1-
verbalized
from cesarean
pain scale of 1-
breathing
10
section.
10
exercise
O- facial
-to prevent
grimaces
- Encouraged
Rated pain as 8
adequate rest
in a pain scale of
period
1-10, 10 being
the highest
-to reduce tension
fatigue
-to reduce
- Encouraged to
pressure on the
from 8 to 5 in a
Guarding
support the
behavior
affected area
affected area
upon movement
Cues
S-ayoko na
Nursing
diagnoses
Disturbed body
Scientific
Explanation
Severity of the
muna dapat
image related to
mabuntis kc
Objective
After 2-4 hrs of
Nursing
intervention
-Encouraged
Rationale
-to begin to
Expected
outcomes
Goal met the
abdominal
nursing
client to looked/
incorporate
patient
pregnancy AEB
wound due to
intervention, the
touch the
changes into
recognized and
papangit ung
changes in
surgery, a new
patient will able
affected body
body image.
verbalized
katawan ko
appearance
type of tissues
to understand the
area
tsaka bat ang
develops that
change of body
itim ng pek-pek
eventually will
image.
ko as pt
verbalized
understanding of
-to bring back
-Encourage the
the usual
causes scar
client to have a
physical images.
formation
daily exercise.
-to feel that the
body changes.
O-presence of
-Advised the SO
patient still
melasma
to give support
worthy.
-presence of
to the pt
bipedal edema
(especially
emotional
feelings)
-to aid in
recovery.
-Assist pt to
identify positive
behavior
Cues
S: bumibilis
Nursing
diagnoses
Decreased
Scientific
Explanation
Pregnancy
nga tibok ng
cardiac output
Induced
puso ko
After 4 hrs of
Nursing
intervention
-Keep client on
- decreases
Expected
outcomes
Goal Met AEB
nursing
bed and in
oxygen
within 4 hrs. of
related to altered Hypertension is a
intervention, the
position of
consumption
nursing
verbalized by
heart rate (111
condition in
patient will
comfort
the patient
bpm) AEB
which
display
tachycardia, pts
vasospasms
hemodynamic
-decrease
-to promote
decreased from
report of
occur. It is caused
stability (heart
stimuli; provide
adequate rest
111 bpm to 100
palpations;
by altered cardiac
rate will decrease quiet envt
(r/t) decreased
output that injures from 111 bpm to
venous return
endothelial cells
100 bpm, BP
-Encouraged
AEB edema
of the arteries.
from 140/100 to
deep breathing
(ankle), SOB
Blood vessels
120/80)
exercise
(28)
become less
O: -with the
tenderness of
abdominal are
-facial grimaces
-BP= 160/100
mmhg
resistant to
Objective
Rationale
intervention the
pt. HR
bpm, BP from
-to reduce
140/100 to
anxiety
120/80 (Normal
BP)
-to reduce risk for

-Encouraged
orthostatic
RR= 28 cycles
per min.
pressor
changing
substances. This
positions slowly
results to
PR= 111 bpm
hypotension
-to provide
vasoconstriction
-give
and increases BP
information
dramatically
about positive
encouragement
signs of
-to prevent in
improvement
changes in
cardiac pressures
-Instruct client to or impede blow

avoid or limit
activities that
may stimulate
valsalva
response (rectal
stimulation,
flow
bearing down
B.M)
Cues
S-
Nursing
diagnoses
Risk for
Scientific
Explanation
Constipation
Objective
After 4 hrs of
Nursing
intervention
- Educate
Rationale
- Information
Expected
outcomes
Goal Met AEB
constipation
may happen due
nursing
patient/ SO
can help client to the patient
O- decreased
related to post
to disturbance of
intervention, the
about safe and
make beneficial
verbalized
ambulation of
CS delivery.
normal bowel
patient will
risky practices
choices when
understanding
the patient bcs
movements
verbalize
for managing
need arises.
about
of pain and the
because
understanding
constipation.
complete bed
intestines were
the etiology and
rest ordered of
displaced during
appropriate
- Instruct balance - To improve
knowledge of
the physician.
surgical
intervention if
fiber and bulk in
consistency of
appropriate
procedure.
constipation may
diet and fiber
stool and
intervention.
occur.
supplements.
facilitate passage
constipation and
gained
through colon.
- Promote
adequate fluid
- To promote
intake, also
soft stool and
suggest drinking
stimulate bowel
warm fluids.
activity.
- Encourage
activity within
-To stimulate
limits of
constrictions of
individual
the intestines
ability.
Cues
O- postpartum
Nursing
diagnoses
Impaired Skin
Scientific
Explanation
The incision
surgery
Integrity related
from the
Objective
After 2-4 hrs of
Nursing
intervention
-stress proper
Rationale
- to control the
Expected
outcomes
Goal Met AEB
nursing
hand hygiene.
spread of
the patient was
to surgery
cesarean section
intervention, the
infection.
able to knew
altered the skin
patient will able
-Encouraged to
integrity making
to know the
increase foods
- to aid in tissue
measures of
it more
preventive
that are rich in
repair
wound healing
susceptible to
measures of
protein
pathogens and
wound healing
the preventive
even the pts
-Encouraged
-to maintained the
normal flora
proper clothing
proper skin
moisture.
-Apply
appropriate
-to help in wound
dressing
healing
VIII. Discharge Plan
General Condition of client upon discharge

During nurse-patient interaction upon discharge, the patient was wearing a
comfortable pair of white shirt and white pajama and a pair of flat slip-ons while being
sealed on a chair cuddling her baby boy. Her hair was untidy and up in a ponytail with
visible infestations. She was oriented enough to follow instructions and answers
questions asked by the student nurse.
Methods
M- Instructed the patient to take the following home medication as ordered by the
physician:
Mefenamic Acid 500mg PRN
Ferrous Sulfate OD
Nifedipine 10mg BID
E- Instructed patient to avoid strenuous activities. And practice deep breathing
exercise.
T- n/a
H- Instructed patient to take a bath everyday. Emphasize the importance of breast

feeding.
O- Advice to visit or have a follow up check-up with her attending physician.
D- Low fat, Low salt diet.
IX. Conclusion
Nurses can help the nation achieve National Health Goals. These goals speak
directly to both fetus and the mother because pregnancy is a high risk factor for them.
Close monitoring in pregnant women and health teaching as much as possible about
pregnancy could definitely reduce life threatening complications.
Studies shows that there is no certain facts that will give us the idea where preeclampsia arise. But there so many factors that could prevent this complication such as
diet modifications, proper compliance with the health care providers, proper exercise.
And if the complication is already present, proper monitoring, proper diet and drug
compliance should be ruled in.
X. Recommendations
With this study, the student nurses were able to gain more knowledge and wider
view and perspective of the complication of pregnancy which is pre-eclampsia. Thus, the
student nurses would like recommend and share some pointers on how to deal with
different diseases with pregnancy specifically pre-eclampsia.
To the government, primarily they should allocate sufficient budget to sustain and
provide better facilities. They must be responsible enough to create awareness program
for care and management for all the Filipino people.
To the health care team, they should righteously implementing basic and ideal
procedures regardless of the health care facilities where they belong. They must observe
and always remember to keep in line with their duties towards both the mother and the
child during the pregnancy.
To 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.
XI. BIBLIOGRAPHY
http:// www.nursingcrib.com
http:// www.medicinenet.com
http:// www.wrongdiagnosis.com
http:// www.umm.edu.com
http:// www.doh.gov.ph

Case Study Pre-Eclampsia

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Case Study Pre-Eclampsia

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Holy Angel University

December 05, 2008

Description of the Disease

Rapid weight gain caused by a significant increase in bodily fluid

Reduced output of urine or no urine

Excessive vomiting and nausea

II. NURSING HISTORY

b.) Socio-Economic and Cultural Factors

Mrs. Ob is plain housewife and her husband is an extra laborer on a

c.) Environmental factors

Ms. Ob resides at Guagua Pampanga and occupies the ancestry house of

Maternal-child Health History

a.) Maternal Obstetric record (for OB cases)

b.) Antepartal/ Prenatal Preparation

c.) Significant Trimestral Changes (1st to 3rd trimester)

Mrs. Ob rxperienced some changes in her pregnancy, such as striae

Family Health Illness History

died of old age

*pink border mother side

skin temperature uniform and within the normal range (37C)

when pinched, skin readily springs back to previous state

moist skin folds

nails with smooth texture

nail beds pink

prompt capillary refill time (2 seconds)

bipedal non-pitting edema

absence of nodules or masses

symmetric facial features and movements

symmetric nasolabial folds

evenly distributed black hair

eyebrows symmetrically aligned with equal movement

eyelashes equally distributed and curled slightly outward

skin of eyelids intact with no discoloration

lids close symmetrically

bilateral blinking exhibited

no discharge, edema or tearing

pink palpebral conjunctiva

iris black in color

pupils equal in size with smooth borders

illuminated pupils constricts

pupils converge when near object is moved toward the nose

both eyes coordinated, move in unison with parallel alignment

color same as facial skin

pinna immediately recoils after it is folded

pinna is not tender

dry cerumen, grayish-tan color

normal voice tones audible

able to hear ticking of a watch in both ears

symmetric and straight

absence of lesions and tenderness

nasal septum intact and in the midline

MOUTH AND THROAT

buccal mucosa is of uniform pink color

gums are pink

tongue pink, moist, at central position

lymph nodes not palpable

generally symmetric in size

symmetric pulse strength

chest wall intact, no tenderness, no masses

symmetric chest expansion and excursion

RR: 29 breaths per minute

striae present at hypogastric and iliac regions

linea nigra present