INTRODUCTION

Preeclampsia is a pregnancy condition in which high blood pressure and protein in the urine develop after the 20th week (late 2nd or 3rd trimester) of pregnancy. Preeclampsia occurs in a small percentage of pregnancies. Risk factors include: First pregnancy Multiple pregnancy (twins or more) Obesity Older than age 35 Past history of diabetes, high blood pressure, or kidney disease Symptoms Often, women who are diagnosed with preeclampsia do not feel sick. Symptoms of preeclampsia can include: Swelling of the hands and face/eyes (edema) Weight gain More than 2 pounds per week Sudden weight gain over 1 - 2 days Note: Some swelling of the feet and ankles is considered normal with pregnancy.

Expectations (prognosis) Usually the high blood pressure, protein in the urine, and other effects of preeclampsia go away completely within 6 weeks after delivery. However, sometimes the high blood pressure will get worse in the first several days after delivery. A woman with a history of preeclampsia is at risk for the condition again during future pregnancies. Often, it is not as severe in later pregnancies. Women who have high blood pressure problems during more than one pregnancy have an increased risk for high blood pressure when they get older. Death of the mother due to preeclampsia is rare in the U.S. The infant's risk of death depends on the severity of the preeclampsia and how prematurely the baby is born.

 IUFD the intrauterine death of a fetus, or the death of a fetus weighing at least 500 g or after 20 or more weeks of gestation.
Symptoms of Fetal death The list of signs and symptoms mentioned in various sources for Fetal death includes the 5 symptoms listed below: Death of a fetus Sudden loss of pregnancy symptoms Sudden cessation of fetal movement Miscarriage Unable to find fetal heartbeat upon examination

 Causes of Fetal death (Diseases Database): The follow list shows some of the possible medical causes of Fetal death that are listed by the Diseases Database: Fryns syndrome 3 Gracile bone dysplasia Multiple pregnancy Rubella, congenital Eclampsia Incontinentia pigmenti Pyelonephritis, acute Haemoglobin Bart's

Urinary tract infection Pre-eclampsia Ethanol Vanishing twin syndrome Syphilis, congenital Down syndrome Chromosome 18 trisomy syndrome Parvovirus B19 infection Uterine anomaly Japanese encephalitis Chorioamnionitis Listeria monocytogenes Chromosome 13 trisomy syndrome Premature labour & delivery De la Chapelle dysplasia Tobacco smoking Chagas' disease

Bloom's syndrome Toxoplasma, congenital Fetal akinesia-hypokinesia sequence Hydrops fetalis Achondrogenesis type 1B Sickle cell disease Gestational diabetes Placental abruption Achondrogenesis, type 1A Atelosteogenesis type 1 Intrauterine growth retardation Placental insufficiency

Demographic Profile
Name: Llobrera, Rhea Age: 29 Address: Mahabang Parang, Batangas Birthday: August 15, 1982 Birthplace: Manila

Fathers name: Roger Llobrera Mothers name: Allea Llobera Oriental Mindoro

Spouse: Roque Megullo (live in) Occupation: none Admission Diagnosis: G3P2 (2013)

PU Preterm breech, delivered by partial breech extraction by maneuvers to a still born baby BW 539 g, PES: PCSI (2007) for multiple gestation: manual extraction of placenta and completion curettage

Admission:
date: 08-14-11 time: 5:00 A.M. Discharge: date: 08-17-11 time: 12 NN

Attending Dr.: Dra Ibanet/ Girao

History
History of present illness
Pain in the hypogastric area felt sometimes No fetal movement No development

Past Medical History

no past medical illnesses

cough and colds with fever (seasonal)

no allergies hospitalizations only when on labor

family history
Father and mother

hypertensive

Genogram

hypertensive

hypertensive

Legend: Grandfather Grandmother Father Mother patient

Social Data
has good relationship with her live-in partner and parents

does not have job but before a sewer

income comes from her parents because as of now, her partner does not have a job graduated only 4th year highschool has good relationship with neighbors as evidence by sharing of joys and in problems

Lifestyle
used to eat fatty foods like chicharon and those fried foods with too much oil plan to have diet to have a healthy body but did not continue because of eating habits sleeps usually late, does not have difficulty in sleeping Cleans house and washes clothes household chores becomes her daily exercise

Psychological Data
usual stressors in daily life is financial problem in coping they do diskarte or part time jobs like washing clothes of their neighbors

Patterns of Health care

when sick, she usually goes to manghihilots and albularyos goes also in health centers

Developmental History
Theory of prenatal attachment (John Bowlby)
- this theory posits that there is a unique relationship that develops between parents and fetus before the child is born - for 4 months that the baby is inside the uterus, there is already a relationship between him and her mother. - IUFD, the mother is really affected with what happen to the baby. The attachment that was developed was lost

Developmental History
Ego identity (Erik Erickson)
- it is a sense of self that we develop through social interactions.

- it changes because of our new experiences that we acquire in our daily lives
- the mother changes after what happened because of death of her child, thus affecting her behavior after the operation, as noticed by frequent irritability in simple situations

Developmental History
Theory of Personality (Abraham Maslow)
Self actualization

Esteem needs

Belonging and love needs

Safety needs

Physiological needs

Theory of Personality (Abraham Maslow) - the mother has achieved something in bearing in her 3rd child thus he is already in the Esteem needs - but because of the IUFD the mother goes down again in the pyramid. - she goes down to belonging and love needs, safety needs and physiological needs

PHYSICAL ASSESSMENT

General Survey:
Vital Signs Temperature Pulse Respiration Blood pressure Hg 36.3 C 115 bpm 20 cpm 140/100 mm

BODY PARTS

METHOD USE

FINDINGS

INTERPRETATION

General appearance
Skin

Inspection

Conscious and coherent

Pallor

Normal

Inspection

Abnormal

Head

Palpation

No tenderness, symmetrical

Normal

Hair

Inspection

Evenly distributed, Black in color

Swollen face

Normal

Face

Inspection

Abnormal

Eyes

Inspection

Not protruding, symmetrical

Normal

Pupils

Inspection

Round, Reactive to light

Normal

BODY PARTS

METHOD USE

FINDINGS

INTERPRETATION

Ears

Inspection

No discharges, no tenderness, symmetrical in position

Normal

Nose

Inspection

No lesions or inflammation

Normal

Mouth

Inspection

Pale lips

Normal

Neck

Inspection Palpation

No palpable mass or Normal lumps,

BODY PARTS

METHOD USE

FINDINGS

INTERPRETATIO N

Heart

Auscultation

Adynamic pericardium, tachycardia,( -) murmur

(-) dentures

Normal

Teeth

Inspection

Normal

BODY PARTS

METHOD USE

FINDINGS

INTERPRETATION

Upper Extremities

Inspection

Equal in size, swelling due to edema Color evenly distributed

Abnormal (the arms of the pt. are swelling)

Lower Extremities

Inspection

Swelling due to edema

Abnormal (the legs of the pt. are swelling)

BODY PARTS Genitalia

METHOD USE Inspection

FINDINGS Post partum bleeding

INTERPRETATION normal

Pathophysiology

Pre-eclapsia
Hypertension in pregnancy
Associated with significant protein in urine

May develop from 20 weeks of gestation/ late 2nd or 3rd trimester involves generalized damage to the maternal endothelium, kidneys, and liver

 involves generalized damage to the maternal endothelium, kidneys, and liver

 Affects 3% of pregnancies Most common in 1st time pregnancies More common in preexisting hypertension, diabetes

 Common in family with past history, obese women, and multiple gestations

Causes
Shallowly implanted placenta

Immune tolerance

Symptoms
Swelling of the hands and face/eyes Weight gain

Symptoms for severe pre-eclampsia

Headaches that are dull or throbbing and will not go away Agitation Abdominal pain

 Decreased urine output, not urinating very often Nausea and vomiting (worrisome sign) Vision changes -- temporary loss of vision, sensations of flashing lights, auras, light sensitivity, spots, and blurry vision

Past medical family history of pre-eclampsia

Hypoxic placenta

Immune response acting on vascular endothelium

Shallowly attached placenta

lacks the receptors for the proteins the placenta is using to downregulate the maternal immune system's response to it.

Hypertension High pressure on renal blood vessels Increased bloo flow through capillaries

Damaged nephrons

Mothers immune system attacks tissues of developing child

Dysfunction of kidneys

Increased difusion

Intrauterine fetal death

Increased amount of protein in urine

Protienuria

Excess fluid in tissues Edema

LABORATORY PROCEDURES

Laboratory or Reference Diagnnostic Values: procedure:

Actual Results:

Interpretatio n:

Glucose SGPT/ALT SGOT/AST

4.1-5.9 0.0-38.0 0.0-0.40

3.89 mmol/L 19.6 IU/L 36.5 IU/L 7.2 mg/dL 0.55 mg/dL

Low Normal Normal Normal Normal

Urea Nitrogen 7.0-18.0 Creatinine 0.5-1.7

Laboratory or Reference Diagnnostic Values: procedure:

Actual Results:

Interpretatio n:

Hemoglobin Hematocrit Total RBC Total WBC Segmenter Lymphocyte

120-150 g/L 0.36-0.45 4-6 x 1012 L 5-10 x 109 L 0.40-0.60 0.20-0.40

124 0.35 4.11 13.6 0.81 0.19

Normal Low Normal High High Low

Urinalysis Date:

Normal value

Result

Color

Yellow to amber

yellow

Transparency
Reaction Sp. Gravity

clear
1.8-7.8 1.015-1.025

light turbid
5.0 1.010

Sugar
Protein Microscopic

Negative
Negative

Negative
Positive

Pus cell (WBC)

0-2hpf

3-5/hpf *high white blood cell may indicate infection

RBC Epithelial cell Bacteria A. Urates

0-1 hpf Few present Few present Few

0-1/hpf Few Few Few

HBsAg
Non-reactive

Blood type: B

Medical Management
Medical Regimen Laboratory Procedures -CBC
-Platelet -HBsAG -Blood Typing -FBS -BUN -Glucose -Creatinine -Hemaglobin

Rationale
-For complete # of blood cells -For blood clotting -For Hepa B -For knowing the blood type -For diagnosis of diabetes milletus -Measures level of urea nitrogen -For the amount of sugar -Measures kidney function
-For protein in red blood cells that carries oxygen

Medical Management
Medical Regimen
-Hematocrit

Rationale
fraction of the blood composed of red blood cells

-Total RBC -Total WBC

IV Infusions -D5LR -20 units oxytoxin -Plain LR -MgSO4

- Total # of red blood cells - Total # of white blood cells

Hypertonic solution Systemic alkalizer; fluid & electrolyte replenisher

Medical Management
Medical Regimen
Follow up Order -Perineal Hygiene -Putting of vaginal packing -Removal of vaginal packing -may have soft diet -putting foley catheter -remove foley catheter -monitor VS q4hrs -follow-up blood chem result

Rationale
-to avoid infection in perineal area
to slow and stop bleeding -To ensure patients digestion to drain the urine -To obtain baselines data -Monitor the levels of blood of the patient

SURGICAL MANAGEMENT

SURGICAL PREPARATION Patient placed in Dorsal Lithotomy position

RATIONALE
This ensures a good view of the genital area for the surgeon or gynecologist to operate For sterility and prevention of infection For urination

Asepsis and antisepsis then drapes applied. Bladder catheterization IT: cervix fully dilated, fully effaced, bulky

SURGICAL PREPARATION The baby delivered spontaneously by partial breech extraction followed by maneuver. Relieved to stillborn baby Umbilical cord dubly elevated and cut in between.

RATIONALE

For separation in placenta

SURGICAL PREPARATION Placenta delivered by manual extraction followed by of completion curretage. Cervical and vaginal due to Laceration Patient tolerated the procedure well.

RATIONALE
to remove fragments of placenta after childbirth or as a method of abortion To stop bleeding

To make sure patient is okay

Post Operative Orders

S/P manual extraction of placenta and completion curretage under IV sedation Back to room DAT once fully awake Please monitor VS q15 until stable and normal Please monitor TiO night shift and record IVF ongoing D5LR + 20units oxytocin X 8hours. IVF to follow ( D5LR + 10units oxytocin X 8hours, PLR7L X 10hours)

DRUG STUDY

Generic name: hydralazine hydrochloride Brand name: Apresoline

Classification: Antihypertensive Mechanism of Action: Decreases blood pressure, increases heart rate, stroke volume and cardiac output.

Indications: Hypertensive

Dosage:5mg
Frequency: q6

Route of Administration: IV

Adverse/Side Effects:GI: CNS: Contraindicatio dizziness, drowsiness,hea ns: dache Hypersensitivit y to the drug or CV: tachycardia, tartarzine angina, Conorary heart arrythmias disease EENT: Mitral valvular lacrimation,nas rheumatic heart al congestion disease GI: nausea, vomitting, diarrhea, constipation SKIN: rashes, blisters

Nursing Responsibilities : Monitor blood pressure, pulse rate, and regularity and daily weight. Monitor CBC, lupus erythematosus cell studies and antinuclear antibody titers before and periodically during therapy.

Generic name: metronidazole Brand name: Flagyl

Classification: Anti-infectives, Anti-protozoals Mechanism of Action: Disrupts DNA and protein synthesis in susceptible organisms. Bactericidal, or amebicida action

Indications: Ambecide in the management of amebic dysentery

Adverse/Side Effects: CNS: seizures, dizziness, headache

Nursing Responsibilities: Inform patient that medication may cause an unpleasant metallic taste.

Dosage:
Frequency:

Contraindications: hypersensitivity

Route of Administration :

GI: abdominal pain, nausea, diarrhea, glossitis, unpleasant taste, vomiting

Inform patient that medication may cause urine to turn dark.

Advise patient to consult health care professional if no improvement in a Hematologic: few days or if signs and leukopenia symptoms of superinfection.

Skin: rashes, urticaria

Generic Name: Ampicillin sodium Brand Name: NovoAmpicillin Dosage: 2mg Frequency:q6 Route of Administration: IV

Classification: Anti- infective Mechanism of action: Inhibits cell-wall synthesis during bacterial multiplication

Indications: intraabdominal, gynecologic and skinstructure infections caused by susceptible strains. Contraindicatio ns:

Adverse Effects/ Side Effects: Nausea Vomiting Diarrhea Pain at injection site Vein irritation

Contraindicated in patients hypersensitive to drug or other penicillins.

Nursing Responsibility: Before giving drug, ask patient about allergic reactions to penicillin If large doses are given or if therapy is prolonged, bacterial or fungal super infection may occur, especially in elderly, debilitated or immunosuppressed patients.

Generic Name: Mefenamic Acid Brand Name: Ponstan Dosage: 500 mg Frequency: q6 Route of Administration: per orem

Classification: Analgesic and antiinflammatory Mechanism of action: Antiinflammatory, analgesic and antipyretic activities related to inhibition of prostaglandin synthesis; exact mechanics of action are not known.

Indications: Relief of moderate pain when therapy will not exceed 1 week. Treatment of primary dysmenorrhea Contraindications Contraindicated with hypersensitivity to mefenamic acid and aspirin allergy

Adverse Effects/ Side Effects: Headache Dizziness Tiredness Rash Hemoptysis Rhinitis Pruritus Fatigue Somnolence

Nursing Responsibility: Check for hypersensitivity to drug. Monitor the adverse effects.

Generic name: Cephalexin Brand name: Keflex

Classification: anti-inefective

Mechanism of Action: Interferes with cell-wall Dosage: 500mg syynthesis, causing cell to Frequency: q6 rupture and die. for 7 days

Indications: For the treatment of respiratory tract infections caused by streptococcus pneumoniae and streptococcus pyogenes.

Route of Administration: per orem

Contraindicatio ns: Hypersensitivit y to cephalosporins or penicillin.

Adverse/Side Effects: CNS: fever, headache, seizures CV: hypotension, edema, chest pain GI: nausea, vomitting, diarrhea, abdominal cramps EENT: hearing loss

Nursing Responsibilities : Assess signs and symptoms of seroius adverse reactions, including hypersensitivity, severe diarrhea and bleeding. During longterm therapy, monitor CBC and liver and kidney function test results.

Generic name: Magnesium sulfate Brand name: Epsom Salts Dosage: Frequency:

Classification: Anticonvulsant Mechanism of Action: Increases osmotic gradient in small intestine, w/c draws water into intestines and causes distention

Indications: Mild magnesium deficiency Contraindicatio ns:

Adverse/Side Effects:

Nursing Responsibilities :

Route of Administration:

Assessment/Cues Subjective Cues: Napansin ko bigla na lang bumigat ang timbang ko as verbalized by the patient

Nursing Diagnosis
Problem: Positive for preeclampsia Etiologic Factors: - Problems with the cells that line the insides of certain blood vessels. - Overproduction, underproduction, or malfunction of proteins needed to grow new blood vessels in the placenta - Abnormal development of capillaries and certain types of muscles within the placenta. - Increased immune system sensitivity which causes the mothers immune system to attack certain molecules that are needed to regulate blood flow into the placenta. - Increased overall sensitivity to hormones that regulate blood pressure and blood flow in different parts of the body.

Case Background

Plan

Goal: To eliminate the presence of pre Abnormal increased eclampsia blood pressure Outcome Criteria: Overproduction, underproduction, or malfunction of proteins needed to grow new blood vessels in the placenta After 8 hours of nursing interventions, the patient will participate activities the reduce blood pressure or cardiac work load

Objective Cues:
Variations in blood pressure Edema non febrile T36.2 C PR: 115 bpm RR: 20 cpm BP: 140/90 mmHg

Pre eclampsia

Signs and Symptoms:

-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 nausea

Interventions

Rationale Comparison of pressures

provide more complete picture of vascular involvement or scope of the problem.

Evaluation

Independent: Monitor blood pressure of the

patient. Measure in both arms or thighs three times , 3-5 minutes apart while patient is at rest, then sitting, standing for initial evaluation. Observe skin color, moisture, temperature, and capillary refill time. Note dependent or general edema Provide calm, restful surroundings, minimize environmental activity or noise.

After 8 hours of nursing interventions, the patient was able to participate in activities that reduce blood pressure or cardiac work load
Goal was met

presence of pallor, cool, moist skin and delayed capillary refill time may due to peripheral vasocontriction. may indicate heart failure, renal or vascular impairment. help reduce sympathetic stimulation promotes relaxation

Maintain activity restrictions

reduces physical stress and tensions that affect blood pressure and course of hypertension

Collaborative:
Implement dietary sodium, fat and cholesterol restrictions as indicated These restriction can help manage fluid retention and associated with hypertensive response which decrease cardiac work

Assessment/Cues Subjective Cues: Hindi na gumagalaw ang baby ko sa tiyan as verbalized by the patient

Nursing Diagnosis Problem: Anticipatory grieving related to fetal loss Etiologic Factors: unexplainable cord accident placental insufficiency, undiagnosed diabetes, partial abruption of the placenta

Case Background

Plan Goal: To help the patient cope up with fetal loss Outcome Criteria: after 8 hours of nursing interventions, the patient will be able to accept their babys loss

unexplainable cord accident, placental insufficiency, undiagnosed diabetes, partial abruption of the placenta .

Objective Cues:
non febrile T37.1 C PR: 78 bpm RR: 20 cpm BP: 140/90 mmHg

IUFD

grieving

Signs and Symptoms

the baby has stopped moving for a long period of time a uterus or womb that fails to get bigger over time an inability to hear the baby's heartbeat with a special heart monitor lack of movement of the baby or no heartbeat during a pregnancy ultrasound a special test that uses sound waves to show the baby an abnormal blood level of the hormone of pregnancy, known as a quantitative HCG test

Interventions
Induce labor to deliver the baby Turn the patient side to side hourly (If the patient has an epidural) check the blood pressure every 30 minutes Monitor patients pain relief admit the patient to an isolated room from the nursery, patients in labor and crying of newborns encourage the patient and significant other/s to verbalize their feelings Involve the patient and significant other/s in all discussions and decisions related to the labor, delivery and after care Provide reading materials for the parents on coping with a

Rationale the mother will be free from

possible infections to ensure the adequate distributions of anesthesia

Evaluation

to know whether the blood

pressure is normal or not

Goal was partially met because after 8 hours of nursing interventions, the patient has slowly accepted their babys loss

to avoid discomfort
to provide peaceful surroundings hence, provide comfort as well to learn more about the patients real feelings towards the situation parents will be more aware about the situation

parents will be more knowledgeable and they will be

NURSING CARE PLAN

Assessment Nursing Dx Subjective: Impaired masakit yung comfort puson ko.. as verbalized by the related to patient. acute pain Pain scale of 7 as Objective: manifested Very minimal by facial movement grimace. Irritable
Restless Facial grimace unesiness
Case Background
Acute pain
Real or potential tissue damage

Plan
Goal: To promote comfort

Outcome Criteria: After 8hours of nursing intervention, patient will: Passes on to nerves 1. Engage in behavior in the spinal cord or lifestyle changes to increase level of Attention as a ease. crucial component 2. verbalized sense of of pain comfort or contentment. Focus is disrupted 3. Participate in desirable and realistic health Impaired comfort seeking behaviors.

NURSING CARE PLAN

Interventions
Independent: 1.) Encouraged adequate rest periods. Promote a healthy lifestyle through intake of proper foods. Review knowledge on how to cope up with unexpected situations 2.) Assist client to more comfortable positions. Provide health teachings on how to promote comfort. 3.) Offer relaxation through headmassage. Discuss potential complications to family of patient. Determine environmental factors that may lead to discomfort. Dependent: Administer analgesics such as aspirin or paracetamol.

Rationale
prevention of fatigue improve body defenses against possible agents for pain bring clients awareness

Evaluation
Goal was completely met because patient was able to verbalize a reduction of pain scale from 7 to 2.
Patient was also able to engage herself in minor physical activities such as morning exercise.

to prevent additional injury to gain knowledge that can be used for self-care. To minimize pain and relax patient. To promote wellness and refocus patient. To provide barriers for those factors. For pain reliever.

SUMMARY DISCHARGE

M.E.T.H.O.D.S
MEDICATIONS Cefalexin 500mg ENVIRONMENT

TREATMENT

HEALTH TEACHINGS

Ponstant 500mg
metronidazole 500mg iberet 500mg with folic

Usually, A medicines comfortable environment and IV fluids characterize are given to D&C patients d by good after the ventilation, surgery. VS clean, quiet, are roomy and monitored with enough until stable. sunlight.

Patient should understand the need for intake of proper nutritious foods to gain energy back, keep self hydrated, prevent self from experiencing fatigues, do not carry too heavy objects, do light exercises such as walking and refrain self from getting injured.

M.E.T.H.O.D.S
OPD follow up
You should not insert anything into the vaginal area, including douche and sexual intercourse, for at least 2 weeks or until the bleeding stops. (Your health care provider should give you specific instruction for when intercourse can resume.) Tampons should not be used until you start your next regular period, which could be anywhere from 2-6 weeks after the D&C procedure. It will be unknown when ovulation will return, so once sexual intercourse is allowed, you should use a method of contraception until your health care provider says it is okay to try to get pregnant again. Make sure to attend your follow up appointment.

DIET

SPIRITUAL
Most importantly, after having a D&C, make sure to nurture yourself. Your body needs time to recover, and you probably need some time to recover emotionally as well. Hopefully, as your body heals, you'll be ready to try again and to have a beautiful pregnancy in the future.

Take vitamins, eat plenty of fruits and vegetables and drink plenty of water.