Professional Documents
Culture Documents
COLLEGE OF NURSING
MALAYBALAY CITY
On
Presentors:
Jennifer P. Barroso
Princess Obrique
Golda-Ria Torayno
I. Introduction
II. Objectives
III. Assessment
a. Demographic Data
d. Systems Involve
V. Pathophysiology
a. Diagnostic Exam
b. Laboratory Exam
c. Drug Study
a. Diagnostic Exam
X. Prognosis
XII. Reference
I. INTRODUCTION
during pregnancies in both small and large arteries. Signs of hypertension, proteinuria,
the United States (Moldenhauer & Sibai, 2003). Despite of years of research, the cause of
the disorder is still unknown. Originally it was called toxaemia because the researchers
pictured a toxin of some kind being produced by a woman in response to the foreign
protein of the growing fetus, the toxin leading to the typical symptoms. No such toxin has
ever been identified. A condition separate from chronic hypertension, PIH tends to occur
most frequently in women of color or with a multiple pregnancy, primiparas younger than
20 years of age and older than 40 years old, women from low socioeconomic
backgrounds (perhaps of poor nutrition), those who have had five or more pregnancies,
those who have hydramnios, or those who have an underlying disease such as heart
has been demonstrated to occur in 38% of cases reported in the United Kingdom.
Similarly, hypertension was absent in 16% of cases reviewed in the United States. Most
cases of eclampsia present in the third trimester of pregnancy, with about 80% of
delivery. Rare cases have been reported prior to 20 weeks' gestation or as late as 23 days’
reported cases have been classified as unpreventable (Michael G. Ross, MD, MPH,
2009).
II. OBJECTIVES
At the end of 4 hours presentation, the student nurse should be able to:
2. Formulate significant nursing diagnosis, with the significantly related nursing care
plan.
3. Identify the different medications administered for this disease, their indications,
4. Identify the laboratory and diagnostic procedure done with the eclamptic patient,
DEMOGRAPHIC DATA
c. Sex : Female
g. Nationality : Filipino
i. Occupation : Cook
gestation
cephalic
3. Gravida 1 Para 0
HISTORY OF PAST ILLNESS
Patient is hard working and responsible adult. She works for hours and she works
hard for her family. Like any other normal adult, she experiences stress from work. She
also feels pain and body aches, for she tries to do any kind of work to help sustain her
family.
In the year 2005, the patient was hospitalized at Bukidnon Provincial Hospital ( BPH )
Malaybalay, City because of Urinary Tract Infection (UTI). She stayed confined for a
couple of days and she got better. After that incidence she hadn’t have any medical
Last February 01, 2010 the patient already experienced discomfort. The patient
interpreted this discomfort as a result of stress from her work. So, she decided to take a
leave and will be back after she will deliver her first baby. Along with her discomfort,
she already knew that her blood pressure is increasing. From her last check-up last
January 25, 2010 it was 220/160mmHg. Since then, she took an antihypertensive drug
(methyldopa) aiming to lower down her blood pressure. A day prior to admission, she
experienced pain in the abdomen with the pain scale of 6/10. On the following day, she
kept on asking her sister to accompany her to Bukidnon Provincial Medical Center.
Along their way, the patient suffered from seizure until they reached ER of the said
hospital. She was admitted and diagnosed as Eclampsia G1P0 31.2 weeks gestational age.
Patient has been working as a cook under Atecle’s Grill as her occupation to support
her family. She has mostly spent her time in her work during weekdays and she could
only rest and give time for comfort during weekends. Accordingly, patient has history of
hypertension. Patient also experienced neck pain, during long hours of work. The patient
was asked about her parent’s disease, she stated that they are hypertensive and maintain
no medicine for hypertension. In addition, the patient’s lower extremities are very evident
Objective Data:
Temperature: 37.2 ̊ C
Pulses
Subjective Data:
Previous/ Recent Illness: “Naa na sa among kaliwat ang taas ug BP” as verbalized
by the patient.
>Patient verbalized that she experienced light headedness, fatigue and weakness.
Remarks:
Patient’s body temperature is within normal range, blood pressure is above normal
(240/180 mmHg), pulses are also within normal range (80 bpm), nail bed color is pinkish
with capillary refill of 2 seconds, pitting edema is also being observed on both lower
extremities, no varicosities seen, and Calf tenderness is negative. Patient also verbalizes
that they have a family history of hypertension. Patient also experienced light
Nursing Diagnosis:
Objective Data:
Edema: pitting edema noted on the lower extremities and swelling on the IV site.
Odor: (catheter)
Subjective Data:
Medication Taken: “wala paman pud ko nag inom ug tambal kibahin sa pampa-daghan
Fluid Intake per Day: “murag 2 ka-litro sa akong pag-estimate” as verbalized by the
patient
Excessive perspiration and odor problem: “dili man kaayo ko gapanington” as verbalized
by the patient
Remarks:
Patient is ambulatory, with indwelling catheter, she has firm abdomen, bowel sounds
is hypoactive then she has pitting edema on both lower extremities. Her urine color is
dark amber.
Nursing Diagnosis:
Functions:
3. Nurturing the development of and providing nourishment for the new individual
1. Carry blood
3. Transport
Structure Functions
Arteries - The walls (outer structure) of Transport blood away from the heart;
arteries contain smooth muscle fiber that Transport oxygenated blood only (except in the
contract and relax under the instructions of the case of the pulmonary artery).
arteries that lead to capillaries. These are also Arterioles are the main regulators of blood flow
blood flow.
Venules - Venules are minute vessels that Drains blood from capillaries into veins, for
drain blood from capillaries and into veins. return to the heart
Structure Functions
Capillaries - Capillaries are tiny (extremely Function is to supply tissues with components of,
narrow) blood vessels, of approximately 5- and carried by, the blood, and also to remove
20micro-metres (one micro-metre = waste from the surrounding cells ... as opposed to
0.000001metre)diameter. simply moving the blood around the body (in the
the organs and tissues of the body. These Exchange of oxygen, carbon dioxide, water,
capillaries are supplied with blood by salts, etc., between the blood and the surrounding
surrounding tissue.
Veins - The walls (outer structure) of veins Transport blood towards the heart;
consist of three layers of tissues that are Transport deoxygenated blood only (except in
thinner and less elastic than the corresponding the case of the pulmonary vein).
layers of arteries.
Arteries Veins
Transport blood away from the heart; Transport blood towards the heart;
(except in the case of the Pulmonary Artery); (except in the case of the Pulmonary Vein);
Have relatively narrow lumens Have relatively wide lumens (see diagram
above);
Have relatively more muscle/elastic tissue; Have relatively less muscle/elastic tissue;
Transports blood under higher pressure (than Transports blood under lower pressure (than
veins); arteries);
Do not have valves (except for the semi-lunar Have valves throughout the main veins of the
valves of the pulmonary artery and the aorta). body. These are to prevent blood flowing in the
NORMA ABNORMA
THE CARDIOVASCULAR SYSTEM
V. ANATOMY AND PHYSIOLOGY OF CARDIOVASCULAR SYSTEM
The cardiovascular system is the lifeline of the body. Its primary function is to as a
transport system, delivering oxygen by way of the red blood and delivering nutrients,
metabolites, and hormones to every cell in the body. At the same time, it transports
metabolic wastes for detoxification and excretion. The cardiovascular system also
Heart- a cone shaped muscle with four chambers; a double pump about the size of
a clenched fist (12cm long and 9cm wide). Weighs 250-390g (8.8-13.8oz) in adult males
and 200-275g (7.0-9.7oz) in adult females. Pumps blood throughout the circulatory
system.
RIGHT SIDE
Right atrium- upper chamber of right heart. Receives unoxygenated blood form
chordate tendineae to papillary muscles, which are attached to inner heart muscle. Valve
Right ventricle- lower chamber of right heart. Receives blood from right atrium
right and left branches supplying respective lungs. Carries unoxygenated blood from right
ventricle to lungs.
Pulmonary veins- veins leading from lungs to left atrium. Carry oxygenated blood
to left atrium.
LEFT SIDE
Left atrium- upper chamber of left heart. Receives oxygenated blood from lungs
Mitral valve- AV valve with two cusps (bicuspid) attached by chordate tendineae
to papillary muscles, which are attached to inner heart muscle. Valve between left atrium
Left ventricle- lower chamber of left half of heart. Receives blood from left
Aortic valve- composed of three cusps. Valve between left ventricle and aorta.
The systemic circulation is responsible for supplying oxygen to every cell in the
body through the arterial system and then returning unoxygenated blood to the heart
through the venous system. Oxygenated blood flows into the left atrium from the
pulmonary circulation. The left atrium the pumps the oxygenated blood into the left
ventricle, which in turn expels the oxygenated blood through the aorta into the arterial
systemic circulation. From the aorta, blood then flows through smaller arterioles to the
systemic capillaries. The systemic capillaries link the arterial and venous systems. At this
point, exchange of oxygen, nutrients and wastes occurs. From the capillaries,
unoxygenated blood then flows through the venules, into the larger veins, and then to the
superior and inferior vena cavae. Unoxygenated blood then enters the right atrium and is
pumped to the right ventricle into the pulmonary circulation to continue the cycle.
The placenta is also a kind of padding, and maintains a unique environment in which
your baby can develop and grow. The placenta forms from the same cells as the embryo
and attaches itself to the inner wall of the uterus, growing as your baby grows and the
volume of your amniotic fluid increases. When it's finished growing, it is circular and
weighs about a pound; when the body expels it after the birth; many women are surprised
FETAL CIRCULATION
Since the lungs and digestive system are not yet functioning in a fetus, all
nutrient, excretory, and gas exchanges occur through the placenta. Nutrients and oxygen
move from the mother’s blood into the fetal blood, and fetal wastes move in the opposite
direction. The umbilical cord contains three blood vessels: one large umbilical vein and
two smaller umbilical arteries. The umbilical vein carries blood rich in nutrients and
oxygen to the fetus. The umbilical arteries carry carbon dioxide and debris-laden blood
from the fetus to the placenta. As blood flows superiorly toward the heart of the fetus,
most of it bypasses the immature liver through the ductus venosus and enters the superior
vena cava, which carries the blood to the right atrium of the heart.
Since fetal lungs are non-functional and collapsed, two shunts see to it that they
are almost entirely bypassed. Some of the blood entering the right atrium is shunted
directly into the left atrium through the foramen ovale, a flaplike opening in the interatrial
septum. Blood that does manage to enter the right ventricle is pumped out the pulmonary
trunk, where it meets a second shunt, the ductus arteriosus, a short vessel that connects
the aorta and the pulmonary trunk. Because the collapsed lungs are a high-pressure area,
blood tends to enter the systemic circulation through the ductus arteriosus. The aorta
carries blood to the tissues of the fetal body and ultimately back to the placenta through
At birth, or shortly after, the foramen ovale closes, and the ductus arteriosus
collapses and is converted to the fibrous ligamentum arteriosum. As blood stops flowing
through the umbilical vessels, they become obliterated, and the circulatory pattern
cord, the peripheral nervous system (PNS) and regulates virtually all human activity.
Involuntary, or "lower," actions, such as heart rate, respiration, and digestion, are
unconsciously governed by the brain, specifically through the autonomic nervous system.
consciously controlled.
Generalized seizures are caused by abnormal electrical activity at multiple locations in
the brain and/or over a large area of the brain. This results in loss of consciousness and
Abnormal electrical activity may start in one part of the brain and cause isolated
symptoms. Sometimes this abnormal electrical activity spreads through the brain,
resulting in a generalized seizure. Seizures can be caused by a specific area of the brain
that is injured or inflamed, or they can be due to stress on the brain from a more
a. Diagnostic Exam
Chest
silhotte appears enlarged with a CT ratio of 0.54. Aorta, trachea, diaphragm, and sinuses
X- Ray report
Pregnancy Evaluation Date ordered: February 24, 2010
Findings: Within the gravid uterus is a single uterine fetus in breech presentation with
Fetal somatic and cardiac activities are not appreciated on real time.
Impressions: Intrauterine fetal demise at 31.2 weeks gestational age by femoral length.
Ultrasound Report
b. Laboratory Exam
a. Diagnostic Exam
Diagnosis is often based on the increase in blood pressure levels, but other
symptoms may help establish Eclampsia as the diagnosis. Tests for Eclampsia
Urinalysis
Blood Chemistry
Hematology
c. Ideal Nursing Care Plan
• Support bed rest. - with severe pre-eclampsia most women are hospitalized so
that bed rest can be in forced and the woman can be observed more closely than she can
be on home care. Visitors are usually restricted to support people. Because a loud noise
private room so she can rest as undisturbed as possible. Raise side rails to help prevent
injury if a seizure should occur. Darken the room if possible because a bright light can
trigger seizures. However, the room should not be so dark that caregivers need to use a
flash light to make assessments. Shining a flashlight beam into a woman’s eyes is the
blood pressure and evoking seizures in a woman receives clear explanations of what is
happening and what is planned. Clear explanations help her accept the need for visitor
restrictions and not to cheat on bedrest. allow her opportunities to express her feelings
about what is happening or how bewildered she is because the few simple symptoms she
noticed 2 weeks ago have now developed into a syndrome that may be lethal for her baby
with a continuous monitoring device to detect any increase, which is a warning that
woman’s condition is worsening. Obtain blood studies as ordered to assess for renal and
liver function and the development of DIC, which often accompanies severe vasospasm.
Because she is at higher risk for premature separation of the placenta and resulting
haemorrhage, a blood sample for type and cross- matched is usually also drawn.
level will rise if increase fluid is leaving the bloodstream for interstitial tissue or edema.
Also, anticipate the need for frequent plasma estriol levels and electrolyte levels. A
woman’s optic fundus is assessed daily for signs of arterial spasms, edema or
haemorrhage. Obtain daily weights at the same time each day to evaluate tissue fluid
retention. Ensure that a woman is wearing approximately the same amount of clothing at
each weighing so any change in weight is not influence by change in the weight of her
clothing.
output and comparison with intake. Urinary output should be more than 600mL/24hours
or more than 30mL/hour; an output lower than this suggests oliguria. Urinary proteins
and specific gravity should be measured and recorded with voiding or hourly if an
indwelling catheter is present. A 24-hour urine sample may be collected for protein and
fetal heart rate may be assessed continuously with an external fetal monitor. A woman
may have an nonstress test or biophysical profile done daily to assess utero-placental
• Support a nutritious diet.- a woman needs a diet moderate to high in protein and
moderate in sodium to compensate for the protein she is losing in urine. An intravenous
fluid line should be initiated and maintained to serve as route for drug administration as
lower blood pressure by peripheral dilatation and thus do not interfere with placental
circulation. They can cause tachycardia. Therefore, assess pulse and blood pressure after
Despite these new drugs, MgSO4 remains the drug of choice to prevent
eclampsia. This drug, classified as a cathartic, reduces edema by causing a shift in fluid
from the extracellular spaces into the intestine. It also has a central nervous system
depressant action.
intravenously in a loading or bolus dose. Given intravenously over 15min, the drug acts
almost immediately; unfortunately, the effect lasts only 30-60 min, so administration
must be continuous.
5-8mg/100mL.if the blood serum level rises above this, respiratory depression, cardiac
decreased urine output, depressed respiration, reduced consciousness, and decrease deep
tendon reflexes. Because Magnesium is excreted from the body almost entirely through
the urine, urine output must be monitored closely to ensure adequate elimination. If
severe oliguria should occur, excessively high serum levels of magnesium can result.
Before you administer further MgSO4, therefore, ensure that urine output is above 25-
The patient should be advised and educated on the course of the disease and any
residual problems.
subsequent pregnancies.
If the patient has pre-existing hypertension, she should have good control prior to
conception and throughout pregnancy. Her case should be followed for recognition and
treatment of preeclampsia.
Follow up 1-2 weeks after delivery to evaluate for blood pressure control and any
residual deficits from the eclamptic seizure. Patients with persistent hypertension past 8
XVI. Prognosis
pregnancies.
primiparous women
Admit to Ob
TPR q4
To assist vital signs
NPO temporarily
UA
Urinalysis is ordered to check for the presence of bacteria, molecules that are
HBsAg
developing hepatitis B.
D5LR 1L @ 30gtts
drug
O2 inhalation 3L/L
Tongue depressors
I and O q4
To monitor the amount of fluids the patient takes in and the amount of output
Refer accordingly
drug
Methyldopa 500mg 1tab q6
To evaluate urinary function through a non-invasive test that uses reflected sound
Continue medication
Continue meds
To continue treatment
Continue medication
Continue BP monitoring
Give methyldopa q8
more sodium intake there is also more fluid retain in the body contributing to
Refer accordingly
Continue meds
Back to ward
DAT
Meds:
o Multivitamins + Fe tab OD
For medication route and for nutrition of the patient; oxytocin promotes
contraction.
For medication route and for nutrition of the patient; oxytocin promotes
contraction.
To prevent bleeding
To prevent infection
Refer accordingly
Continue meds
To follow proper course of treatment
For billing
For billing
Meds:
This is to prevent the patient from getting infected since Cefadroxil is an anti-
infective
o Multivitamins + Fe OD
o Advised
drug
For billing
MGH as ordered
XVIII. References
A. Books
b. Adele. Maternal & Child Health Nursing: Care of the Childbearing and
2007.
2008.
b. Gulanick, Meg et.al. Nursing Care Plans: Nursing Diagnosis and Intervention. 6th
b. Gulanick, Meg. et.al. Nursing Care Plans: Nursing Diagnosis and Intervention. 3rd
B. Journals
b.Tuffnell DJ, Shennan AH, Waugh JJ, Walker JJ. The management of severe pre-
eclampsia/eclampsia. London (UK): Royal College of Obstetricians and Gynaecologists;
2006 Mar.
d. Report of the National High Blood Pressure Education Program Working Group on
High Blood Pressure in Pregnancy. Am J Obstet Gynecol. 2000
i.Fonseca JE, Méndez F, Cataño C, Arias F.Dexamethasone treatment does not improve
the outcome of women with HELLP syndrome: a double-blind, placebo-controlled,
randomized clinical trial. Am J Obstet Gynecol. 2005