1

OBJECTIVES

General Objective: This study is prepared by the 2nd year nursing students of DMMA College of Southern Philippines that aims to present all the details about Preeclampsia, the predisposing and precipitating factor, and underlying complications. This was achieved through research, with the use of patients chart, article, references and other materials, and through patients interview during hospitalization.

Specific Objective: After 2 months of study, the student nurse should be able: 1.)To establish a good rapport and therapeutic relationship with the patient 2.)To gather much information about her personal data and her present condition through interview 3.) To gather pertinent data found in the medical chart 3.) To conduct a thorough physical assessment as a part of the baseline data gathering 4.) To study the anatomy and physiology of the affected system of the patients current condition 5.) To illustrate the pathophysiology of the disease process *6.) To determine the medical management employed including laboratory and diagnostic procedures *7.) To identify the drugs prescribed by the physician which may affects the patients current health condition. 8.) T o f o r m u l a t e n u r s i n g c a r e p l a n s . 9.) To formulate patients prognosis based on the assessment data gathered.

The client should be able to: 1.) 2.) 3.) 4.) Understand the importance of awareness of her disease. Identify the possible causes of the complications of PIH. Relate why such laboratory examinations are being done on her health condition. Discuss the importance of healthy lifestyle to the improvement of her health condition.

PATIENTS PROFILE

Patients Name: Mara Age: 41 yrs. old Sex: Female Birthday: July 24, 1970

Permanent Address: Blk. 8, Lot 28 Susana Homes, Ballok, Davao City Civil Status: Married Citizenship: Filipino Religion: Catholic Educational attainment: College graduate Occupation: None Chief Complaint: vomiting, weaknesses Provisional Diagnosis: PU 32 weeks AOG, GP Hyperemesis gravidarum Pre eclampsia

Admission date: Nov. 27, 2011 Time of Admission: 8:40 pm Ward room: 201 bed 1 Doctor: Fargas, Norille

GENOGRAM

HEALTH HISTORY

Past Health History Mara recalled that she didnt experience serious illnesses. But instead she experienced only childhood illnesses such as; measles, chicken pox and mumps. And sometimes, because of the weather changes she experienced fever but. She cannot remember the medicine she was taken before. She had her first menstruation when she was 13 years old and was irregular (every after two months).

Current Health Status On the 3rd month of pregnancy, she suffered pedal pitting edema and facial edema though her facial edema disappeared in few days. Prior to admission at the ER of Davao Adventist Hospital, the patient had experienced 15 episodes of vomiting associated which cause her weakness. She was diagnosed to have gestational diabetes. She was given 2 shots of insulin but she did not take any anti-diabetic drugs.

Family health Mara, the patient, was youngest child of Clara and Christian. A resident of Cagayan De Oro, Mara has one brother and a sister named RR and Anna respectively. They loved to eat sweets and high in cholesterol foods. They dont have proper physical exercise. RR has vices such as drinking liquor occasionally, and cigarette smoking at one pack per day. Like RR, Anna also has vices she also has vices drinks and smokes. At the age of 40 Clara died due to cardiac arrest, and Christian was diagnosed with liver cirrhosis and died on May 2006 due to cardiac arrest. At the age of 37, Anna suffered stroke, and died after 3 years on November 2009. ***** Suggestion ni sir ang kung ana daw ana tanan, kung rr ,rr tanan.pero ok daw.****

PHYSICAL ASSESSMENT

Functional Area

Initial Assessment

Final Assessment

General Survey

Received this 41 years

Received this 41 years

old, female, married, Filipino, Catholic, sitting on bed. Patient is awake, ambulatory, conscious, oriented to time, place and person and is willing to cooperate but without attending watcher with patent IVF of #3 PLR 500cc. ( iv level ,, infused,

old, female, married, Filipino, Catholic, sitting on bed and alone. On second week of admission. Patient is awake, ambulatory, conscious and coherent, oriented to time, place and person, attentive and is willing to cooperate.

With fair complexion, wearing a t-shirt and shorts with discomfort noted due to stomachache caused by diarrhea. Approximately 5 feet in height and weighs 58 kg. Facial expression is appropriate to mood and conversation. Client is alert and responsive. Voice of tone is moderate; speech. is clear and responds appropriately to questions asked.

With fair complexion, wearing a maternity gown, with unpleasant body odors and with signs of distress. Approximately 5 feet and weighs 58 kg.

Rest and Comfort

Subjective cues: Okay-okay naman ko, wala nako gasuka pero musakit ra panagsa akong ulo tas kalipungon pud ko. Nagasakit pud akong tiyan ug taud-taod ko nagalibang

Subjective cues: Wala ko tarong tulog kay kung gabie sige rako mubangon para mulibang ug ginakuhaan pud sa akong BP

Objective cues: With complaints of dizziness, headache and stomachache as evidenced by facial grimacing. Watery stool. V/S

Circulatory With blood pressure of 160/100 mmHg taken at the left arm in sitting position. With cardiac rate of 85 beats per minute, regular in rate and rhythm and is synchronous with pulse rate; with pitting edema noted on both lower extremities; with pale lips and nail beds and with poor tissue perfusion greater than 3 sec.

Objective cues: Absence of pain as claimed by the patient. Patient complains of lack of sleep due to stomachache. Patient appears uncomfortable. She approximately sleeps 6-7 hours a day including naps. Sleeps with one pillow under head and one on her side.

Reproductive

With pitting edema noted on the upper extremities; +1 pitting bipedal edema noted. With blood pressure of 120/90 mmHg taken at the left arm in supine position; with cardiac rate of 80 beats per minute, regular in rate and rhythm and synchronous with pulse rate.

Respiratory

Breasts are symmetrical; areola and nipples are dark-brown in color and are Other parameters everted. No engorgement remain unchanged. or swelling noted upon palpation.

With non-productive cough. With respiratory rate of 23 breaths per minute, regular in rate and rhythm, spontaneous and non-

Other parameters remain unchanged except respiratory rate of 25 breaths per minute, regular

Motor

labored, with no signs of in rate and rhythm. respiratory distress. With no signs of nasal flaring and use of accessory muscles in breathing. With no retractions and bulging of intercostal spaces. With equal chest expansion upon palpation. No harsh breath sounds noted upon auscultation. With full range of motion on both upper and lower extremities; able to perform activities of daily living with minimal assistance.

Skin Integrity

With limited range of motion on lower extremities. Complete bed rest without bathroom privileges. With poor muscle strength on the lower extremities.

Special Senses: Eyes

Not noted presence of linea nigra and striae gravidarum. With fair complexion, dry and warm to touch.

With absence of linea nigra and striae gravidarum. Other parameters remain unchanged.

With blurry vision on both eyes and unable to read small written text approximately an arms length. Both eyes move parallel to each other, eyebrows are unplucked and evenly distributed on both eyes, with no flakes,

Other parameters remain unchanged.

Ears

eyelashes curved outward away from the eyes. Sclera is white. Blinks involuntarily. No protrusion of the globes noted, and tenderness noted upon palpation. With pink pupillary conjunctiva.

Nose

Color is uniform with the Other parameters face, nasal septum is in the remain unchanged. midline, nostrils are patent, nasal flaring and discharges not noted upon inspection. Nasal mucosa is pink with presence of cilia, swelling and tenderness not noted upon palpation, able to differentiate scents. Other parameters remain unchanged.

Mouth

Lips are pale, smooth and dry. Mucosa and gums are pink; teeth are yellowish in color. Tonsils, uvula and pharynx not swollen upon inspection, presence of gag reflex, can differentiate different kinds of taste.

Able to distinguish light from sharp pain. Touch Defecates watery stool with stomachache. Elimination

Other parameters remain unchanged.

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Nutrition

Approximately 5 feet in height and 58 kg. On diet as tolerated, hypertensive diet, able to consume food served. Prefers to eat vegetables and fruits. Eats 3 times a day with snacks in between. Nausea and vomiting not noted. Drinks approximately 1500ml of fluids per day.

Other parameters remain unchanged.

With complaints of diarrhea, defecates many times a day with watery stool.

Other parameters remain unchanged.

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ANATOMY AND PHYSIOLOGY

Urinary System

13

The urinary system rids the body of nitrogenous wastes while regulating water, electrolyte, and acid base balance of the blood.

Kidneys Maintains the purity and constancy of our internal fluids are perfect examples of homeostatic organs. They also regulate the bloods volume and chemical makeup so that the proper balance between water and salts and between acids and bases is maintained. It also regulates by producing the enzyme renin, they help regulate blood pressure, and their hormone erythropoietin stimulates red blood cell production in bone marrow.

Nephrons Are the structural and functional units of the kidneys and, as such, are responsible for forming urine Consists of glomerulus, which is a knot of capillaries, and a renal tubule. Filtering units of the kidney

Ureters

14

Tubes that carry the urine from the kidneys to the urinary bladder. These tubes are 10 to 12 inches long

Urethra The tube that carries the urine to the outside. The female urethra is about 1 inches long. The opening to the outside is called urinary meatus. The meatus is guarded by a round sphincter muscle that relaxes to release the urine. Urinary bladder Holds the urine until expelled. The urge to urinate (micturate or void) occurs when 150 to 300 mL of urine are in the bladder, although the bladder can hold more urine than this.

The cardiovascular system The cardiovascular system can be compared to a muscular pump equipped with one way valves and a system of large and small plumbing tubes within which the blood travels. Most simply stated, the major function of cardiovascular system is transportation. Using blood as the transport vehicle, the system carries oxygen, nutrients, cell wastes, and hormones, and many other substances vital for the body homeostasis to and from the cells. The force to move the blood around the body is provided by the pumping of the heart.

The heart Heart is flanked on each side by the lungs. Approximately the size of a persons fist, the hollow, cone-shaped heart weighs less than a pound. Snugly enclosed within the inferior mediastinum, the middle cavity of the thorax.

15

It is the most important part of the cardiovascular system. It pumps blood to the various parts of our body by the repeated rhythmic contractions. It beats 72 times a minute. It has four chambers- 2 upper chambers known as atria and 2 lower ones known as ventricles. The atria receive blood and the ventricles pump blood to the various parts of our body and the lungs. Blood vessels: Blood vessels are the tubes that carry the blood. They are of 3 types; 1. Arteries- carry blood from the heart to the different parts of the body 2. Veins- carry blood from the different parts of our body back to our heart 3. Capillaries- small, thin walled vessels that form a network between the arteries and veins in the tissues and function in the exchange of nutrients and gases. Angiotensin II- also known as angiotensin receptor blockers, are group of pharmaceuticals which modulate the renin- angiotensin- aldosterone system. Their main uses are in the treatment of hypertension, diabetic nephropathy and congestive heart failure( http://en.wikipedia.org/wiki/Angiotensin_II_receptor_antagonist). Prostaglandin- is any member of a group of lipid compounds that are derived enzymatically from fatty acids and have important functions in the animal body. They are mediators and have variety of strong physiological effects, such as regulating the contraction and relaxation of smooth muscle tissue(http://en.wikipedia.org/wiki/Prostaglandin).

Blood Blood is a specialized body fluid that flows through the blood vessels. It derives its red color from the presence of the pigment hemoglobin in the red blood cells- which is responsible for the transport of oxygen and carbon dioxide. Blood is composed of the

16

fluid part known as plasma and blood cells. Plasma is mostly made up of water and also contains proteins, salts and other substances. The blood cells are of 3 types Red blood cells (responsible for the transport of respiratory gases), white blood cells (responsible for immunity against diseases) and platelets (responsible for blood clotting.)( http://www.cardiophile.com/77)

SYMTOMATOLOGY

Mild Pre-Eclampsia

17

Sign and Symptoms

Present

Justification A woman is said to be mildly pre-eclamptic when her blood pressure rises to 140/90 mm Hg, taken on two occasions at least 6 hours apart. The diastolic value of blood pressure is extremely important to document because it is this pressure that best indicates to degree of peripheral arterial spasm present. (Maternal and Child Health Nursing 6th Edition Vol. 1, p. 576 by: AdellePilliteri)

Hypertension

Proteinuria

Many women show a trace of protein during pregnancy. Actual proteinuria is said to exist when it register as 1+ or more (this represents a loss of 1 g/L). (Maternal and Child Health Nursing 6t (h Edition Vol. 1, p. 576 by: AdellePilliteri)

Edema develops as mentioned, because of the protein loss, sodium

18

Edema

Cerebral edema

retention, and lowered glomerular rate. A weight gain of more than 2 lb.wk in the second trimester or 1 lb/wk in the third trimester usually indicates abnormal tissue fluid retention. (Pilliteri, 2010) If cerebral edema occurs, reports may be voiced of visual disturbances such as blurred vision or seeing spots before the eyes. Cerebral edema also produces symptoms of severe headache. (Pillitteri, 2010)

PATHOPHYSIOLOGY

19

20

NARRATIVE PATHOPHYSIOLOGY

21 Pregnancy induced hypertension is an endothelial cell disorder resulting in mild to severe microangiopathy of target organs such as liver, kidney, brain and placenta. The vascular spasm may be caused by the increased cardiac output that occurs with the pregnancy and injures the endothelial cells of arteries or the action of prostaglandins. Normally, blood vessels during pregnancy are resistant to the effects of pressor substances such as angiotensin and norepinephrine, so blood pressure remains normal during pregnancy. With PIH, this reduced responsiveness to blood pressure changes appears to be lost. Vasoconstriction occurs and blood pressure increases dramatically.

With hypertension, the cardiac system can become overwhelmed because the heart is forced to pump against rising peripheral resistance. This reduces the blood supply to organs, most markedly the kidney, pancreas, liver, brain, and placenta. Poor placental perfusion may reduce the fetal nutrient and oxygen supply. This may result to placental abruption that leads to fetal distress or eventually death of the fetus. When vasospasm occurs, the spaces in cerebrum may be edematous that will result to headache that will put the mothers life in danger and so the fetus. If this continues, intracranial hemorrhage will likely happen that can cause maternal death. Spasm of the arteries in the retina leads to vision changes. If retinal hemorrhages occur, blindness can result.

Vasospasm in the kidney increases blood flow resistance. Degenerative changes develop in the kidney glomeruli because of back-pressure. This leads to increased permeability of the glomerular membrane, allowing the serum proteins albumin and globulin to escape into the urine (proteinuria). The degenerative changes also result in decreased glomerular filtration, so there is lowered urine output and clearance of creatinine. Increased in kidney tubular reabsorption of sodium occurs. Because sodium retains fluid, edema results. Edema is further increased because as more protein lost, the osmotic pressure of the circulating blood falls and fluid diffuses from the circulatory system into the denser interstitial spaces to equalize the pressure. Extreme edema can lead to cerebral and pulmonary edema and seizures (eclampsia). If the pre-eclampsia becomes more severe, swelling can occur in the liver, leading to severe pain under the right rib cage, and, in rare cases, rupture of the liver with hemorrhage. Sometimes swelling can occur in the brain, leading to seizures, which we call eclampsia.

Medical Management

22

Doctors Order Date 11-27-11 Notes Please admit under the care of Dr. M-Go Hypertensive/ Diabetic diet V/S q4, BP q hourly IVF; PLR 1L @ 60cc/hr Lab= cbc, plt.cnt., hct 24 U/A, BUN, SGPT, creatine, LOH, Na (+), K (+) Progress notes Hgt- 162mg/dL BP- 150/100mmHg T-37 P-125 R-24 FHT-156 Monitor for changes and severity Input and output every shift Refer accordingly Hydralazine 5mg on KVO on IVTT x1 Methyldopa 250mg tab- po TID Metoclopramide 10g IVTT KVO

11-28-11 Referred to Dr. Fargas

Cefuroxime 750mg IVTT q 8h (-)ANST Paracetamol 500 mg tab po q4 po IVF PLR 1L#2 @ 60cc/hour Metoclopramide 1 amp BP q hours and refer for DBP 100 mmHg to POD Increase methyldopa to 250g tab q 6hours PO Refer for RUQ pain, severe headache, disorientation, other

23 unusualities FHT q 4 hours and record please Decrease IVF to KVO IVF PLR 500cc @#3 KVO Nov.29,2011 4:10 pm BP 160/100mmHg Nefidifine 5mg/cap, SL May transfer patient back to room----- Nov. 29, 2011 4:30pm Revise Methyldopa to 250g, 2 tabs TID PO (6am-2pm-8pm) By shift to oral Cefuroxime, 500g cap PO after 6th dose of Cefuroxime IV Metoclopramide amp IVTT now Revise methyldopa to 250 mg. 2 tabs BP 140/90mmHg TID PO ( 6am-2pm-8pm) May shift to oral cefuroxime, 500mg cap po after 6th dose of cefuroxime IV ---- Nov. 29, 2011 5:30pm Metoclopramide amp. IVTT--- Nov. 29, 2011 8:15 pm

11-30-11

Continue methyldopa, cefuroxime po Refer pain CBR with TP

BP 100/80 mmHg 2:30 pm 11-30-11 11-30-11 10pm

Discontinue IVF when consume Continue monitoring Hold 8pm dose of methyldopa Continue monitoring

24 11-30-11 9:15 pm MGH tomorrow Continue meds. Methyldopa 250 mg. tab 1 tab BID po Follow up on Dec. 8, 2011

12-1-11 6:30 am BP 170/100, 180/100 8:20 am BP 180/110 (1) vomiting chest tightness CBS 9:20 am BP 150/90

Please check BP q 30 mins. And refer

Reinsert IVF PLR #1 500cc on kvo Nifedipine 500mg 1 cap SL Metoclopramide O inhalation @ 2:30 pm via nasal cannula

12-2-11 9:55 am 1pm

Methyldopa 250mg 1 tab Hold MGH Will inform AP

6:30

Resume methyldopa 250mg 2 tab po TID Refer

12-2-11 6:30

Dexamethasone 8mg IVTT q 8 Refer Round of Dr. Fargas

12-2-11 2:15pm

Possible transfer to SPMC Please provide discharge summary Facilitate dexamethasone meds. When available

25 Continue medication and monitor CBR without BRP

VITAL SIGNS MONITORING

26 Vital Signs Date 37 C 125 bpm 24 rpm 180/100 mmHg (Nov. 27, Date 36.2C 80 bpm 20 rpm 120/90 mmHg (Dec. 5, Date 36.5C 76 bpm 21 rpm 120/80 mmHg (Dec. 6, Date 36.5C 78 bpm 22 rpm 120/80 mmHg (Dec. 7,

2011) 8:40 p.m Temperature Pulse Respiration Blood Pressure

2011) 2:00 p.m

2011) 2:00 p.m

2011) 2:00 p.m

INTAKE AND OUTPUT December 5, 2011 A.M Oral 600 IVF 200 Urine 100 Vomit

TOTAL INTAKE: 800

TOTAL OUTPUT: 100

P.M Oral 300 IVF 100 Urine 100 Vomit

TOTAL INTAKE: 400

TOTAL OUTPUT: 100

NOC Oral 200 IVF 100 Urine 200 Vomit

TOTAL INTAKE: 300

TOTAL OUTPUT: 200

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December 6, 2011 A.M Oral 400 IVF 300 Urine 400 Vomit

TOTAL INTAKE: 700

TOTAL OUTPUT: 400

December 7, 2011 A.M Oral IVF Urine Vomit

TOTAL INTAKE:

TOTAL OUTPUT:

LABORATORY RESULTS

Parameters

Normal

Result

Indication

Significance

28 Values 5-10x10L

WBC

15.3

increased

WBC plays an important role in immunity, resistance to disease. Increase may signify infection, inflammation, tissue trauma, and polycythemia ( sickle cell anemia and hemolysis)

Hemoglobin

110160g/LF

97

decreased

Hemoglobin is necessary as part of assessment for various types of anemia. Accurate way of measuring the oxygen carrying capacity of blood. Decreased during blood loss and anemia.

Hematocrit

0.37-0.47

0.28

decreased

Hematocrit is the measurement of the percentage of RBC in the total blood volume.

Stabs

0.05-0.10

0.01

decreased

Immature neutrophils that determine alteration in cell production and bone marrow depression

Segmenters

0.50-0.65

0.93

increased

Determine ne presence of infection or inflammation

Lymphocytes

0.25-0.35

0.06

Decreased

Originates from hemocytoblasts in the red marrow. Function is to protect from infectious diseases. Increase may signify infection.

Platelet count

140450x10L

267

Normal

Plays an important role in the clotting of blood and in homeostasis, the process of stopping bleeding. To diagnose a bleeding disorder and clotting ability.

Red cell count

3.40

Red blood cells carry oxygen from the lungs to the tissues around the body. They are also a key player in getting waste carbon dioxide from your

29 tissues to your lungs, where it can breathed out.

URINALYSIS

30 Parameters Normal findings yellow Result Indication Significance

Color

Yellow

Normal

The straw color urine is due largely to the pigment urochrome ( a product of endogenous metabolism, amd under normal conditions it is produced at a constant rate) and to small amounts of urobilins and uroerythrin and pale color urine indicates a high fluid intake.

Transparency

Clear to slightly hazy

Hazy

Normal

Hazy or cloudy urine indicates the presence of WBC, RBC, bacteria, pus, phosphates, urates and uric acid. Urine normally becomes hazy upon standing. Normal acidic urine may also appear cloudy because of precipitated amorphous urates, and calcium oxalate. Presence of squamous epithelial cells and mucous, particularly in specimen from women also result in a hazy but normal urine.

pH Reaction

7.35-7.45

6.0

Below normal

This measures the concentration of particles in the urine. The importance of urinary pH lies primarily as an aid in determining the existence of systematic acid-base disorders of metabolic or respiratory origin and in the management of urinary conditions that require the urine to be maintained at a specific pH.

Specific gravity

1.0051.030

1.030

Normal

This parameter is used for the measurement of the ability of the kidneys to concentrate urine. A

31 decrease may signify distal renal tubular disease and inability of the kidney to concentrate urine to the maximum. Proteins (albumin, globulin) negative + Present Demonstration of proteinuria (albumin) in a routine urinalysis does not always signify renal dysfunction; however, its presence does require additional testing to determine whether the protein represents a normal or pathologic condition. Proteinuria in this case signifies eclampsia. Microscopic Exam. : RBC Negative 0-1 Trace Increased may indicate absolute or relative polycythemia Increase findings may signify bleeding, infection, and trauma. WBC Negative 40-45 Trace Elevated WBC count often signals for infection due to the presence bacteria as evidenced by the patients poor hygienic practices. Squamous epithelial Negative +++ Trace Condition screened for is the index of contamination. They are derived from the linings of the genitor-urinary system. Increase numbers may be seen in females urine that has not been collected using the midstream clean-catch technique. Bacteria + Trace Bacteria are not normally present in the urine. Presence may signify contamination or infection as evidenced by the patients poor

32 hygienic practices. Amorphous sedimentation Volume Sugar Occasion

40 cc trace

CHEMISTRY REPORT

33 Parameters Normal Value Result Indication Significance

An indicator of both the metabolic Blood Urea Nitrogen 1.4-8.3 5.6 normal function of the liver and the excretory function of the kidney. A screening test for renal function. Creatinine 45-84 66 Normal Creatinine is the ideal substance for determining renal clearance because a fairly constant quantity is produce within the body. To determine if your kidneys are functioning normally and to monitor treatment for kidney disease. Serum Glutamic Pyruvic Transaminase (SGPT)or Alanine aminotransferase (ALT) M up to 41 F up to31 15 Below normal Alanine aminotransferase (ALT) catalyzes the reversible transfer of an amino acid group between the amino acid, alanine, and aketoglutamic acid. These enzymes in found in the kidney, heart and skeletal muscle tissues, and liver. Sodium mmol/L 135155mmol/L 142 normal Used to regulate blood volume and blood pressure. Aids in the transmission of nerve impulses. Used to help regulate the acid/base balance in the body. Potassium mmol/L 3.4-5.3 3.1 Below normal Potassium is a very important mineral for the proper function of all cells, tissues, and organs in the human body. It is also an electrolyte, a substance that conducts electricity in the body, along with sodium,

34 chloride, calcium, and magnesium. Potassium is crucial to heart function and plays a key role in skeletal and smooth muscle contraction, making it important for normal digestive and muscular function. Lactodehydrogenase 105 - 333 IU/L (LDH) 129.5 normal Lactate dehydrogenase (LDH or LD) is an present in a wide variety of organisms, including plants and animals

DRUG STUDY

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GENERIC NAME: BRAND NAME: DRUG CLASSES: MECHANISM OF ACTION:

Methyldopa Aldomet Antithypertensive, Sympatholytic Probably due to drugs metabolism, which lowers arterial BP by stimulating CNS alphaadrenergic receptors, which in turn decreases sympathetic outflow from the CNS.

INDICATIONS:

. Hypertension . IV methyldopa: Acute hypertensive crisis; not drug of choice because o slow onset of action . Unable use: Hypertension of pregnancy

CONTRAINDICATIONS:

-Contraindication

with

hypersensitivity

to

methyldopa, active hepatic disease, previos methyldopa therapy associated with liver disorders. - Use cautiously with previous liver disease, renal failure, dialysis, bilateral, pregnancy lactation. DOSAGE & ROUTE: ADVERSE EFFECT: 250mg. 1 tab. PO,TID. -CNS: sedetion, symptoms, astheria, weakness ( usually early and transient), dizziness, light-headed, symptoms o cerebrovascular insuffiency, parenthesias. -CV: Bradycardia, prolonged caroti sinus hypertensivity, aggravation of angina pectoris, paradoxical pressor response, pericarditis, myocarditis, orthostatic hypotension, edema. -GI: Nausea, vomiting, distention, constipation, flatus, diarrhea, colitis, dry mouth, sore or black tounge.

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NURSING INTERVENTIONS:

-Monitor blood counts periodically to detect hemolytic anemia.

-Add a thiazide to drug regimen or increase dosage if methyldopa tolerance occurs. -Discontinue therapy if edema progresses. -Monitor BP carefully when discontinuing methyldopa.

37 GENERIC NAME: BRAND NAME: DRUG CLASSES: Nifedipine Nifedical Antianginal, Antihypertensive, Calcium

channel blockers membranes of cardiac and arterial muscles cells. MECHANISM OF ACTION: Inhibits calcium transport into myocardial and vascular smooth muscles cells, resulting

inhibition of excitation- contraction coupling and subsequent contraction. INDICATION: Management of hypertension ( extendedrelease only) Angina pectoris, Vasospastic (Prinzmetals) prevention angina, of Unlabeled uses:

migraine

headache,

management of cardiomyopathy. CONTRAINDICATION: -Contraindicated with allergy to nifedipine. -Use cautiously with lactation, pregnancy and aortic stenosis. DOSAGE & ROUTE: 5mg 1 cap PO.

ADVERSE EFFECT:

-CNS:

Dizziness, fatigue, blurred

light-

headedness, sleep

headache, disturbances,

nervousness, vision,

weakness,

tremor, mood changes. -CV: Peripheral edema,hypotension,

arrhythmias, AV block, asystole -GI: Nausea, diarrhea, constipation, cramps, flatulence, hepatic injury. NURSING INTERVENTIONS: Monitor patient carefully ( BP, Cardiac rhythm and output) while drug is being adjusted to therapeutic dose: the dosage may be

increased more rapidly in hospitalized patients under close supervision. Do not exceed 30

38 mg/dose increase. -Ensure that the patients do not chew or divide ER tablets. -Taper dosage of beta blockers before

nifedipine therapy. -Protect drug from light and moisture.

39 GENERIC NAME: BRAND NAME: DRUG CLASSES: MECHANISM OF ACTION: Hydralazine Apresoline Antihypertensive, Vasodilator Acts directly on vascular smooth muscles to cause vasodilation, primarily arteriolar, decreasing peripheral resistance, maintains or increases renal and cerebral blood flow. INDICATION: -Parenteral: Severe essential hypertension when drug cannot be given orally or when need to lower BP is urgent. -Unlabeled uses: Reducing afterload in the treatment of heart failure, severe aortic insufficiency, and after valve replacement (does up to 800mg tid). CONTRAINDICATION: Use cautiously with CVAs; increased in tracranial pressure ( drug induced BP decrease increases risk of cerebral ischemia) ; advance renal damage; (higher plasma may be achieved);pregnancy, pulmonary hypertension. DOSAGE & ROUTE: ADVERSE EFFECT: 5mg slow IVTT x1 -CNS: headache, dizziness, tremors, psychotic reaction characterized by depression, anxiety. -CV: Palpitation, hypotension -GI: Anorexia, nausea, vomiting, constipation. NURSING INTERVENTIONS: -Use parenteral drug immediately after opening ampule. Use as quickly as possible after drawing through a needle into syringe. -Withdraw drug gradually, especially from patients who have experienced marked BP reduction. -Discontinue or reevaluate therapy if patient develops fever, chest pain, or continued malaise.

40

GENERIC NAME: BRAND NAME: DRUG CLASSES: MECHANISM OF ACTION:

Cefuroxime Cefutetan Antibiotic, Cephalosporin Bactericidal:Inhibits synthesis of bacterial cell wall, causing cell death. UTIs cause by Escherichia coli, Klebsiella pneumonia.

INDICATIONS:

CONTRAINDICATIONS:

-Contraindicated with allergy to cephalosporins or penicillins. -Use cautiously with real failure, lactation, pregnancy.

DOSAGE & ROUTE: ADVERSE EFFECT:

750mg IVTT q8 hr. -CNS: headache, dizziness, lethargy,

paresthesias -GI: Nausea vomiting, diarrhea, norexia,

abdominal pain, flatulence. NURSING INTERVENTIONS: -Arrange for culture and sensitivity tests of infection before and during therapy if infection does not resolve -Give during with meals if GI complication occur. -Refrigerate suspension, discard after 14 days.

41

GENERIC NAME: BRAND NAME: DRUG CLASSES: MECHANISM OF ACTION:

Dexamethasone Sodium Phosphate Dexasone Corticosteroid, Glucocorticoid, Hormone Enters target cells and binds to specific receptors, initiating many complex reaction that are responsible for its anti-inflammatory and immunosuppressive effects

INDICATION:

-Unlabeled uses: Antiemetic for cisplatininduced vomiting, diagnosis of depression. -Cerebral edema associated with brain tumor, craniotomy, or head injury.

CONTRANIDICATION:

Use cautiously with renal or hypothyroidism, inflammatory bowel disease, heart failure, hypertension, mellitus. seizure disorders, diabetes

DOSAGE & ROUTE: ADVERSE EFFECT:

8mg IVTT q8 -CNS: Seizure, headaches, insomnia,

depression, intracerebral hemorrhage,. -CV: Hypertension, heart failure -GI: Peptic, abdominal distention NURSING INTERVENTIONS: Give daily dose before 9 am to mimic normal peak corticosteroids blood levels. - Monitor blood glucose levels dietary restriction may be needed. - Taper doses when discontinuing highdose or long term therapy. - Do not give live virus vaccines with immunosuppressive doses of corticosteroids.

GENERIC NAME: BRAND NAME: DRUG CLASSES:

Metoclopramide Maxolon Antiemetic, Dopaminergic blocker, GI Stimulant

42 MECHANISM OF ACTION: Stimulates motility of upper GI tract without stimulating gastric, pancreatic secretions; appears to sensitize the tissues to action, little effect of gallbladder or colon motility; increase lower esophageal sphincter pressure; induces relax of prolactin. INDICATION: -Relief of symptoms of acute and recurrent diabetic gastroparesis. -Parenteral: Prevention of nausea and vomiting. -Prophlylaxis of postoperative nausea and vomiting when nasogastric suction is undesirable. -Unlabeled uses: Treatment of nausea and vomiting of variety etiologies: Emesis during pregnancy and labor. CONTRAINDICATION: -GI Hemorrhage -Pregnancy; Fluid overload; Renal impairment DOSAGE & ROUTE: ADVERSE EFFECT: 10mg IVTT x1 amp. -CNS: Restlessness, drowsiness, fatigue, dizziness, anxiety. -CV: Transient hypertension -GI: Nausea, diarrhea. NURSING INTERVENTIONS: -Monitor BP carefully during IV administration. -Monitor patients with diabetes. -Have phentolamine readily available in case of

hypertensive crisis.

GENERIC NAME: BRAND NAME: DRUG CLASSES: MECHANISM OF ACTION:

Paracetamol Acetaminophen Antipyretic, Non- opioid analgesics Inhibits the prostaglandins that may serve as mediators of pain and fever. Has no significant anti-inflammatory property or GI toxicity.

INDICATION: CONTRAINDICATION:

Mild pain, fever -Previous hypersensitivity -Products containing alcohol, sugar or tartrazine should be avoided in patients who have hypersensitivity or intolerance

43 to these compound. DOSAGE & ROUTE: ADVERSE EFFECT: NURSIN INTERVENTIONS: 500mg x1 tab. PRN for fever -hepatic failure, Hepatotoxicity -Assess overall health status and alcohol usage before administering acetaminophen. -Assess amount, frequency and type of drugs taken in patient. -PAIN: assess type, location, and intensity prior to and 3060 mins. Following administration. -FEVER: assess ver, note presence of associated signs( diaphoresis, tachycardia and malaise).

Reference: Amy M. Karch, 2011 Lippincotts Nursing Drug Guide : Davis Nursing Drug Guide

44 NURSING CARE PLAN

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NURSING MANAGEMENT

Discharge Plan Medication: Teach the client the importance of medication, its purpose and its possible side effects. Teach the client about right dosage, route and time on taking medications. Instruct client not to skip on taking medications and do not over and under dose. Encourage the client to comply all the medications.

Exercises: Encourage client to do stretching exercises at least 15 minutes a day. Advice to do deep breathing exercise.

Treatment/Therapy: Advice client to promote bed rest. Encourage to have a good nutrition. Provide emotional support.

Health Teachings: Encourage client not to do stressful and strenuous activities. Advice to rest at home. Advice to sleep atleast 6-8 hours a day. Advice the client to limit OFI.

OPD Units:

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Advice client to visit clinic and have a follow-up chek-up.

Diet and Nutrition: Advice client to eat low salt, low fat foods. To eat nutritious foods that is supplementary to the fetus. Instruct the client to take the supplements ordered by the physician.

Spiritual: Advice the patient to have spiritual activities with her family to gain physical, emotional, and spiritual strength. Advice the patient to have faith in God, for God is the only one that we can turn to in time of difficulties and trials. And for God nothing is impossible.

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PROGNOSIS

CRITERIA

POOR

FAIR

GOOD

JUSTIFICATION Prior to admission, the patient was experiencing nausea and vomiting and is 7 months pregnant.

Onset of illness

She was admitted at Davao Adventist Hospital last Nov. 27, 2011 with admitting diagnosis of gestational diabetes, UTI and Pre-eclampsia.

Client was in the hospital for more Duration of Illness than 1 week and is advice to transfer to another hospital.

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Patient realizes that Attitude and willingness to take medication taking medication is an important part of the therapy. She cooperates even with financial problems.

Apparently client is 41 years old in middle adulthood and pregnant. Age

Family support

Family support is poor and financial support is not rendered. The patient is not in good terms with her husband.

Environment

Environment is not well ventilated. Disturbed by the other patient but provided a comfortable bed by the hospital.

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Computation: Poor: 4/6 x 100 = 67% Fair: 2/6 x 100 = 33% Good: 0/6 X 100 = 0% Overall prognosis: Poor

Conclusion In conclusion client has poor recovery of the illness since pre-eclampsia is a condition which can endanger the life of mother and the fetus, the mother must have OPD visits most of the time because of her condition. This will help her to keep updated with the fetus inside her womb. Base on the clients situation, she should be encouraged and be educated about the disease and ways to prevent further complications of the disease.

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RECOMMENDATION

To the client: Client should be instructed that taking medication must be her top priority. Regular prenatal check-up is important to ensure the health of the mother and the baby. Client should be aware of the dangers of pre-eclampsia.

To the family: Family of the client must be aware of patients condition and the necessary support she needs. Family must watch out for any serious manifestations of preeclampsia . Emotional support should be rendered by the husband, it is necessary for the patients well-being and development of the baby. *husband must give full support to his wife and attention. Emotionally, mentally spiritually and physically are all needed to.

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SCOPE AND LIMITATION

We the 2nd year nursing student with the case study of Pre-eclampsia, would like to present our scope and limitation: 1. Insufficient time and care rendered due short term of stay in the hospital. 2. Patient chart and laboratory results are not completely supplied with necessary data. 3. Home visit was not possible because the address given is not familiar to us, and the call of the group made is not answered. 4. The presentation is only intended to discuss PIH (Pre-eclampsia) only.

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BIBLIOGRAPHY

Marieb, Elaine N., 2006, Essentials of Human Anatomy & Physiology,8th ed., Pearson Education, Inc., pages 347-366 Doenges, Moorhouse, and Murr, Alice, 2010., Nurses Pocket Guide: Diagnoses, Prioritized interventions, Rationales.,12th ed.,F.A Davis Company, Hegner, Acello, and Caldwell, 2004, Nursing Assistant: a Nursing Approach, 9th edition, Thomas Learning, inc. pages 733- 734 Luxner, Karla L.,2005, Delmars Maternal-Infant Nursing Care Plans, 2nd ed.,Thomson Learning, pages 48-53 Nursing 2006 Drug Handbook, 26th ed., Lippincott William & Wilkins Pilllitteri, Adele.,2010, Maternal and Child Health Nursing: C aring of childbearing And Child Rearing Famiy, Vol.1, 6th ed., Lippincott William & Wilkins.pages 575-582 Olds, London, Ladewig, and Davidson, 2004, Maternal- Newborn Nursing & womens Health Care, 7th ed. Pearson Education, Inc. pages 490-496 Case study-Preeclampsia., http://www.docstoc.com/docs/8981344/Case-Study-Pre-

Eclampsia Johnson, Bijoy.2010,Cardiophile: Live Life Heart Healthy! Cardiovascular System, http://www.cardiophile.com/77 University of Maryland Medical Center., 2011: Potassium.,http://www.umm.edu/altmed/articles/potassium-000320.htm#ixzz1lac5zgh6 Lidheimer and Katz 1981., Pathophysiology of Preeclampsia, department of Obstetrics and gynecology and medicine, the University of Chicago, Pritzker School of Medicine, Chicago Illinois 6037

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Mrown, Mark., Preeclampsia. Pathophysiology., http://www.csaol.cn/img/Hypertextbook/a/c39.htm Pre-eclampsia.,http://en.wikipedia.com/pre-eclampsia National institutes of health http://www.medicinenet.com/pregnancy_induced_hypertension/page3.htm List of risk factors for Preeclampsiahttp://www.rightdiagnosis.com/p/preeclampsia/riskfactors.htm Gastroenterology Research online 2010.,Hematoma HELLP syndromehttp://www.gastrores.org/index.php/Gastrores/article/viewArticle/205/246 Amy M. Karch, 2011 Lippincotts Nursing Drug Guide., Davis Nursing Drug Guide