Pre Eclampsia case study

Liceo de Cagayan UniversityCollege of NursingRN Pelaez Boulevard

Submitted as partial fulfillment for the requirements inNCM102 RLE

A case study on Chronic Hypertension withSevere Superimposed Pre-Eclampsia

Submitted by:Ezra Mae G. EbisaAnisa M. UsmanCarl Anthony Q. Parantar

Submitted to:Mrs. Emma M. Dejarme, RN, MAN

January 8, 2014

CONTENTS

TABLE OF CONTENTS

I. INTRODUCTION3II. DATABASE AND HISTORY6III. NURSING SYSTEMS REVIEW CHART7IV. DEVELOPMENTAL DATA18V. MEDICAL MANAGEMENT20VI. PATHOPHYSIOLOGY22VII. DRUG STUDY24VIII. NURSING MANAGEMENT27IX. REFERRALS AND FOLLOW UP38X. EVALUATION AND IMPLICATIONS 38XI. BIBLIOGRAPHY39

I. INTRODUCTIONOverview of the CaseIn the case of Mrs. Irene O. Cabasag, 39 years old from Tambaling 11, Bolobolo, El Salvador, Misamis Oriental, she was admitted to Northern Mindanao Medical Center (A2F1-OB-WARD 7 Service Ward - Bed 5) last December 6, 2013 at 7:00pm with a chief complaint: 3 days prior to admission, patient had onset of headache associated with dizziness and epigastric pain condition tolerated, no consult done. Her admission diagnosis is: Pregnancy uterine, 31 5/7 weeks age of gestation, chronic hypertension with superimposed preeclampsia severe, G2P1(1001). Her principal diagnosis is: Pregnancy Uterine Pre Term, cephalic presentation delivered to a live premature baby girl APGAR 9, BW 2.4kg, via Normal Spontaneous Vaginal Delivery.What Is Chronic Hypertension?There are 2 types of chronic hypertension: essential hypertension and secondary hypertension. We do not know the cause of essential hypertension, but because hypertension commonly runs in families, we know that genes are involved. A minority of individuals has secondary hypertension, which means that the hypertension is explained by another condition such as kidney disease, narrowing of the artery to the kidney, and adrenal tumors. In many such cases, the hypertension will resolve after treatment for the underlying problem. If you are undergoing evaluation for a secondary form of hypertension, it is advisable to be treated for the underlying condition before becoming pregnant. A third type of hypertension is called pregnancy-induced hypertension. Some women develop new-onset hypertension in pregnancy, which can present in the second half of pregnancy, usually in the third trimester.What Are Some of the Complications of Chronic Hypertension During Pregnancy?Most women with chronic hypertension do well in pregnancy. In normal pregnancy, blood pressure falls at the end of the first trimester and then increases to pre-pregnancy values in the third trimester. For the majority of women with chronic hypertension, blood pressure follows the same pattern. Some women, however, experience a rise in blood pressure during pregnancy, which can increase their risk for stroke and other complications and may therefore require more aggressive antihypertensive treatment. A healthcare professional should monitor you to ensure that a hypertension-related complication does not develop. A more worrisome complication of chronic hypertension is the development of superimposed preeclampsia. Preeclampsia is a serious condition that can affect many organ systems and cause liver dysfunction, kidney failure, and an increase in bleeding tendency, and at times it can progress to eclampsia seizures. Superimposed preeclampsia is more likely to occur in women who have poorly controlled hypertension, underlying renal disease, and diabetes mellitus. At present, there is no treatment for preeclampsia except for delivery of the baby; therefore, babies of women who have this condition are frequently born prematurely. Another complication of chronic hypertension that may cause premature birth is placental abruption. An abruption is an early separation of the placenta from the wall of the uterus, usually leading to strong contractions, bleeding, and early delivery.

ObjectiveThe objective of making this case study is to identify the problem of our patient and to determine the factors that contribute to this kind of disease so that specific actions should be done and rendered to our patient. The group has selected the patient having this kind of disease because the primary concept that should fit our study is all about abnormalities pertaining obstetric and gynecologic nursing. Having this kind of case study is a privilege for us because it would be a good learning process by adding new knowledge and concept about different kinds of diseases that may be present in some patients. By making this case study we can identify the disease step by step, its nature on how this disease occur, and nursing actions that would be appropriate for the patient.

SCOPE and LIMITATIONS of the STUDY

The study was conducted at Northern Mindanao Medical Center Delivery Room and OB Ward, Cagayan de Oro City in which observation, analyzing and understanding the patients condition was done. We were only given 24hours on understanding patients problem. The study is also limited to the condition of the patient, which are chronic hypertension with super imposed pre-eclampsia and its effect during pregnancy. The study focuses only on obtaining the patients profile, health history and present health condition; assessing, recording, and gathering of pertinent data about the patient. Estimating the nursing needs and coping capacity of the patient. Finding the primary health problems of the patient and the appropriate nursing interventions to solve the condition of the patient. The objectives, nursing care plans, doctors order, and drug study evaluation for the patient also done in this study.

II.DATA BASE AND HISTORYOur Patient is Irene O. Cabasag, 39 years old married female form Tambaling 11, Bolobolo, El Salvador, Misamis Oriental. G2P1 with an LMP of May 28, 2013 and an EDC of February 4, 2014. Her AOG is 31 5/7weeks and was admitted due to onset of headache associated with dizziness and epigastric pain. While at the Delivery Room her BP was fluctuating from 180/110 to 200/120 mmHg. Patient Cabasag had her first child in 1997 with NSVD, few years after she developed hypertension.During her assessment in the labor room, her fundal height was 27cm. FHB was taken and recorded at 160 BPM RUQ. Internal examination was done. The patient was in active labor. In her ultrasound report, her diagnosis is: Pregnancy Uterine, 29 weeks and 5 days by fetal biometry, singleton, live, cephalic in presentation. Postero-fundal placenta, grade II. Adequate Amniotic Fluid Estimated Fetal weight of 1651.22 gramsHer admitting diagnosis was Pregnancy uterine, 31 5/7 weeks age of gestation, chronic hypertension with superimposed preeclampsia severe, G2P1 (1001)She had previous NSVD delivery in 1997. Coughs and colds with few bouts were also experienced with the date not specifically recalled. She takes OTC medications for common ailments like biogesic for fever and alaxan for pain reliever.Upon interview her hypertension started with her second pregnancy and upon further investigation she had a heredo-familial history of hypertension on her mothers side.The physician in charge of Mrs. Cabasag is Dr. Brobo.III. NURSING SYSTEM REVIEW CHARTName of Patient:Irene O. CabasagDate of Assessment:December 10, 2013

Body Measurements:Weight:67 KgHeight: 52

Vital Signs upon Assessment:Temp:37C PR:106bpmRR:24cpm BP:160/100 mmHg

Blurred Vision

EENTFacial Edema

[ ] Impaired Vision[ ] Blind[ ] PainBP 160/100

[ ] Reddened[ ] Drainage[ ] GumsTachypnea

[ ] Impaired Hearing[ ] Deaf[ ] BurningEpigastric PainTachycardia

[X] Edema[ ] Lesions[ ] TeethProteinuria

Assess Eyes, Ears, Nose, Vaginal Bleeding

and throat for any abnormalitiesEpisiotomy

[ ] No ProblemHyperreflexia

RESPIRATORYSignificant lower extremities edema

[ ] Asymmetrical[X] Tachypnea[ ] Apnea[ ] Rales[ ] Cough [ ] Barrel Chest[ ] Bradypnea[ ] Shallow [ ] Rhonchi[ ] Sputum[ ] Diminished[ ] Dyspnea[ ] Orthopnea[ ] Labored [ ] Wheezing[ ] Pain[ ] CyanoticAssess respiration, rate, rhythm, depth, pattern, breath sounds, comfort[X] No Problem

CARDIOVASCULAR[ ] Arrhythmia [X] Tachycardia[ ] Numbness[ ] Diminished Pulse[ ] Edema[ ] Fatigue[ ] Irregular [ ] Bradycardia[ ] Mur-mur[ ] Tingling [ ] Absent Pulse[ ] PainAssess heart sounds, rate, rhythm, pulse, blood pressure,circulation, fluid retention, comfort [ ] No Problem

GASTROINTESTINALConfused

[ ] Obese [ ] Distension[ ] Mass[ ] Dysphagia[ ] Rigidity[X] PainAssess abdomen, bowel habits, swallowing, bowel sounds, Comfort. [ ] No Problem

GENITO URINARY and GYNE[X] Pain[X] Urine Color[X] Vaginal Bleeding[ ] Hematuria[ ] Discharges[ ] NocturiaAssess Urine frequency, control, color, odor, comfort, Gyne Bleeding,Discharges [ ] No ProblemNEUROLOGIC[ ] Paralysis[ ] Stuporous[ ] Unsteady[ ] Seizure[ ] Lethargic[ ] Comatose[ ] Vertigo[ ] Tremors[X] Confused[X] Vision[ ] GripAssess motor function, sensation, LOC, Strength, Grip, gait, coordination,Speech [ ] No ProblemMUSCULOSKELETAL and SKIN[ ] Appliance[ ] Stiffness[ ] Itching[ ] Petechiae[ ] Hot[ ] Drainage[ ] Prosthesis[ ] Swelling[ ] Lesions[ ] Poor Turgor[ ] Cool [ ] Deformity[ ] Wound [ ] Rash[ ] Skin Color[ ] Flushed[ ] Atrophy[ ] Pain[ ] Echymosis[ ] Diaphoretic[ ] MoistAssess mobility, motion gait, alignment, joint function, Skin color, texture, turgor, integrity[X] No ProblemPlace an (X) in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure if appropriate, using (X).

NURSING ASSESSMENT II

SUBJECTIVEOBJECTIVE

COMMUNICATION: [ ] Hearing Loss [X] Visual Changes [ ] DeniedComments:Ambot di ko ka klaro. As verbalized by the client.

[ ] Glasses [ ] Contact Lens

[ ] Languages [ ] Hearing Aide [ ] Speech Difficulties

Pupil Size: R_3mm _ L _3mm__

Reaction: _PERRLA (Pupil Equally Round & Reactive to Light Accommodation

OXYGENATION: [ ] Dyspnea [ ] Smoking History __ _______________ [ ] Cough [ ] Sputum [X] DeniedComments:Dili man pud ko gapaninigarilyo ug di pud ko ga-lisud bahin sa pag-ginhawa. As verbalized by the client. Respiration: [ ] Regular [X] Irregular Describe: Pt. has a condition of rapid breathing (Tachypnea)

R:Symmetric to left; full chest expansion

L:Symmetric to right; full chest expansion

CIRCULATION: [ ] Chest Pain [X] Leg Pain [X] Numbness of __ extremities [ ] DeniedComments:Gasakit dapit sa akong tiyan og akong tiil oi As verbalized by the client.Heart Rhythm: [ ] Regular [X] Irregular Ankle Edema: Patient has 1+ mild pitting, slight indentation, no perceptible swelling of the leg

PulseCarRadDPFem*

Right+106bpm++

Left+106bpm++

Comments:Pulses on both left and right are present and palpable

NUTRITION:Diet:Low salt, Low fat

[ ] Dentures [X] None

FullIncompleteWith Patient

Upper X

Lower X

[ ] N [ ] V Character _________________ [ ] Recent change in weight, appetite [ ] Swallowing difficulty [X] DeniedComments:dili man pud ko kabati ug kasukaon labi na nuon sa pagsuka. As verbalized by the client.

ELIMINATION: Usual bowel pattern: Thrice a day

[ ] Constipation __ RemedyPapaya

__ Date of last BMDec. 6, 2013

[ ] Diarrhea __ Character

[ ] Urinary Frequency 15 times/day

[ ] Urgency [ ] Dysuria [ ] Hematuria [ ] Incontinence [X] Polyuria [ ] Foly in place [ ] Denied

Comments: No abdominal tenderness upon palpation.Bowel sounds:_normoactive 10 bowel sounds per minute__Abdominal Distention:Present: [X]Yes [ ]No

Urine:Color:Yellowish

Odor:Foully

Consistency:

MGT. OF HEALTH & ILLNESS: [ ] Alcohol [X] Denied __ Amount & FrequencyDili sad koga-inom.as verbalized by the client

SBELast Pap Smear:

LMP:May 28, 2013

Briefly describe the patients ability to follow treatments (diet, meds, etc.) for chronic problems (if present). The patient is following the instructions that is given to her and takes her medications religiously.

SKIN INTEGRITY: [ ] Dry [ ] Itching [ ] Other [X] DeniedComments: ok ra man, dili man ko gapangatol . As verbalized by the client. [ ] Dry [ ] Flushed [ ] Moist [X] Cold [ ] Warm [ ] Cyanotic [ ] Pale

*Rashes, ulcers, decubitus (describe size,*location, drainage):No rashes, ulcers, or decubitus noted; striae gravidarum & linea negra were observed.

ACTIVITY/SAFETY: [ ] Convulsion [X] Dizziness [X] Limited motion of joints

Limitation in ability to: [X] Ambulate [ ] Bathe Self [ ] Other [ ] DeniedComments:Kalipongon ko molakaw. As verbalized by the client.

[ ] Level of Consciousness and OrientationThe client is awake and coherent

__ Gait: __ Walker __ Cane __ Other __ Gait: __ Steady __ Gait: _X_ Unsteady: _______________ [ ] Sensory and motor losses in face or extremities:No sensory and motor loses on face and extremities noted.

[X] Range of Motion Limitations:Client cannot move her legs well

COMFORT/SLEEP/AWAKE: [X] Facial Grimaces [ ] Guarding [X] Other Signs of Pain:Patient is complaining of epigastric pain

[ ] Siderail release form signed (60+ years)None (N/a)

[X] PainLocation:

Pelvic region

Frequency:

8/10

Remedies:

Alaxan/Biogesic

[ ] Nocturia [X] Sleep Difficulties [ ] DeniedComments:Dili kayo ko katulog tarong sakit ako pus-on. as verbalized by the client.

COPING:Occupation:Housewife

Members of household:

Husband and

children

Most supportive person:

Husband

Observe non-verbal behavior:

No eye contact during the assessment.

Patient was grouchy at the time of interview.

The person and his phone number that can

Be reached anytime:

Not on record

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)Not Ordered Daily Weight Not Ordered PT/OT__________Not Ordered BP q Shift Not Ordered IrradiationNot Ordered Neuro VS 12/06/2013 Urine Test: Protein TraceNot Ordered CVP/SG. Reading Not Ordered 24 hour Urine Collection

Date orderedDiagnostic/ Laboratory ExamsDate DoneDate OrderedI.V. Fluids/ BloodDate Disc.

11/06/2013Ultrasound11/06/201312/06/2013D5LR 1L @30gtts/min12/07/2013

12/06/2013Blood Chem12/06/201312/07/2013PNSS 1L + 40 mEq s KCl @30gtts/min12/07/13

12/06/2013Urinalysis12/06/201312/09/2013D5LR 1L @20gtts/minOngoing

12/08/2013CBC12/08/2013

LABORATORY TEST RESULT AND INTERPRETATION:BLOOD COUNT RESULT:Expected ValuesUnitResultTest

5.0 10.0x10^3/uL11.68White Blood Cells

4.2 5.4x10^6/uL3.67Red Blood Cells

12.0 16.0g/dL11.2Hemoglobin

37.0 47.0%32.5Hematocrit

9.0 16.0fL8.9Platelet Distribution Width

4.5 10.5%11.0Monocyte

WHITE BLOOD CELL COUNT: is a blood test to measure the number of white blood cells (WBCs). - The white blood cell count of patient Cabasag was greater than the expected value of or the normal value of white blood cell we have to our body. - The white cell count (the number of cells in a given amount of blood) in someone with an infection often is higher than usual because more WBCs are being produced or are entering the bloodstream to battle the infection.After the body has been challenged by some infections, lymphocytes "remember" how to make the specific antibodies that will quickly attack the same germ if it enters the body again.

RED BLOOD CELL COUNT: is a blood test that tells how many red blood cells (RBCs) you have. - The red blood cell count of patient Cabasag was less than the expected value of or the normal value of red blood cell we have to our body. - Red blood cells carry oxygen to all parts of your body. When your red blood cell (or hemoglobin) count is low, parts of your body do not get enough oxygen to do their work. This condition is called anemia and can make you feel very tired.HEMOGLOBIN: is a protein in red blood cells that carries oxygen. A blood test can tell how much hemoglobin you have in your blood. - The hemoglobin of patient Cabasag was less than to the expected value or normal result.

HEMATOCRIT: is a blood test that measures the percentage of the volume of whole blood that is made up of red blood cells. This measurement depends on the number of red blood cells and the size of red blood cells. -The hematocrit of patient Cabasag was lesser than the expected value of a normal result.

PDW COUNT: Platelet Distribution Width is an indication of variation in platelet size, which can be a sign of active platelet release. -The PDW of patient Cabasag was lesser than the expected value of a normal result.MONOCYTE COUNT: This test measures the amount of monocytes in blood. Monocytes are a type of white blood cell (WBC). This test is used to evaluate and manage blood disorders, certain problems with the immune system, and cancers, including monocytic leukemia. This test may also be used to evaluate for the risk of complications after a heart attack.-The monocyte of patient Cabasag was higher than the expected value of a normal result.

URINALYSISUrine TestA urine test checks different components of urine, a waste product made by thekidneys. A regular urine test may be done to help find the cause of symptoms. The test can give information about your health and problems you may have. -The color of the urine of patient Cabasag was straw and the clarity was turbid, the color of urine is affected to what she taking. The pH result was 6.0 it is an indication that the body's fluids elsewhere are too acid, and it is working overtime to rid itself of an acid medium. They have few epithelial cells, few bacteria and the calcium oxalate was rare in her urine. If theirs bacteria, epithelial cells seen in the urine there was an infection. The ALT(GPT) was in normal result, ASAT(SGOT) was in normal result, Creatinine was in normal result, Blood in uric acid was in normal result. Patient Cabasag has few bacteria in her urine it means she has an infection in her urine that will lead to urinary tract infection. Bacteria are common in urine specimens because of the abundant normal microbial flora of the vagina or external urethral meatus and because of their ability to rapidly multiply in urine standing at room temperature. Therefore, microbial organisms found in all but the most scrupulously collected urines should be interpreted in view of clinical symptoms.Diagnosis of bacteriuria in a case of suspected urinary tract infection requires culture. A colony count may also be done to see if significant numbers of bacteria are present. Generally, more than 100,000/ml of one organism reflects significant bacteriuria. Multiple organisms reflect contamination. However, the presence of any organism in catheterized or suprapubic tap specimens should be considered significant.

ULTRA SOUND:LMP: May 28, 2013AOG: 23 weeks & 1 dayEDC: February 4, 2014

No. of Fetuses: One PLACENTA Location: Postero-fundal Grade: IIDistance from internal os

Presentation: CephalicFHB: 60 bpmAmniotic Fluid Index: 13.5cmRemarks: Pregnancy Uterine, 29 weeks and 5 days by fetal biometry, singleton, live, cephalic in presentation. Postero-fundal placenta, grade II. Adequate Amniotic Fluid Estimated Fetal weight of 1651.22 grams

IV. DEVELOPMENTAL DATAThe term growth and development both refers to dynamic process. Often used interchangeably, these terms have different meanings. Growth and development are interdependent, interrelated process. Growth generally takes place during the first 20 years of life; development continues after that.Growth:1. Physical change and increase in size.2. It can be measured quantitatively.3. Indicators of growth include height, weight, bone size, and dentition.4. Growth rates vary during different stages of growth and development.5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent stages and slows during childhood.6. Physical growth is minimal during adulthood. Development:1. It is an increase in the complexity of function and skill progression.2. It is the capacity and skill of a person to adapt to the environment.3. Development is the behavioral aspect of growth.

Eriksons Stages of Psychosocial Development TheorySTAGEAGECENTRAL TASK

(+) RESOLUTION

(-) RESOLUTION

Young Adulthood

18-40 y/o

Intimacy vs. isolation

Intimate relationship with another person.Commitment to work and relationships.Impersonal relationships.Avoidance of relationship, Career or lifestyle commitments.

Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward longer-term commitments with someone other than a family member. Successful completion can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression.Havighursts Developmental Stage and TasksAdulthood- Selecting a mate- Achieving a masculine or feminine social role- Learning to live with a marriage partner- Starting a family- Rearing children- Managing a home- Getting started in an occupation- Taking on civic responsibility- Finding a congenial social group

It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it.

V. MEDICAL MANAGEMENTDecember 06, 2013

7:00 PMAdmit to OB

TPR every 4 hoursFor further monitoring

Low salt and Low fat DietTo prevent hypertension

Laboratory Exams

Blood Chem, Urinalysis

Start IVF with D5LR 1 L @ 30gtts/minTo replace lost fluids and electrolytes

BP> 200/120 mmHg

Magnesium Sulfate 5gms deep IM on alternate buttocks q6H x 4doses as maintenance dose Anticonvulsant drug

RR 23cpm

FBC F14 attach, I and O q4Hydralazine 5mg IVTT nowMethyldopa 250mg 1tab q8H

Antihypertensive drug for high bloodTreatment of sustained moderate to severe hypertension

CBR with TP

Refer the BP if >160/100

Refer accordingly

December 07, 2013

7:10am Continue medication To maintain blood pressure

Monitor BP Served as baseline data

10:45amFollow-up other labs and refer For the doctor to see the result

Check vital signs every 4 hours To monitor the vital signs

FHB every 4 hours To monitor FHB

Change PNSS 1L + 40 mEq s KCl @30gtts/minSource of water and electrolytes

3:00pmTransport to OB-OPD clinic for fetal heart assessment To check for any abnormalities

Given hydralazine as prescribed Antihypertensive drug for high blood

8:00pmMay transport patient to OB-OPD clinic for fetal heart rate To check for any abnormalities

8:40pmFHT 152bpm Normal FHB

Hydralazine 5mg q15min provide for DBP 110mmHg Antihypertensive drug for high blood

December 08, 2013Continue BP Measure for baseline information.

Continue MedicationTo improve patients condition.

Continue CBR with TP

December 09, 2013Continue BP

8:00 amContinue MedicationTo improve patients condition.

Change IVF with D5LR 1 L @ 20gtts/minTo replace lost fluids and electrolytes

10:00 amFor trans abdominal UltrasoundTo diagnose pregnancy condition

especially the fetus condition

Continue monitoring V/S & FHB Monitor the V/S & FHB whether

every 4hrs.a good base line rate is present.

7:00 pmMay transport patient to Delivery RoomTo prepare for delivery.

V. PathophysiologyChronic Hypertension is characterized by either a BP 140/90 mmHg or greater before pregnancy or diagnosed before 20 weeks' gestation; Preeclampsia is characterized by a BP of 140/90 mm Hg or greater after 20 weeks' gestation

Increase AldosteroneReninJuxtaglomerular CellsBlood PressureDecrease blood flow to OrgansIncrease AfterloadAdrenal Cortex stimulation IIAngiotensin IIIncrease Peripheral ResistanceArteriolar VasoconstrictionAngiotensin IAngiotensinogenIncrease Systemic Vascular ResistancePrecipitating Factors: Stress Sedentary Lifestyle

Chronic Hypertension with superimposed Preeclampsia

Predisposing Factors: Gender Pregnant Age Heredity

Increase Blood Pressure

After 20 weeks ofgestation

Increasing BloodPressure

Effects on FetusI. Premature Placental AgingII. Decreased Placental Flow and FGRIII. Fetal Hypotension and Low Amniotic FluidIV. Increase Risk of DiseasesV. Placental Abruption

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VI. DRUG STUDYGENERIC NAME OF ORDERED DRUGBRAND NAMEDATE ORDERED:CLASSIFICATIONDOSE/FREQUENCY ROUTEMECHANISM OF ACTIONSPECIFIC INDICATIONCONTRAINDICATIONSIDE EFFECTS/TOXIC EFFECTSNURSING PRECAUTION

HydralazineAprsolineDecember 6, 2013antihypertensive5mg IVTTIt works by relaxing the blood vessels so that blood can flow more easily through the body. Hydralazine apparently lowers blood pressure by exerting a peripheral vasodilating effect through a direct relaxation of vascular smooth muscle. Hydralazine, by altering cellular calcium metabolism, interferes with the calcium movements within the vascular smooth muscle that are responsible for initiating or maintaining the contractile state.Treat-ment of severe essential hyper-tension.

Patients with Coronary artery disease; mitral valvular rheumatic heart disease.-flushing (feeling of warmth)-headache-upset stomach-vomiting-loss of appetite-diarrhea-constipation-eye tearing-stuffy nose-rash-in pregnancy (teratogenic)

-the nurse should inform the patient of possible side effects and advised to take the medication regularly and continuously as prescribed by the doctor-advised the patient to avoid alcohol because it can make the side effects from hydralazine worse-the nurse should administer this drug cautiously to postpartum patients with advance renal damage, suspected coronary artery disease.

GENERIC NAME OF ORDERED DRUGBRAND NAMEDATE ORDERED:CLASSIFICATIONDOSE/FREQUENCY ROUTEMECHANISM OF ACTIONSPECIFIC INDICATIONCONTRAINDICATIONSIDE EFFECTS/TOXIC EFFECTSNURSING PRECAUTION

Magnesium Sulfate Epsom Salt December 6, 2013Anti-convulsant5gms deep IM on alternate buttocks q6 4doses as maintenance doseMagnesium is the second most plentiful caution of the intracellular fluids. It is essential for the activity of many enzyme systems and plays an important role with regard to neurochemical transmission and muscular excitability. Magnesium sulfate reduces striated muscle contractions and blocks peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural junction. Additionally, Magnesium inhibits Ca2+influx through dihydropyridine-sensitive, voltage-dependent channels. This accounts for much of its relaxant action on vascular smooth muscle.Indicated to prevent seizures associated with pre-eclampsia, and for control of seizures with eclampsia.

- Patients with allergy to magnesium products; heart block, myocardial damage; hepatitis-CNS:-Weakness, dizziness, fainting, sweatingCV:-PalpationsGI:-Excessive bowel activity, perianal irritationsMetabolic:-Hypomagnesaemia and toxicity in patients with renal failure

-Reserve IV use in eclampsia for immediate life threatening situations-Give IM route for deep IM injection of undiluted (50%) solution-Monitor serum magnesium levels during parenteral therapy-Monitor knee-jerk reflex-Do not give magnesium sulfate to patient with abdominal pain, nausea and vomiting

GENERIC NAME OF ORDERED DRUGBRAND NAMEDATE ORDERED:CLASSIFICATIONDOSE/FREQUENCY ROUTEMECHANISM OF ACTIONSPECIFIC INDICATIONCONTRAINDICATIONSIDE EFFECTS/TOXIC EFFECTSNURSING PRECAUTION

MethyldopaAldometDecember 6, 2013Anti-Hypertensive250mg 1tab q8 Although the mechanism of action has yet to be conclusively demonstrated, the antihypertensive effect of Methyldopa probably is due to its metabolism to alpha-methylnorepinephrine, which then lowers arterial pressure by stimulation of central inhibitory alpha-adrenergic receptors, false neurotransmission, and/or reduction of plasma renin activity. Methyldopa has been shown to cause a net reduction in the tissue concentration of serotonin, dopamine, norepinephrine, and epinephrine.This medication is used alone or with other medications to treat high blood pressure- Patients with active hepatic disease-History of methyldopa-associated liver dysfunction- Drowsiness-Headache-Muscle weakness-Swollen ankles or feet-Upset stomach-Vomiting-Diarrhea-Dry mouth- Tolerance may occur, Monitor hepatic function,- Discontinue drug if fever, abnormalities in liver function tests, or jaundice occur.

- Discontinue if edema progresses or signs of CHF occur.

VII. NURSING MANAGEMENTIdeal Nursing Interventions for Hypertension:

Nursing DiagnosisNursing InterventionsRationale

Risk for decreased cardiac outputrelated to increased afterload, vasoconstriction, myocardial ischemia, and ventricular hypertrophy.

1. Monitor blood pressure, measure in both arms/thighs three times, use correct cuff size and accurate technique.

2. Note dependent/general edema.

3. Note presence, quality of central and peripheral pulses.

4. Observe skin color, moisture, temperature, and capillary refill time.

Comparison of pressures provides a more complete picture of vascular involvement/scope of problem. Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease, when diastolic pressure is elevated.

May indicate heart failure, renal or vascular impairment.

Pulses in the legs/feet may be diminished, reflecting effects of vasoconstriction (increased systemic vascular resistance [SVR]) and venous congestion.

Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation / decreased output.


Acute Pain related to increased cerebral vascular pressure.

1. Assess pain scale. Determine specifics of pain, e.g., location,characteristics.

2. Encourage bed rest during acute phase.

3. Assist patient with ambulation as needed.

4. Minimize vasoconstricting activities that may aggravate headache.

Helpful in evaluating effectiveness of therapy.

Minimizes stimulation/promotes relaxation.

Patient may also experience episodes of postural hypotension, causing weakness when ambulating.

Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure.


Activity Intolerance related to generalized weakness, imbalance between oxygen supply and demand.

1. Instruct patient in energy-conserving techniques, e.g., using chair when showering, sitting to brush teeth or comb hair, carrying out activities at a slower pace.

2. Encourage progressive activity/self-care when tolerated. Provide assistance as needed. Energy-saving techniques reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand.

Gradual activity progression prevents a sudden increase in cardiac workload. Providing assistance only as needed encourages independence in performing activities.


Knowledge deficit related to lack of information about the disease process

1. Define and specify the desired blood pressure limits. Describe hypertension and its effect on the heart, blood vessels, kidneys, and brain.

2. Assist patients in identifying the risk factors that can be modified, for example, obesity, a diet high in sodium,saturated fat, and cholesterol, sedentary lifestyle, smoking, alcohol consumption, and stress lifestyle. Provides a basis for understanding blood pressure elevation, and describes commonly used medical terms. Understanding that high blood pressure can occur without symptoms is the center allows patients to continue treatment, even when it feels good.

Risk factors that have been shown to contribute to hypertension and cardiovascular and renal disease.

Ideal Nursing Interventions for Preeclampsia:


High risk of seizures in pregnant women related todecreasedorgan function (vasospasm and increasedblood pressure). 1. Monitorblood pressureevery 4 hours.

2. Record the patient's level of consciousness.

3. Assesssigns ofeclampsia (hyper active, the patellar reflexes, decreasedpulse and respiration, epigastric pain and oliguria).

4. Monitor forsigns and symptomsof labor or uterine contractions.

5. Collaboration with the medical team in the provision of anti-hypertension. The pressure over 110 mmHg diastole and systole 160 or more an indication of PIH. The decline of consciousness as an indication ofdecreased cerebral blood flow.

The symptoms are a manifestation of changes in the brain, kidney, heart and lung that precedes seizure status.

Seizures will increase the sensitivity of the uterus, which will allow the delivery.

Anti-hypertension to lowerblood pressure.


High risk of fetal distress related to changes in the placenta.

1. Monitor fetal heart rate as indicated.

2. Review on fetal growth.

3. Explainthe signsof solusio placenta (abdominal pain, bleeding, uterine tension,decreasedfetal activity).

4. Collaboration with the medical ultrasound and NST. Increased fetal heart rate as an indication of hypoxia, premature and solusio placenta.

Decrease in placental function may be caused by hypertension, causing IUGR. Pregnant women may know thesigns and symptomsof solutio placenta. Pregnant women can learn from hypoxia in the fetus.

Ultrasound and NST to a known state / welfare of the fetus.


Impaired sense of comfort (pain) related to uterine contractions.

1. Assess the patient's pain intensity level.

2. Explain the causes of pain.

3. Help the pregnant woman by rubbing / massage on the painful part. The threshold of pain everyone is different, thus will be able to determine appropriate action treatment with the patient's response to pain.

Pregnant women can understand the causes of pain.

To distract the patient.

NURSING CARE PLANCuesNursing DiagnosisObjectivesNursing InterventionsRationaleEvaluation

S: Sakit kaayo akong tahi as verbalized by the patient

O: - Facial Grimaces

- Rated Pain as 9 in a pain scale of 1-10, 10 being the highestAcute Pain related to surgical incision as evidenced by facial mask of painAt the end of 1 hr. of nursing care, the patient will:

Identify and use appropriate interventions to manage pain/discomfort

Verbalize lessening of level of pain

Appear relaxed, able to sleep/rest appropriatelyIndependent:1. Reposition client, reduce noxious stimuli, and offer comfort measures, e.g. back rubs

2. Encourage use of breathing and relaxation techniques and distraction (stimulation of cutaneous tissue)

3. Encourage adequate rest period

4. Encourage early ambulation

Dependent:1. Administer analgesics as prescribed by the doctor Relaxes muscles, and redirects attention away from painful sensations

Promotes comfort, and reduces unpleasant distractions, enhancing sense of well-being

To prevent fatigue

To prevent pooling of blood which prevents blood clots

Promotes comfort, which improves psychological status and enhances mobilityAfter of 1 hr. of nursing care, the patient:

Identified and used appropriate interventions to manage pain/discomfort

Verbalized lessening of level of pain

Appeared relaxed, able to sleep/rest appropriately


S: Ga paspas ang akong kasing2x as verbalized by the patient.

O: - BP: 160/100 mmHg

- RR: 24cpm

- PR: 106bpm

- Lower extremities edemaDecreased cardiac output related to altered heart rate (106bpm), as evidenced by tachycardia and increased blood pressure, patients report of palpations; r/t decreased venous return as evidenced by lower extremities edema, SOB (24cpm)At the end of 2 hr. of nursing care, the patient will display hemodynamic stability (heart rate will decrease from 106 bpm to 100 bpm, BP from 160/100 to 120/80)

Independent:1. Keep client on bed and in position of comfort

2. Decrease stimuli; provide quiet environment

3. Encourage deep breathing exercise

4. Encourage changing positions slowly

5. Give information about positive signs of improvement

Dependent:6. Administer antihypertensive drug as prescribed by the doctor. Decreases oxygen consumption

To promote adequate rest

To reduce anxiety

To reduce risk for orthostatic hypotension

To provide encouragement

To treat hypertension

After 2 hr. of nursing care, the patient was able to display hemodynamic stability (heart rate decreased from 106 bpm to 100 bpm, BP from 160/100 to (120/80)


S:

O: - Post surgical incision

Risk Factors (Nanda) Environmental Factor Decreased tissue perfusion Decreased wound healing time

Risk for infection related to post surgical incisionAfter series of nursing interventions the client should:

Short Term Identify the risk factors present in the clients condition Clients partial understanding about infection and its risk factors

Long Term Effective prevention of infection to the client Clients full understanding to the risk of infectionIndependent:1. Teach patient to wash hands often, especially before toileting, before meals and before and after administering self-care

2. Discuss topatients the following signs of infection -redness, swelling, increased pain, or purulent drainage on the site and fever

3. Demonstrate and allow return demonstration of wound care

4. Monitor vital signs

Dependent:1. Administer antibiotics as prescribed by the doctor Hand washing reduces the risks for infection

To impart to the patient when the wound become infected and when to sought medical care

To know if the patient really understand the principle of proper wound care

Temperature elevation and tachycardia may reflect developing sepsis

To prevent infection

After 30 min of nursing interventions, client was able to identify the risk factors present in her condition, able to gain knowledge on effective prevention of infection and full understanding to the risk of infection

Actual nursing management (DAR)D> Received Awake sitting on bed IVF of D5LR 1L @ 900cc

level regulated @ 10 gtts/min

> BP= 160/100 FHB= 134

> 1+ mild pitting, slight indentation noted

A> Vital signs monitored and recorded

> On complete bed rest toilet privilege

> Kept on left lateral decubitus position

> Encouraged deep breathing exercise

> Advised to increase greens in diet like ampalaya & malunggay leaves

> Encouraged to have adequate rest and sleep> Health teachings imparted with emphasis on a) Sodium restrictionb) Avoiding foods rich in oil and fatsc) Limiting daily activities and exercisesd) Proper nutritione) Compliance to medicationf) Proper hygiene> Kept back dry

R> Able to rest well

> Endorsed with latest BP= 160/100

Discharge Plan:

Exercise1. Encourage patients on deep breathing exercises.2. Move extremities when lying.3. Elevate the head part when sleeping, to promote increase peripheral circulation4. Encourage overall passive and active exercises program during pregnancy to prevent need for cesarean birth.5. Exercises like tailor sitting, squatting,kegel exercise, pelvic rocking, and abdominal muscle contraction will promote easy delivery.

Treatment:1. Use of drugs2. Catheterization3. Obtaining labs. (CBC, platelets count, liver function, BUN and creatinine, and fibrin degregation)

Health Teachings imparted with emphasis on:1. Sodium restriction.2. Avoiding foods rich in oil and fats.3. Encourage patient to limit her daily activities and exercises.

Diet:1. Low fats and sodium diet, restriction if possible.2. High in protein, calcium and iron.3. Adequate fluid intake

Sex:1. Limit sexual activity2. Sexual intercourse at 2nd trimester should be avoided.

VIII. REFERRALS AND FOLLOW-UP:Instructed the client to come back one week after discharged for further follow-up and evaluation of the clients health condition. This is very important so that the health condition of the client will be evaluated if there is better improvement. The physician should see and examine the physical appearance of the client.

IX: EVALUATION AND IMPLICATIONS:This care study enables us to further our learning association with disease condition of the patient. From it, we have gained knowledge in the progression of the disease and the reaction of the body to maintain homeostasis and how eventually it causes harm.Through this, we actually improved our understanding and skills in the management of the patient through the experiences weve had in implementing our care. It also enhanced our confidence in intervening because of the input gained form our research.Case studies are a way of getting familiar or get acquainted not only with the patient but also on his or her condition. It provides concrete examples of how the theoretical knowledge learned during lectures was applied. How the concepts of the various disease conditions were manifested through the client. It allows the opportunity to facilitate the acquisition of knowledge through the experiences gained in management and in caring for the patient. As a result, it is a must that case studies should be made not just for requirement purposes but also for the pursuit of knowledge.In general, the case study promoted learning through the research and actual experiences and made us more knowledgeable in caring for the patient and that can really be used in our chosen field.

X. Bibliography

120 Diseases (The essential Guide to more than 120 Medical Conditions, syndromes, and diseases) by Prof. Peter Abrahams 2007 pp. 158Essentials of pathophysiology by Carol Mattson Porth RN, MSN, PhD Pp.605-613Manual of Nursing Practice by Lippincott 10thed. Pp. 1201-1212Maternal and child health nursing by Adele Pillitteri 5th edition; volume 1 page 426-433;page 329-332

WWW.MEDSCAPE.COMWWW.WIKIPEDIA.ORGhttp://nursingcrib.com

Pre Eclampsia case study

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