Table of ContentsChapter 1 – Introduction ObjectivesChapter 2 – Assessment Nursing Health History Personal Data of the Patient Chief Complaints History of Present Illness Past Medical History Family Health History Physical Assessment Diagnostic Procedure Anatomy and Physiology of the Systems affected a. PathophysiologyChapter 3 – Planning A. List of Prioritized Nursing Diagnoses B. NCP C. Drug StudyChapter 4 – Discharge Planning
Chapter 1 – IntroductionWe, group 1 of JRU BSN A314, would like to thank Sta. Rita de Baclaran Hospital for allowingus to choose a patient for our case. We also thank our clinical instructor, Mr. Belocura and ourpreceptor Ms. Hazel Ann Cruz, for patiently teaching us and making sure we learn the mostfrom our clinical exposure.ObjectivesGeneral Objectives – We did this case study for us to have a deeper understanding of whatpreeclampsia is, thus to give us an idea of how we could give proper nursing care for ourclients with this condition.Specific Objective - We hope to be able to address the client’s health needs and also to assessfor any health deficit or risks like acute pain, infection, and self-care.Chapter 2 AssessmentA. Personal DataName: A.K.A ‘CHURVA”Age: 30 yrs oldSex: FemaleAddress: Baclaran CityChief complaint: Labor painsB. Past Medical History The patient’s past history was post CS.C. Present medical History The patient was admitted Dec 1 2007 at 11: am; chief complaint was severe abdominalpain and increasing B/P.She was admitted in Sta. Rita Medical Hospital.D. Family Health History There’s a history of hypertension in the client’s family. Her mother had hypertension.3. Diagnostic Procedures Common laboratory tests to diagnose Pregnancy-induced hypertension would includeblood test, renal function, creatinine, and BUN. But these tests were not noted on the client’schart. What we found out instead is the continual rising of the client’s blood pressure from thetime she got in the hospital at 10am until she was admitted.
Blood pressure taking is one easy method to monitor the client’s blood pressure. Theclient’s blood pressure was at 170/90 at 10am then increased to 170/100 at 12nn and reached190/100 at 1pm. While the normal blood pressure is below 120/80; blood pressure between120/80 and 139/89 is called "pre–hypertension", and a blood pressure of 140/90 or above isconsidered high.4. Anatomy & Physiology The Circulatory (Cardiovascular) SystemThe Circulatory System is designed to deliver oxygen and nutrients to all parts of the body andpick up waste materials and toxins for elimination. This system is made up of the heart, theveins, the arteries, and the capillaries.Circulation is achieved by a continuous one-way movement of blood throughout the body. Thenetwork of blood vessels that flow through the body is so extensive that blood flows withinclose proximity to almost every cell.HeartThe heart is a muscular pump that propels blood throughout the body. The heart is locatedbetween the lungs, slightly to the left of center in the chest. The heart is broken down intofour chambers including: • The right atrium, which is a chamber which receives oxygen- poor blood from the veins. • The right ventricle which pumps the oxygen-poor blood from the right atrium to the lungs. • The left atrium which receives the now oxygen-rich blood that is returning from the lungs. • The left ventricle, which pumps the oxygenated blood through the arteries to the rest of the body.Blood VesselsBlood vessels are broken down into three groups: the arteries which carry blood out of theheart to the capillaries, the veins which transport oxygen-poor blood back to the heart, andthe capillaries which transfer oxygen and other nutrients into the cells and removes carbondioxide and other metabolic waste from these body tissues.Blood PressureBlood pressure is the force exerted by the blood against the walls of the blood vessels. Theoutput or direct pumping of the heart and the resistance to blood flow in the vesselsdetermines blood pressure. Resistance is determined by blood viscosity and by friction
between the blood and the wall of the blood vessel.Blood pressure = blood flow x resistance. PATHOPHYSIOLOGY OF PREGNANCY-INDUCED HYPERTENSION Vasopasm Peripheral Arteriole Vasoconstriction BLURRING OF VISON, HEADACHE INCREASED BLOOD PRESSURE PREGNANCY-INDUCED HYPERTENSION
Chapter 3 – PlanningPriority: 1. Acute pain 2. Risk for infection 3. Self-care deficitASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION DIAGNOSIS IndependentSubjective Cues: Acute pain related Within 8 hrs nursing > Provide information and > Promotes problem Goals met.“Masakit ang tahi ko,” to surgical incision intervention the patient anticipatory guidance regarding solving, helps reduce painas verbalized by the as evidenced by will: causes of discomfort and associated with anxietypatient. facial mask of appropriate interventions. and fear of the unknown, pain. > Identify and use and provides sense of appropriate interventions control. to manage pain/discomfort. > Reposition client, reduce > Relaxes muscles, and noxious stimuli, and offer comfort redirects attention awayObjective Cues: > Verbalize lessening of measures, e.g., back rubs. from painful sensations. level of pain. Encourage use of breathing and Promotes comfort, and(+) Guarding relaxation techniques and reduces unpleasantbehavior > Appear relaxed, able to distraction (stimulation of distractions, enhancing(+) Facial mask of sleep/rest appropriately. cutaneous tissue). sense of well-being.pain > Encourage early ambulation. > Decreases gas formation and promotes peristalsis to relieve discomfort of gas accumulation, which often peaks on 3rd day after Collaborative cesarean birth. > Administer analgesics every 3–4 > Promotes comfort, which hr prn. Medicate lactating client improves psychological 45–60 min before breastfeeding. status and enhances mobility. Use of medication with limited ability to cross into milk allows lactating mother to enjoy feeding without adverse effects on infant.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION DIAGNOSIS Risk for infection At the end of the 3 days IndependentSubjective Cues: related to tissue of nursing intervention, > Encourage and use careful > Helps prevent or retard > Goals met.“Paano maiiwasan ang trauma/broken skin. the client will: handwashing and appropriate spread of infection.impeksyon sa tahi ko?” disposal of soiled perineal pads, > Demonstrate and contaminated linen. techniques to reduce risks Discuss with client theObjective Cues: and/or promote healing. importance of continuing these measures after discharge.[Not applicable; presence of > Display wound free ofsigns/symptoms establishes an purulent drainage with > Prevents dehydration;actual diagnosis] > Encourage oral fluids and diet initial signs of healing high in protein, vitamin C, and maximizes circulation and (i.e., approximation of iron. urine flow. Protein and vitamin wound edges), uterus C are needed for collagen soft/nontender, with formation; iron is needed for normal lochial flow and Hb synthesis. character. > Inspect abdominal dressing > A sterile dressing covering for exudate or oozing. Remove the wound in the first 24 hr dressing, as indicated. following cesarean birth helps protect it from injury or contamination. Oozing may indicate hematoma, loss of suture approximation, or wound dehiscence, requiring further intervention. Removing the dressing allows incision to dry and promotes healing. > Inspect incision, evaluate > These signs indicate wound healing process, noting infection. Wound infections localized redness, edema, pain, are usually clinically apparent exudate, or loss of 3–8 days after the procedure. approximation of wound edges.
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION DIAGNOSIS Self-care deficit related At the end of a two hour IndependentSubjective Cues: to decreased strength nursing intervention, the > Assess client’s > Physical pain experience may Goals met.“Kailan ko kaya maire- and endurance as client will: psychological status. be compounded by mental painresume ang normal na evidenced by inability to that interferes with client’sgawain ko?” ambulate independently. > Verbalization of desire and motivation to inability to participate at assume autonomy.Objective Cues: level desired.Inability to ambulate > Offer assistance as needed > Improves self-esteem;independently. > Demonstrate with hygiene (e.g., mouth increases feelings of well-being. techniques to meet self- care, bathing, back rubs, and care needs. perineal care). > Identify/use available resources. > Offer choices when > Allows some autonomy, even possible (e.g., selection of though client depends on juices, scheduling of bath, professional assistance. destination during ambulation). Collaborative > Administer analgesic agent > Reduces discomfort, which every 3–4 hr, as needed. could interfere with ability to engage in self-care.
Chapter III Implementation Medical Management - Drug StudyName of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibilities Hydralazine is used to Essential Check if the client takes theHydralazine treat high blood pressure. hypertension, alone or medication and if it is in the right(Apresoline) It works by relaxing the as an adjunct. Hypersensitivity to • flushing (feeling of patient and check also the doctor’s hydralazine; coronary warmth) blood vessels so that Management of order. Observe for any reaction to artery disease; mitral blood can flow more easily moderate to severe valvular rheumatic • headache the medication like headache, through the body. hypertension, flushing, vomiting, etc. If any heart disease. congestive heart reaction occurs inform your failure, hypertension • eye tearing physician. secondary to pre- eclampsia/eclampsia; Monitor BP every 5 mins. treatment of primary pulmonary hypertension. Under indications. Start with 10 mg four times daily for the first 2 to 4 days, increase to 25 mg four times daily for the balance of the first week. For the second and subsequent weeks, increase dosage to 50 mg four times daily. For maintenance, adjust dosage to the lowest effective levels.
Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibilitiesArthrotec (Diclofenac Used for treatmentfor Check if the client takes theNa) rheumatoid, ARTHROTEC is ARTHROTEC is • .abdominal pain medication. Check for the doctor’s indicated for contraindicated in • diarrhea arthritis,dysmenorrheal, order and if it is the right patient. treatment of the signs patients with • GI symptoms headache, post partum Observe for any effect and if any and symptoms of hypersensitivity to pain. side effects occur inform physician. osteoarthritis or diclofenac or to Arthrotec contains rheumatoid arthritis in misoprostol or other dicoflenac sodium and Carefully consider the potential patients at high risk of prostaglandins. misoprostol. benefits and risks of ARTHROTEC developing NSAID- Administration of and other treatment options before induced gastric and misoprotol to women who deciding to use ARTHROTEC. Use duodenal ulcers and are pregnant can cause the lowest effective dose for the their complications. abortion, premature birth , shortest duration consistent with or birth defects. Uterine individual patient treatment ... rupture has been reported ARTHROTEC is when misoprostol was asministered in pregnant administered as women to induce labor or to induce abortion beyond ARTHROTEC 50 (50 the 8th week of pregnancy. mg diclofenac sodium/200 mcg misoprostol) or as ARTHROTEC 75 (75 mg diclofenac sodium/200 mcg misoprostol).
Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibiliries Before you administer penicillin,Penicillin G Penicillin G is used look at the solution closely. It should routinely for maternal The early use of A previous • rash be clear and free of floating hypersensitivity infections during penicillin G was linked reaction to any • fever material. Gently squeeze the bag or pregnancy. observe the solution container to penicillin is a • dizziness to increased uterine make sure there are no leaks. Do contraindication. not use the solution if it is activity and abortion. discolored, if it contains particles, or It is not known if the bag or container leaks. Use a new solution, but show the whether this was damaged one to your health care related to impurities in provider. the drug or to penicillin itself.
Chapter IV Discharge PlanningMedication Drug to be continued, Hydralazine (Apresoline) oral. For maintenance, adjust dosage to thelowest effective levels.Exercise The client should limit the no. of stairs she climbs to one flight/dayfor the first week athome. Beginning the second week, if her lochial discharge is normal, she may start to increasethis activity. Limit stair climbing to only when necessary for first two weeks.Treatment Advice client to monitor blood pressure, take prescribed medications and perform woundcare as needed.Health Teaching Teaching should focus on action to maintain comfort, to promote healing and restorewellness. avoid heavy work (lifting or straining) for at least first 3 weeks after birth. (it is usually advised that she doesn’t return to an outside for at least 3 weeks (better 6 weeks) not only for her own health but also for enjoyment of the early weeks with her newborn. Explore with th client what she consider heavy work) get lots of sleep. Sleep when baby sleeps. (Client should at least 1 rest period a day and try to get a good night’s sleep. She can rest during the day when her newborn is sleeping.) take advantage of help from others. avoid having sexual intercourse at least a month call your health care provider if you have any of the warning signs of sickness: (fever greater than100F, severe pain, redness or swelling in the incision site, foul smelling vaginal discharge, increase bleeding, back ache or severe abdominal pain or cramping (unrelieved by medication).) report increasing pain, swelling, or opening or gaping of wound edges. teach the client how to change wound dressings and perform wound care. instruct client to use pain medication as ordered. emphasize the importance of hygiene and hand washing to prevent infectionOut Patient follow-up The client should return to her physician 2-4 weeks after.Diet The client’s diet is high protein and low sodium diet.