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Republic of the Philippines TARLAC STATE UNIVERSITY COLLEGE OF NURSING Lucinda Campus, Brgy.

Ungot, Tarlac City Philippines 2300 Tel.no: (045) 982-6062 Fax: (045) 982-0110

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

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

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

January 2010

I. INTRODUCTION Pre-eclampsia, also referred to as toxemia, is a medical condition where hypertension arises in pregnancy (pregnancy-induced hypertension) in association with significant amounts of protein in the urine. Preeclampsia refers to a set of symptoms rather than any causative factor, and there are many different causes for the condition. Women with preeclampsia will often also have swelling in the feet, legs, and hands. In addition symptoms of preeclampsia can include: Rapid weight gain caused by a significant increase in bodily fluid Abdominal pain Severe headaches A change in reflexes Reduced output of urine or no urine Dizziness Excessive vomiting and nausea

Pre-eclampsia may develop from 20 weeks gestation. Its progress differs among patients. Most cases are diagnosed pre-term. Pre-eclampsia may also occur up to six weeks post-partum. It is the most common of the dangerous pregnancy complications; it may affect both the mother and the unborn child. There are 2 categories of preeclampsia, mild and severe. Severe preeclampsia is defined as the following: blood pressure greater than 160 mm Hg systolic or 110 mm Hg diastolic on 2 occasions 6 hours apart proteinuria exceeding 2 g in a 24-hour period or 2-4+ on dipstick testing increased serum creatinine (> 1.2 mg/dL unless known to be elevated previously) oliguria 500 mL/24 h 2

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

Preeclampsia has been described as a disease of theories, because the cause is unknown. Some theories include endothelial cell injury, ejection phenomenon (insufficient production of blocking antibodies), compromised placental perfusion, altered vascular reactivity, imbalance between prostacyclin and thromboxane, decreased glomerular filtration rate with retention of salt and water, decreased intravascular volume, increased central nervous system irritability, disseminated intravascular coagulation, uterine muscle stretch (ischemia), dietary factors, and genetic factors. A database of hospital discharge data from approximately 300,000 deliveries in the United States found the overall incidence of severe preeclampsia was about 1 percent of pregnancies. Studies of preeclampsia report about 5 percent of nulliparous women develop preeclampsia and 40 to 50 percent of these women develop severe disease. In the Philippines, according to Department of Health, Maternal Mortality Rate(MMR) is 162 out of 10,000 live births (Family Planning Survey 2006). 3

Maternal deaths account for 14% of deaths among women. For the past five years all of the causes of maternal deaths exhibited an upward trend. Preeclampsia showed an increasing trend of 6.89%; 20%; 40%; and 100%. Ten women die every day in the Philippines from pregnancy and childbirth related causes but for every mother who dies, roughly 20 more suffer serious disease and disability. The UNFPA office in the Philippines declared that family planning can help prevent maternal deaths by 35%. (http://hb4110.net/wpcontent/uploads/KIT_MATERNAL%20HEALTH_BASIC %20STATS.doc.) The only known treatments for eclampsia or advancing pre-eclampsia are abortion or delivery, either by labor induction or Caesarean section (and therefore delivery of the placenta). Magnesium sulfate is the first-line treatment of prevention of primary and recurrent eclamptic seizures (it reduces transmission of nerve impulses from brain to muscles). The mother and her family deserve careful teaching regarding the problem, its observation, and its treatment. Regular, adequate prenatal care is the best insurance for control of the complication.

Importance of the case study In the part of the client This case will inform the client of what her condition is all about. It will also lessen the burden of the client increasing her awareness about the whole course of treatments. And also, the client will be able to familiarize herself about the importance taking care of her own self through the use of medical regimens. In the part of the student The student will gain more information and knowledge about the disease and will lead to a certain new facts about the said condition, such as cause of disease, pathophysiology, manifestations, related factors as well as the proper nursing care management and medical regimens to be rendered. This acquired information may also help the students on how to properly manage and care for patients with the same state. On the side of the College of Nursing This study could be a used as a guide for the students and it can be a source of facts and information to students of different colleges and especially to the students of College of Nursing. On the side of nursing profession This study will serve as a basis in gathering facts and sets of information with regards to pre-eclampsia.

OBJECTIVES GENERAL OBJECTIVES Client Centered To assess the health of the patient To develop, implement, and evaluate plans for health promotion To provide client education and involve patient in implementing therapeutic regimen to promote understanding and compliance. Nurse Centered To apply the nursing process in the care of the hospitalized patient To describe effects of illness on individuals and family members roles and functions SPECIFIC OBJECTIVES Client-Centered Discuss indications for and management of a pregnant clients Discuss nursing implications for medications commonly prescribed for pregnant Describe nursing care for the client Use the nursing process to provide individualized care for clients who has experienced pre- eclampsia. Support client and family, and encourage them to ask questions so that information could be clarified and understood Nurse-Centered Identify major risk factors influencing the said condition. Identify the risk factor contributing to the occurrence of the disease. Learn the pathophysiology and manifestations of pre-eclampsia. Identify common diagnostic tests used for the said condition and their nursing implications. 6

Identify and describe nursing measure to promote awareness in the condition

II. NURSING PROCESS A. Assessment Data 1. Personal Data a. Demographic Data Name: Ms. Chi Age: 23 years old Sex: Female Civil Status: Single Occupation: None Religious Affiliation: Roman Catholic Address: Gerona, Tarlac Date of Birth: January 25, 1987 Place of Birth: Gerona, Tarlac Nationality: Filipino Usual Source of Medical Care: Health Center and Hospital Date and Time of Admission: January 09, 2010/3:35 am Chief Complain: labor pains Vital signs on admission: Temp: 38.1C BP: 160/100 mmHg PR: 88 bpm RR: 30 cpm Admitting Impression/Diagnosis: G1P0 PUFT pregnancy uteri to consider pre-eclampsia Surgical Procedure: low transverse cesarean section Date and Time of operation: January 11, 2010/2:00 pm Final Diagnosis: pregnancy uteri delivered via primary cesarean section to a live 7

baby girl arrest in cervical dilatation filled medical induction G1P1, pre- eclampsia 2. Environmental Status The family is composed of eight members living within the house. According to the patient, their house was made from concrete materials and has four bedrooms. They were able to clean the house on a regular basis. Communal water system is the primary source of drinking. They also have their own comfort room inside the house. Transportation available in the family is a tricycle. The location of their house is not easily accessible to hospitals, but a health center was near their house. Ms. Chi did not report any problems regarding her environment which interfered to her pregnancy. 3. Lifestyle The patient usually wakes up eight to nine in the morning and helps her mother and sister in cleaning the house or preparing the food. Hobbies and/or recreational activities were talking with her brother and sisters, texting or watching television and sometimes playing bingo and card games. The patient does not smoke and drink alcoholic beverages. PAST HEALTH HISTORY Ms.Chi experienced measles, mumps, and chickenpox as a child. She also experienced diarrhea, fever, cough, colds and self-medicates with over the counter medications like paracetamol and cough medications before she became pregnant. She has completed all her immunizations and including two shots of tetanus toxoid during her prenatal visits. She has no known allergies. She was never been hospitalized before. This was the first time patient she was admitted in the hospital. She has taken prescribed ferrous sulfate regularly at home. 8

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


Maternal Side

Pater nal Side

13 AREAS OF ASSESSMEN SOCIAL STATUS Ms. Chi is 22 years of age, a high school undergraduate and lives in Gerona, Tarlac together with her family. According to her, she has a good relationship with her family. She talks to her family and able to interact with other patient. Her family was there to give her support and to show their love for her. She is not engaged in any organizations in their community according to her Norms Social functioning of an individual is to form relationships with others. Social support is a perception that one has an emotional and tangible resource to fall on when needed; perceived social support is being followed by the family to express the love of the family, financial aspect is one of the normal constraints in the family. (Nursing fundamentals by Daniels; an introduction to health and physical assessment in nursing by DAmico and Barbarito) Social responsibilities include forming new friendships and assuming some community activities. As the role of woman has change, many women now choose to assume active careers and civic roles in society in addition to their roles as mother and or/wife. (Fundamentals of Nursing by Kozier) Interpretation The client was able to manage to interact with others. She was cooperative during the interview. Emotional Status After surgical procedure the client verbalized pain on the surgical incision with a pain scale of 7 out of 10. Though the father of her child was not there during her delivery, her family especially her mother was there always to support and comfort her emotionally.

Norms A normal person regarding emotions has the ability to manage stress and to express emotions appropriately. It involves the ability to recognize, accept and express feelings and to accept ones limitation. Normal coping pattern or emotions stability could include acceptance of the problem, adjustment to it, expressing of self-perception and self-control of emotions, probable temporary use of defense mechanism and support system (Fundamentals of Nursing by Kozier). Carrying out emotional feelings through words and facial expressions are normal signs of present physical condition (Nursing Fundamentals by Daniels) Interpretation Client was able to cope with problems because her family was there to support and comfort her emotionally. MENTAL STATE a. General Appearance and Behavior Patients appearance is appropriate with age, oriented, awake, coherent, normal, and symmetrical facial features. She was wearing a t-shirt and jogging pants and was properly groomed. She was responsive and eye contact was established during the interview. b. Level of Consciousness The client was conscious and coherent. She was responsive during the interview. Ms. Chi was aware of her present condition. c. Orientation The client stated properly the date, place and time. She can identify things or names being asked and able to answer all questions asked. 2

d. Speech The client speaks Tagalog and Ilokano. She is able to read and speaks clearly and utter words that easily to understand. Norms Clients should be able to reason, to find meaning, and make judgment from information, to demonstrate rational thinking and perceive realistically. Appearance and behavior; posture must be relaxed. Clients should be dressed appropriately with the season, age, and gender. Grooming and hygiene should be proper and neat. Client should typically be able to state their name, location, the date, month, season, and time of the day. Ability to form words (articulation) should be understood and clear. (An Introduction to Health and Physical Assessment in Nursing by DAmico and Barbarito; Physical Examination and Health Assessment by Carolyn Jarvis) The content of the client message should make sense. The ability to read and write should match the clients educational level. The client should be able to correctly respond to questions and to identify all the objects as requested. The client should be able to evaluate and act appropriately in situations requiring judgment. (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes) Anesthetics are agents that interfere with nerve conduction and thereby diminish pain and sensation. General anesthetics are drugs causing a partial or complete loss of consciousness. While regional anesthetics block nerve conduction only in the area to which they are applied and do not cause a loss of consciousness. (Pharmacological Aspects of Nursing Care 7th Edition by Broyles, Reiss and Evans) 3

Interpretation The clients level of consciousness, orientation and speech is normal. BODY TEMPERATURE Heres a table showing the body temperature of the client: Date January13, 2010 January 13, 2010 January 13, 2010 Norms For axillary route, it should range from 35.4-37.4C (95.8-99.4F) obtained 5 minutes time for accurate measurement. . (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes) Interpretation The clients temperature assessed via axillary route and obtained in five minutes was found to be within the normal range. RESPIRATORY STATUS The client has a regular breathing pattern. Bulging of the ICS was not seen as well as retractions in the intercostals spaces. The use of accessory muscles was not seen while the client is breathing. The table below shows the respiratory rate of the client after the surgery: Date January 13, 2010 January 13, 2010 January 13, 2010 Time 3 pm 6 pm 10 pm Respiratory Rate 19 20 20 Interpretation Normal Normal Normal Time 3:00 pm 6:00 pm 10:00 pm Temperature (C) 37.4 37.2 37.3 Interpretation Normal Normal Normal

Her respirations were normally heard by the unaided ear a 2-4 centimeters from the clients nose with absent nasal flaring. There were no pulsations as well as masses and tenderness. There were no rales, wheezes or stridor heard. Norms The normal findings of respiratory status for an adult include the following: 16-20 breaths per minute, no use of accessory muscles when breathing, respirations should be even, not labored and regular and no cough noted. (Weber: Nurses Handbook of Health Assessment) Interpretation The clients respiratory status after was found to be within the normal range. CIRCULATORY STATUS Ms. Chi has pale lips including the nail beds, palm, soles of the feet and her conjunctiva. Her pulse (radial) has a regular rhythm. For the capillary refill time, it ranges from 3-4 seconds. The table below shows the pulse rate of the client as well as her blood pressure. Date Time Pulse Rate Blood (beats/min) Pressure January 13, 2010 January 13, 2010 January 13, 2010 January 13, 2010 January 13, 2010 Norms Both pulse and blood pressure are measurements that determine the blood volume of ejected blood into the arterial system with each ventricular contraction. Normal adult BP is <120/80mmHg and pulse rate is 60-100bpm. 5 3:00 pm 6:00 pm 8:00 pm 9:00 pm 10:00 pm 86 83 86 88 85 (mmHg) 160/100 160/120 160/130 160/120 160/110 Normal PR, High BP Normal PR, High BP Normal PR, High BP Normal PR, High BP Normal PR, High BP Interpretation

Capillary refill is at speed of 4-5seconds. Lips, conjunctiva, gums, nail beds and palms are should be pinkish in colour. (Fundamentals of Nursing by Barbara Kozier, et al.) Interpretation The clients pulse rate is within the normal range, but her blood pressure is above normal and having a capillary refill of 3-4 seconds; pale lips, conjunctiva, soles of the feet, nail beds and palms indicate poor circulation which may be due to vasoconstriction or loss of blood because of the operation held. NUTRITIONAL STATUS Before admission, Ms. Chis typical intake of rice is about 3 cups with favorite viand fish with 1-2 cups of vegetables Lunch foods are usually vegetables paired with rice. During dinner she eats either a fish dish paired with rice or a combination of vegetable and fish dish and rice. According to her she loves eating pinakbet. She takes ferrous sulfate every day. She drinks an average of 8-10 glasses a day. Upon admission, the ordered diet for her was low salt low fat diet, then changed to NPO on January 10, 2010. And at 8:00 am of January 12, 2010 the doctor ordered soft diet (low fat and low salt). Norms: Normal human being usually eats 3 times per day and a fluid intake of 8 10 glasses of water. Nutrients must be taken equally according to their standards. There should be no problem regarding food and drug allergies and anything associated with nutrition. Nutritional of patient is a good determinant of a possible heart condition. Nutrition can be a prevention and treatment for some diseases. . (Kozier et. al., Fundamentals of Nursing 7th edition) Interpretation Ms. Chi can still eat food which is normal.

ELIMINATION STATUS Prior to hospitalization, the client said that she defecates regularly, or even twice day. Her stool differs from soft to hard and is dark brown in color. She voids at least 4 to 5 times a day with yellowish urine output if she suppresses the urge to void and clear if she void immediately when she feels the urge of voiding. According to her, she did not void and defecate immediately the day of her surgery even once. She was able to defecate the next day for only once. Stool was brown semi-formed. Norms Feces are normally brown in color and soft but formed. Black tarry stool is abnormal. Iron salts, bleeding from the upper gastrointestinal tract, diet high in red meat could be the possible causes. Although peoples patterns of urination are highly individual, most people void about 4-5 times a day. (B.Kozier, Fundamentals of Nursing 7th edition). Interpretation The clients lack of bowel movement and urination for the first five hour post-operatively is the result of her anesthesia. Dark brown stool is normal because patient is taking ferrous sulfate . SENSORY PERCEPTION Vision Ms. Chi said that she was able to see far and near objects without difficulty but sometimes she has blurring of vision. Her eyes moved smoothly and symmetrically when asked to follow the finger of the student during the examination. The cornea is moist and shiny. Her pupils were found to be black, round and equal in diameter, and dilates normally. Clients eyes constricts as a reaction to the light during the examination. The conjunctivas were found to be pale during the assessment. Hearing The external ears match the skin color of the client and were positioned centrally in proportion with the head. The external ears were elastic and cool to 7

touch. There were no found obstructions in the ear canals. She has no dry cerumen observed. The patient was able to hear clear sounds in both ears in response to the voice whisper test with a distance of about one foot away. Smell The patients external nose was located symmetrically in the midline of the face. The nostrils are patent. The nasal mucosa was observed to be red and with no deviations and no discharges. The patient was able to smell and distinguish different odors as the client identifies odors such as of the alcohol and perfume. Taste The tongue is in the middle of the mouth. Buccal mucosa was found to be pale. Her tongue is pink and moist. Touch She was able to perceive light touch, superficial pain and temperature accurately. Norms Eyes eyebrows, eyelashes should be equally distributed and symmetrically aligned. Eyelashes should be slightly curled outward. Eyelids should be intact, no discharge, no discoloration, close symmetrically and blinks bilaterally. Sclera should appear whit or dirty white in appearance. Palpebral conjuntiva should be pink or red in color. Pupils should constrict when illuminated. Mostly eyes should be coordinated, move in unison, with parallel alignment. Vision, a person can read from a magazine or newspaper at a distance of 36 cm without use of corrective lenses and able to identify colors. Ears auricles color must be same as facial skin, symmetrical, aligned with the outer canthus of the eyes and 10 degrees from vertical, not tender. Pinna recoils after it is folded. Ear canals sometimes have dry cerumen or sticks wet cerumen. He was able to hear sounds on both ears. Nose external nose is symmetric and straight, no discharge or flaring, not tender, no lesions, air moves freely when breaths though the nares. Nasal 8

cavities should be clear, no lesions, pink in color, nasal septum intact. Frontal and maxillary sinuses are not tender. Mouth lips are uniform in color, pink in color, soft, moist, symmetric in contour. Teeth are 32 for adult, white in color, with pink gums, moist, no lesions. Tongue, uvula, oropharynx should be pink, moist, no lesions and discharge. Touch should feel light touch, sensation. Must be able to discriminate between hot and cold sensations and address a correct facial expression on the given stimuli. (Fundamentals Analysis The patient has a normal tactile perception, normal sense of smell and hearing without any obvious manifestations of abnormalities present. Pale conjunctiva and buccal mucosa indicates poor circulation which may be due to blood loss. Blurring of vision can be caused by vasoconstriction which can be related to hypoxia of the vessels of the head. MOTOR STABILITY Post-operatively the patient looked weak. She cannot tolerate long standing and walking. She was able to move slowly and sit at the edge of the bed. She showed some discomfort upon moving. Norms The client should be able to enter the assessment area via independent ambulation, structural defects should be absent, and no indications of discomfort during performance of movements should be present. There should be symmetry with the other parts of the body. Walking is initiative in one smooth and rhythmic fashion; the lower limbs are able to bear fully body weight during the phase of muscle contraction especially against moderate external resistance normal muscle strength allows for complete voluntary ROM against both gravity and 9 of Nursing, Kozier; Physical Examination and Health Assessment, Estes)

moderate to full resistance. There should no involuntary movements of muscle present (Health assessment and physical examination 3rd edition by Mary Ellen Zator Estes) Interpretation Post-operatively the client had difficulty in moving because she was in pain and weak. STATE of SKIN APPENDAGES The patient has light brown skin all over the body. Increased pigmentation was observed on sun-exposed areas such as the neck, arms, and legs. Presence of striae at hypogastric and iliac regions, linea nigra and surgical incision are noted. Pallor was observed on her face including her conjunctiva, lips, palms, soles of her feet and nail beds. When her skin was pinched it returned to its normal state immediately. Her hair was found to be straight, oily, thick and equally distributed. Her nails were found to be not properly trimmed and traces of dirt are noted. Her capillary refill was 3-4 seconds. Her skin was observed to be without the presence of bruises. Pitting edema grade 2 were observed on the patients lower extremities. Norms Normal skin is a uniform whitish pink or brown color, depending on the patients race. Pallor is due to decrease visibility of the normal oxyhemoglobin. This can occur when the patient has a decreased blood flow in the superficial vessels, as in shock or syncope, or when there is a decreased amount of serum oxyhemoglobin as in anemia. No skin lesson should be present. Normally, the skin is dry with a minimum respiration. It should be smooth, even and firm except when there is a significant hair growth. It should return to its original contour when pinched. (M.E.Z. Estes, Health Assessment and Physical Examination 3rd edition)


Normally the nails have a pink cast in light-skinned individual and brown in dark-skinned individual. Capillary refill is an indicator of peripheral circulation. Normal capillary refill may vary with age but color should return to normal within 2 to 3 seconds.(M.E.Z. Estes, Health Assessment and Physical Examination 3rd edition) Interpretation The patients pale body parts (conjunctiva, lips, palms, nail beds and sole s of the feet) indicate poor circulation which may be due to loss of blood because of the operation held. Presence of edema is abnormal. STATE OF REST AND PHYSICAL COMFORT Before hospitalization, she regularly sleeps for about 10 hours and does not take a nap in the afternoon. After the surgery, Ms. Chi said that she can feel pain on her surgical site that disturbs her sleeping, she also state that he noisy environment of the hospital is another reason. Norms: Adults generally sleep 6-8 hours per night. About 20% of sleep is rapid eye movement. The complete sleep cycle is about 1.5 hours in adults. Maintaining a regular sleep-wake rhythm is more important than the number of hours actually slept. (Kozier et. al., Fundamentals of Nursing 7th edition) Interpretation: Clients sleeping pattern was altered due to surgical operation and the noisy environment.

REPRODUCTIVE STATE Ms. Chi had her menarche when she was 12 years old. She has a regular 28 days menstrual cycle. Her menstrual period last 7 days, 2 nd and 3rd day is commonly has the heaviest menstrual discharge. She consumes 3 pads of 11

sanitary napkin a day during menses. Ms. Chi is 37 weeks pregnant; primigravida. Norms: The female reproductive cycle begins at menarche, the onset of menstruation, which occurs between 9 and 16yrs of age, and ends at menopause, which occurs between 45 and 55 yrs of age. The cycle ends just before the next menstrual period. Menstrual cycles normally range from about 25 to 36 days. Only 10 to 15% of women have cycles that are exactly 28 days. Menstrual bleeding lasts 3 to 7 days, averaging 5 days. Blood loss during a cycle usually ranges from to 2 ounces. A sanitary pad or tampon, depending on the type, can hold up to an ounce of blood. . (Kozier et. al., Fundamentals of Nursing 7th edition) (http://www.merck.com/mmhe/print/sec22/ch241/ch241e.html) Interpretation: The client reproductive status is normal.


Diagnostic/Laboratory Procedure Hematology

Date Results Date Results: January 10, 2010/ 12:15 am



Normal Values (units used in the hospital)

Analysis /Interpretation of Results > below normal Decreased Hgb count on pregnant is normal because of the increase in plasma volume during pregnancy

Specimens of venous blood are taken for a CBC which includes Hemoglobin and Hematocrit measurements, RBC indices and diferential white cell count.

Hemoglobin: 107

120-180 g/L

Hematocrit: 0.345

0.370- 0/510 L/L

> below normal Decreased hematocrit on pregnant is normal because of their increase in plasma


volume. WBC count: 16.8 3.98-10 x 109 g/L >Abnormally high due to presence of infection or inflammation RBC count: 4.96 Lymphocytes: 3.0 0.6-4.1 10.0-58.5%L > Normal 4.20-6.30 T/L >Normal

MCV: 69.5 MCH: 21.6 MCHC: 310 Platelet: 322 Date Hemoglobin:

80-97 fl 26.0- 32.0 pg 310-360 g/L 140-440 G/L

>below Normal >below normal >Normal >Normal > below normal


Results: January 13, 2010/ 11:58 am


Decreased Hgb count on pregnant is normal because of the increase in plasma volume during pregnancy

Hematocrit: 0.104 WBC count: 31.8 RBC count: 1.49

> below normal

>infection or Inflammation is present. >Decreased RBC count on pregnant is normal because of the increase in


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


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

Nursing responsibility: Before:


1. Explain the purpose of the test and the procedure for collection of blood. Client mat experience anxiety about the procedure, especially if it is perceived as being intrusive or if they fear unknown to the result. A clear explanation will facilitate cooperation on the part of the client. 2. Inform the client of the time period before the results will be available. During: 1. Use the correct procedure for obtaining the blood. 2. Aseptic technique should be use in collection to prevent contamination that can cause inaccurate results. 3. Ensure correct labelling, storage and transportation of the specimen to avoid invalid test results. After: 1. Report results to the appropriate health team members. 2. Compare the previous and current test results and modifies nursing interventions as needed.







Blood Typing and cross matching

Date Result: January 18, 2010

Used to determine the blood type of the client and compatibility of a donors blood with that of a recipient after he specimens have been matched for major blood type

Blood type O RH + Compatible

The client was blood type O+ and compatible wih donors blood.

Date Result: January 18, 2010

Blood type O RH + Compatible

The client was blood type O+ and compatible wih donors blood.

Nursing responsibility: Before:


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


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

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


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


There are two circulatory routes of blood as it flows through the blood vessels: the systemic and the pulmonary circulation. In systemic circulation, blood flows from the left ventricle of the heart through blood vessels to all parts of the body (except gas exchange tissues of lungs) and back to the atrium. In pulmonary circulation on the other hand, venous blood moves from the right atrium to right ventricle to pulmonary artery to lung arterioles and capillaries where gases exchanged; oxygenated blood returns to the left atrium via pulmonary veins; from left atrium, blood enters the left ventricle. Vasomotor Control Mechanism Blood distribution patterns, as well as BP can be influenced by factors that control changes in the diameter of arterioles. Such factor might be said to constitute the vasomotor control mechanism. Like most physiological control mechanisms, it consists of many parts. An area in the medulla called vasomotor center/ vasoconstrictor center will, when stimulated initiate an impulse outflow via sympathetic fibers that ends in smooth muscle surrounding resistance vessels, arterioles, and veins of the blood reservoir causing their constriction thus the vasomotor control mechanism plays an important role both in the maintenance of the general BP and in the distribution of blood to areas of special need. Venous return of the Blood Venous return refers to the amount of blood that is returned to the heart by the way of veins. Various factors influence venous return, including the operation of venous pumps that maintains the pressure gradients necessary to keep blood moving into the central veins and from there the atria of the heart. Changes in the total volume of blood vessels can also alter the venous return. The return of venous blood to the heart can be influenced by the factors that change the total volume of blood in the circulatory pathway. Stated simply, the more the total volume of blood, the 26

greater the volume of blood returned to the heart. The mechanism that change the total blood volume most quickly, making them most useful in maintaining constancy of blood flow, are those that cause water to quickly move into the plasma or out of the plasma. Most of the mechanisms that accomplish such changes in plasma volume operate by altering the bodys retention of the water. The primary mechanisms for altering the water retention in the body- they are the endocrine reflexes in the body. One is the ADH mechanism is released in the neurohypophysis and acts on the kidneys in a way that reduces the amount of water lost by the body. ADH does this by increasing the amount of water that kidneys reabsorb from urine before the urine is excreted from the body. The more ADH is secreted, the more water will be reabsorbed into the blood, and the greater the blood plasma volume will become. Another mechanism that changes the blood plasma volume is the renninangiotensin mechanism of aldosterone secretion. Renin is an enzyme that is released when the blood pressure in the kidney is low. Renin triggers a series of events that leads to the secretion of aldosterone. Aldosterone promotes sodium retention by the kidney, which in turn stimulates the osmotic flow of water to the kidney tubules back into the blood plasma- but only when ADH is present to permit the movement of water. Thus, low blood pressure increases the secretion of aldosterone, which in turn stimulates the retention of water and thus an increase in blood volume. Another effect of reninangiotensin is the vasoconstriction of blood vessels caused by an intermediate compound called angiotensin II. This complements the volume-increasing effects of the mechanism and thus also promotes an increase in overall blood flow. Precision of blood volume control contributes to the precision in controlling venous return, which in return yields to the precise overall control of blood circulation EXOCRINE SYSTEM 27

The exocrine systems main function is to regulate the volume and composition of body fluids and excrete unwanted materials, but it is not the only system in the body that is able to excrete unnecessary substances. Kidneys The kidneys resemble the lima beans in shape. The average-sized kidney measures around 11cm by 7cm by 3cm. The left kidney is often larger than the right. The kidneys are highly vascular organs. Approximately, one-fifth of the blood pumped fromthe heart goes to the kidneys. The kidneys process blood plasma and form urine from waste to be excreted and emoved from the body. These functions are vital because they maintain the homeostatic balance of the body. The kidneys maintain the fluid-electrolyte and acid-base balance. In addition, they also influence the rate of secretion of the hormones ADH and aldosterone. Microscopic functional units called nephrons make up the bulk of the kidney. The nephron is uniquely suited to its function of blood plasma processing and urine function. A nephron contains certain structures in which fluid flows through them and they are as follows: renal corpuscle, Bowmans capsule, proximal convulted tubule, Loop of Henle, distal convoluted tubule and the collecting tube. The Bowmans capsule is a cup-shaped mouth of a nephron. It is usually formed by two layers of epithelial cells. Fluids, electrolytes and waste 28

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


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

The female reproductive system produces gametes may unite with a male gamete to form the first cell of the offspring. The female reproductive system also provides protection and nutrition to the developing offspring. The most essential organ is the ovary which carries the ova. The uterus, the fallopian tubes and the vulva are accessory organs. 30

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








NURSING CARE PLANS January 13, 2010 Assessment S - Planning Intervention Expected Outcome After 4 hours of nursing intervention, the client will exhibit decrease in oxygen demand and ability to conserve energy. trendelenburg position. (To promote venous return) >Maintain adequate ventilation.(To promote oxygenation and good blood circulation) Diagnosis Ineffective tissue perfusion >Instruct client to sit and dangle the feet before standing.(To prevent

After 4 hours of nursing >Assist client in performing interventions, the client will ADL. (To promote safety) exhibit decrease in oxygen

O - weak and pale in appearance - capillary refill of 3-4 seconds - RBC level= 1.49 - Hgb level= 34 g/L - BP= 160/110 mmHg




to >Place the client in

conserve energy.


r/t decrease in RBC, hemoglobin and hematocrit level Scientific Explanation Due to the procedure done, the clients RBC level decreased causing ineffective tissue perfusion.

orthostatic hypotension) >Advise client to increase intake of food rich in iron and folate such as liver and green leafy vegetables. (Iron and folate are necessary for red blood cell production).




Expected Outcome


S - After 4 hours of proper nursing intervention the O - weak and pale in appearance cannot tolerate long standing and walking independently - RBC level= 1.49 client will perform ADL with minimal to no assistance.

>Assist client during moving and on going in the comfort room or whenever needs assistance. (Assisting client during moving ensures for client) >Assist client in comfortable position. (To improve comfort) >Assist with ADL as indicated to reduce energy expenditure but avoid doing

The client will perform ADL with minimal assistance after 4 hours of proper nursing intervention as evidenced by: assistance. >With ease in performing ADL >Can tolerate short time of walking and standing with less fatigability. >Client verbalization of increase in energy.

safety and additional support >Able to ambulate with least

Diagnosis Activity intolerance r/t body weakness secondary to low RBC level. Scientific Explanation

for what he can do for herself (to increases clients independence) >Let the client do much of the activities (to increase self-reliance.) >Provided proper ventilation.








(To give enough oxygen supply) Health Teachings: >Instruct client to sit at the edge of the bed then dangle her feet before standing. (To prevent orthostatic hypotension) .>Encourage the client to get adequate rest and sleep. (To conserve energy) >Encourage adequate rest periods before ambulation and meals (To reduce cardiac workload) >Instruct to refrain from performing unnecessary movements (To promote rest) >Encourage passive ROM

(oxygen carrying capacity) oxygen supply into body tissue decreases which result in body weakness.


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

Assessment O- postpartum surgery

Planning After 1-2 hrs of nursing intervention, the patient will

Intervention Independent: >stress proper hand

Expected Outcome After 1-2 hrs of nursing intervention, the patient was


able to know the preventive measures of wound healing Diagnosis Impaired Skin Integrity related to surgery Scientific Explanation The incision from the cesarean section altered the skin integrity making it more susceptible to pathogens and even the patients normal flora

hygiene. - to control the spread of infection >Encouraged to increase foods that are rich in protein - to aid in tissue repair >Encouraged proper clothing -to maintained the proper skin moisture. >Apply appropriate Dressing -to help in wound healing

able to knew the preventive measures of wound healing

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


Paracetamol Brand Name: Biogesic Classifications: Non-opioid analgesic

4:00 am

mechanism of action is the inhibition of cyclooxygena se (COX), an enzyme responsible for the production of prostaglandin s, which are important mediators of inflammation, pain and fever.

moderate pain. It is also used to bring down a high temperature.

temperature is 37.2

Nursing Responsibility: Monitor for signs and symptoms of hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition. Do not take other medications containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. Do not use for fever persisting longer than 3 days ,fever over 39.5 C(103 F), or recurrent fever. Date Route of General action Indications/ Clients reaction

Name of Drug


Generic name: Ferrous Sulfate Brand Name: Ferrous sulfate

Administered 01/11/10 10 am

Administration I cap OD

*Mineral for antianemia *Vital for hemoglobin regeneration, specifically it enables the RBC development and oxygen transport via hemoglobin It elevates the serum iron concentration, which then helps to form Hgb or trapped in the reticuloendothelial cells for storage and eventual conversion to

Purpose Preventing or treating low levels of iron in the blood.

to medicine. Dark brown stool


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

Name of Drug Generic name: Hydrazaline Hydrochloride


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

Instruct patient to check with doctor or pharmacist before taking OTC medications. Inform the patient that orthostatic hypotension can be minimized by rising slowly and avoiding sudden position Changes

Name of Drug Generic name: Magnesium Sulfate

Date Administered 01/09/10 10 am

Route of Administration 5 mg deep IM on each buocks

General action May decrease acetylcholine released by nerve impulses,

Indications/ Purpose Prevention or control of seizures in preeclampsia or eclampsia

Clients reaction to medicine. No signs of irritation and adverse reactions.


Brand Name: Sulfamag Classification: Anticonvulsant, miscellaneous; and laxative saline Nursing Responsibility:

but its anticonvulsant mechanism is unknown..

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


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

Name of Drug Generic name: Cefazolin Brand Name Cefacidal, Classification: Antimicrobial and antiparasitic agents


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


Ketorolac Brand Name: Toradol Classification: non-steroidal antiinflammatory drug

12 am

mechanism of action responsible for ketorolac's antiinflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the the enzyme cyclooxygenase (COX). Like most NSAIDs, ketorolac is a non-selective COX inhibitor. As with other NSAIDs, the mechanism of the

indicated for short-term management of pain (up to five days maximum).

responded well with no signs of irritation and adverse reactions.


drug is associated with the chiral S form. Conversion of the R enantiomer into the S enantiomer has been shown to occur in the metabolism of buprofen; it is unknown whether it occurs in the metabolism of etorolac. Nursing Responsibility: Use as a part of a regular analgesic schedule rather than on an as needed basis. If given on p.r.n. basis, base the size of a repeat dose on duration of pain relief from previous dose. If the pain returns within 3-5 hours, the next dose can be increased by up to 50% (as long as the total daily dose is not exceeded). If the pain does not return for 8-12 hr, the next dose can be decreased by as much as 50% or the dosing interval can be increased to q 8-12 hr.


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

Name of Drug Generic name: Amlodipine Brand Name: Norvasc Classification: Calcium

Date Administered 01/19/10 12 am

Route of Administration 10 mg tab OD

General action Amlodipine inhibits the transmembrane calcium influx with greater effects on vascular smooth muscle than on cardiac

Indications/ Purpose Essential hypertension alone or in combination with other antihypertensives.

Clients reaction to medicine. No signs of irritation and adverse reactions.


Channel blocker Antianginal Antihypertensive

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

Nursing Responsibility:


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

Name of Drug Generic name: Ascorbic acid (Vitamin C) Brand Name: Ascorbic acid Classification: Ant i oxidant

Date Administered 01/13/10 12 am

Route of Administration 1 tab OD

General action Toxicodynamics

Indications/ Purpose Ascorbic acid is recommended for prevention and treatment of scurvy (disorder caused by lack of vitamin C). Its parenteral administration is

Clients reaction to medicine.

Hyperoxaluria may result after administration of ascorbic acid Ascorbic acid may cause acidification of the urine, occassionally leading to precipitation of urate, cystine, or oxalate stones,


or other drugs in the urinary tract. Urinary calcium may increase, and urinary sodium may decrease after 3 to 6 g of ascorbic acid daily. Ascorbic acid reportedly may affect glycogenolysis and may be diabetogenic but this is controversial. harmacodynamics P In humans, an exogenous source of ascorbic acid is required for collagen formation and tissue repair. Vitamin C is a co-factor in many biological processes including the conversion of dopamine to noradrenaline, in the hydroxylation steps in

desirable for patients with an acute deficiency or for those absorption of orally ingested ascorbic acid uncertain. Symptoms of mild deficiency may include faulty bone and tooth development, gingivitis, bleeding gums, and loosened teeth. Febrile states, chronic illness and infection (pneumonia, whooping cough,


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

tuberculosis, diphtheria, sinusitis, rheumatic fever, etc.) increase the need for ascorbic..


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

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


health at risk; although in recent times it has been also performed upon request for births that would otherwise have been natural. Low transverse cesarean section is a type of cesarean section that involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair. Nursing Responsibility: Preoperative care: Assess the client knowledge of the procedure. The client is NPO after midnight. Relieving the patients and the familys anxiety about the outcome with reasonable information Encourage patient to commence deep breathing, coughing and leg exercises. Teach the client post operative expectations. 45

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

Medical Management Medical Management Date Ordered General Description Indication & Purpose Client Response to Treatment IVF D5LRS 1L 30gtts/min January 09, 2010 5% dextrose in lactated ringers Solution (Osmolarity of 527-hyprtonic, pH of 4.9) free water, provides electrolytes. Also contains sodium lactate which is used in treating mild to administered by intravenous infusion for parenteral maintenance of routine daily fluid and requirement with minimal carbohydrates calories and to correct or replace fluid losses due to change in the The patient responded well with no signs of irritation and adverse reactions.

-provides calories and electrolyte


moderate metabolic acidosis. Nursing Responsibilities: Check the doctors order Explain the procedure to the patient

patients diet (NPO) and during the cesarean operation.

Tell the patient that she might feel a discomfort from the tourniquet and the IV insertion Check and monitor IVF regulation and level of fluid Check if there is a need for removal and replacement of fluid Check if the tube is in the vein and signs of edema Check if there is a back-flow of blood Check if there is bubbles present in the tube Always Monitor V/S.


Evaluation Through assessment and data gathering, certain problems and needs of the client post-operatively were identified. Problems on tissue perfusion, impaired mobility (standing and walking) and impaired skin integrity were observed. Nursing care plan was established to improve clients status and recovery. Information and health teachings were imparted which led to increase clients awareness and knowledge with regards to her condition. The student gained additional information about incomplete abortion including diagnostic examination, surgical and medical management needed and as well as the factors affecting the condition which may help the group handle properly this kind of condition that the student may possibly encounter again. lll. Conclusion From the above nursing problems perceived and presented through prioritization and analysis of the gathered data and proper assessment. Through the use of client focus nursing interventions and by following to nursing standards, the perceived problems were managed well. Truly, a clinical eye which is sensitive to clients need for care was established. Loyalty was observed in aiding the clients needs, managing and taking a lead on advocating clients interest and creating ways on how to ensure a quality of care. lV. Recommendation The following are recommended for the client to easily recover after major surgery. Recommend the use of a heating pad or hot water bottle on the abdomen to help relieve pain or discomfort. Encouraged her to begin using birth control immediately after the procedure. Encouraged her to take her prescribed medication on right time and dosage. The patient should attend OPD follow ups The patient should do exercise or activities advised by the doctor, and avoid activities that requires great physical strength.
Instructed to increase intake of food rich in iron like liver, green leafy vegetables

and etc. 48

Encouraged to increase intake of food rich in protein and Vit. C.

Good perineal hygiene should be instructed to avoid infection

Instructed to have adequate rest and try to lower known stresses in life.

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