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Republic of the Philippines

CAVITE STATE UNIVERSITY

(CvSU)

DON SEVERINO DE LAS ALAS CAMPUS

Indang, Cavite

College of Nursing

OB CASE: MILD PRE-ECLAMPSIA

Presented by:

ARDON, CAROLYN C.BSN 3-2

Presented to:

LEVEL IIi INSTRUCTORS

In Partial Fulfillment of the Requirements in NURS 55 for the Degree Bachelorof Science in Nursing

VISION

A premier university

in historic Cavite

recognized for

excellence in the

development of

morally upright and

globally competitive

individuals.

MISSIONCavite State University shall

provide excellent, equitable

and relevant educational

opportunities in the arts,

science and technology

through quality instruction

and relevant research and

development activities.

It shall produce professional,

skilled and morally uprightindividuals for global

competitiveness.

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Republic of the Philippines

CAVITE STATE UNIVERSITY

(CvSU)

DON SEVERINO DE LAS ALAS CAMPUS

Indang, Cavite

College of Nursing

TABLE OF CONTENTS

I. Demographic Data ... 1

II. Reason for Seeking Health Care .. 1

III. History of Present Illness . 2

IV. Past Medical History 2

V. Heredofamilial History 3

VI. Physical Examination

VII. Diagnostic Test

VIII. Review Of System

IX. Case Management

Medical Management

Nursing Management

VISION

A premier university

in historic Cavite

recognized for

excellence in the

development of

morally upright and

globally competitive

individuals.

MISSIONCavite State University shall

provide excellent, equitable

and relevant educational

opportunities in the arts,

science and technology

through quality instruction

and relevant research and

development activities.

It shall produce professional,

skilled and morally uprightindividuals for global

competitiveness.

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I. Demographic Data

A. Clients Name: Evangeline Sanchez Pastoril

B. Address: B41 L5 Tahanan Yaman General Trias Cavite

C. Age: 28 y/o Date Of Admission: June 22 2012

D. Birth date: October 09 1983 Time Of admission : 01:50 am

E. Birth Place: Leyte

F. Gender: Female Date Of Interview: June 22 2012

G. Religion: Catholic Primary Informant: Mrs. E.S.P

H. Occupation: Saleslady Other Source: Chart

II. Reason For Seeking Health Care

For monthly checkup

III. History Of Present illness

Admitting Diagnosis: G1P0 Pregnancy Uterine 32 5/7 weeks AOG not in labor: Mild

Pre-Eclampsia

Mrs. ESP verbalized that during her 2nd check up at Wellness Care

Mangahan, her OB referred her to Trece GEAMH because of her sudden increased of

blood pressure (160/110 mMhg). June 22 2012 she went to Trece GEAMH with her

sister and consult there but the doctor insisted to admit her at that same day. Prior to

admission, she stated that she feels dizziness and light headedness so she drink a

glass of water and take some rest.

IV. Past Medical History

Mrs. ESP has no known childhood/adult disease nor major injuries or accident

met. She has also no known allergies in foods or medicine and doesnt undergo in any

operation. It was her first time to be hospitalized because of her pregnancy at Trece

General Emillio Aguinaldo Memorial Hospital June 12 2012 at 1:50 am due to Mild

Pre-Eclampsia. She stated that she was fully immunized and receive three dosage of

Tetanus Toxoid.

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V. OB GYNECOLOGICAL History

Mrs. ESP verbalized that she had her first menstruation when she was12 years

old. Her last menstruation is on November 05 2011 and stopped at November 08

2011. She has a 28 cycle which happens for three days and consume 2-3 sanitary

napkins per day. When menstruation occurs, she often experience dysmenorrhea and

to relief the pain, she take Mydol and take some snaps. Her EDC is July 12 2012 and

AOG is 32weeks 5/7 days. G1P0T0A0L0M0

VI. HEREDO-FAMILIAL History

Genogram

Paternal Side Maternal Side

MPE

J.D

HPN

JD

AW

CP

AWC.D

AWKP

AW

P

LEGEND:

= DEAD

= MALE

= FEMALE

= PregnantClient

// = SEPARATED

MPE = Mild Pre

Eclampsia

A/W = Alive and

Well

HPN =Hypertension

The diagram shows that the family has knownhereditary disease in both maternal and paternal sideincluding the patient which is hypertension but still alive.The rest of the family is alive and well. The relationship of

the patient and her husband is separated 5 months ago.

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VII. Physical Examination

COMPREHENSIVE PHYSICAL EXAMINATION

DATE ASSESSED: June 22 2012

A. Vital Signs / Fetal Heart Tone

ASSESSED 4 PM 5 PM

TEMPERATURE 37 C 36.6 C

BLOOD PRESSURE 160 / 100 mMhG 170 / 100 mMhg

PULSE RATE 98 bpm 100 bpm

HEART RATE 20 cpm 18 cpm

B. General Survey

ASSESSED ACTUAL FINDING

Posture and Gait Uncoordinated movement along with Activities of

daily Living

Slightly bend during walking and sitting

Over All hygiene and grooming Properly Dressed

Well groomed

Clean and neat appearance

Body and breathe odor Absence of foul body odor and bad breathe

Obvious of signs of distress/ illness (+) Facial grimace due to pain on injected site of

medication

Presence of lesion and edema on both lower

extremities

Attitude Look irritated due to hot environment

Cooperative during interview

Quality and quantity of organization Her voice is clear and understandable

TIME FHT

3 PM 142 b/min

4 PM 138 b/min

5 PM 140 b/min

6 PM 143 b/min

7 PM 148 b/min

8 PM 141 b/min

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of thought/speech Has sense of humor and logical sequence

C. Focused Assessment

BODY PART EXAMINED ACTUAL FINDING

INTEGUMENT

SKIN

I: color, uniformity, edema, lesions

P: moisture, temperature, turgor

Has a slightly dark skin complexion

(+) Edema is graded as 3 as noticeably deep

pitting and swollen lower extremities

(+) Crust lesion in lower extremities

Slightly moist skin

Warmed to touch and uniform temperature

HAIR

I: evenness of growth of hair

thickness, texture, oiliness,

infection or infestation, body hair

P; smoothness

Has evenly distributed thick hair

No infestation or infection

Variable amount of hair

No lice

Nail

I: plate shape, texture, bed color,

surrounding tissues

P:Blanch Test

Round nails

Smooth in texture

Pinkish nail bed

No hangnails

Blanch Test done: generally less than 4 seconds

prompt return usual color

HEAD

SKULL AND FACE

I: size, shape, symmetry, facial

features, eyes for edema and

Rounded

Normocephalic and symmetry prominences

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hollowness

P: nodules, masses, depression

Smooth texture

Absence of nodules and masses

Symmetrical facial movement

Absence of edema

Symmetrical facial features

EYES AND VISION

I; EYEBROWS for distribution and

alignment, quality and movement

I: EYELASHES for evenness of

distribution and direction of curl

I: EYELIDS for surface

characteristics, position in relation

to cornea, ability to blink and

frequency

I: BULBAR AND PALPEBRAL

CONJUCTIVA for color, texture and

lesion

I/P: LACRIMAL GLAND SAC for

edema, tenderness and tearing

I: CORNEA for clarity , texture and

sensitivity

Hair evenly distributed

Symmetrically aligned

Equal movement

Equally distributed

Slightly curled outward

Bilateral blinking

Skin Intact

No discharge and discoloration

No visible lesion

Sclera appears white

Transparent

Palpebral conjunctiva is pink

Not tender

Absence of edema and tearing

Transparent

Smooth and shiny appearance

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I: PUPILS for color, shape,

symmetry of size, direct and

consensual reaction to light and

accommodation

Black in color

Equal in size

Iris is flat and Rounded

EARS AND HEARING

I: AURICLES for color, symmetry

and position,

P: for texture elasticity and areas of

tenderness

Same color as facial skin

Symmetrical

Auricle aligned with outer cantus of eye

Mobile, firm and not tender

Pinna recoils after it is folded

NOSE AND SINUSES

I: NOSE for deviation in shape,

size, color, flaring, discharge

P: for tenderness , masses,

displacement

Symmetric and straight

No discharge and flaring

Uniform color

Absence of lesion

Not tender

Nasal septum is intact and in midline

No masses or nodules

Air moves freely as the client breathe

MOUTH/OROPHARYNX

I: LIPS for symmetry contour, color,

texture, moisture, lesion

I: TEETH for alignment, loss,

dental fillings and caries

Has uniform pink color

Soft moist and smooth texture

Ability to purse lips

32 adult teeth

Absence of fillings and carries

Smooth and slightly yellowish teeth

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I: GUMS for bleeding, color,

retraction, lesions, swelling

I: TONGUE for position, color,

texture, movement, as well as the

base of the tongue, mouth floor

and frenulum

I: UVULA for position and mobility

I: TONSILS for color, discharge

and size

No retraction of gums

Smooth and shiny

No swelling and lesion

Pink in color

Central position

Pink in color

Moist, thin whitish coating

Absence of lesion

Moves freely and not tender

Located at the midline

Pink in color

No discharge

Pink in color

NECK

I: NECK MUSCLE for abnormal

swelling or masses, head

movement and muscle strength

P: LYMPH NODES for

enlargement

P: TRACHEA for lateral division

Muscles are equal in size

Head is centered

Has smooth movements with no discomforts

Has equal strength

Lymph nodes are palpable

Trachea is center

THORAX AND LUNGS

I: for shape and symmetry from

posterior-lateral views, spinal

alignment for deformities

Pa: temperature, bulges,

With a Heart Beat of 98 bpm

With a Respiratory rate of 20 cpm

With equal chest symmetry

Warmed to touched

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tenderness,

Aus: abnormal breath sounds,

No pain felt when palpated

No adventitious sounds

BREAST AND AXILLAE

I: BREAST for size, symmetry,

contour or shape, discoloration,

retraction, swelling or edema

I: AREOLA for size, shape,

position, color, discharge, lesion

I:NIPPLES for size, shape,

position, color, discharge, lesion

The client is refused to assessed

ABDOMEN

I: skin integrity, contour and hernia,

girth

(+) striae

With fundic height of 34 cm

FHT heard upon auscultation on right lower

quadrant

(+) linea nigra

MUSCUSKELETAL

I: MUSCLES for size, contractures,

fasciculation, tremors,

P: tonicity, flaccidity, smoothness

of movement and strength

I: BONES for structure, deformity

P: for edemaand tendreness

(+) edema on both lower extremities

Color is even

Warmed to touched

Can complete range of motion

Can counter act gravity and resistance

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VIII. Diagnostic Test

Name: Evangeline pastoral Room No./Ward:OB Date: 6-22-12

Age:28 y/o ( ) Male ( ) Female Hospital No.: 308267 ( )Main ( ) Annex

B-Date: 10 91893 Case No.: 223292

CLINICAL CHEMISTRY

TEAT RESULT REFERENCE RANGES

RBS 4.4-6.6 mmol/L

FBS 3.8 6.06 mmol/L

BUN 2.95 2.49-6.42 mmol/L

CREATININE 56.5 M- 62-150 mmol/L F- 44-106 mmol/L

URIC ACID 89.25-416.5 mmol/L

CHOLESTEROL 3.0-6.2 mmol/L

TRIGLYCERIDES .40-1.86 mmol/L

HDL 0.78-1.95 mmol/L

LDL 1.71-4.62 mmol/L

VLDL 0-47 IU/L

SGPT( AIT) 12.7 0.26-1.04 mmol/L

SGOT (AST) 30.6 10-4-IU/L

ALK.PHOS 25-90 IU/L

AMYLASE 40-180 I g/L

T.PROTEIN 35-52 g/L

ALBUMIN 23-35 g/L

GLOBULIN 1.1-2.5 g/L

A/G RATIO 1.7-20.5 mmol/L

T. BILIBURIN Up to 5.1 mmol/L

SODIUM 141.5 135-148 mmol/L

POTTASIUM 3.37 3.5-5.6 mmol/L

CHLORIDE 110.3 96-106 mmol/L

CALCIUM 1.13-1.31 Eq/L

HBA1C 4.5-6.3%

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IX. Review Of System

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X. CaseManagement

A. Medical Management

B. Case Management