INTRODUCTION Preeclampsia is a major cause of maternal and perinatal morbidity and mortality. It accounts to 28.

4% of maternal morbidity and mortality in the Philippines according to DOH (as of Feb. 2008). The condition sometimes referred to as pregnancy-induced hypertension is defined by high blood pressure and excess protein in the urine after 20 weeks of pregnancy. Often, preeclampsia causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious even fatal complications for both mother and baby. The only cure for preeclampsia is delivery of the baby. If preeclampsia develops near the end of your pregnancy, delivery is the obvious solution. If you're diagnosed with preeclampsia earlier in your pregnancy, you and your doctor face the delicate task of prolonging your pregnancy to allow your baby more time to mature, without putting you or your baby at risk of serious complications. The signs of preeclampsia are elevated blood pressure (hypertension) and the presence of excess protein in your urine (proteinuria) after 20 weeks of pregnancy. The excess protein is related to problems with your kidneys. Your doctor may identify these signs of preeclampsia at one of your regular prenatal visits. Other signs and symptoms of preeclampsia which can develop gradually or strike suddenly, often in the last few weeks of pregnancy may include: Severe headaches, Changes in vision, including temporary loss of vision, blurred vision or light sensitivity, Upper abdominal pain, usually under the ribs on the right side, Nausea or vomiting, Dizziness, Decreased urine output, Sudden weight gain, typically more than 2 pounds a week Swelling (edema), particularly in the face and hands, often accompanies preeclampsia as well. Swelling isn't considered a reliable sign of preeclampsia, however, because it also occurs in many normal pregnancies. Preeclampsia used to be called toxemia because it was thought to be caused by a toxin in a pregnant woman's bloodstream. Although this theory has been debunked, researchers have yet to determine what causes preeclampsia. Possible causes may include: Insufficient blood flow to the uterus, Damage to the blood vessels, A problem with the immune system. Preeclampsia develops only during pregnancy. Risk factors include: History of preeclampsia. A personal or family history of preeclampsia increases your risk of developing the condition. First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy or your first pregnancy with a new partner. Age. The risk of preeclampsia is higher for pregnant women who are older than age 35. Obesity. The risk of preeclampsia is higher if you're obese. Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or other multiples. Gestational diabetes. Women who develop gestational diabetes have a higher risk of developing preeclampsia as the pregnancy progresses. History of certain conditions. Having certain conditions before you become pregnant such as chronic high blood pressure, diabetes, kidney disease or lupus increases the risk of preeclampsia.

NURSING HEALTH HISTORY Demographic Data Mrs. Preec is a 35 year old client, Filipino citizen, married and plain housewife born on December 2, 1975. She is second among the five siblings of Mr. A and Mr. B. Mrs. Preec has no known vices, does not smoke nor drink. The familial disease that runs in their family is hypertension on the mother side. Past health history Mrs. Preec was first hospitalized last august 2007 during the delivery of her first baby through normal spontaneous delivery at Ospital Ning Angeles. Aside from hypertension which is hereditary n their family. She only experienced mild forms of cough and colds and fever. She takes OTC drugs to treat these problems. She has completed her immunization during her younger years. Present Health History Prior to admission the patient is complaining of nape pain and dizziness. Her initial vital signs upon admission are T=37.0 C, P=89 beats per minute, R=20 breathes per minute, BP= 180/100 mmHg. Her admitting diagnosis is Preeclampsia. Mrs. Preec is pregnant on her second child with and an AOG of 28 weeks and 4 days. She is expected to deliver on April 22, 2011. Maternal Obstetric Record Mrs. Preec is married since she was 27 years old. She had her menarche at age 12. She has 28 day regular cycle and last for 5-6 days. Her last menstruation period was on July 15, 2010. Upon the day of assessment, she has GPTPALM of Gravida-2, Para-1, Term-1, Preterm-0, Living-1, Multiple Pregnancies-0. She is currently on her 28th weeks and 5th day of pregnancy on the day of assessment. She is expected to deliver on April 22, 2011. GORDONS PATTERN Person Approach Self Perception Pattern Mrs. PREEC is a very jolly individual. She seems very satisfied to the life that she has. Just being with her partner she feels complete and secure. She is very appreciative even on the simple things being done to her, especially with her husband. She sees problems as test of courage and faith to Him. Role Relationship Pattern Mrs. PREEC resides with her family including her parents in Balibago, Angeles City. With regard to decision making, it is both of them who decide on whatever actions to be done. Coping Perceptual Pattern Mrs. PREEC has a good vision & hearing. When she feels dizzy, the patient take time to rest by sleeping on the bed or sitting on a chair.

 Coping Stress Tolerance Pattern She is a jolly person that is why coping with stress is not a problem with her. She manages it by simply diverting it to other things like talking to friends, watching TV, listening to radio, etc Her husband has always been the first person she asks for help when she is stressed out or feeling down. Also, they just keep a positive outlook and a strong faith to the Lord whenever things are going really bad. Value Belief Pattern Mrs. PREEC is a catholic. Her husband was an Iglesia ni Cristo member, but was later on was converted when they got married. With her family, they hear mass every Sunday. She has observed the closeness of their family when she was still young. Now that she has her own, she wants that close family ties be observed. She is very satisfied with her life. ELIMINATION She has a regular bowel movement and she defecates regularly. In regards to the amount and character, everything is regular and normal. No discomfort or any pain being felt. She is clean and seems to practice good hygiene routine. She voids 2-3 times a day. Activity Exercise Pattern Doing household chores and her work are the only form of exercise she has. These keep her in good shape. Her leisure activities are just watching TV, listening to radio and chatting with her neighbors. Sleep Rest Pattern Mrs. PREEC has a regular bed time. She has 8 hours of sleep everyday. This is enough for her to do her tasks for the next day. SAFE ENVIRONMENT The patient has no allergies on any medications and/ foods. In regards with her skin integrity there are no evident lesions. It appears to be some how smooth. OXYGENATION Mrs. PREEC has no difficulty in breathing. NUTRITION Mrs. PREEC cooks their food but there would be times that she buys outside. Her favorite foods would be anything with fish and vegetables. There is nothing in particular that she dislikes. She eats three times a day with snacks in the afternoon. She has a big appetite. There are times that quantity and quality of food is being sacrificed because of tight budgeting. PHYSICAL ASSESSMENT On the day of assessment dated January 31 2011, the patient was seen sleeping but still complain of dizziness. The patient has both non-pitting edema on both feet. Patient was awakened, conscious and coherent, able to understand and respond to questions appropriately and reasonably quickly. No signs of respiratory distress. Vital signs were taken and the blood pressure was noticeably high so it was reported to the nurse on duty. The blood pressure is 180/100 mmHg, temperature of 36.9C, pulse of 70 beats per minute and respiration of 20 breathes per minute.

DIAGNOSTIC PROCEDURE 1. Urinalysis Name of Procedure Urinalysis Indication Date Ordered Results Normal Values Analysis / interpretation of results Normal urine color.

It is used to detect or diagnose a urinary tract or kidney infection, to evaluate causes of kidney failure, to screen for progression of some chronic conditions such as diabetes mellitus and hig h blood pressure(hypert ension).

Januray 30, 2011

Color: yellow

It can vary in color from pale (almost colorless) yellow to dark yellow.

Transparency : Turbid

Urine should be clear

Cloudy urine or urine with a high level of sediment may be present in cases of urinary tract infection.

Sugar: negative

normally negative (absent)

Absence of glucose in the urine means it did not indicate diabetes.

Albumin: positive

Negative.

Positive albumin in the urine may indicate may indicate kidney disease.

Reaction: acidic (6.9)

Acidic (6.9-7)

Normal urine ph.

Specific gravity: 1.010

1.003 to 1.030

It means that the concentration of solutes in the urine is normal

NURSING RESPONSIBILITIES FOR URINALYSIS: Before: Verify the doctors order. Explain to the patient the importance of the procedure. The first morning sample is the most valuable because it is more concentrated and more likely to yield abnormal results Assist the patient. During: After: Relay the results to the attending physician. 2. Ultrasound Diagnostic / Laboratory Procedures Pelvic Ultrasound Indications or Purpose Date Ordered/Date Results were released January 30, 2011 Results Normal Values Analysis and interpretation of the results A single live male fetus in cephalic presentation of about 28 weeks and 4 days of AOG. Normohydramnios. Provide privacy. Advise the patient to catch the midstream of the urine. Transport time for culture specimen must be minimized. Handle specimen carefully.

For a better visualization of the fetus as well as to know if there are any abnormalities occurring inside the uterus.

Within the enlarged uterus is a single live fetus in cephalic presentation. The biparietal diameter is measured as 84mm, a femoral length of 69mm and an abdominal

N/A

circumference of 313mm in dm, Nursing Responsibilities for ULTRASOUND (Pelvic) Before: 1. Check doctors orders 2. Ask for the patients identification 3. Explain the procedure properly to the SO. 4. Instruct the client not to void prior the procedure. During: The patient lies on an examining table with the part of the body to be examined exposed. 2. A conductive gel is applied to the skin over the area under examination. 3. You lie quietly as the person performing the examination moves the transducer over the skin surface while watching the monitor. 4. You may be asked to shift positions to obtain other views of the organ(s) under study.
1.

After: 1. Wait for the further results. 2. The patient can void. 3. Wait for the physician to interpret the results ANATOMY AND PHYSIOLOGY CARDIOVASCULAR SYSTEM The cardiovascular system is sometimes called the bloodvascular or simply the circulatory system. It consists of the heart, which is a muscular pumping device, and a closed system of vessels called arteries, veins, and capillaries. As the name implies, blood contained in the circulatory system is pumped by the heart around a closed circle or circuit of vessels as it passes again and again through the various "circulations" of the body. Heart The heart is a muscular pump that provides the force necessary to circulate the blood to all the tissues in the body. Its function is vital because, to survive, the tissues need a continuous supply of oxygen and nutrients, and metabolic waste products have to be removed. Deprived of these necessities, cells soon undergo irreversible changes that lead to death. While blood is the transport medium, the heart is the organ that keeps the blood moving through the vessels. It is located between the lungs in the middle of the chest, behind and slightly to the left of the breastbone (sternum). A double-layered membrane called the pericardium surrounds the heart like a sac. The outer layer of the pericardium surrounds the roots of the heart's major blood vessels and is attached by ligaments to your spinal column, diaphragm, and other parts of your

body. The inner layer of the pericardium is attached to the heart muscle. A coating of fluid separates the two layers of membrane, letting the heart move as it beats, yet still be attached to your body. Blood Blood is actually a tissue. It is thick because it is made up of a variety of cells, each having a different job. In fact, blood is actually about 80% water and 20% solid. Platelets, which help the blood to clot. Clotting stops the blood from flowing out of the body when a vein or artery is broken. Platelets are also called thrombocytes. Blood carries oxygen from the lungs and nutrients from the digestive tract to the bodys cells. It also carries away carbon dioxide and all of the waste products that the body does not need. (The kidneys filter and clean the blood.) Blood also Helps keep your body at the right temperature Carries hormones to the bodys cells Sends antibodies to fight infection Contains clotting factors to help the blood to clot and the bodys tissues to heal

Blood Vessels Blood vessels are the channels or conduits through which blood is distributed to body tissues. The vessels make up two closed systems of tubes that begin and end at the heart. One system, the pulmonary vessels, transports blood from the right ventricle to the lungs and back to the left atrium. The other system, the systemic vessels, carries blood from the left ventricle to the tissues in all parts of the body and then returns the blood to the right atrium. Based on their structure and function, blood vessels are classified as arteries, capillaries, or veins. a. Arteries Arteries carry blood away from the heart. Pulmonary arteries transport blood that has low oxygen content from the right ventricle to the lungs. Systemic arteries transport oxygenated blood from the left ventricle to the body tissues. Blood is pumped from the ventricles into large elastic arteries that branch repeatedly into smaller and smaller arteries until the branching results in microscopic arteries called arterioles. The arterioles play a key role in regulating blood flow into the tissue capillaries. About 10 percent of the total blood volume is in the systemic arterial system at any given time. b. Capillaries Capillaries, the smallest and most numerous of the blood vessels, form the connection between the vessels that carry blood away from the heart (arteries) and the vessels that return blood to the heart (veins). The primary function of capillaries is the exchange of materials between the blood and tissue cells. Smooth muscle cells in the arterioles where they branch to form capillaries regulate blood flow from the arterioles into the capillaries. c. Veins

Veins carry blood toward the heart. After blood passes through the capillaries, it enters the smallest veins, called venules. From the venules, it flows into progressively larger and larger veins until it reaches the heart. In the pulmonary circuit, the pulmonary veins transport blood from the lungs to the left atrium of the heart. This blood has a high oxygen content because it has just been oxygenated in the lungs. Systemic veins transport blood from the body tissue to the right atrium of the heart. This blood has a reduced oxygen content because the oxygen has been used for metabolic activities in the tissue cells. The walls of veins have the same three layers as the arteries. Although all the layers are present, there is less smooth muscle and connective tissue. This makes the walls of veins thinner than those of arteries, which is related to the fact that blood in the veins has less pressure than in the arteries. Because the walls of the veins are thinner and less rigid than arteries, veins can hold more blood. Pulse and Blood Pressure Pulse refers to the rhythmic expansion of an artery that is caused by ejection of blood from the ventricle. It can be felt where an artery is close to the surface and rests on something firm. In common usage, the term blood pressure refers to arterial blood pressure, the pressure in the aorta and its branches. Systolic pressure is due to ventricular contraction. Diastolic pressure occurs during cardiac relaxation. Pulse pressure is the difference between systolic pressure and diastolic pressure. Blood pressure is measured with a sphygmomanometer and is recorded as the systolic pressure over the diastolic pressure. Four major factors interact to affect blood pressure: cardiac output, blood volume, peripheral resistance, and viscosity. When these factors increase, blood pressure also increases. The blood vessels of the body are functionally divided into two distinctive circuits: pulmonary circuit and systemic circuit. The pump for the pulmonary circuit, which circulates blood through the lungs, is the right ventricle. The left ventricle is the pump for the systemic circuit, which provides the blood supply for the tissue cells of the body. KIDNEY The kidneys are organs that filter wastes (such as urea) from the blood and excrete them, along with water, as urine. In humans, the kidneys are located in the posterior part of the abdomen. There is one on each side of the spine; the right kidney sits just below the liver, the left below the diaphragm and adjacent to the spleen. Above each kidney is an adrenal gland (also called the suprarenal gland). The asymmetry within the abdominal cavity caused by the liver results in the right kidney being slightly lower than the left one while the left kidney is located slightly more medial. a. Homeostasis The kidney is one of the major organs involved in whole-body homeostasis. Among its homeostatic functions are acid-base balance, regulation of electrolyte concentrations, control of blood volume, and regulation of blood pressure. The kidneys accomplish these homeostatic

functions independently and through coordination with other organs, particularly those of the endocrine system. The kidney communicates with these organs through hormones secreted into the bloodstream. Glomerular filtration rate (GFR) Glomerular filtration rate (GFR) is a test used to check how well the kidneys are working. Specifically, it estimates how much blood passes through the tiny filters in the kidneys, called glomeruli, each minute. Glomerular filtration is the process by which the kidneys filter the blood, removing excess wastes and fluids. Glomerular filtration rate (GFR) is a calculation that determines how well the blood is filtered by the kidneys, which is one way to measure remaining kidney function.

Pathophysiology (Patient-Centered)

Non-Modifiable Factors Age (35 years old) Family History of hypertension

Modifiable Factors Diet

Increase cardiac output

Damage of endothelial lining of artery

vasospasm

vasoconstriction

vasoconstriction

Decrease organ perfusion

Increase BP

kidneys

Hypertension

Decrease GFR

Increase Permiability

Reabsorption in Tubules

Dec U/O Inc uric acid Inc creatine level

Proteinuria

Increase Na retention + H20

edema

LIST OF PRIORITIZED NUSING DIAGNOSIS 1. INEFFECTIVE TISSUE PERFUSION related to vasoconstriction of blood vessels 2. DEFICIENT FLUID VOLUME related to fluid loss to subcutaneous tissue 3. RISK FOR FETAL VOLUME related to reduced placental perfusion secondary to vasospasm

DISCHARGE PLANNING

Medication Instructed Mrs. PREEC to take Ferrous Sulfate 300mg once a day. Explain medicines administration of antihypertensive drugs. Exercise Provide environment within normal room and body temperature. Maintain safe environment. Institute seizure precaution. Teach patient to perform passive range of motion exercises on patients extremities.

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

Health teaching Encourage and explain the importance of breast feeding to the client. Breastfeeding especially the first milk, colostrum, can reduce postpartum bleeding/hemorrhage in the mother, and to pass immunities and other benefits to the baby

Out-Patient Appointment schedule for follow-up checks Inform relatives regarding importance of compliance on follow-up check up. Instructions or requirements (if any) on scheduled follow-up Clinic Schedules

Diet Advise client to eat proper diet. Pt was on low fat salt and low fat diet. Encourage her to eat more vegetables and frequent intake of liquids. Advise her to eat food which are rich in iron and vitamin C. Iron provides formation of Red blood cells and ascorbic acid for helping absorption of iron.

Sex

Pt will be advice to take child spacing for 2-3 years to prevent occurrence of the disease.

CUES OBJECTIVE: Nahihilo ako. Masakit ang batok ko. as verbalize by the pt.

INFERENCE Due to increase in blood pressure the pt has ineffective tissue perfusion

NURSING DIAGNOSIS Ineffective tissue perfusion related to vasoconstriction of blood vessels As evidenced by blood pressure of 180/100

PLANNING After 8 hours of nursing interventions, the pt blood pressure will decrease from 180/100 to 140/90

IMPLEMENTATION -Monitor vital signs particularly Blood pressure.

RATIONALE To identify physical responses associated with medical conditions. Sodium excretion is faster in this position

EVALUATION The pt blood pressure have decrease from 180/100 to 140/90

SUBJECTIVE: - Edema noted on lower extremities - cold, clammy skin noted. - capillary refill within 6 seconds -Vital signs: BP: 180/100 T:36.9 C P: 70 BPM R: 20 BPM

-Provide complete bed rest in dorsal recumbent position -diet restricted to low salt, low fat diet - Provide quiet and restful environment.

To educe edema It conserves energy/lowers tissue oxygen demand.

DEPENDENT - Administer Antihypertensives help antihypertensive drugs decrease and control as ordered. blood pressure. - Administer Magnesium sulfate as ordered. Magnesium sulfate prevents or controls seizures in preeclampsia brought about by vasospasm secondary to vasoconstriction of blood vessels.

DRUG STUDY DRUG CLASSIFICATION ROUTE/DOSAGE/ FREQEUNCY Generic Anti-Hypertensive IV drip infusion 5 name: mg slow IV Hydralazine Vasodilator Brand name: Apresoline HCL MECHANISM OF ACTION Directly relaxes arteriolar smooth muscles to cause vasodilation and decreased blood pressure CONTRAINDICATION Hypersensitivity, Idiopathic SLE and related diseases. Severe tachycardia and Heart failure SIDE EFFECTS Headache, dizziness, SLE like syndrome, vasomotor reaction(tachyc ardia, hypotesion) NURSING RESPONSIBILITY
Monitor blood pressure before and after administration of drugs. Average maximal decrease occurs in 10-80 min. Eclampsia: 5-10 mg every 20 min via IV bolus: if no response after 20 mg, try another drug. With hold drug if diastolic BP is under 90 mmhg Drug may cause a syndrome resembling systemic lupus erythematosus (SLE). Arrange for CBC, LE cell preparations, and ANA titers before and periodically during prolonged therapy, even in the symptomatic patient. Discontinue if blood dyscrasias occur. Arrange for pyridoxine if patient develops symptoms of

peripheral neuritis. Monitor patient for orthostatic hypotension which is most marked in the morning and in hot weather and with alcohol or exercise. Monitor blood pressure before and after administration of drugs Regularly assess renal status Monitor for allergic reaction. Discontinue drug if allergic reaction occurs

Generic name: Methyldopa Brand Name: Aldomet

Antihypertensive

500 mg oral Q6

Active metabolite alphamethylnoreepinep hrine receptor in CNS, resulting in decreased sympathetic outflow from the brain to the heart, kidneys and peripheral vasculature

Hypersensitivity, therapy with monoamine oxidase (MAO) inhibitors, active hepatic disease

Sedation, headache, edema, decreased libido, weakness