CASE STUDY ON PREECLMAPSIA Presented to The Faculty of the College of Nursing University of Perpetual Help- System Dalta Alabang,

Zapote Road, Pamplona Las Pias City.

In Partial Fulfillment Of the Requirements for the Degree Bachelor of Science in Nursing

SUBMITTED TO: MRS. DAISY LIM RN, MAN, PAFR Shiela Mae M. Macaraeg BSN- 2B December 2010

INTRODUCTION
This a case of MZ, 16 years old of Caloocan City. She came to Dr. Jose Fabella Memorial Hospital on November 13, 2010 at11: 46 pm. Her attending physician was Dr. Estabillo and she was diagnosed with mild preeclampsia pregnancy induced hypertension.

Preeclampsia also referred to as toxemia, preeclampsia 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. 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.
Preeclampsia is most often seen in first-time pregnancies and in pregnant teens and women over 40. Other risk factors include: a history of high blood pressure prior to pregnancy, previous history of preeclampsia, and history of preeclampsia in mother or sisters,

obesity prior to pregnancy, carrying more than one baby, and history of diabetes, kidney disease, lupus, or rheumatoid arthritis.
Preeclampsia can prevent the placenta from receiving enough blood, which can cause your baby to be born very small. It is also one of the leading causes of premature births and the difficulties that can accompany them, including learning disabilities, epilepsy, cerebral palsy, and hearing and vision problems.

GENERAL OBJECTIVE
The general objectives for the conduction of this case study are for students to incorporate concepts and enhanced knowledge in CARE OF MOTHER, CHILD, FAMILY
AND POPULATION GROUP AT RISK OR WITH PROBLEMS to apply appropriate nursing

management for client with mild preeclampsia or pregnancy induced hypertension. This study aims to develop the skills that are applied for the care of patients with her conditions. At the same time, it allows the students to utilize the different skills and attitude instilled on them.

SPECIFIC OBJECTIVE:
At the end of the case presentation, this case study specially aims to: a) Define preeclampsia at young pregnancy accurately. b) Discuss briefly the causative factors that may have precipitated the onset of the condition. c) Discuss thoroughly the signs and symptoms manifested by the client. d) Discuss the different drugs; indications; mechanisms of action, therapeutic effects, and verse effects and contraindications. e) Present the condition of the client accurately. f) Acquire understanding and knowledge on pathophysiology. g) Discuss the nursing care plan appropriately.

h) Identify and provide the health teachings for the continuum of care. i) Using the nursing care plan as the framework of the patients care.

CHIEF COMPLAIN
Prior to delivery of the baby, client MZ suddenly felt abdominal pain and dizziness. The doctor find out that client MZs blood pressure before the delivery of the baby is 140/100. This prompted the doctor to admit client MZ in the hospital.

PATIENTS PROFILE
Patients Name Age Sex Civil Status Birthday Admission Date Admission Time Institution Diagnosis : : : : : : : : : MZ 16 y/o Female Live In September 9, 1994 November 13, 2010 11:46 PM Dr. Jose Fabella Memorial Hospital Preeclampsia

MEDICAL HISTORY
y PAST MEDICAL HISTORY Client MZ has an unremarkable past medical history according to her obstetrical data. Client states that she doesnt have any kind of allergies. FAMILY HISTORY/ GENOGRAM

GRAND FATHER

GRAND MOTHER

GRAND FATHER

GRAND MOTHER

FATHER

MOTHER

PATIENT
LEGENDS:
LIVING DIED BECAUSE OF OLD AGE DIED BECAUSE HEART ATTACK

GORDONS FUNCTIONAL ASSESSMENT

A. HEALTH PERCEPTION AND HEALTH MANAGEMENT
At the time of the interview, MZ thinks and acknowledge that she is not in her perfect state of health. She is aware that she is under observation by the fact that before and after delivery she has a high blood pressure. She is also aware that their might be a risk infection because of her caesarian surgery. To keep her self healthy, she usually does the household chores.

B. NUTRITIONAL- MEATABOLIC PATTERNS

The patient disclosed that she is not a picky eater. Her usual diet includes spaghetti, fish and vegetables. The common foods in their house are meats, chicken, pork or beef and usually vegetables and fish. She admits that she has a good appetite.

C. ELIMINATION
Prior to MZs hospitalization she usually urinates 3-4 times a day and she is not experiencing any problems with urination. MZ usually defecates 1- 2 times a day and she is not experiencing any problems with defecation.

D. ACTIVITY- EXERCISE PATTERN

Prior to hospitalization, MZ is able to do household chores such as cleaning their house. She can do activities of daily living without others help. She

does not usually perform exercise. MZ claims that she doesnt have any time doing exercise.

E. SLEEP- REST PATTERN

MZs average hours of sleep is around 8-10 hours daily, including her afternoon naps, usually goes to bed at 11 PM, and sleeps continuously with ease and no difficult in falling asleep. She usually takes a bath before sleeping. MZ has been expressing her desire to go home.

F. COGNITIVE PERCEPTUAL PATTERN

MZ states that she can able to read and write. She usually speaks Filipino and Bicolano. She didnt experience any problems with hearing. MZ is able to read clearly.

G. SELF- PERCEPTION AND SELF CONCEPT PATTERN

MZ describes herself as a loving daughter to her mother. MZ is most concerned about is her health the fact that she has a high blood pressure. MZ states that sometimes she feels anger because of her live in partner and depression because at her young age she has baby.

H. ROLE RELATIONSHIP PATTERN

MZ lives with her live in partner including her sister and the mother of her partner. MZ states that her live in partner help them financially. MZs mother work

as cook in the carinderia and her partner works as a construction worker. When there is a conflict in the family they talk about the problems and the different solutions.

H. COPING STRESS AND TOLERANCE

MZ stated that she is relaxed most of the time. Sometimes if she is in stressed MZ is asking God for guidance and strength in daily living and is convinced effective.

I. VALUE- BELIEF PATTERN

MZ is a Roman Catholic. Sometimes she goes to church. MZ believes that faith in God is the most important above all.

PHYICAL ASSESSMENT Area Assessed Technique Used SKIN Color Texture Turgor Palpation Palpation Smooth, soft Skin snaps back immediately Smooth, soft Skin snaps back immediately Normal Normal Inspection Normal Findings Tan Actual Findings Tan Normal Analysis

when pinched Hair Distribution Temperature Moisture Palpation Palpation Inspection Evenly distributed Warm to touch Dry, skin folds are normally rare . NAILS Color of Nail bed Texture Shape Palpation Inspection Smooth Convex curvature Nail base Capillary refill time HAIR Color Distribution Inspection Evenly distributed Moisture Inspection Neither excessively dry Inspection Black (varies) Inspection Blanch test Firm 2-3 sec. Inspection Smooth

when pinched Evenly distributed Warm to touch Dry, skin folds are normally rare Normal Normal Normal

Smooth

Normal

Smooth Convex curvature Firm 2-3 sec.

Normal Normal

Normal Normal

Black (varies)

Normal

Evenly distributed Neither excessively dry

Normal

Normal

nor oily Texture HEAD Shape Inspection and palpation FACE Facial movement Skin color EYE Eyebrows Inspection Inspection Tan Symmetrically aligned, equal movement Eyelashes Inspection Slightly curved upward Eyelids Inspection Inspection Inspection Symmetrical Symmetrical Normocephalic Inspection

nor oily Normal Normal Normocephalic Normal

Silky or resilient Silky or resilient

Symmetrical Symmetrical

Normal Normal

Tan Symmetrically aligned, equal movement Slightly curved upward

Normal

Normal

Normal

Smooth, tan, do Smooth, tan, do not cover pupil as sclera, close symmetrically not cover pupil as sclera, close symmetrically Blinks voluntarily and bilaterally 15-20 blinks per min.

Normal

Ability to blink

Inspection

Blinks voluntarily and bilaterally

Normal

Frequency of blinking

Inspection

15-20 blinks per min.

Normal

Ocular movement Position

Inspection

Eyes moves freely

Eyes moves freely Drawn from lateral angle Medium Mobile, firm and non-tender

Normal

Inspection

Drawn from lateral angle

Normal

Size Texture

Inspection Inspection

Medium Mobile, firm and non-tender

Normal

Normal

CONJUCTIVA Color Inspection Transparent with light color Texture Inspection Shiny and smooth Presence of lesions APPARATUS Cornea Color Texture Inspection Shiny and smooth PUPILS Color Size Inspection Inspection Black Equal Black Equal Normal Shiny and smooth Normal Normal Inspection Black Black Normal Inspection No lesions Transparent with light color Shiny and smooth No lesions Normal Normal Normal

Shape

Inspection

Round and constrict briskly

Round and constrict briskly Equal in size Able to read news print When looking straight ahead, client can see objects periphery Eyes moves freely Normal Normal Normal Normal Normal Normal

Symmetry Visual acuity

Inspection Inspection

Equal in size Able to read news print

Visual fields

Inspection

When looking straight ahead, client can see objects periphery

Ocular

Inspection

Eyes moves freely

NOSE Symmetry, shape, size and color Mucosa color Inspection Oval, symmetrical Nasal discharge Sinuses MOUTH Secretions Inspection Inspection No tender (neutral in color) without No tender (neutral in color) without Inspection No discharge Oval, symmetrical No discharge Inspection Symmetrical, smooth and tan Symmetrical, smooth and tan

Normal

Normal

Normal

Normal

mucus production Lips color Inspection Pinkish to slightly brown Symmetry Texture Moisture GUMS Color Moisture BUCCAL MUCOSA Color Texture Moisture TOUNGE Color Size Inspection Medium Palpation Palpation Inspection Soft Moist Pinkish Palpation Inspection Moist Glistening pink Palpation Palpation Palpation Palpation Symmetrical Soft and moist Soft and moist Pinkish

mucus production Pinkish to slightly brown Symmetrical Soft and moist Soft and moist Pinkish Normal Normal Normal Normal Normal

Moist Glistening pink

Normal Normal

Soft Moist Pinkish

Normal Normal

Normal Medium Normal

Symmetry Mobility UVULA Location

Inspection Inspection Inspection

Symmetrical Moves freely At the midline

Symmetrical Moves freely At the midline

Normal Normal Normal

Symmetry TONSILS Color Discharges TEETH Color Number of teeth NECK Position Movement

Inspection Inspection

At the midline Pinkish

At the midline Pinkish

Normal

Normal Inspection Inspection No discharges Ivory yellowish No discharges Ivory yellowish Normal Normal

Inspection

32

32

Normal

Inspection

Head centered

Head centered

Normal

Inspection

Moves freely

Moves freely

Normal

Range of Motion

Inspection

Full range

Full Range

Normal

Consistency

Inspection

No enlargement

No enlargement

Normal

HEART Auscultation Heart Rate 60-100 bpm Normal

Heart Sounds

Auscultation

Clear, without crackles

Clear, without crackles

Normal

Lung Field

Auscultation

Resonant

Resonant

Normal

THORAX & LUNGS PSTERIOR Inspection Symmetrical Symmetrical Normal

THORAX Symmetry

Respiratory Rate

Inspection

12-20 cpm

Normal

Spinal Alignment

Inspection

Spine vertically align

Spine vertically align

Normal

Skin Integrity

Inspection Auscultation

Skin Intact Breathing is automatic and effortless, regular and even and

Skin Intact Breathing is automatic and effortless, regular and even and produces no noise

Normal Normal

ANTERIOR THORAX

Breathing Pattern

produces no noise

Lung/breath sounds ABDOMEN Contour Texture Frequency and character

Auscultation

Bronchovesicular

Bronchovesicular Flat

Normal

Inspection

Flat

Normal

Palpation Auscultation

Smooth Audible, soft gurgling sound occurs irregularly and

Smooth Audible, soft gurgling sound occurs irregularly and

Normal Normal

rages from 5-30 rages from 5-30 mins. UPPER EXTREMITY Inspection Tan mins Tan Normal

Skin Color Movement Inspection With ROM and sensation Size (arms) Symmetry Hair distribution LOWER EXTREMITY Inspection Inspection Inspection Equal Symmetrical Evenly distributed Tan With ROM and sensation Equal Symmetrical Evenly distributed Tan Normal Normal Normal Normal Normal

Skin Color Movement

Inspection Inspection With ROM and sensation With Rom sensation Equal Symmetrical Can follow Normal Normal Normal Normal

Size (LEGS) Symmetry NEURO LOGICAL Level of consciousness Behavioral and appearances

Inspection Inspection Interview

Equal Symmetrical Can follow

instructions and instructions and commands commands

Interview

Makes eye contact with the examiner

Makes eye contact with the examiner Expressing

Normal

Mood

Interview

Expressing

Normal

feeling which corresponds to the examiner MANNERISM & ACTIONS LANGUAGE Voice inflection Tone Interview Fluent and anticipated Manner and Speech TiME Recall recent and remote memory Interview Recall events readily immediate recall of remote information Judgements and thoughts Interview Can make logical decisions Interview Oriented with time Interview Clear and Strong

feeling which corresponds to the examiner Clear and Strong Normal

Fluent and anticipated Oriented with time

Normal

Normal

Normal Recall events readily immediate recall of remote information Can make logical decisions Normal

LABORATORY EXAMINATIONS
DATE AND TIME: 11/14/10 12:43 AM EXAMINATION CBC HEMOGLOBIN HEMATOCRIT RBC COUNT MCV MCH MCHC WBC COUNT DIFFERENTIAL COUNT NEUTROPHILS LYMPHOCYTES BASOPHILS MONOCYTES EOSINOPHILS PLATELET COUNT 0.72 0.21 0.00 0.06 0.01 368 0.00-0.55 0.00-0.34 0.00-0.01 0.00-0.03 0.00-0.03 150-400 % % % % % x10^9/L 114 0.34 3.83 88 30 34 16.5 120-170 0.37-0.54 4.1-5.1 80-96 27-31 34-36 4.5-11 g/L % x10^12/L fL pg g/dL x10^9/L RESULTS NORMAL VALUE UNIT

ANATOMY AND PHYSIOLOGY:

Internal

Reproductive

Organs

A. Located in the Pelvic Cavity

http://obward.com/wpcontent/uploads/2009/12/anato myoffemalereproductivesystem.j pgOvariesfemale gonads

located on each side of the uterus. Functions include (1) Development and release of the ovum (egg) (2) Secretion of the hormones estrogen and progesterone
y

Fallopian tubes (1) Carry the ovum from the ovary to the uterus. (2) Fimbriae sweep ovum into the tube.

Uterus (1) Hollow pear-shaped organ that stretches and enlarges during pregnancy to support the fetus. (2) Other functions include menstruation and expelling of the fetus during labor. (3) Divisions of the uterus are: fundusuppermost portion; corpusthe

body; cervixlower third that exits into the vagina through the cervical os.
y

Vagina (1) Curved tube leading from the uterus to the vestibule. (2) Functions as a passageway for menstrual flow, organ of copulation, and birth canal.

Pelvis

A. Bonessupport and protect pelvic contents

y y y

Sacrumwedge-shaped bone formed by the fusion of five vertebrae Coccyxsmall triangular bone at bottom of the vertebral column. Innominate bones (1) Iliumupper prominence of the hip (2) IschiumL-shaped bone below the ischium. Distance between the ischial spines is the shortest diameter of the pelvic cavity. (3) Pubisslightly bowed front portion of the innominate bone. The pubis meet at the front of the pelvis to make up the joint called the symphysis pubis. Below the symphysis is a triangular space called the pubic arch, under which the fetal head passes during birth.

B. Pelvic floormuscular floor of bony pelvis, supports pelvic contents

Levator animajor portion, made up of four muscles (1) Ileococcygeus

(2) Puboccygeus (3) Puborectalis (4) Pubovaginalis

y

Coccygeal muscleunderlies sacrospinous ligament a thin muscular sheet which helps the levator ani support the pelvic contents

C. Pelvic shapesvaginal birth is never ruled out because of pelvic type without a trial of labor.

Androidnarrow, heart shaped, similar to shape of male pelvisnot favorable for vaginal birth

Anthropoidwidest from front to backusually adequate for vaginal birth

y y

Platypelloidwidest from side to sidenot favorable for vaginal birth Gynecoidclassic female pelvisapproximately 50 percent of women and its the best for vaginal birth

Heart

9. Right Atrium 1. Right Coronary 2. Left Anterior Descending 3. Left Circumflex 4. Superior Vena Cava 5. Inferior Vena Cava 6. Aorta 7. Pulmonary Artery 10. Right Ventricle 11. Left Atrium 12. Left Ventricle 13. Papillary Muscles 14. Chordae Tendineae 15. Tricuspid Valve 16. Mitral Valve

8. Pulmonary Vein

17. Pulmonary Valve

Aortic Valve (Not pictured)

Coronary Arteries

Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue.

The blood leaving the left ventricle exits through the aorta, the bodys main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart.

The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart.

Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon

dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver.

When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack.

Superior Vena Cava

The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right atrium of the heart.

Inferior Vena Cava

The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right atrium of the heart.

Aorta

The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body.

Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.

Pulmonary Vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart.

Right Atrium

The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle.

Right Ventricle

The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle contracts,

the tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs.

Left Atrium

The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle.

Left Ventricle

The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body.

Papillary Muscles

The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles opens these valves. When the papillary muscles relax, the valves close.

Chordae Tendineae

The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings."

Tricuspid Valve

The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery.

Mitral Value

The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta.

Pulmonary Valve

The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right

ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart.

Aortic Valve

The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart.

KIDNEY

The kidneys are dark-red, bean-shaped organs. One side of the kidney bulges outward (convex) and the other side is indented (concave). There is a cavity attached to the indented side of the kidney, called the Renal Pelvis... which extends into the ureter.

Each Kidney is enclosed in a transparent membrane called the renal capsule... which helps to protect them against infections and trauma. The kidney is divided into two main areas... a light outer area called the renal cortex, and a darker inner area called the renal medulla. Within the medulla there are 8 or more cone-shaped sections known as renal pyramids. The areas between the pyramids are called renal columns.

NURSING CARE PLAN

DIAGNOSIS: ACUTE PAIN

ASSESSMENT SUBJECTIVE CUES: y Masakit ang tahi ko as verbalized by the client DIAGNOSIS
Acute pain related to surgical incision a s evidenced by facial mask of pain.

PLANNING
Within 8 hrs nursing intervention the patient will:

INTERVENTIONS

RATIONALE

EVALUATION

Independent > Provide information and anticipatory guidance regarding causes of discomfort and appropriate interventions. > Promotes problem solving, helps reduce pain associated with anxiety and fear of the unknown, and provides sense of control.

Goal Met

> Identify and use appropriate interventions to manage pain/discomfort.

Objective Cues: > Verbalize lessening of level of pain.

(+) Guarding behavior (+) Facial mask of pain

> Appear relaxed, able to sleep/rest appropriately.

> Reposition client, reduce noxious stimuli, and offer comfort measures, e.g., back rubs. Encourage use of breathing and relaxation techniques and

> Relaxes muscles, and redirects attention away from painful sensations. Promotes comfort, and reduces unpleasant distractions,

distraction (stimulation of cutaneous tissue).

enhancing sense of well-being

> Encourage early ambulation.

> Decreases gas formation and promotes peristalsis to relieve discomfort of gas accumulation, which often peaks on 3rd day after cesarean birth.

Collaborative > Administer analgesics every 3 4 hr prn. Medicate lactating client 45 60 min before breastfeeding. > Promotes comfort, which improves psychological 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.

RISK FOR INFECTION

ASSESSMENT
Subjective Cues: Paano maiiwasan ang impeksyon sa tahi ko? Objective Cues:

DIAGNOSIS
Risk for infection related to tissue trauma/broken skin.

PLANNING

INTERVENTIONS
Independent

RATIONALE

EVALUATION

At the end of the 3 days of nursing intervention, the client will: > Demonstrate techniques to reduce risks and/or promote healing. > Display wound free of purulent drainage with initial signs of healing (i.e., approximation of wound edges), uterus soft/no tender, with normal lochial flow and character.

[Not applicable; presence of signs/symptoms establishes an actual diagnosis]

> Encourage and use careful handwashing and appropriate disposal of soiled perineal pads, and contaminated linen. Discuss with client the importance of continuing these measures after discharge. > Encourage oral fluids and diet high in protein, vitamin C, and iron.

> Helps prevent or retard spread of infection.

Goal Met

> Prevents dehydration; maximizes circulation and urine flow. Protein and vitamin C are needed for collagen formation; iron is needed for Hb synthesis.

> Inspect abdominal dressing for exudate or oozing. Remove dressing, as indicated.

> A sterile dressing covering the wound in the first 24 hr 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. > These signs indicate wound infection. Wound infections are usually clinically apparent 3 8 days after the procedure.

> Inspect incision, evaluate healing process, noting localized redness, edema, pain, exudate, or loss of approximation of wound edges.

SELF- CARE DEFICIT

ASSESSMENT
Subjective Cues: Kailan ko kaya ,agagawa ang normal na Gawain ko? Self-care deficit related to decreased strength and endurance as evidenced by inability to ambulate independently. At the end of a two hour nursing intervention, the client will: > Verbalization of inability to participate at level desired. > Demonstrate techniques to meet self-care needs. > Identify/use available resources.

DIAGNOSIS

PLANNING

INTERVENTIONS
Independent > Assess client s psychological status.

RATIONALE

EVALUATION

Objective Cues: Inability to ambulate independently.

> Physical pain experience may be compounded by mental pain that interferes with client s desire and motivation to assume autonomy. > Improves selfesteem; increases feelings of well-being.

Goal Met

> Offer assistance as needed with hygiene (e.g., back rubs, and perineal care). > Offer choices when Possible.

> Allows some autonomy, even though client depends on professional assistance. > Reduces discomfort, which could interfere with ability to engage in self-care.

Collaborative > Administer analgesic agent every 3 4 hr, as needed.

DRUG STUDY

DRUG NAME

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE REACTION

NURSING RESPONSIBILTIES  Monitor the v/s  Monitor for the adverse reactions.  Instruct the client to take only the medicine as prescribed by the doctor.

y y

Zanovic Potein NSAID

 Relief of moderate pain when therapy will not exceed 1 wk.  Treatment of primary dysmenorrhea

 Contraindicated with hypersensitivity to mefenamic acid, aspirin allergy, and as treatment of perioperative pain with coronary artery bypass grafting.

 Headache, dizziness, fatigue, tiredness, nausea, vomiting, dyspnea, dysuria, rhinitis.

GENERIC NAME y Mefenamic acid Classification y NSAID

DRUG NAME

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE REACTION

NURSING RESPONSIBILTIES  Monitor the v/s  Monitor for the adverse reactions.  Instruct the client to take only the medicine as prescribed by the doctor.

Amoxil

Bactericidal: inhibits synthesis of cell wall of sensitive organisms, causing cell death.

GENERIC NAME y Amoxicillin trihydrate Classification y antibiotic

Indicated in the treatment of infections due to susceptible (ONLY lactamasenegative) strains of the designated microorganisms in the conditions listed below: Infections of the ear, nose, and throat due to Streptococcus spp. ( -and hemolytic strains only), S. pneumoniae, Staphylococcus spp., or H. influenzae.

Contraindicated with allergies in penicillins, cephalosporins, or other allergens.

Lethargy, hallucinations, seizures, glossitis, stomatitis,gastritis, nephritis, anemia, leukopenia, fever, sore mouth.

DRUG NAME

MECHANISM OF ACTION
treatment of hypertension

INDICATIONS

CONTRAINDICATIONS

ADVERSE REACTION

NURSING RESPONSIBILTIES

Lodipen

Chronic stable angina, alone or in combination with other drugs.

Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sicksinus syndrome, heart block, lactation.

Dizziness, headache, fatigue, lethargy, arrhythmias , rash, nausea.

 Monitor the v/s  Monitor for the adverse reactions.  Instruct the client to take only the medicine as prescribed by the doctor.

GENERIC NAME y Amlodipine Besylate Classification Antianginal, AntIhypersensitive, Calcium channel blocker

DISCHARGE PLANNING MEDICATIONS  Instruct immediate relative to facilitate the patient to continue taking the drugs given to her on the right time and with the right dose to facilitate continuity of care.  Advise the patient not to skip doses and to inform physician if any signs of toxicity and hypersensitivity occurs.  Inform the client the side effects of the drugs so that the patient will not worry if these manifest.  Take the medicine as prescribed by the doctor.

Hygiene  Instruct the client to change the dressing of the wound twice a day if necessary.

Health teaching    Continue breastfeeding. Proper nutrition Immunization for the baby and tetanus toxoid for the mother.

REFFERENCES:

http://www.scribd.com/doc/17273353/PreEclampsia-A-Case-Study

http://www.scribd.com/doc/44057231/Post-Partum-Preeclampsia-Mild

http://www.scribd.com/doc/6774377/Drug-Study

http://en.wikipedia.org/wiki/Pre-eclampsia

http://www.babycenter.com.ph/pregnancy/complications/pre-eclampsia/