PREECLAMPSIA

INTRODUCTION

Preeclampsia is a major cause of maternal and perinatal morbidity and mortality. It accounts to 28.4% of
maternal morbidity and mortality in the Philippines according to DOH (as of Feb. 2008). The condition — sometimes
referred to as pregnancy-induced hypertension — is defined by high blood pressure and excess protein in the urine after
20 weeks of pregnancy.

Often, preeclampsia causes only modest increases in blood pressure. Left untreated, however, preeclampsia
can lead to serious — even fatal — complications for both mother and baby.
The only cure for preeclampsia is delivery of the baby. If preeclampsia develops near the end of your pregnancy, delivery
is the obvious solution. If you're diagnosed with preeclampsia earlier in your pregnancy, you and your doctor face the
delicate task of prolonging your pregnancy to allow your baby more time to mature, without putting you or your baby at
risk of serious complications.

The signs of preeclampsia are elevated blood pressure (hypertension) and the presence of excess protein in
your urine (proteinuria) after 20 weeks of pregnancy. The excess protein is related to problems with your kidneys. Your
doctor may identify these signs of preeclampsia at one of your regular prenatal visits.

Other signs and symptoms of preeclampsia — which can develop gradually or strike suddenly, often in the last
few weeks of pregnancy — may include:
• Severe headaches
• Changes in vision, including temporary loss of vision, blurred vision or light sensitivity
• Upper abdominal pain, usually under the ribs on the right side
• Nausea or vomiting
• Dizziness
• Decreased urine output
• Sudden weight gain, typically more than 2 pounds a week

Swelling (edema), particularly in the face and hands, often accompanies preeclampsia as well. Swelling isn't
considered a reliable sign of preeclampsia, however, because it also occurs in many normal pregnancies.

CAUSES
Preeclampsia used to be called toxemia because it was thought to be caused by a toxin in a pregnant woman's
bloodstream. Although this theory has been debunked, researchers have yet to determine what causes preeclampsia.
Possible causes may include:
• Insufficient blood flow to the uterus
• Damage to the blood vessels
• A problem with the immune system
RISK FACTORS
Preeclampsia develops only during pregnancy. Risk factors include:
• History of preeclampsia. A personal or family history of preeclampsia increases your risk of developing the condition.
• First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy or your first pregnancy
with a new partner.
• Age. The risk of preeclampsia is higher for pregnant women who are older than age 35.
• Obesity. The risk of preeclampsia is higher if you're obese.
• Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or other multiples.
• Gestational diabetes. Women who develop gestational diabetes have a higher risk of developing preeclampsia as the
pregnancy progresses.
• History of certain conditions. Having certain conditions before you become pregnant — such as chronic high blood
pressure, diabetes, kidney disease or lupus — increases the risk of preeclampsia.
 OBJECTIVES

GENERAL
1. To enhance skills in handling patient with pre-eclampsia.
2. To have an additional knowledge and information about pre-eclampsia.
3. To perform appropriate management by utilizing the nursing process.

SPECIFIC
1. To define what is pre-eclampsia.
2. To discuss the anatomy and physiology of pre-eclampsia.
3. To know the etiology, risk factors and its complication.
4. To plan and execute appropriate nursing interventions.
5. To evaluate the effectiveness of discharge planning.
6. To create awareness about pre-eclampsia to the client and to the family members.

DEMOGRAPHIC

A. PERSONAL DATA
Name:XY
Age:31
Sex: FEMALE
Date of birth: NOVEMBER 1, 1977
Place of birth: MONTALBAN, RIZAL
Civil status: MARRIED
Religion: CATHOLIC
Nationality: FILIPINO

ADMISSION
Date: NOVEMBER 22, 2008
Room: 3016-F2
Diagnosis: G5P4, 32 WEEKS AOG
Attending physician:DR. ALMA F. FONTE-RAMIREZ

ADMITTING HISTORY
XY was 8th month pregnant when she was rushed to East Avenue Hospital in Quezon City on the November 22,
2008. Upon admission, she had pain, headache, bloodshow but no signs of seizure. She was conscious and coherent, not
in cardio respiratory distress. With Bp of 190/110, afebrile, with retractions with clear breath sounds and positive bipedal
edema. She had a previous consultation in Infirmary hospital in Montalban. She had a normal spontaneous delivery last
November 22, 2008, she delivered twin boys.

Past Medical Hospitalization

Appendectomy 1999
Family Medical History
The patient has a family history of hypertension. According to XY, both her parents have hypertension.

Social History
XY, 31 years old, who resides with her husband in Montalban Rizal. According to her though their income is still
insufficient for them, she is still happy and contented. With regard to their community, she said that the environment is
peaceful and their neighbors are very accommodating. According to her that part of her leisure is chatting with her
neighbors.

GORDON’S PATTERN
Person Approach

PSYCHOLOGICAL
• Self Perception Pattern
XY is a very jolly individual. She seems very satisfied to the life that she has. Just being with her partner she
feels complete and secure. She is very appreciative even on the simple things being done to her, especially with her
husband. Though they’re having some problems on their finances she maintains the composure of being fine and happy.
Her family, especially her twins is her inspiration right now. She entrusts everything on the Lord. She sees problems as
test of courage and faith to Him.

• Role Relationship Pattern

XY resides with her family including her parents in Montalban, Rizal. With regard to decision making, it is both
of them who decide on whatever actions to be done. She owned a house with 2 bedrooms .She lives in a community of
very friendly and accommodating neighborhood.. In fact in her free time, she chats with her neighbors. Health center in
their place is very accessible for them. Unlike the wet market, it will take them 15-20 mins to get there.

• Coping Perceptual Pattern

XY has a good vision & hearing. In regards to her mental status, she’s being forgetful at time. She feels pain
and discomfort due to her recent delivery.

• Coping Stress Tolerance Pattern

She is a jolly person that is why coping with stress is not a problem with her. She manages it by simply diverting
it to other things like talking to friends, watching TV, listening to radio, etc… Her husband has always been the first person
she asks for help when she is stressed out or feeling down. Also, they just keep a positive outlook and a strong faith to the
Lord whenever things are going really bad.

PSYCHOSOCIAL - Intimacy vs. Isolation

Characterized by the development of an intimate loving relationship with another.
PSYCHOSEXUAL - has reached the stage of genital
COGNITIVE - has reached the stage of formal operations.

• Value Belief Pattern

XY is a catholic. Her husband was an Iglesia ni Cristo member, but was later on was converted when they got
married. With her family, they hear mass every Sunday. She has observed the closeness of their family when she was still
young. Now that she has her own, she wants that close family ties be observed. She always tells her kids to be a good
person, study well and be God-fearing. She is very satisfied with her life especially now that their twins.

ELIMINATION
 She has a regular bowel movement and she micturates regularly. In regards to the amount and character,
everything is regular and normal. No discomfort or any pain being felt. She is clean and seems to practice good hygiene
routine.

REST AND ACTIVITY

• Activity Exercise Pattern
Doing household chores and her work are the only form of exercise she has. These keep her in good shape.
Her leisure activities are just watching TV, listening to radio and chatting with her neighbors. She wakes up early around
4am to prepare things for her kids. She cooks her food but when she has no time she just buys outside. The usual food
intake would be composed of fish and vegetables. In terms of hygiene, she observes good hygienic practice all the time.
She takes a bath everyday. Their place is just a room with bathroom.

• Sleep Rest Pattern

XY has a regular bed time. She has 8 hours of sleep everyday. This is enough for her to do her tasks for the
next day. Making use of any aids is not needed anymore.

SAFE ENVIRONMENT
The patient has no allergies on any medications and/ foods. In regards with her skin integrity there are no
evident lesions. It appears to be some how smooth.

OXYGENATION
XY has no difficulty in breathing.

NUTRITION
XY cooks their food but there would be times that she buys outside. Her favorite foods would be anything with
fish and vegetables. There is nothing in particular that she dislikes. She eats three times a day with snacks in the
afternoon. She has a big appetite. There are times that quantity and quality of food is being sacrificed because of tight
budgeting.
 PHYSICAL ASSESSMENT

GENERAL ASSESMENT:
VITAL SIGNS (11/23/08):
BP 180/100
PR 83
RR 22
TEMP 36.8 C
HEIGHT 5’1”
WEIGHT 140 lbs

Patient conscious and coherent, able to understand and respond to questions appropriately and reasonably
quickly. No signs of respiratory distress. Skin appears to be dry with some visible scars at both upper and lower
extremities. She has a medium built frame, short stature with apparent globular abdomen. She sat comfortably with a
slouched posture, no involuntary movements shown. Dressed in a simple red/ black duster, appear to be neat. However,
fingers on both hands and feet are noticeably unclean. No odor of body and breath noted. She covers her mouth the
whole time of the conversation, conscious of her uneven lower teeth and the absence of upper incisors. Manner of
speaking is quite unclear. She also has asymmetrical facial features, due to her Bell’s Palsy/ facial hemiparesis.

SPECIFIC ASSESMENT:
PARTS TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
HEAD AND FACE
Skull Inspection Proportional to body size Proportional to the patients Normal Findings
size
Palpation Smooth, uniform Absence of nodules or Normal Findings
consistency, absence of masses
nodules or masses
Scalp Inspection Smooth contour Smooth contour Normal Findings
Palpation No lesions Absence in lesions, mass, Normal Findings
No mass and area of tenderness
No area of tenderness
Hair Inspection Evenly distributed Evenly distributed with a Normal
Condition No gray hair number of gray hair Gray hair is influenced by
decreased in melanocytes due
to aging process
No Seborrhea, No seborrhea, dermatitis Normal Findings
dermatitis
Smooth and shiny Smooth and shiny Normal Findings
Face Inspection Symmetrical facial Asymmetrical Bell’s Palsy (facial hemiparesis
feature due to oedema of 7th /facial
cranial nerve)
- occurred when she was 5y/o,
no continuous treatment /
therapy done

EYES
Eye Inspection Skin Intact; Skin intact Normal Findings
Condition no discharge; No discharge
no discoloration No discoloration
Lids close symmetrically Lids close symmetrically

Sclera Inspection Clear Clear Normal Findings

No shrunken eyeballs Protruding/ bulging Bell’s Palsy (facial hemiparesis
eyeball (R) due to oedema of 7th /facial cranial
nerve)

No dark circles under the
eye
white and clear; capillaries
sometimes evident;
Pupil Inspection Constrict with close light
Dilates with distant light
(PERLA)
Conjuctiva Inspection Pinkish in color and moist
Vision Inspection Both eyes focus on objects
clearly whether near or
distant - EMMETROPIA
With slightly dark circles
under the eyes
Sclera is white w/
prominences of
capillaries.
Constricts with close light
Dilates with distant light
Extremely pale
Both eyes focus on
objects clearly whether
near or distant -
EMMETROPIA
- occurred when she was 5y/o, no
continuous treatment / therapy
done
Lack of sleep
Normal Findings
Normal Findings
Normal Findings
There is paleness due to anemia
because liver is already damage
thus production of globin (which is
a type of proteins) that is essential
in forming hemoglobin is altered.
Normal findings

MOUTH
EARS
Lips
Auricle Inspection
Inspection ColorSymmetry of contour
same as facial skin Asymmetrical
Color same asoffacial
contourskin Bell’s Palsy (facial
Normal Findings
Symmetrical Symmetrical hemiparesis
NormaldueFindings
to oedema
th
Aligned with outer canthus of Aligned with outer canthus of eyeof 7 /facial cranial
Normal nerve)
Findings
eye - occurred when she was
5y/o, no continuous treatment
Pinna recoils after it is folded Pinna recoils after it is folded Normal Findings
/ therapy done
Hearing Whisper Test Responds to normal voice Able to hear normal voice clearly Normal Findings
Tongue Inspection Pinkish to reddish in Pinkish to reddish in color Normal Findings
Activity
color
Nose Inspection Patent and symmetrical Patent and symmetrical Normal Findings
With frenulum at the With frenulum at the center Normal Findings
center
Teeth Inspection No dental caries With dental caries Dental carries, plaque and
No plaque or cavities With plaque and cavities cavities due to poor dental
hygiene.
Gums with no lesions No lesions Normal Findings
32 permanent teeth - 28 permanent teeth with Poor dental hygiene led to
irregularities in growth cavities and decay.
- upper incisors missing
Absence of bleeding Absence of bleeding Normal Findings
Neck Inspection Proportional to the size Proportional to the size of Normal Findings
of the body the body
Palapation No palpable lymph No palpable lymph nodes Normal Findings
nodes
CHEST
Inspection Respiratory rate of 16- RR – 22 bpm The RR was taken on a sitting
20 breaths per min position, there was shortness
of breath due to mechanical
impingement on the
diaphragm.
No mass and are of Absence of mass and Normal Findings
tenderness are of tenderness
Palpation Vesicular and Diminish breath sounds Shallow breath may produces
bronchovesicular diminish breath sounds due to
breath sounds pleural effusion
Auscultation Absence of Absence of adventitious Normal Findings
adventitious and and bronchial breath
bronchial breath sounds
sounds
Lungs Auscultation Symmetric contour, no Symmetric contour, no Normal Findings
lesions, scars and lesions, scars and
rashes rashes
Abdomen Inspection Unblemished skin Unblemished skin Normal Findings
Uniform color Uniform color
Flat, rounded(convex), Distended (bulging Distention is present because
or scaphoid(concave) flanks); abdominal girth of portal hypertension resulting
of 93.98cm to accumulation of fluid in the
peritoneal cavity thus, the
weight of fluid pushes against
the side walls.
Auscultation Audible bowel sounds Absence of bowel Normal Findings
Absence of arterial sounds
bruit Absence of arterial bruits
Absence of friction rub Absence of friction rub
Percussion Tympany over the Tympanitic over the The tympany over the
stomach and gas filled umbilicus and dull over umbilicus occurs in ascites
bowels; dullness, the lateral abdomen and because bowel floats to the
especially over the liver flank areas. top of the abdominal fluid at
and spleen, or full the level of the fluid meniscus.
bladder

Palpation No tenderness; tenderness noted; There is discomfort upon

consistent tension increase tension palpation because of
abdominal distention.

UPPER EXTREMITIES
Arms and Inspection Symmetric, absence of Symmetric, absence of mass and Normal findings
Hands lesions, mass and area of area of tenderness
tenderness - presence of scars noted
Palpation Warm moist skin, pules Dry and scaly skin, Presence of dry
palpable bilateral 2+ Palpable bilateral pulses and scaly skin is
due to the
restriction of fluid
intake and
excessive fluid loss.
Fingers Inspection Complete number of digits Five fingers on both hands Normal findings
Nails Inspection Shiny, smooth, convex Pallor, smooth, convex Pallor is due to poor
curvature circulation
Nails are unclean Unclean nails due
to poor body
hygiene
Palpation of Capillary Refill time less Capillary refill time is about 4 Slight delay in
 Capillary Refill than 3 seconds seconds capillary refill time
Test is due to circulatory
impairment
LOWER EXTREMITIES
Skin Inspection Absence of coldness and Absence of coldness and Normal findings
clamminess clamminess
No lesions No lesions
No bleeding No bleeding
Palpation No mass Absence of masses Normal findings
Legs Inspection Complete legs (left and Both two legs are complete (left Normal findings
right leg) and right)
No mass and lesions Bipedal edema increased plasma
Weak popliteal pulse noted volume and sodium
retention
Pinkish in color Pallor Pallor is due to poor
circulation
Nails Inspection Hard Hard Normal findings
Complete toe nails Complete toe nails Normal findings
Nails are unclean Unclean nails due
to poor body
hygiene
Palpation in Capillary Refill time less Capillary refill time is about 4 Slight delay in
capillary refill than 3 seconds seconds capillary refill time
time is due to circulatory
impairment

DIAGNOSTIC EXAMINATION

1. CBC count
• Microangiopathic hemolytic anemia (HELLP)
• Thrombocytopenia / Platelet count less than 100,000
• Hemoconcentration may occur in severe preeclampsia.
2. Liver function tests: Transaminase levels are elevated from hepatocellular injury and in HELLP syndrome.
3. Serum creatinine level: levels are elevated due to decreased intravascular volume and decreased glomerular filtration
rate (GFR).
4. Urinalysis
• Proteinuria is one of the diagnostic criteria for preeclampsia.
• Proteinuria is defined as greater than or equal to 1+ protein on urine dipstick. Alternatively, protein
concentration of 300 mg/L or more on urine dipstick.
• Proteinuria is also defined as 300 mg or more of protein in a 24-hour urine sample.
5. Elevated PT, aPTT, fibrin split products, and decreased fibrinogen
6. Disseminated intravascular coagulopathy testing
7. Uric acid
• Uric acid levels are increased in preeclampsia.
• Serial levels may be useful to indicate disease progression.
8. Increase in blood pressure

CLINICAL MICROSCOPY
 Laboratory Test Laboratory Normal value Interpretation Remarks
result of result

I. Physical
A. Color Yellow Light yellow - amber Abnormal Often associated with bile
pigments chiefly retention of
bilirubin

B. Transparency Cloudy Clear Abnormal Suggestive of pyuria and slight

hematuria.

C. Specific Gravity 1.015 1.015- 1.030 Normal

D. Reaction 6.0 pH -4.8-7.7 Normal
E. Protein Positive Negative Abnormal Indicator of kidney dysfunction;
suggestive of pre-eclampsia
F. Sugar Negative Negative Normal

II. Microscopic
A. RBC( Red Blood 1 - 3/hpf 0-2/hpf Above the Slight increase is suggestive of
Cell) normal range bleeding but assumption is to be
renal in origin.

B. WBC(White Blood 15 – 20/hpf 0-5/hpf Above the Conclusive of renal disease.

Cell) normal range

C. Epithelial Cells Many Moderate Abnormal Seen in cases of acute tubular

necrosis

D. Mucus Threads Moderate Few present Abnormal Suggestive of advanced renal

disease

E. Bacteria Moderate Few present Abnormal Urinary tract infection is present.

F. Crystals Few A, Urates - Few Normal

G. Cost none none Normal

III. Biochemical
A. Urobilinogen --- 1.20
B. Nitrate --- Negative
C. Blood --- Negative

D. Bilirubin --- Negative

E. Ketone --- Negative

F. Leukocyte --- Negative

IV. Remarks ---

Ca oxalate crystalates ---

CLINICAL CHEMISTRY

Laboratory Test Laboratory Normal Value Interpretation Remarks

Results of Result
BUN 3.7 2.5- 5.1mmol/L Normal
(Blood Urea Nitrogen)

Creatinine 69umol/L 53-115 umol/L Normal

Alp --- 35-125 u/L Normal
SGOT (AST) 48 HIGH 15–37 u/L Abnormal Transaminase levels are
elevated from hepatocellular
injury
SGPT (ALT) 37 30-65 u/L Normal

ANATOMY
CARDIOVASCULAR SYSTEM

The cardiovascular system is sometimes called the blood-vascular or

simply the circulatory system. It consists of the heart, which is a muscular
pumping device, and a closed system of vessels called arteries, veins,
and capillaries. As the name implies, blood contained in the circulatory system is pumped by the heart around a closed
circle or circuit of vessels as it passes again and again through the various "circulations" of the body.

The vital role of the cardiovascular system in maintaining homeostasis depends on the continuous and controlled
movement of blood through the thousands of miles of capillaries that permeate
every tissue and reach every cell in the body. It is in the microscopic capillaries
that blood performs its ultimate transport function. Nutrients and other essential
materials pass from capillary blood into fluids surrounding the cells as waste
products are removed.

Heart

The heart is a muscular pump that provides the force necessary to circulate the
blood to all the tissues in the body. Its function is vital because, to survive, the
tissues need a continuous supply of oxygen and nutrients, and metabolic waste
products have to be removed. Deprived of these necessities, cells soon undergo
irreversible changes that lead to death. While blood is the transport medium, the
heart is the organ that keeps the blood moving through the vessels.

It is located between the lungs in the middle of the chest, behind and slightly to the left of the breastbone (sternum). A
double-layered membrane called the pericardium surrounds the heart like a sac. The outer layer of the pericardium
surrounds the roots of the heart's major blood vessels and is attached by ligaments to your spinal column, diaphragm, and
other parts of your body. The inner layer of the pericardium is attached to the heart muscle. A coating of fluid separates
the two layers of membrane, letting the heart move as it beats, yet still be attached to your body.

Blood

Blood is actually a tissue. It is thick because it is made up of a variety of cells, each having a different job. In fact, blood is
actually about 80% water and 20% solid.
 • Platelets, which help the blood to clot. Clotting stops the blood from flowing out of the body when a vein or artery
is broken. Platelets are also called thrombocytes.
• Red blood cells, which carry oxygen. Of the 3 types of blood cells, red blood cells are the most plentiful. In fact, a
healthy adult has about 35 trillion of them. The body creates these cells at a rate of about 2.4 million a second,
and they each have a life span of about 120 days. Red blood cells are also called erythrocytes.
• White blood cells, which ward off infection. These cells, which come in many shapes and sizes, are vital to the
immune system. When the body is fighting off infection, it makes them in ever-increasing numbers. Still,
compared to the number of red blood cells in the body, the number of white blood cells is low. Most healthy
adults have about 700 times as many red blood cells as white
ones. White blood cells are also called leukocytes. Blood also
contains hormones, fats, carbohydrates, proteins, and gases.
Blood carries oxygen from the lungs and nutrients from the
digestive tract to the body’s cells. It also carries away carbon
dioxide and all of the waste products that the body does not
need. (The kidneys filter and clean the blood.) Blood also
• Helps keep your body at the right temperature
• Carries hormones to the body’s cells
• Sends antibodies to fight infection
• Contains clotting factors to help the blood to clot and the
body’s tissues to heal

Blood Vessels

Blood vessels are the channels or conduits through which blood is

distributed to body tissues. The vessels make up two closed systems of
tubes that begin and end at the heart. One system, the pulmonary vessels, transports blood from the right ventricle to the
lungs and back to the left atrium. The other system, the systemic vessels, carries blood from the left ventricle to the
tissues in all parts of the body and then returns the blood to the right atrium. Based on their structure and function, blood
vessels are classified as arteries, capillaries, or veins.

a. Arteries
Arteries carry blood away from the heart. Pulmonary arteries transport blood that has low oxygen content from the right
ventricle to the lungs. Systemic arteries transport oxygenated blood from the left ventricle to the body tissues. Blood is
pumped from the ventricles into large elastic arteries that branch repeatedly into smaller and smaller arteries until the
branching results in microscopic arteries called arterioles. The arterioles play a key role in regulating blood flow into the
tissue capillaries. About 10 percent of the total blood volume is in the systemic arterial system at any given time.
The wall of an artery consists of three layers. The innermost layer, the tunica intima (also called tunica interna), is simple
squamous epithelium surrounded by a connective tissue basement membrane with elastic fibers. The middle layer, the
tunica media, is primarily smooth muscle and is usually the thickest layer. It not only provides support for the vessel but
also changes vessel diameter to regulate blood flow and blood pressure. The outermost layer, which attaches the vessel
to the surrounding tissue, is the tunica externa or tunica adventitia. This layer is connective tissue with varying amounts of
elastic and collagenous fibers. The connective tissue in this layer is quite dense where it is adjacent to the tunic media,
but it changes to loose connective tissue near the periphery of the vessel.

b. Capillaries
Capillaries, the smallest and most numerous of the blood vessels, form the
connection between the vessels that carry blood away from the heart (arteries) and
the vessels that return blood to the heart (veins). The primary function of capillaries
is the exchange of materials between the blood and tissue cells. Smooth muscle
cells in the arterioles where they branch to form capillaries regulate blood flow from
the arterioles into the capillaries.

c. Veins
Veins carry blood toward the heart. After blood passes through the capillaries, it enters the smallest veins, called venules.
From the venules, it flows into progressively larger and larger veins until it reaches the heart. In the pulmonary circuit, the
pulmonary veins transport blood from the lungs to the left atrium of the heart. This blood has a high oxygen content
because it has just been oxygenated in the lungs. Systemic veins transport blood from the body tissue to the right atrium
of the heart. This blood has a reduced oxygen content because the oxygen has been used for metabolic activities in the
tissue cells. The walls of veins have the same three layers as the arteries. Although all the layers are present, there is less
smooth muscle and connective tissue. This makes the walls of veins thinner than those of arteries, which is related to the
fact that blood in the veins has less pressure than in the arteries. Because the walls of the veins are thinner and less rigid
than arteries, veins can hold more blood.

Blood Flow

Blood flow refers to the movement of blood through the vessels from arteries to the capillaries and then into the veins.
Pressure is a measure of the force that the blood exerts against the vessel walls as it moves the blood through the
vessels. Like all fluids, blood flows from a high pressure area to a region with lower pressure. Blood flows in the same
direction as the decreasing pressure gradient: arteries to capillaries to veins.

The rate, or velocity, of blood flow varies inversely with the total cross-sectional area of the blood vessels. As the total
cross-sectional area of the vessels increases, the velocity of flow decreases. Blood flow is slowest in the capillaries, which
allows time for exchange of gases and nutrients.

Resistance is a force that opposes the flow of a fluid. In blood vessels, most of the resistance is due to vessel diameter.
As vessel diameter decreases, the resistance increases and blood flow decreases.
Very little pressure remains by the time blood leaves the capillaries and enters the venules. Blood flow through the veins
is not the direct result of ventricular contraction. Instead, venous return depends on skeletal muscle action, respiratory
movements, and constriction of smooth muscle in venous walls.

Pulse and Blood Pressure

Pulse refers to the rhythmic expansion of an artery that is caused by

ejection of blood from the ventricle. It can be felt where an artery is
close to the surface and rests on something firm.

In common usage, the term blood pressure refers to arterial blood

pressure, the pressure in the aorta and its branches. Systolic pressure
is due to ventricular contraction. Diastolic pressure occurs during
cardiac relaxation. Pulse pressure is the difference between
systolic pressure and diastolic pressure. Blood pressure is
measured with a sphygmomanometer and is recorded as the
systolic pressure over the diastolic pressure. Four major factors
interact to affect blood pressure: cardiac output, blood volume,
peripheral resistance, and viscosity. When these factors increase,
blood pressure also increases.

The blood vessels of the body are functionally divided into two
distinctive circuits: pulmonary circuit and systemic circuit. The
pump for the pulmonary circuit, which circulates blood through the
lungs, is the right ventricle. The left ventricle is the pump for the
systemic circuit, which provides the blood supply for the tissue
cells of the body.

a. Pulmonary Circuit
Pulmonary circulation transports oxygen-poor blood from the right
ventricle to the lungs where blood picks up a new blood supply.
Then it returns the oxygen-rich blood to the left atrium.

b. Systemic Circuit
The systemic circulation provides the functional blood supply to all body tissue. It carries oxygen and nutrients to the cells
and picks up carbon dioxide and waste products. Systemic circulation carries oxygenated blood from the left ventricle,
through the arteries, to the capillaries in the tissues of the body. From the tissue capillaries, the deoxygenated blood
returns through a system of veins to the right atrium of the heart.
LIVER

The liver is an organ present in vertebrates and some other animals. It plays a major role in metabolism and has a
number of functions in the body, including glycogen storage, decomposition of red blood cells, plasma protein synthesis,
and detoxification. This organ also is the largest gland in the human body. It lies below the diaphragm in the thoracic
region of the abdomen. It produces bile, an alkaline compound which aids in digestion, via the emulsification of lipids. It
also performs and regulates a wide variety of high-volume biochemical reactions requiring very specialized tissues.

KIDNEY

The kidneys are organs that filter wastes (such as urea) from the blood and excrete them, along with water, as urine. In
humans, the kidneys are located in the posterior part of the abdomen. There is one on each side of the spine; the right
kidney sits just below the liver, the left below the diaphragm and adjacent to the spleen. Above each kidney is an adrenal
gland (also called the suprarenal gland). The asymmetry within the abdominal cavity caused by the liver results in the right
kidney being slightly lower than the left one while the left kidney is located slightly more medial.

a. Homeostasis
The kidney is one of the major organs involved in whole-body homeostasis. Among its homeostatic functions are acid-
base balance, regulation of electrolyte concentrations, control of blood volume, and regulation of blood pressure. The
kidneys accomplish these homeostatic functions independently and through coordination with other organs, particularly
those of the endocrine system. The kidney communicates with these organs through hormones secreted into the
bloodstream.

b. Acid-base balance
The kidneys regulate the pH, by eliminating H ions concentration called augmentation mineral ion concentration, and
water composition of the blood.

c. Blood pressure
Sodium ions are controlled in a homeostatic process involving aldosterone which increases sodium ion reabsorption in the
distal convoluted tubules.

When blood pressure becomes low, a proteolytic enzyme called Renin is secreted by cells of the juxtaglomerular
apparatus (part of the distal convoluted tubule) which are sensitive to pressure. Renin acts on a blood protein,
angiotensinogen, converting it to angiotensin I (10 amino acids). Angiotensin I is then converted by the Angiotensin-
converting enzyme (ACE) in the lung capillaries to Angiotensin II (8 amino acids), which stimulates the secretion of
Aldosterone by the adrenal cortex, which then affects the renal tubules.

Aldosterone stimulates an increase in the reabsorption of sodium ions from the kidney tubules which causes an increase
in the volume of water that is reabsorbed from the tubule. This increase in water reabsorption increases the volume of
blood which ultimately raises the blood pressure.

d. Plasma volume
Any significant rise or drop in plasma osmolality is detected by the hypothalamus, which communicates directly with the
posterior pituitary gland. A rise in osmolality causes the gland to secrete antidiuretic hormone, resulting in water
reabsorption by the kidney and an increase in urine concentration. The two factors work together to return the plasma
osmolality to its normal levels.
Hormone secretion
The kidneys secrete a variety of hormones, including erythropoietin, urodilatin, renin and vitamin D.

ANGIOTENSIN
Angiotensin is an oligopeptide in the blood that causes vasoconstriction, increased blood pressure, and release of
aldosterone from the adrenal cortex. It is a
powerful dipsogen. It is derived from the
precursor molecule angiotensinogen, a serum
globulin produced in the liver. It plays an
important role in the renin-angiotensin system.
Renin's primary function is therefore to
eventually cause an increase in blood
pressure, leading to restoration of perfusion
pressure in the kidneys.

Types of Angiotensin

a. Angiotensin I
Angiotensin I is formed by the action of renin
on angiotensinogen. Renin is produced in the
kidneys in response to both decreased intra-
renal blood pressure at the juxtaglomerular
cells, or decreased delivery of Na+ and Cl- to
the macula densa. If more Na+ is sensed,
renin release is decreased. Renin cleaves the
peptide bond between the leucine (Leu) and
valine (Val) residues on angiotensinogen,
creating the ten amino acid peptide (des-Asp)
angiotensin I.

b. Angiotensin II
Angiotensin I is converted to angiotensin II
through removal of two terminal residues by
the enzyme Angiotensin-converting enzyme
(ACE, or kinase), which is found
predominantly in the capillaries of the lung. ACE is actually found all over the body, but has its highest density in the lung
due to the high density of capillary beds there. Angiotensin II acts as an endocrine, autocrine/ paracrine, and intracrine
hormone. ACE is a target for inactivation by ACE inhibitor drugs, which decrease the rate of angiotensin II production.
Angiotensin II increases blood pressure by stimulating the Gq protein in vascular smooth muscle cells (which in turn
activates contraction by an IP3-dependent mechanism). ACE inhibitor drugs are major drugs against hypertension.

c. Angiotensin III
Angiotensin III has 40% of the pressor activity of Angiotensin II, but 100% of the aldosterone-producing activity.
d. Angiotensin IV
Angiotensin IV is a hexapeptide which, like angiotensin III, has some lesser activity.

Cardiovascular effects
It is a potent direct vasoconstrictor, constricting arteries and veins and increasing blood pressure.

Renal effects
Angiotensin II has a direct effect on the proximal tubules to increase Na+ absorption. Although it slightly inhibits glomerular
filtration by indirectly (through sympathetic effects) and directly stimulating mesangial cell constriction, its overall effect is
to increase the glomerular filtration rate by increasing the renal perfusion pressure via efferent renal arteriole constriction.
Angiotensin II causes the release of prostaglandins from the kidneys.

Glomerular filtration rate (GFR)

Glomerular filtration rate (GFR) is a test used to check how well the kidneys are working. Specifically, it estimates how
much blood passes through the tiny filters in the kidneys, called glomeruli, each minute.
Glomerular filtration is the process by which the kidneys filter the blood, removing excess wastes and fluids. Glomerular
filtration rate (GFR) is a calculation that determines how well the blood is filtered by the kidneys, which is one way to
measure remaining kidney function.

HYPERTENSION

Vasospasm  effects on vascular system  vasoconstriction  impaired organ perfusion  hypertension

EDEMA

It is the medical term for when excess fluid collects in your tissue. It's normal to have a certain amount of this swelling
during pregnancy because you retain more water while you are pregnant, and certain changes in your blood chemistry
cause some fluid to shift into your tissue.

When one is pregnant, the growing uterus puts pressure on the pelvic veins and on the vena cava (a large vein on the
right side of your body that receives blood from your lower limbs and carries it back to the heart). The pressure slows
down circulation and causes blood to pool in your legs, forcing fluid from your veins into the tissues of your feet and
ankles. This increased pressure is relieved when you lie on your side. And since the vena cava is on the right side of your
body, left-sided rest works best.

A certain amount of edema is normal in the ankles and feet during pregnancy. However, swelling in of face or puffiness
around the eyes, more than slight swelling of the hands, or excessive or sudden swelling of feet or ankles could be a sign
of preeclampsia, a serious condition. A
Edema forms in people with kidney disease primarily for one of two reasons: either a heavy loss of protein in the urine or
impaired kidney (renal) function. In the first situation, the people have normal or fairly normal kidney function. The heavy
loss of protein in the urine (over 3.0 grams per day) is termed the nephrotic syndrome and results in a reduction in the
concentration of albumin in the blood (hypoalbuminemia). Since albumin helps to maintain blood volume in the blood
vessels, a reduction of fluid in the blood vessels occurs. The kidneys then register that there is depletion of blood volume
and, therefore, attempt to retain salt. Consequently, fluid moves into the interstitial spaces, thereby causing pitting edema.

People who have kidney diseases that impair renal function develop edema because of a limitation in the kidneys' ability
to excrete sodium into the urine. Thus, people with kidney failure from whatever cause will develop edema if their intake of
sodium exceeds the ability of their kidneys to excrete the sodium.

Vasospasm  effects on the interstitial tissues  fluid diffusion from vascular space into interstitial space  edema

ALBUMINURIA/ PROTEINURIA

The presence of excessive protein (chiefly albumin but also globulin) in the urine; usually a symptom of kidney disorder.

Vasospasm  effects on renal system  reduced glomerular filtration rate; increased glomerular membrane permeability
 increased serum blood urea nitrogen and creatinine levels  oliguria and protenuria

PATHOPHYSIOLOGY
BOOK BASED
NORMAL PLACENTAL DEVELOPMENT
From 9-12 weeks gestation the uterine spiral arteries are
transformed from thick-walled, muscular vessels, to more
flaccid tubes to accommodate a 10-fold increase in uterine
blood flow to support the pregnancy

Uterine spiral artery remodeling takes place by

the invasion of trophoblast cells into the uterine
lining.

These trophoblasts enter the arterial walls and

replace parts of the vascular endothelium so that
smooth muscle is lost and the artery dilates

An immune response facilitates normal placental

development:
 In the uterine decidua, maternal lymphocytes and
macrophages assist the trophoblasts to invade into the
uterine myometrium and the spiral arteries.
The mechanism by which preeclampsia occurs is not certain, and the diagnosis may represent a diversity of
pathophysiologies that proceed to a common final pathway. The inciting event is believe to be placental hypoperfusion,
which may result because the uteroplacental spiral arterioles are abnormally formed, leaving them highly sensitive to
vasoconstriction. Both maternal and paternal factors have been implicated in the development of preeclampsia.

Placental hypoperfusion leads by an unclear pathway to the release of systemic vasoactive compounds that cause an
exaggerated inflammatory response, vasoconstriction, endothelial damage, capillary leak, hypercoagulability, and platelet
Stage 2 all
dysfunction, begins when
of which maternal
contribute clinical
to organ features
dysfunction and appear.
the various clinical features of the disease.
> Cause is most likely related to the hypoxic and dysfunctional placenta releasing
Preeclampsia
factorsis into
a state
theof high systemic vascular
maternal resistanceresulting
circulation with normal or relatively
from low intravascular
cell death.
the These factorsvolume.
target
maternal endothelium,
TWO-STAGEcausing
MODEL vascular damage
OF THE PATHOPHYSIOLOGY OF PREECLAMPSIA

Perfusion is reduced to virtually every organ

With maternal endothelial damage:

> Decreased production of vasodilators (prostacyclin and nitric oxide)
> Inactivation of circulating
PLACENTALnitric oxide (vasodilator)
PATHOPHYSIOLOGY
STAGE 1

Trophoblasts fail to completely remodel the uterine

Theoretical basis for incomplete remodeling:
spiral arteries.
> Production failure of endothelial adhesion
> Remodeling either absent or
molecules from trophoblasts or
> Remodeling limited to the superficial
> Failure of/ or weak signaling of immune
portion of the artery located in the decidua, ratherVASOSPASM
cells by trophoblasts prevents deep invasion
than extending into the inner third of the
necessary for normal artery remodeling.
myometrium.

Poor placentation, or a decreased capacity of the

Poor tissue perfusion to all
maternal organs
* Vasospasm causes poor
tissue perfusion to all organs,
leading to organ dysfunction.
* Decreased perfusion to the
kidney results in decreased
(EVIDENCE OF MATERNAL
glomerular filtration, allowing
protein, mainly
albumin, to be lost into the
urine. Oliguria develops as the
disease worsens
uteroplacental circulation. This causes placental
hypoxia, resulting in oxidative stress.
Increases total Increases
peripheral endothelial cell
resistance resulting in permeability, (“leaky
elevated blood pressure capillaries”) fluid shifts from
intravascular to intracellular
space resulting in:
* Vasospasm and endothelial
> Decreased plasma volume,
damage upset the delicate increased hematocrit
balance between
MULTISYSTEMIC, MATERNAL SYNDROME > Generalized tissue and organ
vasoconstrictors
and edema
DISEASE PROCESS)
vasodilators. This imbalance
STAGE 2
causes generalized * Vasospasm of maternal blood
vasoconstriction, which vessels causes damage to
increases peripheral vascular endothelial cells, causing them
resistance, resulting in to become more permeable.
hypertension Fluid “leaks” out of the blood
vessels into the tissues,
causing tissue and organ
edema
CLIENT BASED:

Risk factors of Pre-eclampsia includes:

• History of preeclampsia. A personal or family history of preeclampsia increases your risk of developing the condition.
• First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy or your first pregnancy with a
new partner.
• Age. The risk of preeclampsia is higher for pregnant women who are older than age 35.
• Obesity. The risk of preeclampsia is higher if you're obese.
• Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or other multiples.
• Gestational diabetes. Women who develop gestational diabetes have a higher risk of developing preeclampsia as the
pregnancy progresses.
• History of certain conditions. Having certain conditions before FACTOR RISK RATIO
you become pregnant — such as chronic high blood pressure,
diabetes, kidney disease or lupus — increases the risk of Family history of PIH 5:1
preeclampsia.
Diabetes mellitus 2:1

Twin gestation 4:1

 Client reported of having chronic HPN before pregnancy

Family history also reveals HPN of both parents

Client is also in multiple pregnancies/ carrying twins

> Multiple pregnancy doubles the risk of preeclampsia. The placental
mass is large in multiple pregnancy. Hypoxia or reperfusion injury during
placentation might account for the endothelial damage that is
increasingly recognized as playing a part in the client’s pathogenesis of
preeclampsia.

The placenta doesn't grow normally in the first half of pregnancy/ blood
vessels that go to the placenta don't grow properly. This means not
enough blood reaches the placenta in the second half of pregnancy/
placenta doesn't get enough blood from the client.

The unhealthy placenta sends harmful chemicals back into the client’s
bloodstream. The chemicals damage the lining of the blood vessels,
causing high blood pressure, problems with the kidneys, and swelling.
 NURSING CARE PLAN

CUES NURSING INFERENCE NURSING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS PLANNING

Subjective: Altered Tissue Increased cardiac After 8 hours of Independent:

Perfusion r/t output continuous nursing • Take v/s every 1 – 2 hours • To detect early signs Goal met.
vasoconstriction of intervention patient initially, then every 4 hours of decreased cerebral After 8 hours of
blood vessels Injury of endothelial will maintain or after the patient becomes perfusion or ICP. continuous nursing
cells of the arteries improve current LOC. stable. intervention patient’s
LOC improved as
Objective: Reduced • Elevate head of patient’s • To promote venous evidenced by the
BP:180/100 responsiveness to bed 30 degrees. drainage reducing latter regaining sense
RR:28 blood pressure cerebral edema. of orientation.
PR:114 changes
• Keep patients head in • To keep the carotid
Vasoconstriction neutral alignment. flow unobstructed,
thereby promoting
perfusion.
• Keep the environment and
patient quiet. • Reduce increase in
ICP.
• Measure accurate intake
and output.
• To prevent volume
Dependent: overload or deficit.
• Administer diuretics such
as mannitol, as ordered.
• To prevent increased
ICP.
 CUES NURSING INFERENCE NURSING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS PLANNING

Subjective: Acute pain r/t to Episiotomy Short term: Independent: Goal met.
“Masakit pa rin po episiotomy. • Assess perineum for • To verify extent of wound. After 8 hours of
ang sugat ko.”as Cellular Injury After 8 hours of edema. continuous nursing
verbalized by the continuous nursing intervention the
patient. Vasodilation intervention the • Apply ice pack for • Cold compress constricts mother stated that
mother will state that 20mins.remove for at least blood vessels therefore discomfort has
Objective: Vasoconstriction discomfort has 10mins. Before reapplying. reduces pain. decreased as
Facial Grimacing decreased. evidenced by
Pain scale of 7 Increase Vascular • Teach mother to squeeze absence of facial
BP:180/100 permeability buttocks together before • To prevent pressure on the grimace pain scale
RR:28 sitting, release after sitting. area. of 0.
PR:114 Inflammation
• Encourage mother to
Pain practice kegel exercise.
• Kegel exercise is deisgned
to strengthen
Dependent: pubococcygeal muscles.
• Administer analgesic as
ordered.
• Relief of pain.
 CUES NURSING INFERENCE NURSING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS PLANNING

Subjective: Activity Increase Cardiac Short term: Independent: Goal met.

“Konting galaw ko intolerance related output • Discuss with patient the • Which will improve physical After 8 hours of
lng po kinakapos to imbalance After 8 hours of need for activity. and psychosocial well- continuous nursing
na po ako ng oxygen supply Increased Peripheral continuous nursing being. intervention the
hininga”as and demand. resistance intervention the patient expresses
verbalized by the patient will report • Evaluate current • Provides comparative satisfaction with
client. vasoconstriction measureable limitations/degree of deficit baseline. increase in activity
increase in activity in light of usual status. level.
Objective: Decreased Blood intolerance
RR:28 Supply • Monitor physiologic
PR:114 To organs(kidney, responses to increased • To ensure return to normal
pancreas, activity (including a few minutes after
Liver, brain) respirations, heart rate and exercising.
rhythm, and blood
Tissue hypoxia pressure).

• Adjust activities.
• Support and encourage
activity to patient’s level of
tolerance.
• To prevent overexertion.
• This helps develop the
patient’s independence.
 CUES NURSING INFERENCE NURSING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS PLANNING

Subjective: Excess fluid Vasoconstriction Short term: Independent: Goal met;

volume r/t to • Monitor v/s and breath • Changed parameters may After 8 hours of
increased isotonic Increase hydrostatic After 8 hours of sounds at least every 4 indicate altered fluid or continuous nursing
fluid retention. pressure continuous nursing hours; record and report electrolyte status. intervention the
Objective: intervention patient changes. patient verbalized
Urine output of Fluid from the will verbalize understanding of
<30ml/hr capillaries understanding of • If oral fluids are allowed, • Patient involvement fluid and dietary
Pitting Edema:3 accumulate into individual dietary and help patient make a encourages compliance. restrictions as
seconds interstitial space fluid restrictions. schedule for fluid intake evidenced by
Lower extremities: . patient plans own
Bipedal Edema Edema formation • Explain the reasons for • To prevent dehydration. menu and selects
fluid and dietary food low in sodium
restrictions. and potassium.

• Provide mouth care every 4 • To enhance patients

hours. understanding and
compliance.

• Provide sour hard candy. • To decrease thirst and

improve taste.
Dependent:
• Administer medications. • To promote fluid excretion.
 NURSING
CUES DIAGNOSIS INFERENCE PLANNING NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Self care deficit: Delivery Short term: Independent: Goal met
bathing/hygiene ↓ Within 1 hour Within 1 hour of
“Hndi pa. Ang related to pain (Tissue of continuous • Assist within meeting client’s needs when • To assist in dealing with current continuous
hirap din kasi trauma) nursing he is unable to meet own needs situation nursing
tumayo Pain intervention • Develop plan of care appropriate to intervention the
papuntang CR ↓ the patient patient’s situation, scheduling activities to patient
kaya minsan Hesitation to will conform to patient’s usual schedule. demonstrated
ngpapapunas move demonstrate techniques to
na lang ako”, ↓ techniques to • Promote client’s relative’s participation in • To enhance commitment to plan, meet self care
as verbalized Inability to meet self problem identification and desired goals optimizing outcomes and needs.
by the patient. access care needs. and decision making supporting recovery and health
bathroom, promotion.
Objective: wash body and
dry oneself • Plan time for listening to patient’s • To discover barriers to
• Inability to ↓ concerns participation in regimen and to
wash body Self care work on problem solutions
• Inability to deficit on
access hygiene • Practice and promote short-term goal • To recognize that today’s
bathroom setting and achievement success is as important as any
• Inability to long-term goal, accepting ability
dry body to do one thing at a time, and
conceptualization of self-care in
a broader scene.

• Provide privacy and equipment within • To enhance coordination and

easy reach during personal care activities. continuity of care.

• Provide for communication among those

who are involved in caring /assisting for • To encourage patient and build
patient. on success
 CUES NURSING INFERENCE PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Anxiety:mild The anxiety of the Short term: Independent:

related to treat patient is brought Goal met.
"Hay. Ang to health status about the threat to After 2 hours of • Note degree of anxiety and • Understanding that feelings After an hour of nursing
taas nga ng her health status nursing intervention fear. Inform patient/SO that (which are based on intervention patient’s
presyon ko, because of being pre- patient’s anxiety will feelings are normal and stressful situation plus an anxiety was reduced as
pano ba yan," eclamptic during the be reduce encourage expression of oxygen imbalance that is evidence by relaxed
As verbalized latter part of feelings being treated) are normal voice and absence of
by the patient pregnancy. may help the patient regain tension.
some feeling of control over
Objective: emotions
• Explain disease process and
- procedures within level of • Allays anxiety related to the
Restlessness patient's ability to unknown and reduces the
- Irritability understand and handle the fears concerning personal
- Voice information. Review current safety. In the early phases
quivering situations and the measures of the illness, explanations
- Sympathetic being taken to remedy the need to be short and
stimulation problems repeated frequently
e.g sweating because the patient will
have a reduced attention
• Stay with the patient or span
make arrangements for
someone else to be there • Helpful in reducing anxiety
during acute attack associated with perceived
abandonment in presence
of severe dyspnea/feelings
• Provide comfort measures, of impending doom
e.g back rub, position
changes • Aids in reducing stress and
redirecting attention to
enhance relaxation and
• Assist patient to identify coping abilities
helpful behaviors e.g
assuming position of • Gives patient measure of
comfort, focused breathing, control to reduce anxiety
relaxation techniques and muscle tension

• Support patient/SO in
 dealing with the realities of
the situation, especially in
planning for long recovery
period. Involve patient in
planning and participating in
care
• Develop activity program
within limits of physical
ability
DRUG STUDY
DRUG NAME ACTION INDICATION CONTRAINDICATION
Mefenamic Acid Anti-inflammatory, Short-term relief of Contraindicated in:
500 mg/cap analgesic, and anti- mild to moderate hypersensitivity to drug, GI
D: q6 for pain pyretic activities related pain inflammation, or ulceration.
to inhibition of Safe use in children < 14y,
Drug Class: prostaglandin synthesis. during pregnancy (Category
NSAID C), and in nursing mothers
not established.
Brand names:
Apo-Mefenamic Caution use in: history of
Ponstan renal or hepatic disease;
Ponstel blood dyscrasias; asthma;
diabetes mellitus;
hypersensitivity to aspirin.
• Coping mechanisms and
participation in treatment
regimen may be enhanced
as patient learns to deal
with the outcomes of the
illness and regains some
sense of control
• Provides a healthy outlet
for energy generated by
feelings
ADVERSE EFFECT
CNS: drowsiness,
insomnia, dizziness,
vertigo, unsteady gait,
nervousness, confusion,
headache, status
epilepticus with overdose.
GI: Severe diarrhea, GI
inflammation, ulceration,
and bleeding; nausea,
vomiting, abdominal
cramps, flatus,
constipation.
NURSING
RESPONSIBILITY
> Administer with
meals, food, or milk to
minimize GI adverse
effects.
> Use of drug for a
period exceeding 1 wk
is not recommended
> Patients who develop
severe diarrhea and
vomiting should be
assessed for
dehydration and
electrolyte imbalance.

Hematologic: prolonged
prothrombin time, severe
autoimmune hemolytic
anemia (long-term use),
leucopenia, eosinophilia,
agranulocytosis,
Thrombocytopenic
purpura, megaloblastic
anemia, bone marrow
hypoplasia.
Renal: nephrotoxicity,
dysuria, albuminuria,
hematuria, elevation of
BUN.
Skin: Urticaria, rash, facial
edema.
Other: Eye irritation, loss
of color vision (reversible),
blurred vision, ear pain,
perspiration, increased
need for insulin in diabetic
patients, hepatic toxicity,
palpitation, dyspnea;
acute exacerbation of
asthma;
bronchoconstriction (in
patients sensitive to
aspirin).
> Patients on long-term
therapy should have
periodic blood counts.
Hct and Hgb, and renal
function tests.
>Mefenamic acid should
be discontinued
promptly if diarrhea,
dark stool,
hematemesis,
ecchymoses, epistaxis,
or rash occur and
should not be used
thereafter. Advise
patients to report these
signs to the physician.
> Advise patient to
notify physician if
persistent GI discomfort,
sore throat, fever, or
malaise occurs.
Ferrous Sulfate Elevate serum iron > Iron deficiency Contraindicated in patients CNS: coma and death > Give drug with meals
D: 1 tab OD concentration, which > Iron Supplement with hemosiderosis primary with overdose (avoiding milk, eggs,
helps to form Hgb or hemochromatosis, hemolytic coffee and tea) if GI
Drug Class: trapped in aneuria (unless patient also GI: GI upset, anorexia, discomfort is severe,
Iron Preparation reticuloendothelial cells has IDA), peptic ulceration, nausea and vomiting, slowly increase to build
for storage and ulcerative colitis or regional constipation up tolerance
Brand names: eventual conversion to enteritic and in those > Warn patient that
Apo-FeSO4 usable form of iron receiving repeated blood stool may be dark or
Feosol transfusion green
Fer-Gen-Sol > Arrane for periodic
Fer-In-Sol monitoring of Hct and
Hgb levels
> Report severe GI
upset, lethargy, rapid
respirations,
constipation
Cephalexine HCl Bactericidal: Inhibits > Respiratory tract Contraindicated in patients GI: Nausea, vomiting, > Ask patient about post
(Cephalexine synthesis of bacterial infections caused by hypersensitive to diarrhea, anorexia, reaction to
Monohydrae) cell wall, causing cell Streptococcus cephalosporins or penicillins abdominal pain, cephalosporins or
D: 1 tab OD death Pneumoniae flatulence, penicillin therapy before
> Skin and skin Caution: renal failure, pseudomembranous giving 1st dose
Drug Class: structure infections lactation, pregnancy colitis > Obtain specimen for
Antibiotic (Staphylococcus and culture and sensivity
Cephalosporin streptococcus) Hematologic: Bone tests before giving 1st
(first generation) > Otitis Media marrow depression dose. Therapy may
> Bone infections begin while awaiting
Brand names: > GU infections Hypersensitivity: Ranging results.
Apo-Cephalex from rash to fever to > Take drug with food
Keflex anaphylaxis > Complete full course
Novo-Lexin of drug even if feel
Other: Superinfections better
> Report: severe
diarrhea with blood,
rash/ hives, DOB,
unusual tiredness,
fatigue, unusual
bleeding/ bruising
Amoxicillin Trihydrate Bactericidal: Inhibits > Infections due to Contraindicated with GI: glossitis, stomatitis, > Give in oral
500 mg/cap synthesis of bacterial susceptible strains of allergies to penicillins, gastritis, sore mouth, preparations only, not
D: q8 for 7 days cell wall, causing cell Haemophillus influenza, cephalosporins or other nausea, vomiting, affected by food
death Escherichia Coli allergens diarrhea, abdominal pain > Take full course of
Drug Class: > Helicobacter pylori therapy
Antibiotic (penicillin infection in combination Caution: renal disorders, Hypersensitivity: rash, > Report: unusual
– ampicillin type) with other agents lactation fever, wheezing, bleeding/ bruising, sore
> Chlamydia anaphylaxis throat, fever, rash,
Brand names: Trachomatis in hives, severe diarrhea,
Amoxil pregnancy Other: Superinfections DOB
Apo- Amoxi
Dispermox
Novamoxin
Nu-Amoxi
Trimox
Methylergonovine A partial agonist or > Routine management Contraindicated with CNS: Dizziness, headache > Monitor postpartum
Maleate antagonist at alpha after delivery of the allergy to women for BP changes
125 mg/tab receptors; as a result, it placenta methylergonovine, CV: Transient hypertension and amount and
D: q8 for 3 days increases the strength, > Treatment of postpartum hypertension, toxaemia, character of vaginal
duration, and frequency of atony and hemorrhage, lactation, pregnancy GI: Nausea bleeding
Drug Class: uterine contractions subinvolution of uterus > Drug should not be
Oxytoxic > Uterine stimulation Caution: sepsis, needed for longer than
during the second stage of obliterative vascular one week
Brand names: labor following the delivery disease, hepatic or renal > Discontinue if signs of
Methergine of the anterior shoulder, impairment toxicity occurs
under strict medical > Report: DOB,
supervison headache, numb/ cold
extremities, severe
abdominal cramping
Metronidazole Bactericidal: Inhibits DNA > Acute infection with Contraindicated with CNS: Headache, > Take full course of
500 mg/tab synthesis in specific susceptible anaerobic hypersensitivity to dizziness, ataxia drug therapy, take drug
D: q8 for 7 days (obligate) anaerobes, bacteria metronidazole, pregnancy with food if GI upset
causing cell death; > Acute intestinal GI: unpleasant metallic occurs
Drug Class: antiprotozoal – amebiasis Caution: CNS diseases, taste, anorexia, nausea, > Don’t drink alcohol
Antibiotic trichomonacidal, amebicidal > Amebic liver abscess hepatic disease, vomiting, diarrhea (beverages containg
Antibacterial > Trichomoniasis candidiasis, blood alcohol; cough syrup),
Amebicide > Preoperative, dyscrasias, lactation GU: darkening of the urine severe reactions my
Antiprotozoal intraoperative, post- occur
operative prophylaxis for > Urine may be darker in
Brand names: patients undergoing color
Apo-metronidazole colorectal surgery > Report: svere GI upset,
Flagyl > Prophylaxis for patients dizziness, unusual
MetroGel undergoing gynaecologic, fatigue/ weakness, fever,
NidaGel abdominal surgery, hepatic chills
Noritate encephalopathy, antibiotic
Protostat associated
pseudomembranous colitis
Senna Concentrate The laxative effect is due to Short term relief of Contraindicated in px with Excessive bowel activity, o Between-meal doses
D: HS for 2 weeks the action of sennosides constipation; to prevent peptic ulceration, regional perianal irritation, are preferable, butdrug
and their active metabolite, straining; to evacuate the enteritis, ulcerative colitis, abdominal cramps, can be given with some
Drug Class: rhein anthrone, in the colon. bowel for diagnostic hemosiderosis, primary weakness, dizziness, foods, although
Stimulant laxative The laxative effect is procedures; to remove hemochromatosis or cathartic dependence absorption may be
realized by inhibition of ingested poisons from the haemolytic anemia and in decreased.
Brand Name: water and electrolyte lower GI; as adjunct in those receiving repeated o Enteric-coated
Black-Draught, Ex- absorption from the large anthelmintic therapy blood transfusion products reduce GI upset
lax,Senna-Gen, intestine, which increases but also reduce amount
Senokot the volume and pressure of of iron absorbed.
the intestinal contents. This o Check for constipation,
will stimulate the colon record color and amount
motility resulting in of stools
propulsive contractions o Tell patient to take
tablets with juice
(preferably orange juice)
or water, but not with
milk or antacids.
 DISCHARGE PLANNING

Discharge Planning is a process of preparing a client to leave one level of care for another

DISCHARGE CONSIDERATION:

Starts from the moment patient is admitted to the hospital, where length of stays are considerably shortened.

INVOLVES THE FOLLOWING:

• Ongoing assessment to obtain comprehensive information about the clients ongoing needs
• current health status; prognosis; surgery
• neighbors & friends; community health care & facilities
• stairways; bathroom/ hallways/ floorings; lightings; ambulatory devices
• ambulating; meal preparation; transportation
• wound care assistance, ostomies; tubes; IV medications
• equipment; supplies; medications; special foods required

MANAGEMENT & NURSING RESPONSIBILITIES:

Pre-eclampsia occurs only in the presence of a placenta. The management of pre-eclampsia is complicated
by the presence of the fetus. The only definitive therapy for preeclampsia is delivery. After birth, most women will
stabilize within 48 hours. However, because of the risk of eclampsia during the first 24 to 48 hours, careful monitoring
of vital signs, level of consciousness, and DTRs and laboratory assessments are continued.

Nursing Responsibilities such as:

• Instructions of care
• Health teachings
• Advices on follow up, schedules of examination
• Referrals

Either in written form or verbally depending on clients or family members level of education & maturity.

Discharge teaching should begin during the perinatal period, and continue throughout the intrapartum and
postpartum period. The main tasks of the caregiver who attends the postpartum period is to measure and record blood
pressure after delivery, to swiftly identify symptoms that could be indicative of preeclampsia (headache, visual
disturbances, epigastric pain), to protect the woman from damage during fits, and to arrange transport to a hospital or
referral centre in case of a serious rise of blood pressure combined with these symptoms.

Attention should also be given to signs of emotional and physical fatigue and other problems that might arise
from them.

Community health nurses have the opportunity to have ongoing assessments as well as caregivers in their
environment. They can provide support and resources as needed.

DISCHARGE GOALS:

• Hemodynamically stable, free-of-seizure activity

• Condition, prognosis, therapeutic regimen understood
• Participating in care with plan in place for home monitoring/management

DISCHARGE SUMMARY OF PATIENT:

• Age: 31
• G5P4
• BP: 180/100
• HR: 83
 • RR: 22
• Temp: 36.8 C
• Pale palpebral conjuctiva, anicteric sclera
• Supple neck, no clads
• Symmetrical chest expansion
• Clear breath sounds
• Globular abdomen with abdominal girth of 93.98cm
• (+) bipedal edema

Upon admission, the patient was placed on NPO temporarily and was hooked to IVF. Vital signs were
monitored. Laboratories were done. Patient underwent NSD. Patient tolerated the procedure well and had routine
post-op care. Patient eventually transferred to ward and eventually cleared for discharged.

DISCHARGE INSTRUCTIONS:
M - MEDICATION
E - EXERCISE/ ENVIRONMENT
T - TREATMENT
H - HYGIENE/ HEALTH TEACHINGS
O - OUT-PATIENT FOLLOW-UPS
D - DIET
S - SPIRITUAL
MEDICATION REGIMEN

1. Explain medicines administration procedure (if any per Rx)

2. Uses, action of medicine, schedule & cycle, intervention to side effects
3. Alternative therapeutic medicines

Recognizing that there are finite limits to the amount of money and health care providers available, desirable
outcomes often compete for the resources.

High blood pressure and protein in the urine resolve after delivery, usually within a few days. Severe
hypertension should be treated, and some women will require a high blood pressure medication after being discharged
from the hospital. This can be discontinued when the blood pressure returns to normal levels, usually within six weeks.

Blood pressure that continues to be elevated beyond 12 weeks after delivery is unlikely to be related to
preeclampsia and may require long-term treatment.

Reinforce importance of medication compliance to patient and her relatives; its time, frequency, duration
dosage and route.

Advice to report unusual manifestations and side effects of drugs to physician.

Monitor and evaluate effectiveness of medication regimen.

MEDICATION DOSAGE

Mefenamic Acid 1 tab, q6 for pain

500 mg/cap
Ferrous Sulfate 1 tab OD
Cephalexine HCl 1 tab OD
(Cephalexine Monohydrae)
Amoxicillin Trihydrate 1 tab, q8 for 7 days
500 mg/cap
Methylergonovine Maleate 1 tab, q8 for 3 days
125 mg/tab
Methergine Metronidazole 1 tab, q8 for 7 days
500 mg/tab
Senna Concentrate 1 tab, HS for 2 weeks
EXERCISE & ENVIRONMENT

Incorporating regimen to ADL such as:

1. Breathing
2. Walking
3. Calisthenics
4. Reading & other
5. Mental exercises
6. Relaxation

• After delivery, the mother needs time to rest, sleep, and regain her strength.
• After 3 weeks, the uterine lining is normally completely healed and a new endometrium regenerated. At this
point, most normal activities can be resumed, although strenuous physical activity is usually restricted until
after 6 weeks.
• Prolonged bedrest is neither necessary nor desirable. There are a few cautionary notes:
 While she may be up walking, strenuous physical activity will
increase her bleeding and is not a good idea.
 The first time she gets up, someone should be with her to
assist in getting her back down if she feels light-headed.
• Encourage the patient to do some exercise every morning such as a simple walking.
• Provide environment within normal room and body temperature.
• Maintain safe environment.
• Institute seizure precaution.
• Teach patient to perform passive range of motion exercises on patient’s extremities.
• Education about abdominal muscle tone and exercises is explained.

TREATMENT

• Management of adverse effects of medicines

 Knowledgeability of drugs
• Alternative therapeutic medicines
 Nursing care process and procedure, or referral to seek community health services, or to the
hospital.

Maternal temperature should be periodically assessed. Any persistent fever (>100.4 twice over at least 6
hours) indicates the possibility of infection and should be investigated.

Blood pressure should also be checked several times during the first day and periodically thereafter.
Abnormally high blood pressure can indicate late-onset pre-eclampsia. Low blood pressure may indicate hypovolemia.

HYGIENE AND HEALTH TEACHING

1. Refers to client’s ability

a. dressing up
b. eat
c. toilet activity
d. bathing (tub, shower, sponge)
2. Refers to ambulating (with or without aids)
3. Refers to transferring (assistance/ aide)
a. from bed to chair
b. in and out of bath
c. in and out of car
4. Refers to meal preparation
5. Refers to Transportation
6. Refers to shopping
 Encourage and explain the importance of breast feeding to the client. Breastfeeding especially the first milk,
colostrum, can reduce postpartum bleeding/hemorrhage in the mother, and to pass immunities and other benefits to
the baby.

Advice client to let her child expose to mild sunlight in order to balance and avoid excess bilirubin in the
blood.

Mother and her support person are informed of abnormal signs or symptoms to watch for in the first several
days following discharge and given written instructions on how to receive assistance if questions or emergencies arise.

It is important to establish bladder function early in the post partum phase. Because bladder distention due to
post partum bladder atony or urethral obstruction is common, encourage the woman to void early and often.

Stress on proper oral and body hygiene.

Provide information to enhance self-care

OUT-PATIENT

1. Appointment schedule for follow-up checks

2. Inform relatives regarding importance of compliance on follow-up check up.
3. Instructions or requirements (if any) on scheduled follow-up
4. Clinic Schedules

DIET (collaborative)

Advice client to eat proper diet. Encourage her to eat more vegetables and frequent intake of liquids. Advise
her to eat food which are rich in protein, iron and vitamin C. Protein helps to repair body tissues, iron provides
formation of Red blood cells and ascorbic acid for helping absorption of iron.

Refer to dietician for dietary instructions.

SPIRITUAL ASPECT

• Belief
• Faith
• Hope
• Verbalization with significant others