Stifany Agbo

Mary Joy Borres

Hazel Lorelie Espinosa

Judy Ann Galve

Sofia Michie Lim

Rubie John Mangubat

Reyna Mae Quio

Rogen Khyla Segovia

Keith Wesley Ybut

A Case Study submitted to the Faculty of the

College of Nursing Central Mindanao University

Musuan, Bukidnon

In Partial Fulfillment of the Requirements for the Course

NCM 62.1 Care of Mother, Child, Family and Population Groups

At risk or with Problems, RLE

May 2017
 Table of Contents

CONTENT PAGE

Table of Contents

List of Tables

List of Figures

Introduction

Rationale

Objectives

Scope and Limitation

Nursing Theories

Health Assessment

Biographical Data

Reason for Seeking Healthcare/Chief Complaints

History of Present Illness

Past Health History

Family History (Genogram)

Developmental Consideration

Psychosocial Profile (Gordons)

Review of System

Physical Assessment

Doctors Order

Diagnostic Test and Laboratory Test

Anatomy and Physiology

Pathophysiology

Medical/Surgical Management

Pharmacologic Management (Drug Study)

Nursing Care Plan

Discharge Plan

References

Appendices
INTRODUCTION

Pre-eclampsia is a condition that can occur in pregnant women when there is a

problem with the placenta (the organ that links the baby's blood supply to the mother's).
As a result, the mother can develop: high blood pressure (hypertension); protein in her
urine (proteinuria); fluid retention (edema). In the unborn baby, pre-eclampsia can cause
growth problems (intrauterine growth retardation).
Pre-eclampsia usually occurs during the second half of pregnancy (from around week
20), or immediately after the delivery of a baby. Pre-eclampsia may not be noticeable to
the woman who has it, but it will show up during routine antenatal appointments. In
most cases, the symptoms will be monitored with regular blood pressure and urine tests.
But some women will need to be admitted to hospital. The only way to prevent pre-
eclampsia is to induce labour (start labour artificially) and deliver the baby.
Whether this can be done will depend on how far along the pregnancy is. Being born
prematurely (before the 37th week of pregnancy) can be dangerous for the baby, but this
may sometimes be necessary to relieve the mother's symptoms. Mild pre-eclampsia can
affect up to 10% of first-time pregnancies. More severe pre-eclampsia can affect 1-2% of
pregnancies. If you have pre-eclampsia during your first pregnancy, you will be more
likely to have it again in subsequent pregnancies. While certain factors have been
identified that increase the likelihood of pre-eclampsia, such as having a family history of
the condition, the cause of pre-eclampsia is still not fully understood.

RATIONALE

A. Overview of the Case

This case study entails information about the patients physical and health
history, data analysis from the assessment, diagnosis, problems, actions
designed to resolve the problem, implement the plan and evaluate the
development of the plan.

GENERAL OBJECTIVES

At the end of the exposure in the clinical area, the nursing students were able to acquire
information, provide intervention and deliver optimum level of care to the patients need.
The goal of the study is to employ closely the nursing process to a patient with the
collaboration and deliberation of the students. The proponents this goal to achieve the
development of attitude, enhancement of skills and attainment of advance knowledge of
student nurses.

SPECIFIC OBJECTIVES

At the end of the case presentation, the proponents will be able to:

Knowledge:

Describe the full text of facts and ideas in Nursing Care Plans that is necessary
which is specific, measurable, attainable, realistic and time bounded for the
optimum level of care of the patient.
 Implement deep examination in cognizance of the disease process and actual
situation encountered by the student nurses.
Provide rationalization to the most priority management and appropriate
intervention to the presenting symptoms.
Offer a safe way to apply theoretical and actual knowledge to an actual or potential
patient scenario.

Skills:

Employ decision-making skills, use critical thinking to analyze the situation and
develop cognitive reasoning abilities without harming the patient.
Convey information in the different key aspects of the case study by delivering a
systemic, organized and analytical presentation.
Involve in improving and prioritizing management in Nursing Care Plan to obtain
its effectiveness in rendering assessment through utilization of the nursing
process.
Present supported facts and references when addressing the question given by the
panel.

Attitude:

Exhibit a culturally sensitive approach to the patient when dealing them with
different opinions and shared ideas to foster respect to their thoughts and
understanding to their various concepts.
Build rapport to the patient to develop trust-worthiness with student nurses and
to influence them by showing good example.
Present the data with honesty, accuracy without bias and modification to provide
correct data to the proponents.
Develop positive attitude, open-mindedness and willingness to listen any criticism
of panelist to help improve discrepancies of the case study.

SCOPE AND LIMITATION

The study covers overall data gathered in the medical records, physical assessment and
observation of the patients physical appearance. It also gives the certain information
that the student observed within the span of time given. The study was dependent in the
objectives, all data and information presented were based on the clients and his
significant others response to the queries of the proponents. The intervention given is
due to the assessment findings of the client and was within the boundary of the student
nurses with the guidance of the clinical instructor following the physicians medical
management and the independent nursing intervention.

THEORY

HEALTH ASSESSMENT

Biographical Data

Name: Mother

Address: Maramag, Bukidnon

Age: 42 years old

 Birth Date: March 1, 1974

Place of Birth: Don Carlos, Bukidnon

Sex: Female

Nationality: Filipino

Religion: Roman Catholic

Marital Status: Married

Educational Level: TESDA

Occupation: Housewife

Source of History:

Date of Admission: March 20, 2017

Admitting Diagnosis:

Final Diagnosis:

Reason for Seeking Healthcare/Chief Complaints

The patient was prior admission due to Elevated blood pressure and post
CS.

History of Present Illness

Past Health History

Childhood Illness

Previous Hospitalization

Surgery

Serious Injuries

Serious/Chronic Illness

Immunization

Allergies

Medications

Recent Travel

Family History (Genogram)

Developmental Task

According to Sigmund Freuds Stages of Growth and Development, the patient is under middle adulthood,
and the significant characteristics of a person during this stage is that, his/her lifestyle changes due to
other changes; for example children leave home, and also their occupational goals changes. According to
the patient, aside from being a housewife she decided to have a small business which is according to her is
necessary to sustain the needs of her children especially since she has five children in which two of them
are still studying in college, she needs to earn more money. As observed, the patients goal has already
shifted from her own interest to her childrens better future.
According to Erik H. Eriksons Eight Stages of Development, the patient is under Adulthood, during this
stage a persons central task is Generativity vs. stagnation. This stage has indications of positive and
negative resolution. Wherein the indications of positive resolution is creativity, productivity, and concerns
for others, while the indications of negative resolution are, self-indulgence, self concern, lack of interests
and commitments. During the assessment, the patient manifested indications for positive resolution for
the patient strive to create or nurture things that will outlast her by contributing to positive changes that
concerns and benefits her children.
According to Robert Havighursts Developmantal Tasks the patient is under Middle Age, wherein the
patients task are as follows: achieving adult civic and social responsibility, establishing and maintaining an
economic standard of living, assisting teenage children to become responsible and happy adults,
developing adult leisure-time activities, relating ones spouse as a person, accepting and adjusting to the
physiologic changes of middle age and adjusting to aging parents.
According to Lawrence Kholbergs theory of Moral Development, our patient is under the conventional
level, since our patient is 42 years old. The conventional level of Kholberg focuses on the society,and by
that , a person is concerned with maintaining expectations and rules of the family, group, nation, or
society. A sense of guilty has developed and affects behaviour. The person values conformity, loyalty, and
active maintenance of social order and control. Conformity means good behaviour or what pleases or helps
another and is approved. Kholbergs theory has different stages and since our patient belongs to
adulthood, she is under the Law-and-Order Orientation. During this stage the person wants established
rules from authorities, and the reason for decisions and behaviour is that social and sexual rules and
traditions demand the response. ( Ill do something because its the law and my duty.)

Psychosocial Profile (Gordons Functional Pattern)

Health perception and health management

The patient health status was fair. She does not engage in smoking nor
drinking alcoholic beverages. Immunization of the patient is incomplete when she was in
her childhood but during her pregnancy she completed the tetanus toxoid. She do a
breast examination once a month. She hasnt gone through any accident. She
experienced pre-eclampsia due to family history.

Upon the recent assessment in their home, the patient health status was
good.

Nutritional-Metabolic Pattern

She typically ate vegetables and fruits sometimes she likes to eat large
amount of meat. She took Multivitamins plus iron. According the patient she gained four
kilograms since pregnancy. She has a good appetite. No food and eating discomfort. No
problems in swallowing, chewing, nausea and vomiting. Her skin turgor is good, she has
no signs skin problems. Her oral mucous membrane is pink in color, moist, and no signs
of lesions. Her actual weight is 68.2 kilograms and 5 foot and 3 inches in height.
Elimination Pattern
She eliminated bowel every other day with a color of brown, without any discomfort,
according to her she has no problem in control, and she has no excessive perspiration
and odour problems and urinated 5-8 times a day with a urine color of yellow.
Activity Exercise Pattern
She able to sit, stand and move around the home, but more on rest, shes not doing any
household chores anymore. She hasnt done any exercises. Shes more on babysitting.
Sleep Rest Pattern
She able to sleep at 9pm and wake up at midnight due to baby cries and its demand of
feeding , go back to sleep after awhile and wake up at 5am. No nightmares, and have a
nap time in afternoon from 1pm-3pm.
Cognitive Perceptual Pattern
She doesnt have any difficulty in hearing, she doesnt use hearing aid and she able to
see things clearly and she doesnt use any eye glasses. No change in memory lately, and
decide in things easily.
Self perception and self concept pattern
According to her she can manage her daily routine like doing household chores but then
her family didnt let her do it and any heavy work. Patient maintains eye contact
throughout the assessment. She appears to be calm, cooperate and smiley when being
interviewed.
Role Relationship Pattern
She has a nuclear family and lived with her husband and children, according to her she
doesnt have any problem with her family, her family and relatives are worried when they
know about her illness and hospitalizations. According to her she didnt feel any
loneliness and much more she feel happy.
Sexually Reproductive Pattern
Patient is on her middle adulthood stage, she is now 42 years old and according to her
she is satisfied with her sex life and now in bilateral tube ligation. At the age of 13 she
had her first menstruation. She have 5 children, all lived, she didnt experience
miscarriage.
Coping Stress Tolerance Pattern
The recent operation caused the patient to be stressed and frightened but upon seeing
her baby her worries fade away and it makes her happy. And shes adjusting at first
about handling a baby again and now she already managed to babysit her new baby.
Value belief Pattern
According to her, she is satisfied with the way her life develop even the hospitalization
doesnt interfere with her spiritual practices.
Review of System

Physical Assessment

General Survey: The appearance of the patient was vary on her age and the face
and the body are symmetrical. The way she dressed is appropriate to her age,
gender, culture and weather. Minimal foul odor noted according to the different
activities. The hair is evenly distributed. She has a good skin turgor.

INSPECTION PALPATION PERCUSSION AUSCULTATION NURSING

DIAGNOSIS
Skin
Inspection Skin turgor is n/a n/a
reveals evenly good and skin
colored skin is smooth. No
tones without tenderness
unusual or upon
prominent palpation.
discoloration
Head and Face
Hair is fully No n/a n/a
distributed, tenderness
no dentures, upon
good in palpation in
appearance, the head
nasolabial
fissure is
symmetrical,
head is round
Eyes
Eyes are Corneal n/a n/a
symmetrically sensitivity
aligned, eye reflex
brows and present,
eyelids are
symmetrically
aligned, color
of the sclera is
white and
conjunctiva is
pinkish, no
abnormal
discharges.
Skins on both
eyelids have
no lesions, no
discolorations,
and no
swelling. The
upper and
lower lids
close easily
and meet
completely
when closed.
Eye lashes are
evenly
distributed
and curve
outward along
the lid
margins.
Ears and Hearing
Ears are equal The ear skins n/a n/a
in size and is smooth
aligned with and have no
the outer lesions,
canthus of the nodules nor
eyes. Ear skin lumps
color is
consistent on
facial color.
Nose and Sinuses
Nose are No pain upon No n/a
symmetrical , palpation, no accumulation
no nasal tenderness. of fluid inside
flaring, the sinuses.
Neck
No obvious Lympnodes n/a n/a
pounding of are not
vein in the swelling
neck.
Thorax and Lungs
She does not No No No adventitious
use accessory tenderness, accumulation sounds heard
muscle to pain, and of fluid and upon
assist unusual air in the auscultation.
breathing. sensations. posterior and
anterior chest
cavity.
Heart

Upper Extremities (Arms)

n/a

Breast (Female)
Color of her Texture is n/a n/a
breast is smooth and
brown same no edema. No
as her skin tenderness
tone, no upon
obvious palpation,
distended temperature
vein, areolas are
color is dark symmetrical
brown and on both
round, no breast, no
lesions, masses
bleedings nor palpated.
discharges,
her nipple is
inverted,
Abdomen

Lower Extremities
n/a

Musculoskeletal System
n/a

Neurological System
n/a

Doctors Order

Date/Doctor Order Rationale

Diagnostic Test and Laboratory Test

Diagnostic/Laboratory Normal Result Interpretation Implication Nursing

Test Values Responsibilities
Anatomy and Physiology

Pathophysiology (Schematic Diagram)

Medical/Surgical Management

Pharmacologic Management (Drug Study)

Generic Name: Mechanism Of Contraindication Adverse Effects Nursing

Action Responsibility

Pharmacologic
Class:

Therapeutic
Class:

Dosage:

Frequency:

Route:

Generic Name: Mechanism Of Contraindication Adverse Effects Nursing

Action Responsibility

Pharmacologic
Class:

Therapeutic
Class:

Dosage:

Frequency:

Route:
Generic Name: Mechanism Of Contraindication Adverse Effects Nursing
Action Responsibility

Pharmacologic
Class:

Therapeutic
Class:

Dosage:

Frequency:

Route:

Generic Name: Mechanism Of Contraindication Adverse Effects Nursing

Action Responsibility

Pharmacologic
Class:

Therapeutic
Class:

Dosage:

Frequency:

Route:

Generic Name: Mechanism Of Contraindication Adverse Effects Nursing

Action Responsibility

Pharmacologic
Class:

Therapeutic
Class:

Dosage:

Frequency:

Route:
Nursing Management

Nursing Diagnosis:
Evaluation Impaired skin integrity related to post surgery of the abdomen
as evidenced by sutures in the abdominal area. O>
-disruption of skin surface-destruction of skin layers

Cues Objectives Interventions Rationale Evaluation

Subjective: Long-Term: Independent: To document The client
By the end of 1. Note skin status and developed
the shift, the colour, provide and
client will texture, and baseline for maintained
Objectives:
develop and turgor. future optimal
maintain 2. Palpate comparisons. conditions
optimal skin lesions NANDA 11th for wound
conditions for size, Edi. p.620- healing as
for wound shape, 621 evidenced by
healing. consistency, responses to
texture, interventions
Short-Term temperature, and teaching
After 30 and and actions
minutes, the hydration. performed
nurse will be 3. Determine and gradual
able to degree or healing of his
assess the depth of wound.
extent of injury or
involvement damage to
or injury. skin.
4. Measure
length, width,
depth of
wound.
5. Inspect
surrounding
skin for
erythema,
induration,
and
maceration.
6. Note
odors

Collaborative:
Nursing Diagnosis:
Fluid volume excess related to compromised regulatory mechanism as evidenced by tissue
edema

Cues Objectives Interventions Rationale Evaluation

Subjective: Long-Term: Independent: > for confusion or Intervention
Restlessnes > Evaluate personality changes Goal was
s To evaluate degree of mentation > To emphasize met after 2-
>wt: 60kgs excess > Restrict Na dietary/fluid restriction 3hours
and fluid > To reduce tissue of nursing
> To Promote intake pressure and risk for interventions
mobilization/eliminatio > Advised to skin breakdown patient was
Objectives: n of excess fluid elevate the >To prevent stasis and able
Edema, > To promote wellness edematous risk of tissue injury verbalized
grading extremities, >To ensure timely understanding
edema of change position evaluation/interventio of individual
2+ Short-Term: frequently n dietary/fluid
disappears After 2-3hours of nursing > Stress the restriction.
10-15secs. interventions patient will be need for
able to verbalize mobility and
understanding of individual frequent
dietary/fluid restrictions position
changes

Collaborative:
>Identify signs
requiring
notification
of health care
provider

Nursing Diagnosis:
Deficient Knowledge: New condition, procedure, treatment

Cues Objectives Interventions Rationale Evaluatio

n
Subjective: Long-Term:

Based on
Patient
Maslows theory,
explains basic
Objectives: disease state, physiological
needs must be
recognizes addressed before
Verbalizing need for Render physical the patient
inaccurate comfort for the education.
medications, patient. Ensuring physical
information and comfort allows
Exaggerated the patient to
understands concentrate on
behaviours treatments. what is being
Inaccurate follow- discussed or
Patient
demonstrated.
through of demonstrates
instruc how to
Questioning incorporate
 members of new health
health care team regimen into
Incorrect task lifestyle.
performance
Expressing Short-Term:
frustration
or confusion whe Patient exhibit

n performing s ability to

task deal with

tion health
situation and
remain in
control of life.
Patient shows
motivation to
learn.
Patient lists
resources that
can be used
for more
information or
support after
discharge.
Patient
identifies
learning
needs.

A calm
environment
Grant a calm and
allows the patient
peaceful environment
to concentrate
without interruption.
and focus more
completely.

Conveying
respect is
especially
Provide an
important when
atmosphere of
providing
respect, openness,
education to
trust, and
patients with
collaboration.
different values
and beliefs about
health and illness.

Goal setting
allows the learner
Include the patient in
to know what will
creating the teaching
be discussed and
plan, beginning with
expected during
establishing
the session.
objectives and goals
Adults tend to
for learning at the
focus on here-
beginning of the
and-now,
session.
problem-centered
education.
 Allowing the
patient to identify
the most
Consider what is
significant
important to the
content to be
patient.
presented first is
the most
effective.

Involve patient in Patient

writing specific involvement
outcomes for the improves
teaching session, such compliance with
as identifying what is health regimen
most important to and makes
learn from their teaching and
viewpoint and learning a
lifestyle. partnership.

Assessment
assists the nurse
in understanding
how the learner
Explore reactions and may respond to
feelings about the information
changes. and possibly how
successful the
patient may be
with the expected
changes.

Patients know
what difficulties
will transpire in
their own
Support self-directed, environments,
self-designed and they must be
learning. encouraged to
approach learning
activities from
their priority
needs.

This technique
aids the learner
Help patient in make
integrating adjustments in
information into daily daily life that will
life. result in the
desired change in
behavior.

Informatiom that
is in direct
conflict with what
Give adequate time
is already held to
for integration that is
be true forces a
in direct conflict with
reevaluation of
existing values or
the old material
beliefs.
and is thus
integrated more
slowly.

Patients are
Provide clear,
better able to ask
thorough, and
questions when
understandable
they have basic
explanations and
information about
demonstrations.
what to expect.
Give information with
the use of media. Use
visual aids like
Different people
diagrams, pictures,
take in
videotapes,
information in
audiotapes, and
different ways.
interactive Internet
websites, such as
Nurseslabs.

Adequate
preparation is
Check the availability
especially
of supplies and
important when
equipment.
teaching in the
home setting.

When presenting a
This method
material, start with
allows the patient
the basics or familiar,
to understand
simple, and concrete
new material in
information to less
relation to
familiar, complex
familiar material.
ones.

Clearly focuses
teaching allows
Focus teaching the learner to
sessions on a single concentrate more
concept or idea. completely on
material being
discussed.

Learning requires
energy, so
shorter, well-
Pace the instruction
paced sessions
and keep sessions
reduce fatigue an
short.
d allow the
patient to absorb
more completely.

In patients with
low literacy skills,
When teaching, build materials should
on patients literacy be short and have
skills. culturally
sensitive
illustrations.

Patients are
expected to read
Identify patients
and understand
understanding of
labels on
common medical
medicine
terminology, such as
containers,
empty stomach,
appointment
emesis, and
slips, and
palpation.
informed
consents.

Use the teach-back The teach-back

technique to technique
determine the consists of
patients specific steps in a
understanding of what repetitive order to
was taught: evaluate the
recipients
knowledge of the
The nurse content
gives discussed.
Patients who are
informatio not able to do
 this method after
n in a
multiple cycles is
caring considered
manner, cognitively
impaired.
using plain
language.
Ask the
patient to
explain in
his or her
own
words.
Rephrase the
informatio
n if unable
to repeat it
accurately.
Again ask the
patient to
teach-back
the
informatio
n using his
or her own
words until
the nurse
is
comfortabl
e that is
understood
.
If the patient
still does
not
understand
, consider
other
strategies.

Providing patients
with preadmission
Provide preadmission information about
self-instruction exercises has
materials to prepare been shown to
patient for increase positive
postoperative feelings and the
exercises. ability to perform
prescribed
exercises.
Immediate
feedback allows
Provide immediate the learner to
feedback on make corrections
performance. rather than
practicing the skill
wrongly.
 Repeated practice
Allow repetition of the allows patient
information or skill. gain confidence in
self-care ability.

A positive
approach by the
patient will help
Render positive, him or her feel
constructive good about
reinforcement of learning
learning accomplishments,
gain confidence,
and maintain self-
esteem.

Rewards help to
Incorporate rewards
make learning fun
into learning process.
and exciting.

Documentation
allows additional
Note progress of teaching to be
teaching and learning. based on what
the learner has
completed.

Learning occurs
through imitation,
so persons who
are currently
involved in
Help patient identify lifestyle changes
community resources can help the
for continuing learner anticipate
information and adjustment
support. issues.
Community
resources can
offer financial and
educational
support.
Instances of
disrespect and
Approach individuals
lack of caring
of color with respect,
have special
warmth, and
significance for
professional courtesy.
individuals of
color.

Nursing Diagnosis:
 Cues Objectives Interventions Rationale Evaluation
Subjective: Long-Term: Independent:

Dependent:
Objectives: Short-Term

Collaborative:

Nursing Diagnosis:

Cues Objectives Interventions Rationale Evaluation

Subjective: Long-Term: Independent:

Dependent:
Objectives: Short-Term

Collaborative:

Nursing Diagnosis:

Cues Objectives Interventions Rationale Evaluation

Subjective: Long-Term: Independent:

Dependent:
Objectives: Short-Term

Collaborative:

Nursing Diagnosis:
 Cues Objectives Interventions Rationale Evaluation
Subjective: Long-Term: Independent:

Dependent:
Objectives: Short-Term

Collaborative:

Discharge Plan

Medication

Exercise

Treatment

Health Teaching

Out-patient

Visit/Follow-up

Diet

References

Appendices

Vital Signs Monitoring

Intake and Output Monitoring

Include other monitoring, if any, such as: GCS, RBS, etc.