Severe Preeclampsia

SEVERE PRE ECLAMPSIA: A CASE STUDY PRESENTATION
I.
INTRODUCTION Pregnancy-induced hypertension is a condition in which vasospasm occurs during
pregnancy. Signs of hypertension, proteinuria, and edema develop. PIH, a condition separate from chronic hypertension tends to occur most frequently in primiparas younger than age 20 years or older than 40 years, women who have had five or more pregnancies, women of color, women with a multiple pregnancy, women with hydramnios and women with underlying disease such as heart disease, diabetes with vessel or renal involvement and essential hypertension. The condition may be associated with poor calcium or magnesium intake. A woman has passed from mild to Severe Preeclampsia when her blood pressure has risen to 160mmHg systolic and 110mmHg diastolic or above on at least two occasions 6 hours apart at bed rest or her diastolic pressure is 30mmHg above the prepregnancy level. Marked proteinuria, 3+ or 4+ on a random urine sample, or more than 5g in a 24 hours sample, and extensive edema are also present. The hypertension, albuminuria and edema of preeclampsia, usually arise 32 weeks into a first pregnancy, and are often accompanied by headache and disruptions of vision. Preeclampsia seems to originate from an implantation abnormality that affects placental blood vessels. The resulting placental ischemia may be severe enough to produce placental infarcts. Complications of hypertension are the third leading cause of pregnancy-related deaths, superseded only by hemorrhage and embolism. Preeclampsia is associated with increased risks of placental abruption, acute renal failure, cerebrovascular and cardiovascular complications, disseminated intravascular coagulation, and maternal death. Pre-eclampsia is a medical condition where hypertension arises in pregnancy in association with significant amounts of protein in the urine. Because pre-eclampsia refers to a set of symptoms rather than any causative factor, it is established that there are many different causes for the syndrome. With the elevation of blood pressure, it is the most visible sign of the disease, it involves generalized damage to the maternal endothelium, kidneys and liver, with the release of vasopressive factors only secondary to the original damage.
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Pre-eclampsia may develop from 20 weeks gestation and its progress differs among patients. And most cases are diagnosed pre-term. Apart from abortion, Caesarean section, or induction of labor, and therefore delivery of the placenta, there is no known cure. And if no interventions where made, iIt could lead up to six weeks post-partum As of 2010, preeclampsia in the Philippines is the 3rd maternal mortality cause. And according to internet sources, out of 86, 241. 6972 estimated population, there are 46,392 mothers who were or are affected with preeclampsia. And in all over the world, India got the highest incidence rate which is 572, 945 mothers. While on the other hand, Monaco got the lowest which is 17 mothers only. Current trends in preeclampsia and pregnancy induced hypertension is about adding calcium supplement to the mothers nutrition to prevent preganancy induced hypertension and preeclampsia. Pregnancy-induced hypertension and preeclampsia are important causes of maternal and fetal morbidity in the US. Epidemiology. And intervention studies have shown an inverse relationship between calcium intake and the risk of these complications of pregnancy. A small meta-analysis has also supported this association. This report, from McMaster University in Hamilton, Ontario, describes the findings of a new, larger meta-analysis of previously published randomized trials of calcium supplementation during pregnancy. Fourteen randomized trials involving 2,459 women were included in the meta-analysis; most involved calcium supplementation at a dose of 1500-2000 mg/ day. The pooled analysis showed significant reductions in systolic and diastolic blood pressures, by 5.40 and 3.44 mm Hg, respectively, in women who received calcium supplemetation. The odds ratio for preeclampsia in women with calcium supplementation was 0.38 (95% CI 0.22-0.65). Nonsignificant trends toward reductions in adverse outcomes of pregnancy, including preterm delivery, caesarean delivery, intrauterine growth retardation, and intrauterine or neonatal death, were observed in women receiving calcium supplementation. The results of this meta-analysis support the conclusion that calcium supplementation during pregnancy leads to important reductions in blood pressure and the risk of preeclampsia. However, a beneficial effect of calcium on serious morbidity resulting from preeclampsia has
not been established. The possibility that calcium supplementation may merely correct mild preeclampsia, without affecting the risk of more serious complications, cannot be ruled out. The authors conclude that "the current, limited evidence supports a policy of offering calcium supplementation to all pregnant women in whom there is a concern about the development of preeclampsia. Preeclampsia is usually diagnosed late in pregnancy although it can occur earlier. When it is diagnosed, the patient has to be very carefully monitored because of the risk of seizures in the mother or other problems that can affect the baby, often leading to a premature delivery of the baby. When preeclampsia occurs in a patient, it can progress and become severe enough to require delivery of the baby, even if it is premature, in order to save the life of the mother. Usually, delivery of the baby will treat the condition and prevent progress of the disorder. If pre eclampsia does get worse before the delivery of the baby, it can lead to bleeding disorders in addition to seizures, and is thus considered as a potentially life threatening condition. This type of severe hypertension is called Eclampsia. Objectives of the Study Short- Term Objectives: In completing the study, the nurse researcher shall have: 1. Explained the anatomy and physiology of the Circulatory system. 2. Identify the factors that cause Severe Pre-Eclampsia. 3. Describe this disease condition. 4. Describe the clinical symptoms of this kind of disease. 5. Identified the diagnostic tools use for Severe Pre-Eclampsia. 6. Familiarized the procedure needed for the correction of Severe Pre-Eclampsia. 7. Formulated nursing care plan related to the potential and existing problems effective for the improvement of the patients condition.
Long- Term Objectives: 1. Develop plan of care for the client who Severe Pre-Eclampsia. 2. Provided documentation of the case that will serve as a reading source of information for the other nurses on matter related to this case.
II.
NURSING HISTORY a. BIOGRAPHIC DATA Mrs. JC (a pseudo name given by the student nurses) currently lives on the city of San Fernando. She is 37 years old and was born on October 15, 1975. She is married with 4 male children residing with them. She is a native Capampangan. She is currently just a plain housewife. She speaks Kapampangan and Tagalog. She and her family are Roman Catholics. She was admitted to JBL with a chief complain of dizziness, elevated blood pressure with sudden abdominal cramps. (01/29/13, 4:30pm). b. PAST MEDICAL HISTORY Mrs. JC was completely immunized before her first birthday. According to her, she never had a chicken pox or any childhood diseases. She was never admitted to hospital before. Even the first 4 pregnancies she had, she never went to hospital. She had a miscarriage on her 4th pregnancy. According to her, she never had any difficulties on that miscarriage. She did not felt any abnormalities during that pregnancy nor any accidents. The only physical complaint she uttered was her abdominal cramps which according to her was quite common to their family. c. HISTORY OF PRESENT ILLNESS January 29, 2013, 4:30 pm, Mrs. JC felt sudden dizziness and abdominal cramps while doing her usual day to day routine. Her husband took her to the nearby clinic in their residence but transferred to JBL right away due to abnormal elevation of her blood pressure reaching the 200/110 mmHg level. She is in her 38 weeks of gestation and starting to labor.
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LIFESTYLE Mrs. JC usually wakes up around 5:30 in the morning. She usually drink coffee
for her breakfast. She prepares her children to school- cook their breakfast and other stuffs. She help her husband too in preparing for work and usually went to their destination around 7:00 in the morning with their children. During the day, she just play bingo with her neighborhood until afternoon. She do manicure and pedicure service as her part-time job. Before, they have their own sari sari store but they stopped it due to financial difficulties. According to her, their usual menu includes fish, vegetables and meat. They are not fond in eating preserved foods as well as meat also. Soft drinks are something she likes to drink every day. She consumed around 2-3 bottles of it every day. She does not smoke ever since but has a sedentary lifestyle in general. During evening they just usually watch televisions with her family and go to bed usually at 10:00 in the evening.
E. FAMILY HISTORY OF ILLNESS
Legends:
According to the patient, her family has no history of any serious illnesses. Her parents died at old age (her father at 76 years old and mother at 82 years old). Her husbands parents also died at old age. She does not remember her parents having any diseases at all. The only thing she remembered is that her father is a smoker. They are eight siblings in their family and she is the 3rd among them. She, together with her mother, oldest sister and her younger sister experience abdominal cramping which is for her is somewhat normal to them. According to her, she already consulted a physician regarding this, had an UTZ and there is nothing they found out. Last 2011, she had a miscarriage on her 3 month child supposedly. According to her, she cannot remember a thing that may contributed to the miscarriage. Well, except for the fact that she never delivered her babies in a hospital or clinic. Her newly born child is the first one she delivered in a hospital. She usually deliver her babies from a hilot only. Her family relies on herbolaryos in their place for the treatment of their diseases.
Admitting Assessment and Diagnosis January 29, 2013 at exactly 4:30 in the afternoon SKIN: (-) rash HEAD- EENT: pp1-Ar LYMPHNODES: (-) CLAD CHEST AND LUNGS: SCF CBS Cardiovascular AP NRRR (-) murmur ABDOMEN: FH- 30 FHT-140 IE- CX 8cm dilated, fully effaced (+) BOW, Vx, ST-2 ADMITTING IMPRESSION: G5P3 (3013) PU 38 6/7 wk AOG vx, 1L PE Severe ADMISSION DIAGNOSIS: G5P3 (3013) PU 38 6/7 wk AOG vx, 1L PE Severe
OTHER DIAGNOSIS: Severe Pre Eclampsia FINAL DIAGNOSIS: G5P4 (4014) PU Delivered to a live term boy, cephalic AS, 8,9, AOG via NSD PE Severe HEAD: N NECK: N EYES: N EARS: N NOSE: N BREAST: N- not tender, symmetrical ARMS: N LEGS: N BACK: N PADS: 2 per day, soaked, red First Day (February 5, 2013) a. General Survey At 9:00 am, physical assessment was done during the actual nurse-patient interaction. She was lying on bed, conscious and coherent with an ongoing D5LRS 1L X 30-31 gtts/min infusing well on his left hand. The client has a large stature body. The client is observed to be kempt and well-groomed. The patient is observed to be quite but cooperative. b. Vitals Signs Blood Pressure 110/80 mmHg Pulse rate 78 bpm Respiratory rate 20 cpm
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Temperature 37 C
c. IPPA (Cephalocaudal) SKIN Upon inspection, the skin was observed to have a fair complexion, with uniform pigmentation. Upon palpation, the clients skin feels smooth and warm. It is relatively dry, without excessive perspiration or red, flaky areas. Slight edema has been observed on her extremities.. HEAD Skull size was normocephalic. Skull and face were symmetrical with an equal distribution of hair. Hair was black in color with fair amount of white and gray strands, short, dry, and fine. There was no dandruff or infestation present. No lesions, lacerations, tenderness, masses and depressions noted.
FACE Face portrayed emotions with symmetrical movements. No masses or involuntary movement. The face was round, with no edema, lesions, discolorations present. EYES Upon inspection, the clients eye is non-edematous, without scaling or lesions on eyelids. Eyelids completely cover the corneas when closed and its color is the same as surrounding skin color. Eyelashes are evenly distributed and curved outward. Eyebrows are of equal size, color, and distribution. Conjunctiva of both eyes is pale. Pupils are equal and respond to light spontaneously. Lacrimal structures are free from exudate, swelling, and excessive tearing. Eyes are properly aligned. Upon palpation, eyelids show no evidence of swelling or tenderness.
EARS Ears were symmetrical with same size bilaterally and color consistent with face. Pinnas were free from lesions, masses, swelling, redness, tenderness, and discharges and were in line with the eyes. External canals were clear with no cerumen seen. No inflammation, masses, discharges and foreign bodies noted. Gross hearing acuity was good. No pain on the mastoid process was reported upon palpation.
NOSE The nose was symmetrical with no deformities, skin lesions, masses present. Nasal septum is intact and in midline. No nasal flaring was observed. No discharges were present. No tenderness in his sinuses upon palpation.
MOUTH
Mouth was proportional and symmetrical. Lips were rust colored and were dry with no presence of ulcerations, sores or lesions. Teeth were yellowish in color with some dental caries noted. Right upper first premolar tooth was absent. Tongue was in central position and moves freely with no swelling or ulcerations observed. Gag reflex was present as evidenced by patient swallowing. Tonsils were not inflamed. Halitosis was not noted.
NECK
Neck was symmetrical with no masses or swelling noted. No jugular vein distention was noted. Range of motion was normal and moves easily without discomfort upon rotation, flexion, extension and hyperextension.
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Thyroid was not enlarged has no nodules, masses, and irregularities upon palpation. Trachea is symmetrical and in midline without deviation. CHEST and LUNGS
No thorax deformity observed. Respiratory rate was 20 cycles per minute with regular breathing pattern. Symmetrical chest expansion was observed during respiration. No use of accessory muscles during breathing observed. Chest wall was intact; no tenderness and masses noted. Uniform temperature also noted. No adventitious breath sounds heard upon auscultation. No cough present. No dyspnea, hemoptysis, hiccups noted. HEART
Apical heart beat was present upon auscultation with a point of maximal impulse at the 5th intercostal space left midclavicular line; with cardiac rate of 78 beats per minute with a regular rhythm. No abnormal beats, palpitations, thrills or murmurs present upon auscultation.
ABDOMEN
Abdomen was slightly enlarged and globular when patient was in supine position. Pulsations were not visible. The abdomen had hypoactive bowel sounds of two bowel sounds per minute.
BACK & EXTREMITIES
Symmetrical shoulder movement observed during respiration. Spine was located at the midline with no discrepancies noted. Shoulders, arms, elbows and forearms were free from nodules, deformities and atrophy. Range of motion was not limited. Neither pallor nor bone enlargements were noted upon inspection of the upper extremities. Upper and lower extremities were slightly edematous. Radial and brachial pulses were
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present. Hip joint and thighs were symmetrical with no deformities present.. No inflammation noted in the lower extremities. Range of motion was active and not limited.
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IV.
DIAGNOSTIC AND LABORATORY PROCEDURES HEMATOLOGY Diagnostic/ Laboratory Procedures Indications or purpose Date Ordered Date Results were released It is an important screening test that includes RBC count, hemoglobin, hematocrit, RBC induces, WBC count, with or without differential count and platelet count Normal Values Results Analysis and Interpretation of results
Complete Blood Count (CBC) or Hematology Test
Blood Typing
The process of identifying an individual's blood group by serologic testing of a sample of blood.
Jan. 29, 2013
O+
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Hemoglobin
Hemoglobin is the main component of a red blood cell. Each RBC contains 250 million molecules of Hb. Therefore, Hb concentration correlates closely with the RBC count. HB level is a good indicator of anemia. Jan. 29, 2013 F: 115-155g/L 126g/L Hemoglobin count is within the normal range.
Hematocrit
Routine for screening of CBC. Diagnosis suspected anemia and monitors treatment in blood loss. It is the percentage of the volume of a blood sample
F: 0.38- 0.48
.37
Hematocirt level is below the normal range which may indicate decrease in plasma level and/or increase in the blood concentration.
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occupied by cells. WBC A WBC count can be useful in diagnosing infection and inflammation 5-10x 10g/L 10.7g/L WBC count is within the normal level which is an indicator of nonexistence of an inflammation or infection. Neutrophils This respond more rapidly during inflammatory and tissue damage. May indicate bacterial infection and also may be raised in acute viral infections. Lymphocytes A white blood cell formed in lymphatic tissue throughout the body (e.g., lymph nodes,
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0.45- 0.65
.75g/L
Neutrophils count is above the normal level which is an indicator of an existence of an inflammation.
0.20-0.35
.25
Lymphocytes count is within the normal range.
spleen, thymus, tonsils, Peyer patches) from precursor cells originating in bone marrow and in normal adults making up approximately 22 28% of the total number of leukocytes in the circulating blood. They plays a major role in immune system response. Platelet This was order for the patient in order to measures the 150-400x109/L 231 Platelet count is within the normal range.
number of platelet per mm3 of blood. -assess the severity

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of thrombocytopenia, which can result in spontaneous bleeding, as wll as thrombocytosis Nursing Responsibilities Explain to the client that this test detects anemia and other abnormal conditions of the blood. This test also indicates if the individual has infection. Inform the client that she needs not restrict food or fluids before the test. Maintain aseptic technique when performing this procedure.
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URINALYSIS Diagnostic/ Laboratory Procedures Color This was order for the patient in order to screen for renal Transparency or urinary tract diseases and to determine metabolic or systemic disease Albumin related to renal disorder. negative +2 Jan. 29, 2013 Clear Slightly turbid Slightly turbid urine means that there is protein traced in the urine. Albumin is increased which signifies protenuria. Specific gravity 1.001-1.025 1.020 Specific gravity is within the normal range. pH 5.5-6.5 acidic Urine is has been detected to be acidic Pus Cells 0-1 hpf 8.10 hpf Pus cells level is increased which indicates
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Indications or purpose
Date Ordered Date Results were released
Normal Values
Results
Analysis and Interpretation of results
Pale yellow to deep amber
Yellow
Urine is in normal color.
inflammation or infection in the patient. Epithelial Cells Few few Epithelial cells are within the normal range.
Nursing Responsibilities: Before Check the doctors order. Inform the patient that urine specimen is needed. Explain to the patient the procedure and its significance. Explain to the patient how the procedure is done. Fill up request form properly. Provide a clean container for collection of urine.
During: Instruct to collect a clean catch, mid-stream urine. Send the specimen to the laboratory properly labeled together with laboratory slip.
After: Chart time of collection of urine. Attach results to the chart as soon as they are available.
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V.
THE PATIENT AND HIS ILLNESS
A. Anatomy and Physiology
CARDIOVASCULAR SYSTEM THE HEART
The human heart, through rhythmic contraction, provides the pressure necessary to propel blood through the body. Blood flow is essential to deliver nutrients to the tissues of the body and to transport metabolic wastes, including heat, to removal sites. The presence of an arterial pulse caused by the beating of the heart is appropriately designated as a vital sign. The heart weighs about 300 g and is located within the mediastinum, it is cone-shaped and tilted forward and to the left. Because of its orientation during fetal development, the apex of the heart (tip of the cone) is at its bottom and lies left of the midline. The base is at the top, where the great vessels enter the heart and lies posterior to the sternum. The heart consists of four
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chambers: two smaller atria at the top (the base) of the heart and two larger ventricles at the apex. A band of fibrous tissue separates the atria from the ventricles and seats the four cardiac valves. A muscular septum separates the right from the left atrium and the right from the left ventricle. Functionally, the heart is actually two pumps working simultaneously. The right atrium and right ventricle generate the pressure to propel the oxygen-poor blood through the pulmonic circulation; the left atrium and left ventricle propel oxygen-rich blood to the remainder of the body through the systemic circulation. At rest, each side of the heart pumps approximately 5000 ml of blood per minute (cardiac output). This is accomplished by a contraction frequency (heart rate) of 72 beats/min, with each contraction ejecting a volume of 70 lm (stroke volume) into the arterial system. Cardiac output can increase five-fold during exercise as a result of increases in both heart rate and stroke volume. STRUCTURES OF THE HEART LAYERS OF THE HEART
The heart consists of three distinct layers of tissue: endocardium, myocardium and epicardium. The endocardium (innermost layer) consists of thin endothelial tissue lining the inner cahmbers and the heart valves. The myocardium (middle layer) consists of striated muscle fibers froming interlaced bundles and is the actual contracting muscle of the heart. The epicardium or visceral pericardium covers the outer surface of the heart. It closely adheres to the heart and to the first several centimeters of the pulmonary artery and aorta. The visceral pericardium is encased by the parietal pericardium, a tough, loose-fitting, fibrous outer membrane that is attached anteriorly to the lower half of the sternum, posteriorly to the thoracic vertebrae and inferiorly to the diaphragm. Between the visceral pericardium and the parietal pericardium is the pericardial space, which holds 5 to 20 ml of pericardial fluid. This fluid lubricates the pericardial surfaces as they slide over each other when the heart beats. CHAMBERS OF THE HEART
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The heart consists of four chambers: two upper collecting chambers (atria) and two lower pumping chambers (ventricles). A muscular wall (septum) separates the chambers of the right side from those of the left side. The right atrium receives deoxygenated blood from the body. The blood moves to the right ventricle, which pumps it to the lungs against low resistance. The left atrium receives oxygenated blood from the lungs. The blood flows into the left ventricle (the hearts largest, most muscular chamber), which pumps it against high resistance into the systemic circulation. CARDIAC VALVES
The cardiac valves are delicate, flexible structures that consist of endothelium covered by fibrous tissue. They permit only unidirectional blood flow through the heart. The valves open and close passively, determined by pressure gradients between the cardiac chambers. Leaky valves that do not seal when closed are called regurgitant or insufficient. Stiff valves that cannot open completely are called stenotic. Cardiac valves are of two types: (1) atrioventricular (AV) and (2) semilunar. Atrioventricular valves lie between the atria and ventricles. The tricuspid valve, on the right side, is composed of three leaflets. The mitral (bicuspid) valve, on the left is composed of two. Attached to the edges of the AV valves are strong, fibrous filaments called chordae tendineae, which arise from papillary muscles on the ventricular walls. The papillary muscles and chordae tendineae work together to prevent the AV valves from bulging back into the atria during ventricular contraction. The semilunar valves consist of three cup-like cusps that open during ventricular contraction and close to prevent backflow of blood into the ventricles during relaxation. Unlike the AV valves, the semilunar valves open during ventricular contraction. The pulmonic semilunar valve (right ventricle to pulmonary artery) and the aortic semilunar valve (left ventricle to aorta) do not have papillary muscles. CARDIAC BLOOD SUPPLY
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The heart muscle requires a rich oxygen supply to meet its own metabolic needs. The coronary arteries (right and left) branch off the aorta just above the aortic valve, encircle the heart and penetrate the myocardium. Coronary vessel distribution can vary greatly. Contraction of the muscle of the left ventricle generates enough extravascular pressure to occlude the coronary blood vessels and prevent blood flow to the muscle of the heart during ventricular systole. Thus 75 % of the coronary artery blood flow occurs during diastole, when the heart is relaxed and resistance is low. For adequate blood flow through the coronary arteries, the diastolic blood pressure must be atleast 60 mmHg. Coronary blood flow increases with increased heart work load. The coronary veins return blood from most of the myocardium to the coronary sinus of the right atrium. Some areas, particularly on the right side of the heart, drain directly into the cardiac chambers. CORONARY ARTERIES
The heart, just like all other muscles in the body, needs its own supply of oxygen in order to function properly. Although its chambers contain blood, the heart receives no nourishment from the blood inside the chambers. The heart gets its blood supply from the coronary arteries. The two major coronary arteries, the right coronary artery and the left main coronary artery, branch off the aorta, and then divide into many smaller arteries that lie in the heart muscle and feed the heart. FUNCTIONS OF THE HEART ELECTROPHYSIOLOGIC PROPERTIES
The electrophysiologic properties of cardiac muscle regulate the heart rate and rhythm. These properties include excitability, automaticity, contractility, refractoriness and conductivity. EXCITABILITY
The ability of cardiac muscle cells to depolarize in response to a stimulus, excitability, is influenced by hormones, electrolytes, nutrition, oxygen supply, medications, infection and autonomic nerve activity.
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In myocardial cell, as in other types of muscle and neurons, differences in intracellular and extracellular ion concentrations create electrical and concentration gradients for ionic movement across the semipermeable cell membrane. At rest, the inside of a myocardial cell is more negative than the outside. This resting membrane potential results primarily from the differences in concentrations of potassium and sodium. Although both ions are present on either side of the cell membrane, potassium has a greater extracellular concentration. Selective channels can increase membrane permeability for specific ions, allowing the ion to move down the electrochemical gradient and to alter the resting membrane potential. When the cardiac cell is stimulated to a certain threshold, a sequence of ion permeability changes cause a dramatic change in the transmembrane potential, this is known as action potential. The action potential consists of depolarization and repolarization phases. The electrocardiogram (ECG) reflects currents generated during the depolarization and repolarization of regions of the heart. Depolarization is caused by an increase in cell membrane permeability to sodium. The cell returns to its resting (relaxed) state during repolarization. Sodium permeability drops sharply and potassium permeability increases, returning the membrane to the negative resting potential. In the process of depolarization and repolarization, small amounts of sodium leak into the cell and potassium leaks outward. The cell compensates for this by actively pumping sodium back out and potassium inward. Other ions, such as calcium and chloride, also play a role in the action potential and the contraction it causes. For the heart, calcium is especially important because it initiates contraction. During depolarization, myocardial cell membrane permeability to calcium increases and calcium moves into the cell. This inward calcium triggers the release of more calcium stored in the sarcoplasmic reticulum. As the intracellular concentration of calcium increases, calcium reacts with contractile elements and myocardial muscle fibers contract. AUTOMATICITY (RHYTHMICITY)
The ability of cardiac pacemaker cells to initiate an impulse spontaneously and repetitively, without external neurohormonal control, is known as automaticity or rhythmicity. Given the
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proper conditions, the heart can continue to beat outside the body. In contrast, skeletal muscle must be stimulated by a nerve to depolarize and contract. The sinoatrial (SA) node pacemaker cells have the highest rate of automaticity of all cardiac cells. The conduction tissue area with the highest automaticity, or rate of spontaneous depolarization, assumes the role of pacemaker. SA node cell automaticity is due to changes in ionic permeability of the membrane. Even at rest, a decreasing potassium permeability and increasing slow channel permeability. Move the cell membrane potential more positively toward threshold voltage. When threshold is reached, the cell initiates an action potential. Norepinephrine and acetylcholine cause heart rate to increase and decrease, respectively. The rate of spontaneous depolarization can also be affected by other hormones, body temperature, drugs and disease. CONTRACTILITY
The heart muscle is composed of long, narrow cells or fibers. Cardiac muscle fibers, like striated skeletal muscle contain myofibrils, Z bands, sarcomeres, sarcolemmas, sarcoplasm and sarcoplasmic reticulum. Contraction results from the same sliding filament mechanism described for skeletal muscle. The action potential initiates the muscle contraction by releasing calcium through the T-tubules of the cell membrane. The calcium reaches the sarcoplasmic reticulum causing additional calcium release. The intracellular calcium diffuses to myofibrils, where it binds with troponin. When the actin filaments become activated by calcium, the heads of the cross-bridges from the myosin filaments immediately become attracted to the active sites of the actin. Contraction then occurs by power stroke repetition. After contraction, free calcium ions are actively pumped back into the sarcoplasmic reticulum and muscle relaxation begins. One important difference between cardiac and skeletal muscle is that cardiac muscle needs extracellular calcium. All the calcium involved in skeletal muscle comes from the sarcoplasmic reticulum. In cardiac muscle, however, extracellular calcium enters through the T tubules and triggers the release of more calcium from the sarcoplasmic reticulum. Because of this, calcium channel blockers can alter contraction of the heart, but not the contraction of skeletal muscle. REFRACTORINESS
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Refractoriness is the hearts inability to respond to a new stimulus while still in a state of depolarization from an earlier stimulus. Refractoriness develops when the sodium channels of the cardiac cell membrane become inactivated and unexcitable during an action potential. Thus the heart muscle does not respond to restimulation, preventing the possibility of titanic contractions that are seen in skeletal muscle. Refractoriness occurs in two periods. The absolute refractory period occurs during depolarization and the first part of repolarization. During this period, cardiac cells do not respond to any stimuli, however strong. The relative refractory period occurs in the final stages of repolarization; refractoriness diminishes and a stronger-than-normal stimulus can excite the heart muscle to contract. At the end of the refractory period, there is transient hyperexcitability. The sodium channels are rest and the cardiac cells can again conduct action potentials. Normally, the ventricles have an absolute refractory period of 0.25 to 0.3 seconds, which approximates the duration of the action potential. The relative refractory period for the ventricles lasts about 0.05 seconds. The atria have a refractory period of about 0.15 seconds, and they can therefore contract rhythmically much more quickly than the ventricles. The duration of the action potential and the refractory period are not fixed, however; both can shorten as heart rate increases. CONDUCTIVITY
Conductivity is the ability of heart muscle fibers to propagate electrical impulses along and across cell membranes. The heart muscle must conduct the action potential from its origin throughout the heart both rapidly and smoothly so that the atria and ventricles contract as a unit. Intercalated disks join adjacent myocardial cells, allowing the action potential to travel over the entire muscle mass. However, the fibrous band of tissue that separates the atria and ventricles lack intercalated disks. Thus the atria are isolated electrically from the ventricles except for the only normal conduction pathway, the atrioventricular node. The conduction system consists of the following major parts: 1. The Sinoatrial (SA) node, or pacemaker, is located at the junction of the superior vena cava and the right atrium. Under normal circumstances, the SA node initiates electrical
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impulses (heartbeats) approximately 60 to 100 times per minute, but it can adjust its rate. Three internodal and one interatrial tract carry the wave of depolarization through the right atrium to the AV node and to the left atrium, respectively. The sympathetic and parasympathetic nervous systems regulate the SA node. Any myocardial tissue that generates impulses at a higher rate than the SA node can become an abnormal pacemaker. 2. The atrioventricular (AV) node, or AV junction, is located in the lower aspect of the atrial septum. The AV node can be secondary cardiac pacemaker, but it normally receives electrical impulses from the SA node and is the only pathway for conducting impulses from the atria to the ventricles. Within the AV node, the impulse is delayed 0.07 seconds whikle the atria contract. This delay enables atrial contraction to be completed before the ventricles contract. 3. The common bundle of His in the interventricular septum is relatively short, branching into the right and left segments. The right bundle branch (RBB) courses down the right side of the interventricular septum. The left bundle branch (LBB) bifurcates into anterior and posterior fascicles, both of which extend into the left ventricle. The right and left bundle branches terminate in Purkinje fibers. 4. Purkinje fibers are a diffuse network of conducting strands beneath the ventricular endocardium; they rapidly spread the wave of depolarization through the ventricles. Activation of the ventricles begins in the septum and then moves from the apex of the heart upward. Within the ventricular walls, depolarization proceeds from the endocardium to epicardium. Repolarization occurs in each cell and does not involve the conduction system. Repolarization occurs in reverse order, so that the last cells to depolarize are the first to repolarize. The action potentials of Purkinje fibers have the longest duration and their repolarization is occasionally seen as a U wave of the electrocardiogram (ECG).
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B.
Pathophysiology a. Book based i. Schematic Diagram
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ii. Synthesis of the Disease IV. Synthesis of the disease 1. Definition of Severe preeclampsia (book based) Preeclampsia is a condition in which vasospasm occurs during pregnancy in which it leads to an increase in blood pressure. Its concern is about the hypertension that develops as direct result of pregnancy and is characterized by hypertension with proteinuria and edema that develops after 20th week of gestation. 2. Predisposing or precipatory factors Predisposing (Non modifiable) factors Sex Female Age of Pregnancy below 20 y/o - due to their lifestyle Age above 35 y/o- chances of giving birth to babies with genetic defects Primiparas Familial history of Hypertension- higher chances of acquiring
hypertension Familial history of heart disease- higher possibility of acquiring heart disease Multigravida heart disease- the heart might not meet the demand for the heart during pregnancy diabetes- could lead to gestational diabetes and lead to complications like PTL and preeclampsia renal/kidney malfunction- can lead to an increased glomerular filtration rate
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Precipitating Factors Modifiable Diet / Nutrition- poor nutrition can weaken the bodys deffenses Weight(overweight)- are linked to conditions like preeclampsia Lack of Exercise- may increase blood pressure and pulse rate 3. Signs and symptoms with rationale
A.
Hypertension or increased blood pressure- due to an increase in the resistance of blood vessels. This may hinder blood flow in many organ systems in the expectant mother including the liver, kidneys, brain, uterus, and placenta. protein in the urine because of damaged blood vessels that may lead to kidney failure Edema (swelling) due to the large increase in body fluids, or because of the growing uterus pressing on the pelvic veins and thus slightly obstructing blood flow.
B. C.
D. E. F.
Blurring of vision - caused by an increase in blood pressure during pregnancy Continuous headache- may signal cerebral edema Nausea and vomiting could be because of the combination of the many physical changes taking place in your body such as the higher levels of hormones
G.
changes in liver or kidney function tests- due to protein in the urine
4. Health promotion and preventive aspect of the disease Consult the physician regularly- to prevent further complications Place patient in a lateral recumbent position- to reduce pressure in the vena cava Elevate lower extremities- to facilitate venous return Dangle the feet of the patient at the edge of the bed before letting her stand- to prevent orthostatic hypotension. Provide a low salt and low fat diet to Provide adequate nutrition Advice patient to drink at least 8 glasses of fluid per day- to replace fluid loss Advice patient to add fiber to her diet- to prevent constipation
30
If allowed, advice patient to do gentle stretching exercises of her legs, feet, arms and handto improve circulation and increase muscle tone. Provide emotional support- for the patient to feel better b. Patient Centered
i. schematic diagram
31
PREDISPOSING FACTORS Sex- Female Age > 35 years old Multigravida
PRECIPITATING FACTORS Diet Overweight Lack of exercise Sedentary life style
Cerebral Vasospasm
Vascular Effects
Kidney Effects
Interstitial Effects
Increased Plasma Volume
Headache and Peripheral vasoconstriction
Increase glomeruli infiltration rate and increases permeability of glomeruli membranes
Diffusion of fluid from the blood stream into interstitial tissue
vasoconstriction
Edema
32
Poor organ Perfusion
Increased blood urea nitrogen, uric acid and creatinine
Circulatory Compensation Mechanism
Increased Blood Pressure 200/110 mmHg
Increased urine output and protenuria
33
1. Definition of Severe Preeclampsia
Preeclampsias progress differs among patients. It was diagnosed on the later part of pregnancy wherein the patient manifested hypertension, preinuria and edema on the lower extremities.
2. Predisposing or precipatory factors Predisposing (Non modifiable) factors Sex Female Age Pregnancy 38 years old Multigravida Precipitating Factors Modifiable Diet / Nutrition poor nutrition can weaken the bodys deffenses Weight(overweight)- are linked to conditions like preeclampsia Lack of Exercise/sedentary lifestyle- may increase blood pressure and pulse rate 3. Signs and symptoms with rationale A. Hypertension or increased blood pressure- due to an increase in the resistance of blood vessels. This may hinder blood flow in many organ systems in the expectant mother including the liver, kidneys, brain, uterus, and placenta. B. +2 Proteinuria (protein in the urine) because of damaged blood vessels that may lead to kidney failure C. Edema (swelling) due to the large increase in body fluids, or because of the growing uterus pressing on the pelvic veins and thus slightly obstructing blood flow.
34
4. Health promotion and preventive aspect of the disease Patient Consulted the Physician- to prevent further complications Monitored vital sign esp. the pt.s blood pressure- to determine if there are alterations in the blood pressure Provided complete bed rest- it can help reduce high readings of blood pressure Instructed the pt. to increase oral fluid intake- to replace fluid loss Low salt and low fat diet- to prevent further edema Delivery of the baby- to cure pre-eclampsia
35
VI.
THE PATIENT AND HIS CARE 1. Medical Management a. IVFs, BT, NGT feeding, Nebulizations, TPN, Oxygen Therapy, etc Indications/ Purpose Date ordered, date preformed, date changed or D/C Clients response to treatment Nursing Responsibilities
Medical Management
General Description
D5LRS 1L
5% Dextrose in Lactated Ringers solution is used to supply the patient with glucose in order to sustain nourishment.
Indicated to Patients who are unable to maintain adequate fluid balance and need replacement fluid. To supply nutrients directly into the bloodstream To provide fluid and electrolyte replacement. MgSO4 to lower patients BP and
January 30, 2013
There were no signs and symptoms noted upon administration of fluid such as pain swelling and January 29, 2013 tenderness at the insertion site, patient didnt manifest S/SX of fluid overload.
PNSS 1L + 20 g MgSO4
It contains 0.9 NaCl to provide the patient fluid and electrolyte replacement. It has the same plasma concentration with
36
the blood. MgSO4 relaxes smooth muscles of the uterus through Calcium displacement, thus, decreasing uterine motility. Better to use than sympathomimetics because it has fewer side effects. MgSO4 is also a CNS depressant which prevents convulsions
increase perfusion to the uterus which has a therapeutic effect to the fetus. Prophylaxis for seizures in severe preeclampsia without producing deleterious CNS depression in mother or infant.
Indwelling Foley Catheter
An indwelling, or foley catheter is a thin, flexible
To closely monitor patients urine
The catheter was placed and successfully

37
drainage tube that drains urine when a person is unable to empty his /her bladder independently.. Once inserted, a small balloon inside the catheter is then inflated to anchor the catheter in place. The catheter is attached to a drainage bag , which collects the urine. NURSING RESPONSIBILITIES

output to determine fluid balance between intake and output.
inserted at the pts urethra, intact and patent.
Check for the doctors order for oxygen therapy Acquaint the patient with requirement and need for oxygen therapy. Check the patency of the equipments use in oxygen therapy. Regulate well the oxygen being given to the client.
38
b.
Drugs General Action Indications/ Purpose Date ordered, date preformed, date changed or D/C Clients response to medication with actual side effects The patient did not develop allergy to the drug. -Before administering, make sure patient is not allergic to penicillins or cephalosporins. - Absorption of cefuroxime is enhanced by food. - may be crushed if swallowing is a difficulty -may be dissolved in small amounts of apple, orange or grape juice, even chocolate milk. However, drugs bitter taste is difficult to mask even with food. -High-fat meals increased drug bioavailability -If large doses are given, therapy is prolonged, or patient is at high
39
Generic Name and Brand Name
Nursing Responsibilities
Generic Name: cefuroxime Sodium
Second Generation cephalo sporinsInhibits bacterial Cellwall Synthesis
-Treatment of UTI - Peri-operative Prevention
January 29,2011
Brand Name: Kefox (500mg/cap BID)
Promoting Osmotic instability
risk, monitor patient for signs and symptoms of superinfection -Unlike other second generation cephalosporins, cefuroxime can cross the blood-brain-barrier. Generic Name: Metronidazole AntibioticsMetronidazole is converted to reduction Brand Name: Flagyl (500mg/cap TID) products that interact with DNA to cause destruction of helical DNA structure and strand leading to a protein synthesis inhibition and cell death in susceptible organisms. It is effective against a wide range of organisms including E. histolytica, T. vaginalis, Giardia,
40
-amoebic hepatic abscess -bacterial infection caused by anaerobic microorganisms -to prevent post operative infection in contaminated colorectal surgery -pelvic inflammatory disease
January 29,2011
Dizziness was experience by the patient.
-watch carefully for edema because it may cause sodium retention -Tab: Should be taken with food. Susp: Should be taken on an empty stomach. (Take at least 1 hr before meals.) - metallic taste and dark or red brown urine may occur
anaerobes e.g. Bacterioides sp, Fusobacterium sp, Clostridium sp,Peptococcus sp and Peptostreptococcus sp Generic Name: FESO4 Antianemic, Ironabsorbed from the duodenum and Brand Name: Iron Sulfate (350mg tab OD) upper jejunum by an active mechanism through the mucosal -Prophylaxis and treatment of iron deficiency and irondeficiency anemia. -Dietary supplement for iron. Optimum January 29,2011 Patients stool turned black. -best taken n an empty stomach/ with full glass of water/ orange juice -remind patient that stool may turn black -do not crush or chew
cells where it combines therapeutic with the protein transferrin. responses are usually noted within 2-4 weeks. Generic Name: Mefenamic acid non-steroidal antiinflammatory drug (NSAID)Brand Name: Ponstel (500mg/ exhibits antiinflammatory, -for mild to moderate pain and inflammation January 29,2011 Dizziness was experience by the patient. -should be taken with food - Discontinue drug promptly if diarrhea, dark stools, hematemesis, ecchymoses, epistaxis, or rash occur and do not use again. Contact
41
cap TID)
analgesic, and antipyretic activities in animal models. The mechanism of action of MEFENAMIC ACID, like that of other NSAIDs, is not completely understood but may be related to prostaglandin synthetase inhibition.
physician. -Do not breast feed while taking this drug without consulting physician.
Generic Name: Nifedipine
Antihypertensive, Antihypertensive,
- To lower high blood pressure. This reduces the possibility of having an angina pectoris attack.
January 29,2011
Blood pressure of patient went
-Assess the history of allergies to nifedipine and also pregnancy and lactation
Brand Name: Apo- Nifed (10mg/ tab BID)
Calcium Channel Blockers -inhibits the movement of
from 200/110 -Monitor patients Blood Pressure to 130/80 and cardiac input and output carefully. -Ensure that patient does not chew
42
calcium ions across the membranes of cardiac and arterial muscle cells, inhibition of transmembrane calcium flow results in the depression of impulse formation in specialized cardiac pacemaker cells, in slowing of the velocity of the conduction of the cardiac muscle impulse, in the depression of the of myocardial contractility and in the dilation
or divide sustained-release of tablet
43
of coronary arteries, arterioles. These effects lead to decreased cardiac work, decreased cardiac energy consumption, and increased delivery of oxygen to myocardial cells. Generic Name: Spironolactone Diureticcompetes with aldosterone for Brand Name: Aldazide (25mg/tab BID) receptor sites in the distal renal tubules, increasing sodium chloride and water excretion while conserving potassium and hydrogen ions, may
44
-for essential hypertension
January 29,2011
Patient experienced increased urinary output
-Take with meals or milk; avoid excessive ingestion of food high in potassium or use of salt substitutes -Diuretic effect may be delayed 2-3 days and maximum hypertensive may be delayed 2-3weeks -monitor I and O ratios and daily weight, BP, serum electrolytes (K, Na) and renal function
block the effect of aldosterone on arteriolar smooth muscle as well c. Diet General Description Indications/ Purpose Date ordered, date preformed, date changed or D/C Low salt, low fat diet The average adult intake of salt is 5 to 15 g/day, the therapeutic effect of sodium reduction on blood pressure does not occur until salt intake is reduced below 5g/day. Cholesterol is contained in animal fats and dairy products. Saturated fat occurs To maintain a normal blood To reduce or decrease cholesterol levels For muscle strength For regular functioning of the body For bodys resistance Jan 30, 2013 Clients response and/or reaction to diet At first the client is not use to eat bland
Type of Diet
Educate
client
about his diet Avoid client
food. She had a hard time in modifying her diet. Reinforcement of instruction that he needs to eat low salt and low fat was done. The client complied with the instruction but with not much enthusiasm.
from aspirating by proper positioning
Instruct
to
increase fruit juices and low fat milk in diet for nourishment
Avoid food rich sodium like food,
in
processed
dried food and can good food.

45
predominantly in animal fats and tropical oils. Unsaturated fats predominate in most plant derived fats.
pressure
Read label of
food carefully for the
amount
of
sodium in it. Encourage others
significant
not to prepare food rich in sodium.
Avoid too much fat and using
saturated cooking
animal oil, instead use vegetable oil
d.
Activity General Description Indications/ Purpose Date ordered, date preformed, date changed or D/C Clients response and/or reaction to activity Client obediently follow the activity restrictions
Type of Activity
Bed Rest
The client ordered to stay on bed due to the risk of blood
To conserve strength and energy and to avoid
January 29, 2013
Educate
client her
regarding activity
46
pressure elevation
physical exertion to the client
Assisting client her bathroom
to
privileges Explain the of in
purpose restrictions
activity and position in bed as ordered.
Assist
the
patient to maintain the position.
prescribed
Encourage
the
patient to adhere to ordered activity.
Accomplish
necessary documentation of patients reaction to the ordered activity restrictions.
47
VII.
NURSING MANAGEMENT A. Nursing Care Plans Scientific Explanation Objectives Intervention Rationale To gain pts trust and cooperation To obtain baseline The pts pain scale shall havel reduced To determine presence of abnormality from 6/10 to 4/10. Expected Outcome
Assessment
Nursing Diagnosis
The pt may verbalize:
Acute pain
Pain is a subjective unpleasant
SHORT-TERM:
> Establish rapport
After 3 hrs of nursing interven tions, the pts pain scale will be reduced to 4/10 >Perform a comprehensive assessment of LONG TERM: pain noting its location, After intensity, and To determine precipitating or aggravating factors. The pt shall have demonstrated use of relaxation skills and >Monitor and assess VS >Assess the pts general physical condition
Discomfort In the Lower Abdomen
sensation resulting from stimulation of sensory nerve endings by
Intolerance to some activities
injury, or other harmful factors. Pain is activated when a pts pain threshold is reached. Pain threshold is the point at which
constant pain in the postsurgical site
48
The pt manifested:
a stimulus activates pain receptors to
3 days of nsg interventions,
provocation. >Perform pain assesment everytime each time pain occurs
divers ional activities as indicated for To rule out worsening of underlying condition/ development of complications. individual situation.
Facial grimaces
produce a
feeling of pain. the pt will Pain usually demonstrate use of relaxation skills and divers ional activities as indicated for individual
Sharp stabbing pain that radiates from the incision site with a pain scale of 5/10. Guarding behavior Narrowed focus
accompanies inflammation. It results from the synthesis of
Pain is a subjective Accept clients description of pain experience and cannot be felt by others.
prostaglandins, situation. which are hormones produced during the inflammatory
Timely Instruct client to report pain as soon as it begins interventions are more likely to be successful in alleviating pain
The pt may manifest:
process.
Restlessness Listlessness
Provide quiet environment and
To lessen discomfort felt by
49
Sleep disturbance Reduced interaction with people and environment Panic Worry regarding the duration of pain
calm activities
the client
Provide comfort measure (change of position) Encourage use of relaxation exercise such as deep breathing technique
To provide nonpharmacological pain management To divert pts attention away from the pain sensation
To reduce concern Encourage diversional activities such as socializing with others Review procedures/ expectations and tell client whet
50
of the unknown and associated muscle tension
To reduce fatigue to reduce pain
treatment will hurt Encourage adequate rest periods Administer prescribed meds
51
Assessment
Nursing Diagnosis
Scientific Explanation
Objectives
Intervention
Rationale To gain pts trust and cooperation To obtain baseline To determine
Expected Outcome
The pt may verbalize:
Decreased Cardiac output Inadequate r/t decreased venous return secondary to blood is pumped by the
SHORT-TERM: After 3 hrs of nursing interventions, the pt will display
> Establish rapport >Monitor and assess VS >Assess the pts general physical condition Determine baseline vital signs/hemodyna
The pt shall have displayed hemodynamic stability (blood pressure within closer range)
Palpitations Fatigue Shortness of breath/dyspnea anxiety
severe preeclampsia AEB heart to meet altered BP and edema the metabolic
demands of the hemodynamic body. It stability (blood
presence of abnormality
resulted from a pressure within systemic vaso closer range)
The pt manifested:
constriction in the body caused by
Provides opportunities to track changes The pt shall have demonstrated activities that reduce the workload of the heart (stress
Weight gain Edema Variations in BP reading Restlessness
preeclampsia. Vasoconstricti on is the decrease in the
LONG TERM: After 3 days of nursing interventions, the
mic parameters including peripheral pulses.
diameter of the pt will demonstrate blood vessels which occur in diseases like activities that reduce the workload of the Review signs of impending failure /shock. To prevent hypovolemic shock
management, therapeutic medication regimen

52
The pt may manifest:
pregnancyinduced hypertension.
heart (stress management, therapeutic medication regimen program, balanced activity/ rest plan) Position with HOB flat or keep trunk horizontal while raising legs 20 to 30 degrees (contraindicated in congestive state in which semi-fowlers position is preferred) To increase venous return
program, balanced activity/ rest plan)
Jugular vein distention Cold clammy skin Arrhythmaia crackles Prolonged capillary refill
Decreased blood supply leads to a decrease in venous return, thus there is a relatively smaller amount of blood expelled by the ventricles of the heart.
Promote adequate To maximize sleep rest, by decreasing stimuli, providing quiet environment periods
Maintain patency of invasive
To prevent air embolus and/or
53
intravascular monitoring and infusion lines. Tape connections.
exsanguination.
Avoid activities such as isometric exercises, rectal stimulation, vomiting, and spasmodic coughing. Administer stool softener as indicated.
May stimulate a valsalva response
Encourage pt to to breathe deeply in/out during activities that increase risk for
This prevents exertion of too much workload to the heart.
54
valsalva effect.
Provide psychological support. Maintain calm attitude but admit concerns if questioned by the client.
Honesty can be reassuring when so much activity and worry are apparent to the patient.
Encourage relaxation techniques.
To reduce anxiety
Elevate edematous extremities and avoid restrictive clothing.
To promote comfort
Provide for diet restrictions.
To enhance pts therapeutic regimen
55
Monitor intake and output.
To determine fluid balance
Discuss significant signs and symptoms that need to be reported to the healthcare provider ( e.g. muscle cramps, d/a, dizziness, skin rashes).
May be sign of drug toxicity and/or mineral loss , especially potassium.
Encourage changing positions slowly,
To reduce risk of orthostatic hypotension
56
dangling legs before standing.
Give information about positive signs of improvement such as decreased edema, improved vital signs / circulation). Administer supplemental oxygen as indicated.
To provide encouragement.
Administer due meds.
To increase oxygen available to tissues.
57
Assessment
Nursing Diagnosis
Objectives
Intervention
Rationale To gain pts trust and cooperation To obtain baseline To determine
Expected Outcome
The patient may verbalize: fatigue weakne ss lack of interest in activity The patient manifested: prolong ed hours in a supine / lying position
Activity Intolerance secondary to severe pre eclampsia AEB prolonged hours in a supine / lying position
In severe pre eclampsia the cardiac system can become overwhelmed because the heart is forced to pump against peripheral resistance. Avoiding strenuous and/or unnecessary activities may reduce workload of
SHORT-TERM: After 3 hrs of nursing interventions, the patient will demonstrate a decrease in physiologic signs of intolerance (decrease in BP)
> Establish rapport >Monitor and assess VS >Assess the pts general physical condition
The patient shall have demonstrated a decrease in physiologic signs of intolerance (decrease in BP)
presence of abnormality
The patient shall have reported a measurable increase in activity
Evaluate current LONG TERM: After 3 days of nursing interventions, the patient will report measurable increase in activity limitations / degree of deficit in light of visual status Assess cardiopulmonary response to physical activity, Provides comparative baseline
tolerance.
To note for prgression/ accelerating degree
58
appears weak and restless The patient may manifest: Abnormal heart rate or blood pressure in rsponse to activity
the heart Bed rest, which resulted to activity intolerance, is the best method to aid in the evacuatioevac uation of excess sodium and in the promotion of diuresis that will result to a decrease in BP. When the body is in a recumbent position, sodium tends
tolerance.
including VS, before, during and after activity. Assess emotional/psycho logical factors affecting the current situation
of fatigue
Stress and/or depression may be increasing the effects of an illness, or depression may be the result of being forcec into inactivity
Adjust activities, reduce intensity levels or discontinue activities that cause undeserved physiological changes To prevent overexertion
59
to be excreted at a faster rate than during activity Increase activity/exercise level gradually, teach methods such as stopping for rest during a ten minute walk, sitting down instead of standing to brush hair Plan care with rest periods Provide positive atmosphere while acknowledging difficulty of the situation for the Helps to minimize frustration To reduce fatigue To conserve energy
60
client Assist client To protect pt from injury
To enhance pt Promote comfort measures and provide pain relief ability to participate in activities
Check and regulate IVF
To obtain the desired rate
Give due meds
To treat abnormalities
61
Assessment
Nursing Diagnosis
Objectives
Intervention
Rationale To gain pts trust and cooperation To obtain baseline
Expected Outcome the patients fluid volume shall have stabilized AEB
The patient may verbalize: Shortness of breath orthopnea The patient manifested: pitting edema in lower extremities restlessness The patient may manifest: oliguria dyspnea
Excess fluid volume r/t compromised regulatory mechanism secondary to severe preeclampsia
In PIH, vasospasm occurs in the kidney which increases blood flow resistance. Degenerative changes develop in kidney glomeruli because of back pressure. These degenerative changes result in decreased glomeruli filtration, so
SHORT TERM: After 3 hrs of nursing interventions, the patients fluid volume will stabilize AEB balanced I/O. LONG-TERM: After 3 days of nursing interventions, the patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid
> Establish rapport >Monitor and assess VS
balanced I/O. The patient shall have
>Assess the pts general physical condition To determine presence of abnormality To calculate fluid >Monitor I/O balance
demonstrated behaviors to monitor fluid status and reduce recurrence of fluid excess
>Review pts sodium intake >Compare current weight
Sodium attracts water To determine rate of weight gainTp

62
azotemi a
there is a lkowered urine output and clearance of creatinine. Increased kidney tubular reabsorption of sodium occurs. Because sodium retains fluid, edema results.
excess.
with admission and/or previously stated weight >Auscultate breath sounds
determine presence of crackles or congestion May indicate increasing fluid or edema To detect
>Measure abdominal girth for changes
impoairment in urinary elimination
Sodium and addl >Note patterns and amount of urination fluid intake may aggravate edema
To reduce tissue >Restrict fluid and sodium intake as pressure and risk of skin breakdown
63
indicated >Evaluate edematous extremities, change position frequently >Place the pt in a semi-fowlers position as appropriate >Discuss importance of fluid restrictions and hidden sources of intake (such as foode high in h20 content >Set appropriate To obtain desired To facilitate movement of diaphragm to improve respiratory effort Reinforces the need for sodium and water intake restriction To prevent peaks / valleys in fluid level
64
rate of fluid intake / infusion >Administer due meds >Check and regulate IVF >Attend to pts needs
rate
To facilitate faster recovery
65
Assessment
Nursing Diagnosis
Objectives
Intervention
Rationale To gain pts trust and cooperation
Expected Outcome
The pt manifested: A systemic vasoconstrictio n
Risk for fetal injury r/t maternal regulatory dysfunction
With severe preeclampsia, the cardiac system can become overwhelmed because the
SHORT-TERM: After 3 hrs of nursing interventions, the pts placental persfusion will increase.
Establish rapport
The pts placental persfusion shall have increased. >Monitor and assess VS >Assess the pts To obtain baseline The pt shall have To determine presence of abnormality demonstrated a decrease in systemic vasoconstriction to increase uteroplacental To avoid putting pressure on the inferior vena cava. circulation general physical condition
The pt (fetus) may manifest: Meconium staining Increased pulse rate
heart is forced to pump against rising peripheral resistance.This reduces blood supply to organs, most markedly in the kidneys, LONG-TERM: After 3 days of nursing interventions, the pt will demonstrate Instruct mother to a decrease in systemic vasoconstriction to Promote bed rest To increase uteroplacental assume a left lateral position.
pancreas, liver, increase brain, and uteroplacental
66
PLACENTA. Poor placental perfusion may reduce the fetal nutrient and Oxygen supply.
circulation
circulation and prevent too much workload on the heart.
Encourage relaxation techniques such as deep breathing.
To provide comfort.
Straining during defacation might Avoid constipation. put pressure on the uterus which could injure the already compromised fetal health.
67
To enhance pts Instruct mother on the possible complications the disease can cause to the fetus. Discuss importance of having an adequate blood circulation going to the placenta. Administer oxygen as indicated Administer medications as prescribed. To facilitate faster recovery participation in the treatment regimen.
68
Assessment
Nursing Diagnosis
Objectives
Intervention
Expected Outcome
The patient may verbalize: pain on the site of IFC insertion palpitations thirst The patient manifested: An indwelling foley catheter is inserted into her urethra The patient
Risk for infection r/t invasive procedure
Instrumentatio n of the urinary tract or catheterization can be a precipitating cause in the development of UTI especially if the catheter is unsterile or contaminated with pathogens. The most common route of infection is
SHORT-TERM: After 3 hrs of nursing interventions, the patient will demonstrate techniques to prevent / reduce risk of infection
> Establish rapport >Monitor and assess VS >Assess the pts general physical condition Observed for localized signs of infection at the
The pt shall have To obtain baseline demonstrated techniques to prevent Risk of infection. To determine presence of abnormality The pts IFC shall To detect presence of infection have remained intact without any purulent drainage
LONG TERM: After 3 days of nursing interventions, the patients IFC will remain intact
insertion site Stress proper handwashing techniques by all caregivers handling /
A first line defense against nosocomial infections / cross contamination
69
may manifest: Increased pulse rate Increased respiratory rate Fever Chills diaphoresis
transurethral (ascending infection), in which bacteria colonize the periurethral area and subsequently enter the bladder by means of the urethra. In women, the short urethra offers little resistance to the movement of uropathogenic bacteria.
without any purulent drainage
coming in contact with the pt Maintain sterile technique for invasive procedures (IFC insertion) Cleanse insertion site daily and prn with povidone iodine or other appropriate solution To reduce risk of ascending infections and to provide comfort which will enhance pts well-being To reduce risk of acquiring UTI
Provide regular catheter / perineal care Instruct pt to wash hands when Friction and
70
To help flush out bacteria or pathogens
coming in contact running water with the insertion site effectively remove microorganisms from hands To give appropriate Instruct significant others of measures to prevent spread of infection >Administer due meds To obtain desired flow rate treatment to abnormalities as early as possible
>Check and regulate IVF >Attend to pts needs
71
72
Assessment
Nursing Diagnosis
Objectives
Intervention
Expected Outcome
The patient may verbalize: Change in bowel pattern Unable to pass stool The patient manifested: Pt spends most of the time lying in bed Perform little gross motor movement 32 weeks
Risk for constipation r/t insufficient physical activity
Pregnancy, tegether with an insufficient physical activity slows intestinal peristalsis / decreases gastric motility and emptying time of the stomach which may lead to constipation
SHORT-TERM: After 3 hrs of nursing intervent ions, the pt will dwmonstrate behaviors leading to prevention of constipation such as intake of fruits and vegetables
The pt shall have To obtain baseline demonstrated behaviors leading to prevention of To determine presence of abnormality constipation such as intake of fruits and vegetables
Auscultate the abdomen for LONG TERM: After 3 days of presence, location, and characteristics of bowel sounds Evaluate current dietary and fluid intake and To determine which food must be increased to reduce This reflects bowel activity
The pt shall have performed range of motion exercises as appropriate for her condition
Physical activity increases peristalsis
nursing interventions ions,the pt will perform range of
73
pregnant The patient may manifest: dry, hard, formed stool strainig with defecation severe flatus
which could lead to evacuation of bowel contents
motion exercises as appropriate for her condition
implications for effect on bowel function Review medication (new and chronuc use)
risk of constipation
To evaluate if any drugs is being taken which has a corresponding effect on bowel function To improve
Instruct pt to eat a balanced high fiber diet
consistency of stool and facilitate passage through the colon To stimulate contractions of the intestine
Encourage activity or exercise within limits of individual ability
74
Discuss physiology and acceptable variations in elimination Encourage patient to maintain elimination diary if appropriate
May help reduce concerns /anxiety about situations
To help monitor bowel pattern
Check and regulate IVF Give due meds
To obtain the desired rate To treat abnormalities
75
>Attend to pts needs
Assessment
Nursing Diagnosis
Objectives
Intervention
Rationale To gain pts trust and cooperation To obtain baseline
Expected Outcome
The patient may verbalize: lack of sufficient skills in parenting The patient manifested: young age (15 years old) with an AOG of 32 weeks low self-esteem The patient may manifest:
Risk for impaired parenting r/t physical illness secondary to severe preeclampsia
Due to patient manifesting different objectives of lack of optimum growth, the risk for impaired parenting increase which can reslut to bad / negligent actions done by the parent
SHORT-TERM: After 3 hrs of nursing interventions,the pt will verbalize understanding of the health teachings given LONG TERM: After 3 days of nursing interventions, the pt will manifest good hygiene, strong body, joy,
the pt shall have verbalized understanding of the health teachings given The pt shall have manifestes good hygiene, strong body, joy, and
To determine presence of abnormality To reduce risk of
optimism
Encourage personal hygiene Create an environment in which
infection
Learning is more effective when
76
stress
and optimism
relationships can be developed and
individual feel safe
anxiety
needs of each individual met Make time for listening to concerns of pt
To have a deeper understanding on the pts emotional status and to promote respect
Encourage pt to identify positive outlets for meeting their own nee Check and regulate IVF Give due meds To obtain the desired rate To treat abnormalities To obtain the desired rate Promotes general well-being
77
To treat abnormalities
>Attend to pts needs
78
VIII. CLIENTS DAILY PROGRESS CHART Admission DAYS 01-29-13 NURSING PROBLEMS 1.Acute Pain + 2. Decreased Cardiac Output 3. Activity Intolerance 4. Excess Volume Fluid + + + + + + + + + + + 02-05-13 02-06-13 Day 2 Day 3 Discharge
5. Risk for Fetal Injury 6. Risk for infection 7. Risk for constipation
79
8. Risk for impaired parenting Vital Signs
+ Blood Pressure 110/80 mmHg Pulse rate 78 bpm Respiratory rate 20 cpm Temperature 37 C
+ Blood Pressure 120/80 mmHg Pulse rate 70 bpm Respiratory rate 22 cpm Temperature 36.5 C
Blood Presure200/110 mmHg
DX AND LAB PROCEDURES + HEMATOLOGY + URINALYSIS DRUGS Cefuroxime Metronidazole FESO4 + + + + + +
80
+ Mefenamic Acid Nifedipine Aldazide MEDICAL MANAGEMENT 1. PNSS MgSO4 2. D5LRS 1L + + + +
+ +
DIET Diet as tolerated, low salt low fat ACTIVITY Bed Rest + + + + + + + +
81
IX.
DISCHARGE PLAN
DISCHARGE PLAN
METHOD M- Instruct patient to continue medication as ordered E- Instruct the patient to do minimal exercise as tolerated such as walking to prevent contractures and bedsores and further complications T- Instruct the patient to comply with treatment regimen H Instruct to increase fruit juices and low fat milk in diet for nourishment Instruct to avoid food rich in sodium like processed food, dried food and can good food. Avoid too much saturated fat and cooking using animal oil, instead use vegetable oil Instruct client regarding his activity
O- Instruct to come back for follow-up check up on the Doctors schedule date D- Instruct the patient to a diet as tolerated but preferably avoiding salty and fatty foods
82
X.
CONCLUSION AND RECOMMENDATION The key to the successful management of patient with severely elevated blood pressure is
to differentiate hypertensive crisis from hypertensive urgencies. Patients with hypertensive urgencies, but without clinical evidence of acute end organ damage. Rapid antihypertensive therapy is not warranted for these patients. Hypertensive crisis constitute a distinct group of clinicophatological entities associated with acute target organ injury. These patients require immediate BP reduction to prevent end organ damage. Hypertension associated with cerebral infarction or intra cerebral hemorrhage only rarely requires treatment. The time frequency of heart rate variability showed different change during cooling in pregnancy induced hypertension as compared to normal control but the blood pressure and heart rate themselves showed no fixed tendency. Those findings indicate that time frequency analysis is of importance to evaluate the physiological stress test. Our recommendation would be to increase fluid as well as protein; we all know that cell membranes are composed of protein molecules which govern the passage of fluid into and out of each cell. Blood vessel walls are particularly sensitive to this lack of protein. As the protein is needed in third trimester for the needs of the fetus, protein molecules are robbed from wherever they are most available. So, logically, one would increase dietary protein, and allow sufficient water to ease the strain on the kidneys and allow protein re-absorption into the general blood flow. But not to overload the kidneys with excess fluid, which dulls the appetite.
83
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CONCLUSION AND RECOMMENDATION
http://en.wikipedia.org/wiki/Intravenoustheraphy http://www.worcestershirehealth.nhs.wk/WAHTLibrary http://www.greenhosp.org/pe_dpf/surgery http://nwmdgp.org-au/pages/afterhours www.guideline.gov http://www.ashfordstpeters.nhs.uk/intranet/ashferel http://www.healthsystem.virginia.edu/uvahealth/peds_hrpregnant/pih.cfm http://prenatal-health.suite101.com/article.cfm/pregnancyinduced_hypertension http://findarticles.com/p/articles/mi_m0887/is_n5_v15/ai_18403814 http://www.fagellaw.com/Information_Center/Pregnancy_Induced_Hypertension.aspx http://www.doh.gov.ph/chdcar/index.php?option=com_content&task=view&id=49&Itemid=1 Black, Joyce M. and Jane Hokanson Hawks. Medical-Surgical Nursing: Clinical Management and Positive Outcome Volume 1.USA.2005. Udan, Josie Q. Medical-Surgical Nursing: Concepts and Clinical Application-A Reference Book and Study Guide First Edition. Philippines.2002
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Severe Preeclampsia

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Severe Preeclampsia

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SEVERE PRE ECLAMPSIA: A CASE STUDY PRESENTATION

INTRODUCTION Pregnancy-induced hypertension is a condition in which vasospasm occurs during