Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
Tel.no: (045) 982-6062 Fax: (045) 982-0110

A CASE PRESENTATION
ON PRE-ECLAMPSIA
Presented to the Faculty of
Tarlac State University
College of Nursing

In Partial Fulfilment
of Requirements of the Subject
NCM 105 R.L.E.

Presented by:

Paras, Caselyn G.
BSN IV A
Group A2
Batch 2006-2010

January 2010

1
I. INTRODUCTION
Pre-eclampsia, also referred to as toxemia, is a medical
condition where hypertension arises in pregnancy (pregnancy-induced
hypertension) in association with significant amounts of protein in the urine. Pre-
eclampsia refers to a set of symptoms rather than any causative factor, and there
are many different causes for the condition. Women with preeclampsia will often
also have swelling in the feet, legs, and hands. In addition symptoms of
preeclampsia can include:

• Rapid weight gain caused by a significant increase in bodily fluid

• Abdominal pain
• Severe headaches
• A change in reflexes
• Reduced output of urine or no urine
• Dizziness
• Excessive vomiting and nausea

Pre-eclampsia may develop from 20 weeks gestation. Its progress differs

among patients. Most cases are diagnosed pre-term. Pre-eclampsia may also
occur up to six weeks post-partum. It is the most common of the dangerous
pregnancy complications; it may affect both the mother and the unborn child.

There are 2 categories of preeclampsia, mild and severe.

Severe preeclampsia is defined as the following:

• blood pressure greater than 160 mm Hg systolic or 110 mm Hg

diastolic on 2 occasions 6 hours apart
• proteinuria exceeding 2 g in a 24-hour period or 2-4+ on dipstick
testing
• increased serum creatinine (> 1.2 mg/dL unless known to be
elevated previously)
• oliguria ≤500 mL/24 h

2
 • cerebral or visual disturbances
• epigastric pain
• elevated liver enzymes
• thrombocytopenia (platelet count < 100,000/mm3)
• retinal hemorrhages, exudates, or papilledema
• pulmonary edema

Preeclampsia has been described as a disease of theories, because the cause

is unknown. Some theories include

• endothelial cell injury,

• ejection phenomenon (insufficient production of blocking antibodies),
• compromised placental perfusion,
• altered vascular reactivity,
• imbalance between prostacyclin and thromboxane,
• decreased glomerular filtration rate with retention of salt and water,
• decreased intravascular volume,
• increased central nervous system irritability,
• disseminated intravascular coagulation,
• uterine muscle stretch (ischemia),
• dietary factors, and
• genetic factors.

A database of hospital discharge data from approximately 300,000

deliveries in the United States found the overall incidence of severe
preeclampsia was about 1 percent of pregnancies. Studies of preeclampsia
report about 5 percent of nulliparous women develop preeclampsia and 40 to 50
percent of these women develop severe disease.

In the Philippines, according to Department of Health, Maternal Mortality

Rate(MMR) is 162 out of 10,000 live births (Family Planning Survey 2006).

3
Maternal deaths account for 14% of deaths among women. For the past five
years all of the causes of maternal deaths exhibited an upward trend.
Preeclampsia showed an increasing trend of 6.89%; 20%; 40%; and 100%. Ten
women die every day in the Philippines from pregnancy and childbirth related
causes but for every mother who dies, roughly 20 more suffer serious disease
and disability. The UNFPA office in the Philippines declared that family planning
can help prevent maternal deaths by 35%.
(http://hb4110.net/wpcontent/uploads/KIT_MATERNAL%20HEALTH_BASIC
%20STATS.doc.)

The only known treatments for eclampsia or advancing pre-eclampsia are

abortion or delivery, either by labor induction or Caesarean section (and
therefore delivery of the placenta). Magnesium sulfate is the first-line treatment of
prevention of primary and recurrent eclamptic seizures (it reduces transmission
of nerve impulses from brain to muscles). The mother and her family deserve
careful teaching regarding the problem, its observation, and its treatment.
Regular, adequate prenatal care is the best insurance for control of the
complication.

4
Importance of the case study
In the part of the client
This case will inform the client of what her condition is all about. It
will also lessen the burden of the client increasing her awareness about the
whole course of treatments. And also, the client will be able to familiarize
herself about the importance taking care of her own self through the use of
medical regimens.

In the part of the student

The student will gain more information and knowledge about the
disease and will lead to a certain new facts about the said condition, such
as cause of disease, pathophysiology, manifestations, related factors as
well as the proper nursing care management and medical regimens to be
rendered. This acquired information may also help the students on how to
properly manage and care for patients with the same state.

On the side of the College of Nursing

This study could be a used as a guide for the students and it can be
a source of facts and information to students of different colleges and
especially to the students of College of Nursing.

On the side of nursing profession

This study will serve as a basis in gathering facts and sets of

information with regards to pre-eclampsia.

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OBJECTIVES
GENERAL OBJECTIVES
Client Centered
• To assess the health of the patient
• To develop, implement, and evaluate plans for health promotion
• To provide client education and involve patient in implementing
therapeutic regimen to promote understanding and compliance.
Nurse Centered
• To apply the nursing process in the care of the hospitalized patient
• To describe effects of illness on individuals and family members’
roles and functions

SPECIFIC OBJECTIVES
Client-Centered
• Discuss indications for and management of a pregnant clients
• Discuss nursing implications for medications commonly prescribed
for pregnant
• Describe nursing care for the client
• Use the nursing process to provide individualized care for clients
who has experienced pre- eclampsia.
• Support client and family, and encourage them to ask questions so
that information could be clarified and understood

Nurse-Centered
• Identify major risk factors influencing the said condition.
• Identify the risk factor contributing to the occurrence of the disease.
• Learn the pathophysiology and manifestations of pre-eclampsia.
• Identify common diagnostic tests used for the said condition and
their nursing implications.

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 • Identify and describe nursing measure to promote awareness in the
condition
II. NURSING PROCESS

A. Assessment Data
1. Personal Data
a. Demographic Data

Name: Ms. Chi

Age: 23 years old
Sex: Female
Civil Status: Single
Occupation: None
Religious Affiliation: Roman Catholic
Address: Gerona, Tarlac
Date of Birth: January 25, 1987
Place of Birth: Gerona, Tarlac
Nationality: Filipino
Usual Source of Medical Care: Health Center and Hospital
Date and Time of Admission: January 09, 2010/3:35 am
Chief Complain: labor pains
Vital signs on admission:
Temp: 38.1°C
BP: 160/100 mmHg
PR: 88 bpm
RR: 30 cpm
Admitting Impression/Diagnosis: G1P0 PUFT pregnancy uteri to consider
pre-eclampsia
Surgical Procedure: low transverse cesarean section
Date and Time of operation: January 11, 2010/2:00 pm
Final Diagnosis: pregnancy uteri delivered via primary cesarean section to a live

7
 baby girl arrest in cervical dilatation filled medical induction
G1P1, pre- eclampsia
2. Environmental Status

The family is composed of eight members living within the house.

According to the patient, their house was made from concrete materials and
has four bedrooms. They were able to clean the house on a regular basis.
Communal water system is the primary source of drinking. They also have
their own comfort room inside the house. Transportation available in the
family is a tricycle. The location of their house is not easily accessible to
hospitals, but a health center was near their house. Ms. Chi did not report any
problems regarding her environment which interfered to her pregnancy.

3. Lifestyle

The patient usually wakes up eight to nine in the morning and helps
her mother and sister in cleaning the house or preparing the food. Hobbies
and/or recreational activities were talking with her brother and sisters, texting
or watching television and sometimes playing “bingo” and card games. The
patient does not smoke and drink alcoholic beverages.

PAST HEALTH HISTORY

Ms.Chi experienced measles, mumps, and chickenpox as a child.

She also experienced diarrhea, fever, cough, colds and self-medicates
with over the counter medications like paracetamol and cough
medications before she became pregnant. She has completed all her
immunizations and including two shots of tetanus toxoid during her
prenatal visits. She has no known allergies. She was never been
hospitalized before. This was the first time patient she was admitted in the
hospital. She has taken prescribed ferrous sulfate regularly at home.

8
PRESENT HISTORY

Three days prior to admission, the patient experienced labor pains. She
went to the health center that day for her prenatal visit. The health care worker
advised her to have her delivery at the hospital because she has a high blood
pressure. The health worker also instructed her that when contractions became
frequent with long durations she must go immediately at the hospital. 3:35 am of
January 09, she complained of labor pain. She was admitted at Tarlac Provincial
Hospital for further evaluation and tests. After being seen and examined by her
attending physician, high blood pressure, and pitting edema of about 2mm prior
to her admission were noted and diagnosed G1P0 PUFT to consider severe
preeclampsia.

9
 GENOGRAM Maternal Side

Pater nal Side

1
13 AREAS OF ASSESSMEN
SOCIAL STATUS
Ms. Chi is 22 years of age, a high school undergraduate and lives in
Gerona, Tarlac together with her family. According to her, she has a good
relationship with her family. She talks to her family and able to interact with other
patient. Her family was there to give her support and to show their love for her.
She is not engaged in any organizations in their community according to her

Norms
Social functioning of an individual is to form relationships with others.
Social support is a perception that one has an emotional and tangible resource to
fall on when needed; perceived social support is being followed by the family to
express the love of the family, financial aspect is one of the normal constraints in
the family. (Nursing fundamentals by Daniels; an introduction to health and
physical assessment in nursing by D’Amico and Barbarito)

Social responsibilities include forming new friendships and assuming

some community activities. As the role of woman has change, many women now
choose to assume active careers and civic roles in society in addition to their
roles as mother and or/wife. (Fundamentals of Nursing by Kozier)

Interpretation
The client was able to manage to interact with others. She was
cooperative during the interview.

Emotional Status
After surgical procedure the client verbalized pain on the surgical
incision with a pain scale of 7 out of 10. Though the father of her child was not
there during her delivery, her family especially her mother was there always to
support and comfort her emotionally.

1
Norms
A normal person regarding emotions has the ability to manage stress
and to express emotions appropriately. It involves the ability to recognize, accept
and express feelings and to accept one’s limitation.
Normal coping pattern or emotions stability could include acceptance of the
problem, adjustment to it, expressing of self-perception and self-control of
emotions, probable temporary use of defense mechanism and support system
(Fundamentals of Nursing by Kozier).
Carrying out emotional feelings through words and facial expressions
are normal signs of present physical condition (Nursing Fundamentals by
Daniels)

Interpretation
Client was able to cope with problems because her family was there to
support and comfort her emotionally.

MENTAL STATE
a. General Appearance and Behavior
Patient’s appearance is appropriate with age, oriented, awake,
coherent, normal, and symmetrical facial features. She was wearing a t-shirt and
jogging pants and was properly groomed. She was responsive and eye contact
was established during the interview.
b. Level of Consciousness

The client was conscious and coherent. She was responsive during the
interview. Ms. Chi was aware of her present condition.

c. Orientation

The client stated properly the date, place and time. She can identify
things or names being asked and able to answer all questions asked.

2
d. Speech

The client speaks Tagalog and Ilokano. She is able to read and speaks
clearly and utter words that easily to understand.

Norms

Clients should be able to reason, to find meaning, and make judgment

from information, to demonstrate rational thinking and perceive realistically.
Appearance and behavior; posture must be relaxed. Clients should be dressed
appropriately with the season, age, and gender. Grooming and hygiene should
be proper and neat. Client should typically be able to state their name, location,
the date, month, season, and time of the day. Ability to form words (articulation)
should be understood and clear. (An Introduction to Health and Physical
Assessment in Nursing by D’Amico and Barbarito; Physical Examination and
Health Assessment by Carolyn Jarvis)

The content of the client message should make sense. The ability to read
and write should match the client’s educational level. The client should be able to
correctly respond to questions and to identify all the objects as requested. The
client should be able to evaluate and act appropriately in situations requiring
judgment. (Health assessment and physical examination 3rd edition by Mary
Ellen Zator Estes)

Anesthetics are agents that interfere with nerve conduction and thereby
diminish pain and sensation. General anesthetics are drugs causing a partial or
complete loss of consciousness. While regional anesthetics block nerve
conduction only in the area to which they are applied and do not cause a loss of
consciousness. (Pharmacological Aspects of Nursing Care 7th Edition by
Broyles, Reiss and Evans)

3
Interpretation
The client’s level of consciousness, orientation and speech is normal.

BODY TEMPERATURE
Here’s a table showing the body temperature of the client:
Date Time Temperature (C) Interpretation
January13, 2010 3:00 pm 37.4 Normal
January 13, 2010 6:00 pm 37.2 Normal
January 13, 2010 10:00 pm 37.3 Normal

Norms
For axillary route, it should range from 35.4-37.4C (95.8-99.4F) obtained 5
minutes time for accurate measurement. . (Health assessment and physical
examination 3rd edition by Mary Ellen Zator Estes)

Interpretation

The client’s temperature assessed via axillary route and obtained in five
minutes was found to be within the normal range.
RESPIRATORY STATUS

The client has a regular breathing pattern. Bulging of the ICS was not
seen as well as retractions in the intercostals spaces. The use of accessory
muscles was not seen while the client is breathing. The table below shows the
respiratory rate of the client after the surgery:

Date Time Respiratory Rate Interpretation

January 13, 2010 3 pm 19 Normal
January 13, 2010 6 pm 20 Normal
January 13, 2010 10 pm 20 Normal

4
 Her respirations were normally heard by the unaided ear a 2-4 centimeters
from the client’s nose with absent nasal flaring. There were no pulsations as well
as masses and tenderness. There were no rales, wheezes or stridor heard.
Norms
The normal findings of respiratory status for an adult include the following:
16-20 breaths per minute, no use of accessory muscles when breathing,
respirations should be even, not labored and regular and no cough noted.
(Weber: Nurse’s Handbook of Health Assessment)

Interpretation
The client’s respiratory status after was found to be within the normal
range.

CIRCULATORY STATUS

Ms. Chi has pale lips including the nail beds, palm, soles of the feet
and her conjunctiva. Her pulse (radial) has a regular rhythm. For the capillary
refill time, it ranges from 3-4 seconds. The table below shows the pulse rate of
the client as well as her blood pressure.

Date Time Pulse Rate Blood Interpretation

(beats/min) Pressure
(mmHg)
January 13, 2010 3:00 pm 86 160/100 Normal PR, High BP
January 13, 2010 6:00 pm 83 160/120 Normal PR, High BP
January 13, 2010 8:00 pm 86 160/130 Normal PR, High BP
January 13, 2010 9:00 pm 88 160/120 Normal PR, High BP
January 13, 2010 10:00 pm 85 160/110 Normal PR, High BP

Norms
Both pulse and blood pressure are measurements that determine the
blood volume of ejected blood into the arterial system with each ventricular
contraction. Normal adult BP is <120/80mmHg and pulse rate is 60-100bpm.

5
Capillary refill is at speed of 4-5seconds. Lips, conjunctiva, gums, nail beds and
palms are should be pinkish in colour. (Fundamentals of Nursing by Barbara
Kozier, et al.)

Interpretation
The client’s pulse rate is within the normal range, but her blood pressure is
above normal and having a capillary refill of 3-4 seconds; pale lips, conjunctiva,
soles of the feet, nail beds and palms indicate poor circulation which may be due
to vasoconstriction or loss of blood because of the operation held.

NUTRITIONAL STATUS
Before admission, Ms. Chi’s typical intake of rice is about 3 cups with
favorite viand fish with 1-2 cups of vegetables Lunch foods are usually
vegetables paired with rice. During dinner she eats either a fish dish paired with
rice or a combination of vegetable and fish dish and rice. According to her she
loves eating “pinakbet”. She takes ferrous sulfate every day. She drinks an
average of 8-10 glasses a day.
Upon admission, the ordered diet for her was low salt low fat diet, then
changed to NPO on January 10, 2010. And at 8:00 am of January 12, 2010 the
doctor ordered soft diet (low fat and low salt).
Norms:
Normal human being usually eats 3 times per day and a fluid intake of 8 -
10 glasses of water. Nutrients must be taken equally according to their
standards. There should be no problem regarding food and drug allergies and
anything associated with nutrition. Nutritional of patient is a good determinant of
a possible heart condition. Nutrition can be a prevention and treatment for some
diseases. . (Kozier et. al., Fundamentals of Nursing 7th edition)

Interpretation
Ms. Chi can still eat food which is normal.

6
ELIMINATION STATUS
Prior to hospitalization, the client said that she defecates regularly, or even
twice day. Her stool differs from soft to hard and is dark brown in color. She voids
at least 4 to 5 times a day with yellowish urine output if she suppresses the urge
to void and clear if she void immediately when she feels the urge of voiding.
According to her, she did not void and defecate immediately the day
of her surgery even once. She was able to defecate the next day for only once.
Stool was brown semi-formed.
Norms
Feces are normally brown in color and soft but formed. Black tarry
stool is abnormal. Iron salts, bleeding from the upper gastrointestinal tract, diet
high in red meat could be the possible causes. Although peoples patterns of
urination are highly individual, most people void about 4-5 times a day. (B.Kozier,
Fundamentals of Nursing 7th edition).
Interpretation
The client’s lack of bowel movement and urination for the first five hour
post-operatively is the result of her anesthesia. Dark brown stool is normal
because patient is taking ferrous sulfate .

SENSORY PERCEPTION
Vision
Ms. Chi said that she was able to see far and near objects without
difficulty but sometimes she has blurring of vision. Her eyes moved smoothly and
symmetrically when asked to follow the finger of the student during the
examination. The cornea is moist and shiny. Her pupils were found to be black,
round and equal in diameter, and dilates normally. Client’s eyes constricts as a
reaction to the light during the examination. The conjunctivas were found to be
pale during the assessment.
Hearing
The external ears match the skin color of the client and were positioned
centrally in proportion with the head. The external ears were elastic and cool to

7
touch. There were no found obstructions in the ear canals. She has no dry
cerumen observed. The patient was able to hear clear sounds in both ears in
response to the voice whisper test with a distance of about one foot away.
Smell
The patient’s external nose was located symmetrically in the midline of the
face. The nostrils are patent. The nasal mucosa was observed to be red and with
no deviations and no discharges. The patient was able to smell and distinguish
different odors as the client identifies odors such as of the alcohol and perfume.
Taste
The tongue is in the middle of the mouth. Buccal mucosa was found to be
pale. Her tongue is pink and moist.
Touch
She was able to perceive light touch, superficial pain and temperature
accurately.
Norms
Eyes – eyebrows, eyelashes should be equally distributed and symmetrically
aligned. Eyelashes should be slightly curled outward. Eyelids should be intact,
no discharge, no discoloration, close symmetrically and blinks bilaterally. Sclera
should appear whit or dirty white in appearance. Palpebral conjuntiva should be
pink or red in color. Pupils should constrict when illuminated. Mostly eyes
should be coordinated, move in unison, with parallel alignment. Vision, a person
can read from a magazine or newspaper at a distance of 36 cm without use of
corrective lenses and able to identify colors.

Ears – auricles’ color must be same as facial skin, symmetrical, aligned with the
outer canthus of the eyes and 10 degrees from vertical, not tender. Pinna recoils
after it is folded. Ear canals sometimes have dry cerumen or sticks wet cerumen.
He was able to hear sounds on both ears.

Nose – external nose is symmetric and straight, no discharge or flaring, not

tender, no lesions, air moves freely when breaths though the nares. Nasal

8
cavities should be clear, no lesions, pink in color, nasal septum intact. Frontal
and maxillary sinuses are not tender.

Mouth – lips are uniform in color, pink in color, soft, moist, symmetric in contour.
Teeth are 32 for adult, white in color, with pink gums, moist, no lesions. Tongue,
uvula, oropharynx should be pink, moist, no lesions and discharge.

Touch – should feel light touch, sensation. Must be able to discriminate between
hot and cold sensations and address a correct facial expression on the given
stimuli.
(Fundamentals of Nursing, Kozier; Physical Examination and Health
Assessment, Estes)
Analysis
The patient has a normal tactile perception, normal sense of smell and
hearing without any obvious manifestations of abnormalities present. Pale
conjunctiva and buccal mucosa indicates poor circulation which may be due to
blood loss. Blurring of vision can be caused by vasoconstriction which can be
related to hypoxia of the vessels of the head.

MOTOR STABILITY
Post-operatively the patient looked weak. She cannot tolerate long
standing and walking. She was able to move slowly and sit at the edge of the
bed. She showed some discomfort upon moving.
Norms
The client should be able to enter the assessment area via independent
ambulation, structural defects should be absent, and no indications of discomfort
during performance of movements should be present. There should be symmetry
with the other parts of the body. Walking is initiative in one smooth and rhythmic
fashion; the lower limbs are able to bear fully body weight during the phase of
muscle contraction especially against moderate external resistance normal
muscle strength allows for complete voluntary ROM against both gravity and

9
moderate to full resistance. There should no involuntary movements of muscle
present (Health assessment and physical examination 3rd edition by Mary Ellen
Zator Estes)

Interpretation
Post-operatively the client had difficulty in moving because she was in
pain and weak.

STATE of SKIN APPENDAGES

The patient has light brown skin all over the body. Increased pigmentation
was observed on sun-exposed areas such as the neck, arms, and legs.
Presence of striae at hypogastric and iliac regions, linea nigra and surgical
incision are noted. Pallor was observed on her face including her conjunctiva,
lips, palms, soles of her feet and nail beds. When her skin was pinched it
returned to its normal state immediately. Her hair was found to be straight, oily,
thick and equally distributed. Her nails were found to be not properly trimmed and
traces of dirt are noted. Her capillary refill was 3-4 seconds. Her skin was
observed to be without the presence of bruises. Pitting edema grade 2 were
observed on the patient’s lower extremities.
Norms
Normal skin is a uniform whitish pink or brown color, depending on the
patient’s race. Pallor is due to decrease visibility of the normal oxyhemoglobin.
This can occur when the patient has a decreased blood flow in the superficial
vessels, as in shock or syncope, or when there is a decreased amount of serum
oxyhemoglobin as in anemia.

No skin lesson should be present. Normally, the skin is dry with a

minimum respiration. It should be smooth, even and firm except when there is a
significant hair growth. It should return to its original contour when pinched.
(M.E.Z. Estes, Health Assessment and Physical Examination 3rd edition)

10
 Normally the nails have a pink cast in light-skinned individual and brown in
dark-skinned individual. Capillary refill is an indicator of peripheral circulation.
Normal capillary refill may vary with age but color should return to normal within 2
to 3 seconds.(M.E.Z. Estes, Health Assessment and Physical Examination 3rd
edition)

Interpretation
The patient’s pale body parts (conjunctiva, lips, palms, nail beds and sole
s of the feet) indicate poor circulation which may be due to loss of blood because
of the operation held. Presence of edema is abnormal.

STATE OF REST AND PHYSICAL COMFORT

Before hospitalization, she regularly sleeps for about 10 hours and does not take
a nap in the afternoon. After the surgery, Ms. Chi said that she can feel pain on
her surgical site that disturbs her sleeping, she also state that he noisy
environment of the hospital is another reason.
Norms:

Adults generally sleep 6-8 hours per night. About 20% of sleep is rapid
eye movement. The complete sleep cycle is about 1.5 hours in adults.
Maintaining a regular sleep-wake rhythm is more important than the number of
hours actually slept. (Kozier et. al., Fundamentals of Nursing 7th edition)
Interpretation:
Client’s sleeping pattern was altered due to surgical operation and the
noisy environment.

REPRODUCTIVE STATE
Ms. Chi had her menarche when she was 12 years old. She has a regular
28 days menstrual cycle. Her menstrual period last 7 days, 2 nd and 3rd day is
commonly has the heaviest menstrual discharge. She consumes 3 pads of

11
sanitary napkin a day during menses. Ms. Chi is 37 weeks pregnant;
primigravida.
Norms:
The female reproductive cycle begins at menarche, the onset of
menstruation, which occurs between 9 and 16yrs of age, and ends at
menopause, which occurs between 45 and 55 yrs of age. The cycle ends just
before the next menstrual period. Menstrual cycles normally range from about 25
to 36 days. Only 10 to 15% of women have cycles that are exactly 28 days.
Menstrual bleeding lasts 3 to 7 days, averaging 5 days. Blood loss during a cycle
usually ranges from ½ to 2½ ounces. A sanitary pad or tampon, depending on
the type, can hold up to an ounce of blood. . (Kozier et. al., Fundamentals of
Nursing 7th edition)
(http://www.merck.com/mmhe/print/sec22/ch241/ch241e.html)

Interpretation:
The client reproductive status is normal.

12
Diagnostic/Laboratory Date Indications/Purposes Results Normal Values Analysis
Procedure Results (units used in /Interpretation of
the hospital) Results
Hematology Date Specimens of venous Hemoglobin: 120-180 g/L > below normal
Results: blood are taken for a 107 Decreased
January CBC which includes Hgb count on
10, 2010/ Hemoglobin and pregnant is
12:15 am Hematocrit normal
measurements, RBC because of the
indices and diferential increase in
white cell count. plasma volume
during
pregnancy
Hematocrit: 0.370- 0/510 > below normal
0.345 L/L Decreased
hematocrit on
pregnant is
normal
because of
their increase
in plasma

24
 volume.
WBC count: 3.98-10 x 109 >Abnormally high
16.8 g/L due to presence of
infection or
inflammation
RBC count: 4.20-6.30 T/L >Normal
4.96

Lymphocytes: 0.6-4.1 > Normal

3.0 10.0-58.5%L

MCV: 69.5 80-97 fl >below Normal

MCH: 21.6 26.0- 32.0 pg >below normal

MCHC: 310 310-360 g/L >Normal

Platelet: 322 140-440 G/L >Normal

Date Hemoglobin: > below normal

25
Results: 34 Decreased
January Hgb count on
13, 2010/ pregnant is
11:58 am normal
because of the
increase in
plasma volume
during
pregnancy
Hematocrit: > below normal
0.104

WBC count: >infection or

31.8 Inflammation is
present.
RBC count: >Decreased
1.49 RBC count on
pregnant is
normal
because of the
increase in

26
 plasma volume
during
pregnancy.
Lymphocytes: > Normal
4.1
MCV: 69.7 >below Normal
MCH: 22.86 >below normal
MCHC: 327 >Normal
Platelet: 300 >Normal
Hemoglobin: > below normal
Date 49 Decreased
Results: hgb on
January pregnant is
14, 2010/ normal
6:34 am because of
their increase
in plasma
volume.
Hematocrit: > below normal
0.144 Decreased
hematocrit on

27
 pregnant is
normal
because of
their increase
in plasma
WBC count: >Abnormally high
31.0 due to
RBC count: >below Normal
1.49
Lymphocytes: > Normal
3.6
MCV: 72.1 >below Normal
MCH: 24.5 >below normal
MCHC: 340 >Normal
Platelet: 404 >Normal

Nursing responsibility:
Before:

28
 1. Explain the purpose of the test and the procedure for collection of blood. Client mat experience anxiety about the
procedure, especially if it is perceived as being intrusive or if they fear unknown to the result. A clear explanation
will facilitate cooperation on the part of the client.
2. Inform the client of the time period before the results will be available.

During:
1. Use the correct procedure for obtaining the blood.
2. Aseptic technique should be use in collection to prevent contamination that can cause inaccurate results.
3. Ensure correct labelling, storage and transportation of the specimen to avoid invalid test results.

After:
1. Report results to the appropriate health team members.
2. Compare the previous and current test results and modifies nursing interventions as needed.

DIAGNOSTIC/LABO DATE RESULTS INDICATION/S OR RESULTS ANALYSIS OR

RATORY PURPOSE/S INTERPRETATION
PROCEDURE OF THE RESULTS

29
 Blood Typing and Date Result: January Used to determine Blood type “O” The client was blood
cross matching 18, 2010 the blood type of the type O+ and
client and RH “+” compatible wih
compatibility of a donor’s blood.
donor’s blood with Compatible
that of a recipient
after he specimens
have been matched
for major blood type

Date Result: January Blood type “O” The client was blood
18, 2010 type O+ and
RH “+” compatible wih
donor’s blood.
Compatible

Nursing responsibility:
Before:

30
 3. Explain the purpose of the test and the procedure for collection of blood. Client mat experience anxiety about the
procedure, especially if it is perceived as being intrusive or if they fear unknown to the result. A clear explanation
will facilitate cooperation on the part of the client.
4. Inform the client of the time period before the results will be available.
During:
4. Use the correct procedure for obtaining the blood.
5. Aseptic technique should be use in collection to prevent contamination that can cause inaccurate results.
6. Ensure correct labelling, storage and transportation of the specimen to avoid invalid test results.
After:
3. Report results to the appropriate health team members.

31
ANATOMY AND PHYSIOLOGY
CARDIOVASCULAR SYSTEM
The Heart
The heart lies in the mediastinum, behind the body of the
sternum. The shape of the heart tends to resemble the chest. The
heart has chambers divided into four cavities with the right and left
chambers (atria and the ventricles) separated by the septum.
The Blood Vessels

There are 3 types of blood vessels: the arteries, the veins and
the capillaries. An artery is a vessel that carries blood away from the
heart. It carries oxygenated blood. Small arteries are called arterioles.
Veins, on the other hand are vessels that carries blood toward the
heart. It contains the deoxygenated blood. Small veins are called
venules. Often, very large venous spaces are called sinuses. Lastly,
capillaries are microscopic vessels that carry blood from small arteries
to small veins (arterioles to venules) and back to the heart. The walls
of the blood vessels, the arteries and veins have three main layers:

24
tunica adventitia, tunica media and tunica intima. Tunica adventitia
which is a fibrous
type of vessel is a connective tissue that helps hold vessels open and
prevents tearing of the vessel wall during body movement. Tunica
media is a smooth muscle, sandwiched together with a layer of elastic
connective tissue. It permits changes of the blood vessel diameter. It
allows the constriction and dilation of the vessels. Last but not the
least is the tunica intima. Tunica intima, which in Latin means inner
coat, is made up of endothelium that is continuous with the
endothelium that lines the heart. In arteries, it provides a smooth
lining. However in veins it maintains the one-way flow of the blood. The
endothelium, which makes up the thin coat of the capillary, is
important because the thinness of the capillary wall allows the
exchange of materials between the blood plasma and the interstitial
fluid of the surrounding tissues.
Circulation of the blood in blood vessels

25
There are two circulatory routes of blood as it flows through the blood
vessels: the systemic and the pulmonary circulation. In systemic
circulation, blood flows from the left ventricle of the heart through
blood vessels to all parts of the body (except gas exchange tissues of
lungs) and back to the atrium. In pulmonary circulation on the other
hand, venous blood moves from the right atrium to right ventricle to
pulmonary artery to lung arterioles and capillaries where gases
exchanged; oxygenated blood returns to the left atrium via pulmonary
veins; from left atrium, blood enters the left ventricle.
Vasomotor Control Mechanism
Blood distribution patterns, as well as BP can be influenced
by factors that control changes in the diameter of arterioles. Such
factor might be said to constitute the vasomotor control mechanism.
Like most physiological control mechanisms, it consists of many parts.
An area in the medulla called vasomotor center/ vasoconstrictor center
will, when stimulated initiate an impulse outflow via sympathetic fibers
that ends in smooth muscle surrounding resistance vessels, arterioles,
and veins of “the blood reservoir” causing their constriction thus the
vasomotor control mechanism plays an important role both in the
maintenance of the general BP and in the distribution of blood to areas
of special need.
Venous return of the Blood
Venous return refers to the amount of blood that is
returned to the heart by the way of veins. Various factors influence
venous return, including the operation of venous pumps that maintains
the pressure gradients necessary to keep blood moving into the central
veins and from there the atria of the heart. Changes in the total
volume of blood vessels can also alter the venous return.
The return of venous blood to the heart can be influenced by
the factors that change the total volume of blood in the circulatory
pathway. Stated simply, the more the total volume of blood, the

26
greater the volume of blood returned to the heart. The mechanism that
change the total blood volume most quickly, making them most useful
in maintaining constancy of blood flow, are those that cause water to
quickly move into the plasma or out of the plasma. Most of the
mechanisms that accomplish such changes in plasma volume operate
by altering the body’s retention of the water.
The primary mechanisms for altering the water retention in
the body- they are the endocrine reflexes in the body. One is the ADH
mechanism is released in the neurohypophysis and acts on the kidneys
in a way that reduces the amount of water lost by the body. ADH does
this by increasing the amount of water that kidneys reabsorb from
urine before the urine is excreted from the body. The more ADH is
secreted, the more water will be reabsorbed into the blood, and the
greater the blood plasma volume will become.
Another mechanism that changes the blood plasma volume
is the renninangiotensin mechanism of aldosterone secretion. Renin is
an enzyme that is released when the blood pressure in the kidney is
low. Renin triggers a series of events that leads to the secretion of
aldosterone. Aldosterone promotes sodium retention by the kidney,
which in turn stimulates the osmotic flow of water to the kidney
tubules back into the blood plasma- but only when ADH is present to
permit the movement of water. Thus, low blood pressure increases the
secretion of aldosterone, which in turn stimulates the retention of
water and thus an increase in blood volume. Another effect of
reninangiotensin is the vasoconstriction of blood vessels caused by an
intermediate compound called angiotensin II. This complements the
volume-increasing effects of the mechanism and thus also promotes
an increase in overall blood flow. Precision of blood volume control
contributes to the precision in controlling venous return, which in
return yields to the precise overall control of blood circulation
EXOCRINE SYSTEM

27
 The exocrine system’s main function is to regulate the
volume and composition of body fluids and excrete unwanted
materials, but it is not the only system in the body that is able to
excrete unnecessary
substances.
Kidneys
The kidneys resemble the
lima beans in shape. The
average-sized kidney
measures around 11cm by
7cm by 3cm. The left kidney
is often larger than the right.
The kidneys are highly
vascular organs.
Approximately, one-fifth of
the blood pumped fromthe heart goes to the kidneys. The kidneys
process blood plasma and form urine from
waste to be excreted and emoved from the body. These functions are
vital because they
maintain the homeostatic balance of the body. The kidneys maintain
the fluid-electrolyte and acid-base balance. In addition, they also
influence the rate of secretion of the
hormones ADH and aldosterone.
Microscopic functional units called nephrons make up the
bulk of the kidney. The nephron is uniquely suited to its function of
blood plasma processing and urine function. A nephron contains
certain structures in which fluid flows through them and they are as
follows: renal corpuscle, Bowman’s capsule, proximal convulted tubule,
Loop of Henle, distal convoluted tubule and the collecting tube. The
Bowman’s capsule is a cup-shaped mouth of a nephron. It is usually
formed by two layers of epithelial cells. Fluids, electrolytes and waste

28
products that pass through the porous glomerular capillaries and enter
the space that constitute the glomerular filtrate, which will be
processed in the nephron to form urine.
The Glomerulus is the body’s well-known capillary network
and is surely one of the most important ones for survival. Glomerulus
and Bowman’s capsule together are called renal corpuscle. The
permeability of the glomerular endothelium increases sufficiently to
allow plasma proteins to filter out into the capsule.
ENDOCRINE SYSTEM
The endocrine system performs their regulatory functions
by means of chemical messenger sent to specific cells. The endocrine
system, secreting cells send hormones by way of the bloodstream to
signal specific target cells throughout the body. Hormones diffuse into
the blood to be carried to nearly every point in the body. The
endocrine glands secrete their products, hormones, directly into the
blood. There are two classifications of hormones: steroid hormones and
non-steroid hormones. The steroid hormones which are manufactured
by the endocrine cells from cholesterol, is an important lipid in the
human body. Non-steroid hormones are synthesized primarily from
amino acids rather from the cholesterol. Non-steroid hormones are
further subdivided into two: protein hormones and glycoprotein
hormones.
Aldosterone
Its primary function is the maintenance of the sodium
homeostasis in the blood byincreasing the sodium reabsorption in the
kidneys. It is secreted from the adrenal cortex; it triggers the release of
ADH which results to the conservation of water by the kidney.
Aldosterone secretion is controlled by the rennin- angiotensin
mechanism.
Estrogen

29
 It is secreted by the cells of the ovarian cells that promote
and maintain the female sexual characteristics.
Progesterone
It is secreted by the corpus luteum. It is also known as a
pregnancy- promoting steroid and it prevents the expulsion of the
fetus in the uterus.
Anti-diuretic hormone (ADH)
It is secreted in the neurohypophysis (posterior pituitary);
it literally opposes the formation and production of a large urine
volume. It helps the body to retain and conserve water from the
tubules of the kidney and returned to the blood.
REPRODUCTIVE SYSTEM

The female reproductive system produces gametes may

unite with a male gamete to form the first cell of the offspring. The
female reproductive system also provides protection and nutrition to
the developing offspring. The most essential organ is the ovary which
carries the ova. The uterus, the fallopian tubes and the vulva are
accessory organs.

30
Ovaries
It is an almond-shape organ. It contains the ova and is
responsible in expelling the ova. It also produces estrogen and
progesterone.
Fallopian Tubes
It usually measures approximately 10- 12 cm. It has two parts:
the ampullae and the fimbriae. The ampullae which is the largest part
is where the fertilization takes place. The fimbriae on the other hand,
are responsible for the transportation of the ovum from ovary to
uterus. It holds the ovary.
Uterus
The uterus is a pear-shaped organ and has three parts: the
fundus (upper), corpus (body), and the isthmus (lower). It is known as
the organ for menstruation. When pregnant, it gives nourishment to
the growing fetus.

31
BOOK-BASED PATHOPHYSIOLOGY

24
25
PATIENT-BASED PATHOPHYSIOLOGY

26
27
NURSING CARE PLANS

January 13, 2010

Assessment Planning Intervention Expected Outcome

S - Ø After 4 hours of nursing >Assist client in performing After 4 hours of nursing

interventions, the client will ADL. (To promote safety) intervention, the client will
exhibit decrease in oxygen exhibit decrease in oxygen
O - weak and pale in demand and ability to >Place the client in demand and ability to
appearance conserve energy. trendelenburg position. (To conserve energy.
- capillary refill of 3-4 promote venous return)
seconds
- RBC level= 1.49 >Maintain adequate
- Hgb level= 34 g/L ventilation.(To promote
- BP= 160/110 mmHg oxygenation and good blood
circulation)

Diagnosis >Instruct client to sit and

dangle the feet before
Ineffective tissue perfusion standing.(To prevent

24
r/t decrease in RBC,
hemoglobin and hematocrit
level
Scientific Explanation
Due to the procedure done,
the client’s RBC level
decreased causing
ineffective tissue perfusion.
Assessment
orthostatic hypotension)
>Advise client to increase
intake of food rich in iron
and folate such as liver and
green leafy vegetables. (Iron
and folate are necessary for
red blood cell production).
Planning Intervention Expected Outcome
25
S - Ø
O - weak and pale in
appearance
- cannot tolerate long
standing and walking
independently
- RBC level= 1.49
Diagnosis
Activity intolerance r/t body
weakness secondary to low
RBC level.
Scientific Explanation
After 4 hours of proper
nursing intervention the
client will perform ADL with
minimal to no assistance.
>Assist client during moving
and on going in the comfort
room or whenever needs
assistance. (Assisting client
during moving ensures
safety and additional support >Able to ambulate with least
for client)
>Assist client in comfortable
position. (To improve
comfort)
>Assist with ADL as
indicated to reduce energy
expenditure but avoid doing
for what he can do for
herself (to increases client’s
independence)
>Let the client do much of
the activities (to increase
self-reliance.)
>Provided proper ventilation.
The client will perform ADL
with minimal assistance after
4 hours of proper nursing
intervention as evidenced
by:
assistance.
>With ease in performing
ADL
>Can tolerate short time of
walking and standing with
less fatigability.
>Client verbalization of
increase in energy.
-.
26
Due to low RBC level (To give enough oxygen
(oxygen carrying capacity) supply)
oxygen supply into body
tissue decreases which Health Teachings:
result in body weakness. >Instruct client to sit at the
edge of the bed then dangle
her feet before standing. (To
prevent orthostatic
hypotension)
.>Encourage the client to get
adequate rest and sleep. (To
conserve energy)
>Encourage adequate rest
periods before ambulation
and meals (To reduce
cardiac workload)
>Instruct to refrain from
performing unnecessary
movements (To promote
rest)
>Encourage passive ROM

27
 exercises (To maintain
muscle strength and joint
range of motion)
>Teach energy conservation
techniques (To reduce
oxygen consumption,
allowing more prolonged
activity)
>Encourage client to avoid
over exertion and straining
of activities (Over exertion of
activities may cause fatigue)

Assessment Planning Intervention Expected Outcome

O- postpartum After 1-2 hrs of nursing Independent: After 1-2 hrs of nursing
surgery intervention, the patient will >stress proper hand intervention, the patient was

28
 able to know the preventive hygiene. able to knew the preventive
measures of wound healing - to control the measures of wound healing
Diagnosis spread of infection
Impaired Skin Integrity >Encouraged to increase
related to surgery foods that are rich in protein
- to aid in tissue repair
Scientific Explanation >Encouraged proper
The incision from the clothing
cesarean section altered the -to maintained the proper
skin integrity making skin moisture.
it more susceptible to >Apply appropriate
pathogens and even the Dressing
patients’ normal flora -to help in wound healing

Drugs
Name of Drug Date Route of General action Indications/ Client’s reaction
Administered Administration Purpose to medicine.
Generic: 01/09/10 500 mg tablet Its main To relieve mild to Client’s

29
Paracetamol 4:00 am mechanism moderate pain. temperature is
of action is It is also used to 37.2
Brand Name: the inhibition of bring down a high
Biogesic cyclooxygena temperature.
se (COX), an
Classifications: enzyme
Non-opioid responsible for the
analgesic production of
prostaglandin s,
which are
important
mediators of
inflammation, pain
and fever.
Nursing Responsibility:
• Monitor for signs and symptoms of hepatotoxicity, even with moderate acetaminophen doses, especially in
individuals with poor nutrition.
• Do not take other medications containing acetaminophen without medical advice; overdosing and chronic use can
cause liver damage and other toxic effects.
• Do not use for fever persisting longer than 3 days ,fever over 39.5° C(103° F), or recurrent fever.
Name of Drug Date Route of General action Indications/ Client’s reaction

30
 Administered Administration Purpose to medicine.
Generic name: 01/11/10 I cap OD *Mineral for Preventing or Dark brown stool
Ferrous 10 am antianemia treating low
Sulfate *Vital for levels of iron
hemoglobin in the blood.
Brand Name: regeneration,
Ferrous specifically it
sulfate enables the RBC
development and
oxygen transport
via hemoglobin
It elevates the
serum iron
concentration,
which then helps to
form Hgb or
trapped in the
reticuloendothelial
cells for storage
and eventual
conversion to

31
 a usable form of
iron..

Nursing Responsibility:
• Administer vitamins with food to prevent GI upset.
• Caution on intake of chamomile, feverfew, peppermint and St. John’s wort for it interfere with the absorption of iron
and other minerals.
• Increased effect of iron with vitamin C, decreased effect of tetracycline, antacids, penicillamine
Name of Drug Date Route of General action Indications/ Client’s reaction
Administered Administration Purpose to medicine.
Generic name: 01/09/10 5 mg IVP Directly relaxes To reduce after load No signs of
Hydrazaline 10 am arteriolar in severe CHF ( with irritation and
Hydrochloride smooth muscle. nitrates); and severe adverse
essential reactions.
Brand Name: hypertension
Apresoline, (parenteral to lower
blood pressure
Classification: quickly).
Antihypertensive

Nursing Responsibility:

32
 • Give slowly and repeat as necessary, generally q 4 to 6 hours. Switch to oral antihypertensive as soon as possible.
• Use cautiously in cardiac diseases, CVA, or severe renal impairment and in those taking other hypertensive.
• Monitor patient’s Vital signs and body weight frequently. Some clinicians combine hydralazine therapy with
diuretics agents to decrease sodium retention and tachycardia, and to prevent anginal attacks.
• Watch patient closely for signs of lupus erythematosus-like syndrome (sore throat, fever, muscle and joint aches,
skin rash). Call doctor immediately if any of these develops.
• Teach patient about his disease and therapy. Explain the importance of taking this drug as prescribed, even when
he’s feeling well. Tell outpatient not to discontinue this drug suddenly, but to call the doctor if unpleasant
adverse reactions occurs
• Instruct patient to check with doctor or pharmacist before taking OTC medications.
• Inform the patient that orthostatic hypotension can be minimized by rising slowly and avoiding sudden position
Changes

Name of Drug Date Route of General action Indications/ Client’s reaction

Administered Administration Purpose to medicine.
Generic name: 01/09/10 5 mg deep IM May decrease Prevention or No signs of
irritation and
Magnesium 10 am on each buocks acetylcholine control of seizures
adverse
Sulfate released by in preeclampsia or reactions.
nerve impulses, eclampsia

33
Brand Name: but its
Sulfamag anticonvulsant
Classification: mechanism is
Anticonvulsant, unknown..
miscellaneous;
and laxative
saline
Nursing Responsibility:
• Use cautiously in impaired renal function, myocardial damage, and heart block, and in women in labor.
• Drug can decrease the frequency and the force of uterine contraction.
• Keep I.V. calcium glucanate available to reverse magnesium intoxication; however, use cautiously in patients
undergoing digitalization due to danger of arrhythmias.
• I.V. use: Monitor vital signs every 15 mins.
• When giving drug I.V. Watch for respiratory depression and signs of heart block. Respirations should should be
approximately 16/mins before each dose given.
• Monitor I & O. urine output should be 100ml or more in 4 hr period before each dose.
• Check blood magnesium levels after repeated doses. Disappearance of knee-jerk and patellar reflexes is a sign of
pending magnesium toxicity.
• Maximum infusion rate is 150mg/min. rapid drip will induce uncomfortable feeling of heat.

34
 • Especially when given I.V. to toxemic mothers within 24 hrs before delivery,observe neonates for signs of
magnesium toxicity, including neuromuscular or respiratory depression.
• Signs of hypermagnesemia begin to appear at blood levels of 4 mEq/L.
• Has been used as a tocolytic agent (suppresses uterine contractions) to inhibit premature labor.
Name of Drug Date Route of General action Indications/ Client’s reaction
Administered Administration Purpose to medicine.
Generic name: 01/10/10 1g IVP Inhibits cell wall Cefazolin is mainly No signs of
Cefazolin 6 am synthesis, used to treat irritation and
promoting osmotic bacterial infections adverse
Brand Name instability. Usually of the skin. It can reactions.
Cefacidal, bactericidal. also be used to treat
moderately severe
Classification: bacterial infections.
Antimicrobial and It is clinically
antiparasitic effective against
agents infections
caused by
staphylococci and
streptococci species
of Gram positive
bacteria. These

35
 organisms are
common on normal
human skin.

Nursing Responsibility:
• Use cautiously in impaired renal function and in those with history of sensitivity to penicillin.
• Ask patient if he’s ever had any reaction to cephalosporin or penicillin therapy before administering first dose
• Avoid doses greater than 4 g daily in patients with severe renal impairment.
• Obtain specimen for culture and sensitivity test before first dose. Therapy may begin pending test results.
• Because of long duration of effect, most infections can be treated with dose q 8 hrs.
• Not as painful as other cephalosporin when given I.M.
• I.V. use: alternate injection sites if I.V. therapy last longer than 3 days
• Considered the first-generation cephalosporin of choice by most authorities.
• With large doses or prolonged therapy, monitor for superinfection, especially in high risk patients.
• Reconstituted cefazolin sodium is stable for 24 hrs at room temp. or 96 hours under refrigerator.
• About 40% - 70% of patients receiving cephalosporin shows a false positive direct Coombs’ test; only a few of
these indicate hemolytic anemia.
Name of Drug Date Route of General action Indications/ Client’s reaction
Administered Administration Purpose to medicine.
Generic name: 01/11/10 30 mg IVP The primary Ketorolac is The patient

36
Ketorolac 12 am mechanism of indicated for responded well
action short-term with no signs of
Brand Name: responsible for management of irritation and
Toradol ketorolac's pain (up to five days adverse
antiinflammatory, maximum). reactions.
Classification: antipyretic and
non-steroidal analgesic effects is
antiinflammatory the inhibition of
drug prostaglandin
synthesis by
competitive
blocking of the the
enzyme
cyclooxygenase
(COX). Like most
NSAIDs, ketorolac
is a non-selective
COX inhibitor.
As with other
NSAIDs, the
mechanism of the

37
 drug is associated
with the chiral S
form. Conversion of
the R enantiomer
into the S
enantiomer has
been shown to
occur in the
metabolism of
buprofen; it is
unknown whether it
occurs in the
metabolism of
etorolac.

Nursing Responsibility:
• Use as a part of a regular analgesic schedule rather than on an as needed basis.
• If given on p.r.n. basis, base the size of a repeat dose on duration of pain relief from previous dose. If the pain
returns within 3-5 hours, the next dose can be increased by up to 50% (as long as the total daily dose is not
exceeded). If the pain does not return for 8-12 hr, the next dose can be decreased by as much as 50% or the
dosing interval can be increased to q 8-12 hr.

38
 • Shortening the dosing intervals recommended will lead to an increased frequency and duration of side effects.
• Correct hypovolemia prior to administering.
• Protect the injection from light
• Document indications for therapy, onset, location, pain intensity/level, and characteristics of the symptoms.
• Note any previous experience with NSAIDs and the results.
• Determine any renal or liver dysfunction; assess hydration.
• Avoid alcohol, ASA, and all OTC agents without approval.
• Report any unusual bruising/bleeding, weight gain, swelling of feet and ankle, increased joint pain, change in urine
patterns or lack of response.

Name of Drug Date Route of General action Indications/ Client’s reaction

Administered Administration Purpose to medicine.
Generic name: 01/19/10 10 mg tab OD Amlodipine inhibits Essential No signs of
Amlodipine 12 am the hypertension irritation and
transmembrane alone or in adverse
Brand Name: calcium influx combination with reactions.
Norvasc with greater effects other
on vascular antihypertensives.
Classification: smooth muscle
• Calcium than on cardiac

39
• Channel blocker muscle. Its main
• Antianginal action is to cause

• Antihypertensive peripheral arterial

vasodilatation and
therapy a
reduction in after
load and blood
pressure. Hence, it
reduces
myocardial oxygen
demand
more by an indirect
effect than
direct on cardiac
muscle. Reflex
tachycarida does
not occur due
to slow onset of
action.
Nursing Responsibility:

40
 • Monitor patient carefully (BP cardiac rhythm and output) while adjusting drug to therapeutic dose; use special
caution if patient has CHF.
• Monitor BP carefully if patient is also on nitrates
• Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy.
• Administer drugs without regard to meals .Take with meals if upset stomach occurs
• Tell patient to report irregular heartbeat, shortness of breath, swelling of the hands or feet, pronounce dizziness, &
constipation.

Name of Drug Date Route of General action Indications/ Client’s reaction

Administered Administration Purpose to medicine.
Generic name: 01/13/10 1 tab OD • Toxicodynamics Ascorbic acid is
Ascorbic acid 12 am Hyperoxaluria may result recommended for
(Vitamin C) after administration of prevention and
ascorbic acid Ascorbic acid treatment of scurvy
Brand Name: may cause acidification of (disorder caused
Ascorbic acid the urine, by lack of
occassionally leading to vitamin C). Its
Classification: precipitation of urate, parenteral
Ant i –oxidant cystine, or oxalate stones, administration is

41
or other drugs in the urinary desirable for
tract. Urinary patients with an
calcium may increase, and acute deficiency or
urinary sodium may for those
decrease after 3 to 6 g of absorption of
ascorbic acid daily. Ascorbic orally ingested
acid reportedly ascorbic acid
may affect glycogenolysis uncertain.
and may be diabetogenic Symptoms of mild
but this is controversial. deficiency may
include faulty
 P harmacodynamics bone and tooth
In humans, an exogenous development,
source of ascorbic acid is gingivitis, bleeding
required for collagen gums, and
formation and tissue repair. loosened teeth.
Vitamin C is a co-factor in Febrile states,
many biological processes chronic illness and
including the conversion of infection
dopamine to noradrenaline, (pneumonia,
in the hydroxylation steps in whooping cough,

42
 the tuberculosis,
synthesis of adrenal steroid diphtheria,
hormones, in tyrosine sinusitis,
metabolism, in the rheumatic fever,
conversion of folic acid to etc.) increase
folinic acid, in the need for
carbohydrate metabolism, in ascorbic..
the synthesis of lipids and
proteins, in iron metabolism,
in resistance
to infection, and in cellular
respiration. Vitamin C may
act as a free oxygen radical
scavenger. The usefulness
of the antioxidant properties
of vitamin C in reducing
coronary heart disease
were found not to be
significant.
Nursing Responsibility:
• Use cautiously in G6PD deficiency.

43
 • I.V. use: administer I.V. infusion cautiously in patients with renal insufficiency.
• Avoid rapid I.V.administration.
• When administering for urine acidification, check urine pH to ensure efficacy.
• Protect solution from light

SURGICAL MANAGEMENT

Name of Date performed Brief description Indication/ purpose Client’s response

Procedure
Low transverse 01/11/10 A form of childbirth in which
cesarean section a surgical incision is made
through a mother's
abdomen and uterus to
deliver one or more babies.
It is
usually performed when a
vaginal delivery would put
the baby's or mother's life or
to operation
Caesarean section is Live baby girl with
recommended when vaginal apgar score 8/9
delivery might pose a risk to
the mother or babylike in case
of pre-eclampsia

44
 health
at risk; although in recent
times it has been also
performed upon request for
births that would otherwise
have been natural. Low
transverse cesarean section
is a type of cesarean
section that involves a
transverse cut just above
the edge of the bladder and
results in less blood loss
and is easier to repair.

Nursing Responsibility:
Preoperative care:
• Assess the client knowledge of the procedure.
• The client is NPO after midnight.
• Relieving the patient’s and the family’s anxiety about the outcome with reasonable information
• Encourage patient to commence deep breathing, coughing and leg exercises.
• Teach the client post operative expectations.

45
Post operative care:
• Monitor vital sign every 15 minutes until the client is stable.
• Assess the need for pain relief.
• Assess the client for vaginal bleeding.

Medical Management
Medical Management Date Ordered General Description Indication & Purpose Client Response to
Treatment

IVF January 09, 2010 5% dextrose in administered by The patient responded

D5LRS 1L lactated ringers intravenous infusion well with no signs of
30gtts/min Solution (Osmolarity for parenteral irritation and adverse
of 527-hyprtonic, pH maintenance of reactions.
of 4.9) routine daily fluid and
-provides calories and electrolyte
free water, provides requirement with
electrolytes. Also minimal carbohydrates
contains sodium calories and to correct
lactate which is used or replace fluid losses
in treating mild to due to change in the

46
 moderate metabolic patient’s diet (NPO)
acidosis. and during the
cesarean operation.
Nursing Responsibilities:
• Check the doctor’s order
• Explain the procedure to the patient
• Tell the patient that she might feel a discomfort from the tourniquet and the IV insertion
• Check and monitor IVF regulation and level of fluid
• Check if there is a need for removal and replacement of fluid
• Check if the tube is in the vein and signs of edema
• Check if there is a back-flow of blood
• Check if there is bubbles present in the tube
• Always Monitor V/S.

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Evaluation

Through assessment and data gathering, certain problems and needs of the
client post-operatively were identified. Problems on tissue perfusion, impaired mobility
(standing and walking) and impaired skin integrity were observed. Nursing care plan
was established to improve client’s status and recovery. Information and health
teachings were imparted which led to increase client’s awareness and knowledge with
regards to her condition. The student gained additional information about incomplete
abortion including diagnostic examination, surgical and medical management needed
and as well as the factors affecting the condition which may help the group handle
properly this kind of condition that the student may possibly encounter again.
lll. Conclusion

From the above nursing problems perceived and presented through prioritization
and analysis of the gathered data and proper assessment. Through the use of client
focus nursing interventions and by following to nursing standards, the perceived
problems were managed well. Truly, a clinical eye which is sensitive to client’s need for
care was established. Loyalty was observed in aiding the client’s needs, managing and
taking a lead on advocating client’s interest and creating ways on how to ensure a
quality of care.
lV. Recommendation
The following are recommended for the client to easily recover after major surgery.
 Recommend the use of a heating pad or hot water bottle on the abdomen to help
relieve pain or discomfort.
 Encouraged her to begin using birth control immediately after the procedure.
 Encouraged her to take her prescribed medication on right time and dosage.
 The patient should attend OPD follow ups
 The patient should do exercise or activities advised by the doctor, and avoid
activities that requires great physical strength.
 Instructed to increase intake of food rich in iron like liver, green leafy vegetables
and etc.

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  Encouraged to increase intake of food rich in protein and Vit. C.
 Good perineal hygiene should be instructed to avoid infection
 Instructed to have adequate rest and try to lower known stresses in life.

References
Mosby’s Pocket Dictionary
Maternal & Child Health Nursing, 4th Edition by Pillitteri
Health assessment and physical examination 3rd edition by Mary Ellen Zator
Estes
http:// www.medicinenet.com
http:// www.wrongdiagnosis.com
http:// www.umm.edu.com
http:// www.doh.gov.ph
http:// www.expectantmothers.com
http:// www.health.am/pregnancy/.com

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