ST.

MARYS COLLEGE
NURSING PROGRAM
Tagum City
CASE STUDY
on
Preeclampsia
Presented to
Ms. Lesley Cadua RN,MN
Ms. Joan Calzada RN, MN
In Partial Fulfillment of the Requirements
In
Related Learning Experience
(RLE)
By
BSN 2-A
Pinky Rose Jean Marfil

Ian mizzelDulfina

Yvonne Obra

RondelDadula

Axel Mae Abarico

Jose Mari Bernardino

Zhendy Solis

John Occeo

Holly Eve Pasuquin

Niel Sabino

February 2013

TABLE OF CONTENTS

INTRODUCTIONI
ASSESSMENT..II
A. BIOGRAPHICAL DATA
B. CHIEF COMPLAINT
C. HISTORY OF PRESENT ILLNESS
D. PAST MEDICAL AND NURSING HISTORY
E. PERSONAL, FAMILY AND SOCIO ECONOMIC HISTORY
F. PATIENT NEED ASSESSMENT
G. COURSE IN THE WARD
LABORATORY AND DIAGNOSTIC EXAMINATIONSIII
REVIEW OF ANATOMY AND PHYSIOLOGY.IV
SYMPTOMATOLOGYV
ETIOLOGY OF THE DISEASEVI
PATHOPHYSIOLOGY..VII
A. Written
B. Diagram
PLANNING
A. Nursing Care Plan
B. Discharge Plan
PHARMACOLOGICAL MANAGEMENTIX
SYNTHESIS OF CLIENTS CONDITION/STATUS FROM ADMISSION TO PRESENT.X
EVALUATION OF THE OBJECTIVES OF THE STUDYXI

BIBLIOGRAPHYXII

I. Introduction
Pre-eclampsia, formerly called toxemia of pregnancy is an abnormal condition of
pregnancy characterized by the onset of an acute hypertension after the 24 th week of
gestation. The classic triad of preeclampsia is elevated BP 140/90, proteinuria and
edema. The cause of the disease remains unknown despite 100 years of research by
thousands of investigators. Pre-eclampsia commonly causes abnormal metabolic
function, including negative nitrogen balance, increase central nervous system
irritability, hyperactive reflexes, compromised renal function, hemoconcentration, and
alteration of the fluids and electrolytes balance. It occurs in 5-7% of pregnancies. Most
often in primigravida and is more common in some areas of the world than others, the
incidence is particularly high in the southern part of the U.S. The incidence increases
with increasing gestational age and it is more common in cases of multiple gestation, H.
Mole or hydramnios. A typical lesion in the kidney, glomerulo endotheliosis is
pathognomonic termination of the pregnancy results in the resolution of the signs and
symptoms of the disease and in healing of the renal lesion. Preeclampsia is classified
as mild or severe. Mild eclampsia is diagnosed if one or more of the following signs
develop after 24th week of gestation. Systolic BP of140 mmHg or more or an increase of
30 mmHg of more above the womans systolic BP; proteinuria and edema. Severe
preeclampsia is diagnosed if one or more of the following signs is present.; systolic BP
160 mmHg and above, diastolic Bp of 110 mmHg above on two occasions 6 hours apart
with the woman on bed rest; proteinuria of 5g or more within 24 hours; oliguria of less
than 400cc in 24 hours; ocular or cerebral vascular disorders; and cyanosis or
pulmonary edema. Complications include premature separation of the placenta,

hemolysis,

cerebral

hemorrhage,

ophthalmologic

damage,

pulmonary

edema,

hepatocellular changes, fetal malnutrition and lower birth rate. The most common
complication is eclampsia, which can results to both maternal and fetal death. Healthy
living conditions including a diet with high in proteins, calories and essential nutritional
elements, rest and exercise are associated with decrease incidence of pre-eclampsia.
Treatments include rest sedation, magnesium sulfate, and antihypertensive. Ultimately if
eclampsia threatens delivery by induction of labor or CS may be necessary. (Mosbys
dictionary of Medicine, Nursing and Health Professions,)
In developing countries, preeclampsia impact 4.4% of all deliveries. The
incidence of preeclampsia as of 2002 up to present raises to 146, 320 cases annually. It
affects 5% of pregnancies worldwide. In United States, approximately 1 in 1858 cases
or

0.05%

equivalent

to 146,320

people

in

the

U.

S have

preeclampsia.

(cureresearch.com/p/preeclampsia/stats-country.htm). In the Philippines, cases of

preeclampsia exceeds up to 0.05% of pregnancies annually or 46,392 cases out of
86,241,697 as of 2009. (www.doh.gov.ph). In local setting, 25 cases of preeclampsia
were recorded at the Tarlac Provincial Hospital from January-December of the year
2008. (TPH records).

IMPORTANCE OF THE CASE STUDY

We chose this case because we are aware that pregnancy - related
complications or abnormalities, is not a simple problem, which can even lead to both
fetal and maternal death that is why this case in very significant. Knowing that Mrs. X is
experiencing hypertension during her pregnancy (preeclampsia) and is at risk for
complications such as eclampsia (a life threatening condition), we, as the student
nurses in charge of taking care and rendering healthcare services to her, must know
well about the course of her condition and the possible nursing interventions we can
provide to manage her condition. This case is also significant in the actual practice of
our nursing profession.
Objectives

Define what is preeclampsia

Trace the pathophysiology of preeclampsia

Enumerate the different signs and symptoms of preeclampsia

Formulate and apply nursing care plans utilizing the nursing process

To learn new clinical skills as well as sharpen our current clinical skills
required in the management of the patient with preeclampsia.

To develop our sense of unselfish love and empathy in rendering nursing

care to our patient so that we may be able to serve future clients with
higher level of holistic understanding as well as individualized care.

II. ASSESSMENT
A. BIOGRAPHICAL DATA
Patients Name: Mrs. X
Address: Prk. 5, Sindahon, Panabo City, Davao del Norte
Sex: Female
Age: 39 years old
Civil Status: Married
Birthdate: 03/05/1973
Birthplace: MATI, DAVAO ORIENTAL
Nationality: Filipino
Religion: Catholic
Occupation: House keeper
B. CHIEF COMPLAINT
Dyspnea
C. History of present illness
Morning prior to admission patient notice onset of labor pains 6hours prior
to admission patient had persistent labor pains associated with dyspnea.
D. Past medical and Nursing History
Positive outer neck mass for 3 years
E. Personal, family and socio-economic history
Mrs. X is plain housewife and her husband is a farmer. She graduated at a
Public Elementary School. And she didnt continue her studies due to financial
problem. On prenatal care with poor compliance.

F. Patient need assessment

I. OXYGENATION
BP__160/110__ RR 49 cpm____CR___149bpm
(CHARACTER)tachypnia___
LUNGS (per auscultation: character, lung sound, symmetry of chest
expansion, breathing character and pattern):crackles sounds heard upon
auscultation, with symmetrical chest expansion, intercostals retraction
noted, use of accessory muscles noted.
CARDIAC STATUS (per auscultation) sounds, character, chest pain.
__Lub-dubb sound heard with increased intensity per auscultation,
chest pain not noted

CAPILLARY REFILL 4-5 sec._

SKIN CHARACTER AND COLOR_skin is brown, dry, flaky and

wrinkled.
II. TEMPERATURE MAINTENANCE
TEMPERATURE: 36.8oC_
SKIN CHARACTER_Skin is dry, flaky, wrinkled and not warm to touch_
III NUTRITIONAL FLUID
HEIGHT/WT 52/45 kg _ AMT. FOOD CONSUMED: with good appetite, able to
consumed the OF served
PRESCRIBED DIET: low salt low fat
EATING PATTERN: 3x a day_
INTAKE (IVF; FLUID/WATER: with IVF of D5LR 1L@30cc/hr, water = 300cc

 Other OBSERVATION (related): Skin is dry, has poor skin turgor

IV ELIMINATION
Last BOWEL MOVEMENT(frequency, amount, character)__able to defecate,
NORMAL PATTERN 1- 2x a day
URINATION(Frequency, character, sensation)_able to urinate
V REST-SLEEP
BED TIME _6-7 pm_WAKING UP__5:30 am_
SLEEP (pattern, amount of sleep)_5-6hrs_
PROBLEM AS VERBALIZED dili ko kayo makatulog OTHER OBSERVATION (related)_Patient can easily be distracted, thus, having
difficulty in sleeping back again
VI PAIN AVOIDANCE
RATE PAIN_-cant able to verbalize- TIME STARTED__7:30 PM_
LOCATION _abdomen__BEHAVIOR (restlessness, facial expression, irritable,
diaphoretic)frequent change of position noted, grimace face and guarding
behavior noted on abdomen area
FREQUENCY_intermittent_
CHARACTER cant able to describe, cant able to verbalize
OTHER observation (related) Patient has difficulty in sleeping due to pain felt
VII SEXUALITY REPRODUCTIVE
LMP__N/A__
GRAVIDA/PARITY__G7P6__
FMILY PLANNING METHOD USE: calendar method

 CHILDREN (no.) __6__

VIII STIMULATION ACTIVITY
WORK: Before: plain housewife

During:

needs assistance in performing

activities
HOBBIES/VICES: sleeping, a moderate smoker and drinker before
SAFETY AND SECURITY
MENTAL STATUS (Coherent, Responsive, conscious, unconscious) conscious,
able to respond by making incomprehensible sounds
EMOTIONAL PROBLEM (diaphoretic, trembling, restless)_restlessness: frequent
change of position due to pain felt________
LOVE BELONGING NEED
CHILDREN (living with?) Patient is loving and supportive
Wife (living with) husband. Due respect and care was given to her
SELF ESTEEM NEED
she is a good person and a loving mother. she has a moderate self
esteem, also because she is a friendly type of person and being loved by family
members.
GENERAL SURVEY
Date of Assessment: January 24, 2013
On bed, awake, responsive and tachypneic. Pale conjunctiva of the eye noted.
With IVF of # 4 D5LR 1L @ KVO rate @ Left metacarpal vein. Pale nailbeds noted with
capillary refill returns within 4-5 seconds. Bladder distention noted. Bipedal edema
noted.
Nutritional Status

Mrs. X stands 51 and weighs 49 kilos. On low salt, low fat diet. With IVF of #4
D5LR 1L @ KVO rate infusing well at Left metacarpal vein. With poor skin turgor.
Denies malnutrition during childhood.
Physical Assessment
Skin

Brown skin generally uniform in color except in areas exposed to the sun

Skin temperature uniform and within the normal range (36.80C)

Dry skin folds

Nails with smooth texture

cyanotic nail beds

Prompt capillary refill time (4-5 seconds)

Head

Present 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

Presence of discharge,

Yellowish sclera

Pale 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

Eyeballs protruding

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

Nasal septum intact and in the midline

Mouth and Throat

Outer lips uniform bluish in color with symmetric contour,

Buccal mucosa is of uniform pale in color

Gums are pink

Tongue slightly pale, not so moist, at central position

Neck

Head centered

Lymph node palpable

Breast

Firm

Generally symmetric in size

Cardiovascular

BP 160/110

PR 149

Symmetric pulse strength

Respiratory/Chest

Chest symmetric

Chest wall intact, no tenderness, no masses

Symmetric chest expansion and excursion

RR: 49bpm

Gastrointestinal/Abdomen

Straie present at hypogastric and iliac regions

Linea nigra present

No tenderness

Urinary

Absence of nocturia, dysuria, urgency, hesitancy

Light yellow urine

Reproductive

Regular menstrual cycle

G7p6

Musculoskeletal/Extremities

Muscle equal size on both sides of the body

No tenderness

Presence of edema

Smooth coordinated movements

Neurologic

Can respond to verbal commands

Oriented

Conscious

G. COURSE IN THE WARD

DATE

SHIFT

NURSES

NURSES

MEDICAL

ASSESSMENT INTERVENTION MANAGEMENT

01-18-13

73

Repiratory rate

Encourging

Oxygen

49

position

theraphy

changes(semifowlers)
Elevated BP

Ecourging

Antihypertensive

160/110

bedrest

theraphy

III. Laboratory and Diagnostic examinations

LAB EXAM
WBC Count

NORMAL VALUE
5-10x 10g/L

RESULT
16.8

RBC Count

4.20-6.30 T/L

1.49

Hemoglobin

115-155g/L

34g/L

Hematocrit
Platelet count

0.370-0.47g/L
140-440 G/L

0.123
120g/L

Urine protein
collection

+4

INTERPRETATION/IMPLICATION
Abnormally high due to presence
of inflammation
Decreased RBC due to
generalized vasospasm
Decreaseed hemoglobin due to
liver injury
decreased due to liver injury
Endothelial injury occurs, leading
to subsequent platelet adherence
Abnormally high due to severe
preeclampsia

IV.

REVIEW OF ANATOMY AND PHYSIOLOGY

THE PLACENTA

The placenta is an organ unique to mammals that connects the developing fetus
to the uterine wall. The placenta supplies the fetus with oxygen and food, and allows
fetal waste to be disposed of via the maternal kidneys. Protherial (egg-laying) and
metatherial (marsupial) mammals produce a choriovitelline placenta that, while
connected to the uterine wall, provides nutrients mainly derived from the egg sac. The
placenta develops from the same sperm and egg cells that form the fetus, and functions
as a fetomaternal organ with two components, the fetal part (Chorion frondosum), and
the maternal part (Decidua basalis). In humans, the placenta averages 22 cm (9 inch)
in length and 22.5 cm (0.81 inch) in thickness (greatest thickness at the center and
become thinner peripherally). It typically weighs approximately 500 grams (1 lb). It has a
dark reddish-blue or maroon color. It connects to the fetus by an umbilical cord of
approximately 5560 cm (2224 inch) in length that contains two arteries and one vein.

The umbilical cord inserts into the chorionic plate (has an eccentiric attachment).
Vessels branch out over the surface of the placenta and further divide to form a network
covered by a thin layer of cells. This results in the formation of villous tree structures.
On the maternal side, these villous tree structures are grouped into lobules called
cotelydons. In humans the placenta usually has a disc shape but different mammalian
species have widely varying shapes. The placenta begins to develop upon implantation
of the blastocyst into the maternal endometrium. The outer layer of the blastocyst
becomes the trophoblast which forms the outer layer of the placenta. This outer layer is
divided into two further layers: the underlying cytotrophoblast layer and the overlying
syncytiotrophoblast layer. The syncytiotrophoblast is a multinucleate continuous cell
layer which covers the surface of the placenta. It forms as a result of differentiation and
fusion of the underlying cytotrophoblast cells, a process which continues throughout
placental development. The syncytiotrophoblast (otherwise known as syncytium),
thereby contributes to the barrier function of the placenta. The placenta grows
throughout pregnancy. Development of the maternal blood supply to the placenta is
suggested to be complete by the end of the first trimester of pregnancy (approximately
1213 weeks). The placenta functions in two purposes. The perfusion of the intervillous
spaces of the placenta with maternal blood allows the transfer of nutrients and oxygen
from the mother to the fetus and the transfer of waste products and carbon dioxide back
from the fetus to the mother. Nutrient transfer to the fetus is both actively and passively
mediated by proteins called nutrient transporters that are expressed within placental
cells. In addition to the transfer of gases and nutrients, the placenta also has metabolic
and endocrine activity. It produces, among other hormones, progesterone, which is

important in maintaining the pregnancy; somatomammotropin (also known as placental

lactogen), which acts to increase the amount of glucose and lipids in the maternal
blood; estrogen; relaxin, and beta human chorionic gonadotrophin (beta-hCG).

PLACENTAL CIRCULATION

Maternal placental circulation

In preparation for implantation, the uterine endometrium undergoes 'decidualisation'.
Spiral arteries in the decidua are remodelled so that they become less convoluted and their
diameter is increased. This increases maternal blood flow to the placenta and also decreases
resistance so that shear stress is reduced. The relatively high pressure as the maternal blood
enters the intervillous space through these spiral arteries bathes the villi in blood. An exchange of

gases takes place. As the pressure decreases, the deoxygenated blood flows back through the
endometrial veins. Maternal blood flow is approx 600700 ml/min at term.
Fetoplacental circulation
Deoxygenated fetal blood passes through umbilical arteries to the placenta. At the
junction of umbilical cord and placenta, the umbilical arteries branch radially to form chorionic
arteries. Chorionic arteries also branch before they enter into the villi. In the villi, they form an
extensive arteriocapillary venous system, bringing the fetal blood extremely close to the maternal
blood; but no intermingling of fetal and maternal blood occurs ("placental barrier").
V.

SYMPTOMATOLOGY
Severe preeclampsia

Clinical Manifestation
Diastolic blood pressure
110mmHg or Higher

Proteinuria < 5g/24hr or >2+

or 3+

ACTUAL SYMPTOMS

IMPLICATION
Generalized
vasospasm results
elevation of blood
pressure
Decreased liver
perfusion

Increased hematocrit,
creatinine, and uric acid
levels
Thrombocytopenia with a
platet count < 100,000
platelets/mm3

Decreased kidney
perfusion

Oliguria <400mL in 24hours

Endothelial injury
occurs, leading to
subsequent platelet
adherence
Reduced blow flow to
kidneys

Epigastric or right upper

quadrant pain linked to
swelling of hepatic capsule

Cerebral or visual

Decreased liver
perfusion leads to
impaired liver function
and subcapsular
hemorrhage.
Decreased brain

disturbances

Hyperreflexia of DTRs

Elevated liver enzymes

Pulmonary edema with

cyanosis

Fetal growth restiction

perfusion leads to
small cerebral
hemorrhages and
symptoms of arterial
vasospasm
Decreased brain
perfusion leads to
arterial vasospasm
Decreased liver
perfusion
Reduces plasma
colloid osmotic
pressure and moves
more fluid into
extracellular spaces
Poor placental
perfusion

(S.Ricci, Essentials of maternity, newborn, and womens health Nursing (2nd ed.))

VI.

ETIOLOGY OF THE DISEASE

Gestational hypertension remains an enigma. The condition can be devastating to

both the mother and her unborn child, and yet the etiology still remains a mystery to
medical
science, despite decades of research. Many different theories regarding it exist, but
none have truly explained the widespread pathologic changes that result in pulmonary
edema, oliguria, seizures, thrombocytopenia, and abnormal liver enzymes (Sibai, 2003).
Despite the results of several research studies, the use of aspirin or supplementation
with calcium, vitamins C and E, magnesium, zinc, or fish oils has not proved to prevent
this destructive condition.

Factors associated with an increase risk for developing gestational hypertension have
been identified and include
Primigravida status
History of preeclampsia in a previous pregnancy
Excessive placental tissue, as is seen in women with GTD and multiple gestations
Family history of preeclampsia (mother or sister)
Lower socioeconomic group
History of diabetes, hypertension, or renal disease
Women with poor nutrition
African-American ethnicity
Age extremes of younger than 17 years or older than 35 years old
Obesity (Green & Wilkinson, 2004)
((S.Ricci, Essentials of maternity, newborn, and womens health Nursing (2nd ed.))

VII. PATHOPHYSIOLGOY
A. Written
Vasospasm and hypoperfusion are the underlying mechanisms involved with this
disorder. Several other changes are associated with gestational hypertension.
Endothelial injury occurs, leading to subsequent platelet adherence, fibrin deposition,
and the presence of schistocytes (fragment of an erythrocyte). Generalized vasospasm
results in elevation of blood pressure and reduced blood flow to the brain, liver, kidneys,
placenta, and lungs. Decreased liver perfusion leads to impaired liver function and
subcapsular hemorrhage. This is demonstrated by epigastric pain and elevated liver
enzymes in the maternal serum. Decreased brain perfusion leads to small cerebral
hemorrhages and symptoms of arterial vasospasm such as headaches, visual
disturbances, blurred vision, and hyperactive deep tendon reflexes (DTRs). A
thromboxane/prostacyclin

imbalance

leads

to

increased

thromboxane

(potent

vasoconstrictor and stimulator of platelet aggregation) and decreased prostacyclin

(potent vasodilator and inhibitor of platelet aggregation), which contribute to the
hypertensive state. Decreased kidney perfusion reduces GFR, resulting in decreased
urine output and increased serum levels of sodium, BUN, uric acid, and creatinine,
which further increases extracellular fluid and edema. Increased capillary permeability in
the kidneys allows albumin to escape, which reduces plasma colloid osmotic pressure
and moves more fluid into extracellular spaces, and leads to pulmonary edema and
generalized edema. Poor placental perfusion resulting from prolonged vasoconstriction
helps to contribute to intrauterine growth restriction, premature separation of the
placenta (abruptio placenta), persistent fetal hypoxia, and acidosis. In addition,

hemoconcentration (resulting from decreased intravascular volume) causes increased

blood viscosity and elevated hematocrit (ACOG, 2002).

B. Diagram of the pathophysiology

PATHOPHYSIOLOGY (Book-Based)

RISK AND PREDISPOSING FACTORS

MODIFIABLE
Sodium intake, Poor Nutrition,
Hypercholesterolemia, lack of activities
during pregnancy, inadequate prenatal
care

NON - MODIFIABLE
Age (<20,>35 years old), family history of
Hypertension, primipara, Diabetes Mellitus,
Chronic Renal Disease, heart diseases, multi
gestation (twins)

Damage to the endothelium cells

(cells that line in the blood vessels)

Endothelium cells releases

endothelin (a potent
vasoconstrictor)

Injury to uterine vessels

Renal perfusion

Placental ischemia

Impaired kidney function

renin, prostaglandin
production

Activation of reninangiotensin system

Glomerular
Filtration Rate

Sensitivity of arterioles to
angiotensin
BLOOD PRESSURE

Na retention &
water reabsorption

EDEMA
Headache

Visual
disturbances

Permeability of
renal tubules

PROTEINURIA

Cold-clammy skin

Weak thready pulse

Delayed capillary refill

PATHOPHYSIOLOGY (Client-Based)

RISK AND PREDISPOSING FACTORS

MODIFIABLE
Sodium intake, Poor Nutrition, lack of
activities during pregnancy

NON - MODIFIABLE
Age (39 years old), family history of
Hypertension

Damage to the endothelium cells (cells that line in

the blood vessels)

Endothelium cells releases endothelin (a potent

vasoconstrictor)

Injury to uterine vessels

Renal perfusion

Placental ischemia

Impaired kidney function

renin, prostaglandin
production

Activation of reninangiotensin system

Glomerular
Filtration Rate

Sensitivity of arterioles to
angiotensin
BLOOD PRESSURE

Na retention &
water reabsorption

EDEMA
Headache

Visual
disturbances

Permeability of
renal tubules

PROTEINURIA

Cold-clammy skin

Weak thready pulse

Delayed capillary refill

VIII.

Planning

A. Nursing Care Plan

Assessment
Subjective
Cues:
medyo
naglisod ko
og ginhawa
labi na kung
mag uboko,
as verbalized
by the client
Objective
Cues:
> (+) crackles
>rapid,
shallow,
irregular
respiration
> use of
accessory
muscles
when
coughing
> abnormal
blood gases
> abnormal
chest x-ray
result

Nursing
Diagnosis
Ineffective
breathing
pattern r/t
lung
complianc
e as a
result of
accumulati
on of fluid
in the
pulmonary
interstitium

Objective
At the end
of the
nursing
shift, the
patient will
be able to
experienc
e
adequate
respiratory
function.

Nursing
Intervention
INDEPENDEN
T
> place patient
in a semi to
high fowler
position if not
contraindicated

> instruct &

assist patient to
change
position, deep
breathe, &
cough or huff
every 1-2 hours

> implement
measures to
reduce pain
splint incision

Rationale

>this position
allow
increased
diaphragmati
c excursion &
maximum
lung
expansion,
which
promotes
optimal
alveolar
ventilation
>frequent
repositioning
helps loosen
secretions &
promotes a
more
effective
cough. It also
promotes
maximum
lung
expansion &
stimulates
surfactant
production.
Coughing or
huffing
mobilizes
secretions &
facilitates
removal of
these
secretions

Evaluation
At the end
of the
nursing
shift, the
patient was
able to
experience
adequate
respiratory
function. as
evidenced
of the ff.:
> normal
rate, rhythm
& depth of
respiration
> improved
breath
sounds
> (-)
crackles
> blood
gases
within
normal
ranges
>Patient
verbalizes
relief from
difficulty of
breathing

with pillow
during coughing
& deep
breathing

DEPENDENT
> implement
measures to
facilitate
removal of
pulmonary
secretions
suction as
orders
> maintain
O2therapy as
ordered

> administer
meds that may
be ordered to
improve patient
respiratory
status

from the
respiratory
tract
> a patient
with pain
often guards
respiratory
efforts pain
reduction
enables the
client to
breathe more
deeply which
enhances
alveolar
ventilation&
O2/CO2
exchange
> excessive
secretions
and inability
to clear
secretions
from the
respiratory
tract lead to
stasis of
secretions
>
supplemental
O2 increases
the
concentration
of oxygen in
the alveoli,
which
increases the
diffusion of
O2 across the
alveolar
capillary
membrane
> medication
therapy is an
integral part
of treating

many
respiratory
condition

Assessment

Nursing
Diagnosis

Fear r/t
Subjective Cues:
persistent
nahadl ok judk o, kay
headache
ingon sa doctor naa
daw koy high blood.
Unya cge pa jud ko
gka lipong. Mao nang
paminaw nako laing
jud kayo ako lawas. Dili
pa jud ko katulog og
tarong sa cge hunahuna, as verbalized by
the client
Objective Cues:
> disturbed sleep
pattern
> weak appearance

Objecti
Nursing
ve
Interventio
ns
At the
INDEPEN
end of
DENT
the
>
nursing encourage
shift,
verbalizatio
the
n of
patient feelings &
will be
concerns
able to
experie
nce a
> assure
reducti patient that
on of
staff
fear
members
are nearby;
respond to
call signal
as soon as
possible

Rational
e

>
verbaliza
tion of
feelings
&
concerns
helps
client
identify
factors
that are
causing
anxiety
> close
contact
&a
prompt
response
to
requests
provide a
sense of
security
> reinforce &
physicians facilitate
explanation s the
s & clarify
develop
misconcept ment of
ions the
trust,
patient has thus
about the
reducing
diagnostic
the
tests,
clients
disease
anxiety

Evaluatio
n
At the end
of the
nursing
shift, the
patient
will be
able to
experienc
ea
reduction
of fear as
evidenced
by the ff:
>
verbalizati
on of
decrease
d fear &
understan
ding of
the
medical
procedure
s

condition,
treatment
plan &
prognosis
>
implement
measures
to reduce
distress

DEPENDE
NT
>
administer
prescribed
anti anxiety
agents if
indicated

> factual
informati
on & an
awarene
ss of
what to
expect
help
decrease
the
anxiety
that
arises
from
uncertain
ty

>
improve
ment of
respirato
ry status
helps
relieve
anxiety
associat
ed with
the
feeling of
not being
able to
breathe
> helps
reduce
the
patients
anxiety

Assessment

Ojective cues:
Weak and pale in
appearance
- Capillary
refill of 3-4
seconds
- RBC
Level=1.49
- Hgb level=
34g/L
- Bp=160/110
mmHg

Nursing
Diagnosi
s
Ineffective
tissue
perfusion
related to
decrease
in RBC,
hemoglobi
n and
hematocrit
level

Objective

After 4
hours of
nursing
intervention
s, the client
will exhibit
decrease in
oxygen
demand
and ability
to conserve
energy.

Nursing
Interventio
ns
Assist client
in
performing
ADL
Place the
client in
trendelenbur
g position.
Maintain
adequate
ventilation.

Instruct
client to sit
and dangle
the feet
before
standing.
Advise client
to increase
intake of
food rich in
iron and
folate such
as liver and
green leafy
vegetables.

Rationale

Evaluatio
n

To
promote
safety

After 4
hours of
nursing
interventio
n, the
client will
exhibit
decrease
in oxygen
demand
and ability
to
conserve
energy.

To
promote
venous
return

To
promote
oxygenatio
n and
good
blood
circulation

To prevent
orthostatic
hypotensio
n

Iron and
folate are
necessary
for red
blood cell
production
.

Assessmen
t
Subjective:
wala ko
kabalo ko
unsa nga
mga
pagkaon
ang ga
pataas og
blood
pressure
Objective:
>Cohorent
>Responsiv
e
>conscious
>Edema
noted at
Lower
extremeties
>Pallor
Noted
>Afebrile
>cyanosis
noted at
Lower
extremities
V/S
BP: 160/110
Temp: 36.6
o
c
PR:149bpm
RR:49cpm

Nursing
Diagnosis
Knowledg
e Deficit
related to
Blood
Pressure
as
evidenced
by wala
ko kabalo
ko unsa
nga mga
pagkaon
ang ga
pataas og
blood
pressure
Rationale:
Knowledg
e deficit
absence
or
deficiency
of
cognitive
informatio
n related
to patient
has
incapacity
to
understan
d her
condition

Objective
General:
After 8 hours
of rendering
nursing
interventions
the patient will
be able acqure
knowledge
about her
condition.
Specific:
After 8 hours
of nursing
interventions
the patient will
be able to:
>participate in
nursing
process.
>identify the
inconvenience
to her learning
and specific
action to them.
>exhibit
increase
interest/assum
e responsibility
to own learning
by beginning to
look for
information
and ask and
question.
>verbalized
understanding
learning
condition.
>initiate
necessary
lifestyle

Nursing
interventions
>Build rapport

>Check and
monitor vital
signs
>determine the
client
ability/readines
s and
anticipatory
needs

Rationale

Evaluatio
n
>to gain
Goad
patient
partially
cooperation met, has
.
slightly
acquired
>for
knowleged
baseline
about her
data
conditions
as patient.
>to
Verbalized
determine
ah amo
factors
din a
pertinent & silang mga
the learning pagkaona.
process.

>provide
information
relevant only to
the situation to
prevent
overload.

>to assess
the client
motivation.

>identify
information
what needs to
be
remembered.

>to
established
the content
to included

>recognized
level of
achievement,
time factors,
short term &
long.

To
developed
learners
objectives

>discuss topic
at a time,
avoiding giving
to much
information.

>to
facilitate
learning

>provide
mutual goal

>to identify
teaching

changes and
participate in
treatment
regimen.

setting &
learning
contacts.

methods to
be used

>provide asses
information for
contact person
to answer
questions.

>to
promoted
wellness

B. Discharge plan

Medicines:
Diuretics: This medicine is given to remove excess fluid from
around your lungs and decrease your blood pressure. You may
urinate more often when you take this medicine.
Heart medicine: These medicines may be given to make your
heartbeat stronger or more regular, or to lower your blood pressure.
Vasodilators: Vasodilators may improve blood flow by making the
blood vessels in your heart and lungs wider. This may decrease the
pressure in your blood vessels and improve your symptoms.
Take your medicine as directed: Call your primary healthcare
provider if you think your medicine is not helping or if you have side
effects. Tell him if you are allergic to any medicine. Keep a list of
the medicines, vitamins, and herbs you take. Include the amounts,
and when and why you take them. Bring the list or the pill bottles to

follow-up visits. Carry your medicine list with you in case of an

emergency.
Follow up with your primary healthcare provider or pulmonologist in 7 to
10 days or as directed.
You may need to return for more tests. Write down your questions
so you remember to ask them during your visits.
Manage pulmonary edema
Limit your liquids as directed. Follow

your primary healthcare

provider or pulmonologists directions about how much liquid you

should drink each day. Too much liquid can increase your risk for
fluid buildup.
Weigh yourself daily. Weigh yourself at the same time every
morning after you urinate, but before you eat. Weight gain can be a
sign of extra fluid in your body.
Rest as needed. Return to activities slowly, and do more each day.
You may have trouble breathing when you are lying down. Use
foam wedges or elevate the head of your bed. This may help you
breathe easier while you are resting or sleeping. Use a device that
will tilt your whole body, or bend your body at the waist. The device
should not bend your body at the upper back or neck.
Use a device that will tilt your whole body, or bend your body at the
waist. The device should not bend your body at the upper back or
neck.

 Limit or avoid alcohol: You will need to limit the alcohol you drink,
or avoid alcohol completely. Alcohol can worsen your symptoms
and increase your blood pressure. If you have heart failure, alcohol
can make it worse.
Do not smoke or take drugs: If you smoke, it is never too late to
quit. Do not take street drugs, such as cocaine. Smoking and drugs
can make your condition and symptoms worse. Ask for information
if you need help quitting.
limb to high altitudes slowly: Go slowly to allow your body to get
used to a higher altitude. Ask your primary healthcare provider
about the symptoms of high altitude pulmonary edema (HAPE). Ask
what to do if you get these symptoms.
Contact your primary healthcare provider or pulmonologist if:
you have a fever
you gain weight for no known reason
you urinate more than usual
you have new or increased swelling when you breathe
you have questions or concerns about your condition or care.

IX.

PHARMACOLOGICAL MANAGEMENT

Drug study

Drug

magnesium sulfate

hydralazine
hydrochloride
(Apresoline)

Action

Indications

Blockage of
neuromuscular
transmission,
vasodilation

Prevention and
treatment of
eclamptic seizures,
reduction in blood
pressure in
preeclampsia and
eclampsia

Vascular smooth
muscle relaxant,
thus improving
perfusion to
renal, uterine,
and ce

Reduction in blood
pressure

Nursing
Responsibilities
Administer IV
loading dose of 4-6
over 30 minutes,
continue
maintenance
infusion of 24g/hour as ordered
monitor serum
magnesium levels
closely assess
DTRs and check for
ankle clonus have
calcium gluconate
readily available in
case of toxicity
monitor for signs
and symptoms of
toxicity, such as
flushing, sweating,
hypotension, and
cardiac and central
nervous system
depression
Administer 510 mg
by slow IV bolus
every
20 minutes
Use parenteral form
immediately after
opening
ampule
Withdraw drug
slowly to prevent
possible
rebound
hypertension
Monitor for adverse
effects such as
palpitations,

labetalol
hydrochloride
(Normodyne)

Alpha 1 and beta

blocker

Reduction in blood
pressure

nifedipine
(Procardia)

Calcium channel
blocker/dilation
of coronary
arteries,
arterioles, and
peripheral
arterioles

Reduction in blood
pressure,
stoppage of
preterm labor

Sodium
nitroprusside

Rapid vasodilation
(arterial and
venous)

Severe
hypertension
requiring rapid
reduction in blood

headache,
tachycardia,
anorexia, nausea,
vomiting, and
diarrhea
Be aware that drug
lowers blood
pressure
without decreasing
maternal heart rate
or
cardiac output
Administer IV bolus
dose of 1020 mg
and then
administer IV
infusion of 2
mg/minute until
desired blood
pressure value
achieved
Monitor for possible
adverse effects
such as
gastric pain,
flatulence,
constipation,
dizziness, vertigo,
and fatigue
Administer 10 mg
orally for three
doses and
then every 48
hours
Monitor for possible
adverse effects
such as
dizziness,
peripheral edema,
angina,
diarrhea, nasal
congestions, cough
Administer via
continuous IV
infusion with dose
titrated according to

pressure
Pulmonary

furosemide
(Lasix)

Diuretic action,
inhibiting the
reabsorption of
sodium and
chloride from
the ascending
loop of Henle

Pulmonary edema

blood pressure
levels
Wrap IV infusion
solution in foil or
opaque
material to protect
from light
Monitor for possible
adverse effects,
such as
apprehension,
restlessness,
retrosternal
pressure,
palpitations,
diaphoresis,
abdominal pain
Administer via slow
IV bolus at a dose
of
1040 mg over 12
minutes
Monitor urine output
hourly
Assess for possible
adverse effects
such as
dizziness, vertigo,
orthostatic
hypotension,
anorexia, vomiting,
electrolyte
imbalances,
muscle cramps, and
muscle spasms

X.

SYNTHESIS OF CLIENTS CONDITION/STATUS FROM ADMISSION TO

PRESENT

Conclusion
We therefore conclude that the study portrayed its importance and helped us
know all about preeclampsia. It also helped us understood the causes and effects of the
diseases that enabled us to determine the predisposing and precipitating factors and
traced the pathophysiology of these disorders. This also had given us the knowledge to
identify where and when it had started and how the disease progressed and we had
also interpreted the laboratory and diagnostic exam results of the client and recognized
the implication of it. We also identified the different pharmacologic treatments indicated
to the condition, considering the effects, actions and different nursing considerations
with regards to the administration of the medications. We have also identified and
formulated the nursing interventions that we could render to the patient that will help us
attain our goal of care to our patient basing from the nursing care plan we have
formulated.
Patients prognosis
After some point in time, as the medical and the nursing management of
the patient is constantly done, a development of her present health status is anticipated.
Continuous administration of medications will result to termination of the signs and
symptoms that was caused by the patients disease such as shortness of breaths,
paleness, swelling, high blood pressure, face and hand edema, and dyspnea.
Furthermore, vital signs are expected to stabilize.

Recommendation
On the basis of the findings of this study, the following measures are
recommended:
1. Client should take his prescribed medications religiously. He must create a
schedule in order for him to be guided as when to take the medicines and for him
not to be able to forget in doing so.
2. Follow the prescribed diet. His prescribed diet is a low-salt, low-fat diet, therefore
client should avoid salty and fatty foods and client must take note that all canned
goods are high in sodium even if it says that it is good for the heart.
3. Have an oral fluid intake with in cardiac tolerance.
4. Lifestyle modification is also important in order to prevent the severity of the
condition that will further contribute complications such as cessation of smoking
and drinking alcoholic beverages.
5. Visit his doctor regularly for constant check-ups and to continuously monitor his
condition.
XI.

Evaluation of the objectives of the study

After few days of conducting study about the case of Mrs. X, we were able to trace the
history of her disease locally, nationally and globally. We have come up with a
comprehensive assessment of the patients biographical data, cephalo-caudal physical
assessment as well as pertinent medical information with regards to the clients health
condition. Apart from that, we were also able to have a clearer view on how the disease
affects the patients body by tracing the pathophysiology of the disease process and

identifying the different organs involved by reviewing its anatomy and physiology. By
understanding fully the mechanism and effects of the disease to the patient, we have
interpreted different laboratory results related to her condition. We have also identified
and traced some medications and how these drugs affect the patients physiological
functioning. Appropriate therapeutic care was well planned and provided to the client.
And lastly, we have come up with a discharge plan pertaining to the patients early
recovery.

XII.

BIBLIOGRAPHY
BOOKS
1. Pillitteri, Maternal & Child Health Nursing, 4th Edition
2. Lippincott Williams & Wilkins,Nursing Student Drug Handbook 2009
3. Doenges, Moorhouse, Geissler-Murr Nurses Pocket Guide 9th edition
4. Mosbys dictionary of Medicine, Nursing and Health Professions
5. S.Ricci, Essentials of maternity, newborn, and womens health Nursing
2nd edition

Internet
1. (cureresearch.com/p/preeclampsia/stats-country.html)February
2013
2. (www.doh.gov.ph) February 24, 2013
3. (www.nursingcrib.com) date February 24, 2013

24,