I

INTRODUCTION

Pre- eclampsia, also referred to as toxemia, is a medical condition where

hypertension arises in pregnancy in association with significant amounts of protein in
the urine. Pre- eclampsia refers to a set of symptoms rather than any causative factor,
and there are many causes for the condition.
A woman has passed from mild to Severe Pre- eclampsia when her blood
pressure has risen to 160mmHg systolic and 110mmHg diastolic or above on at least
two occasions 6 hours apart at bed rest or her diastolic pressure is 30mmHg above the
pre- pregnancy level.
Complications of hypertension are third leading cause of pregnancy- related
deaths, superseded only by hemorrhage and embolism. Pre- eclampsia is associated
within increased risk of placental abruption, acute renal failure, cerebrovascular and
cardiovascular complications, disseminated intravascular coagulation, and maternal
death. Magnesium Sulfate is the first- line treatment of prevention of primary and
recurrent eclamptic seizures. 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.
In the case of Mrs. EQ, 29 years old from Purok 3 Brgy. 16 GingoogCity. She was
admitted to MOPH- Gingoog (OB Ward) last January 19, 2015 at 11:35 AM with
diagnosis of labor pain and mild pre-eclampsia.

II OBJECTIVES

General Objectives:
At the end of this Abnormal OB case study, knowledge and ideas will be gained
about abnormal pregnancy, the diagnoses, causes, effects, planning and implementing
interventions for the health benefit of the client and also practice skills and deal
appropriate attitudes towards the client. And also we did this case study for us to have a
deeper understanding of what is preeclampsia is thus to give us an idea of how we
could give proper nursing care for our client with this condition.

Specific Objectives:
The students will be able to:
A. Present a complete assessment regarding (mild preeclampsia), through
nursing health history, physical assessment and the interpretation of the
laboratory examinations done on the patient.
B. Discuss the anatomy and physiology of the reproductive, Pathophysiology
of the patients condition, usual clinical manifestation and possible
complication of the condition.
C. Enumerate the necessary medications needed and be familiar to its mode
of action.
D. Formulate a workable nursing care plan on the subjective and objective
cues gathered through nurse-patients interaction to be able to help the
patient towards wellness.

III

DEMOGRAPHIC DATA

Name

Ms. EQ

Address

P-3, Brgy. 16, Gingoog City

Age

29 years old

Gender

Female

Occupation

House Wife

Religion

Roman Catholic

Civil Status

Single

Nationality

Filipino

Educational Attainment

High School Graduate

Date of Admission

January 19, 2015, 11:35 AM

Room Number

OB ward

Physician

Dr. Marlene Coronado

Chief Complain

Labor pain

Diagnosis

PUFT in labor with Mild Pre Eclampsia. G5 P5

LMP

April 09, 2014

EDD

January 16, 2015

AOG

40 weeks

IV

Developmental Theories

Erick Ericksons Psychosocial Theory

(Ego Development Outcome: Generativity vs. Self absorption or Stagnation)
The significant task is to perpetuate culture and transmit values of the
culture through the family (taming the kids) and working to establish a stable
environment. Strength comes through care of others and production of
something that contributes to the betterment of society, which Erickson calls
Generativity, so when were in this stage we often fear inactivity and
meaninglessness.
Mrs. G, do not want to stay longer in the hospital because she felt useless
that she cannot do things she wants and felt stuck in the room frequently to
protect herself from infection. She felt hopeless with her condition.

Sigmund Freuds Psychosexual Theory (Genital Stage)

Ms. EQ is now on the genital stage, wherein Freud said that on this stage
a person will develop a heterosexual relationship.

Our client has indeed

developed it, lived together with her partner and is now a mother to her kids.

Jean Piagets Cognitive Theory (Formal Operational Stage)

Our client is on the last stage of cognitive theory, which is the formal
operational theory.

In this stage, client will show understanding in abstract

concepts and Ms. Je has shown that by means of communicating to us when she
verbalized that everything that has happened to her during the course of her
pregnancy has a reason. She viewed her life positively, and is very welcoming of
what future will await her.

Lawrence Kohlbergs Moral Development Theory

In Stage five (social contract driven), the world is viewed as holding different
opinions, rights, and values. Such perspectives should be mutually respected as
unique to each person or community.
We observed that she respect and listen to the opinion of others and view
herself as different to others having unique attitudes and personality. Shes very
cooperative.

ASSESSMENT

FAMILY HISTORY
Ms. EQ is the youngest of 3 children. She originally lives in Villanueva, Misamis
Oriental. 13 years ago, she met Mr. EQ. Mr. EQ was working on a construction site in
Villanueva. He was a middle child of 9 children. He originally was from P-3, Brgy. 16,
Gingoog City, their current residence.
The love story of Mr. and Ms. EQ can be considered as something out of track.
Ms. EQ got pregnant with her first daughter with the hopes that they will get married
soon. However, until now with five children, they were still not able to have their
relationship blessed with the sacred sacrament of marriage.
Mr. and Ms. EQ together with their five children live in P-3, Brgy. 16, Gingoog
City.They moved from Villanueva to Gingoog City upon Ms. EQs first pregnancy. Mr. EQ
is a pedicab driver and Ms. EQ is a plain housewife. Mr. EQ sets off at 7 oclock and
return home for lunch at 11 oclock. At 5 in the afternoon, Mr. EQ would return home
with P150.00 for the family.

OB HISTORY
Ms. EQ has had five normal spontaneous vaginal deliveries. Her first child was a
baby girl born last January 23, 2002. She gave birth at a public hospital in Villanueva,
Misamis Oriental. Her second child was a baby boy born last November 15, 2004 at
home with the help of a midwife. Her third child was also delivered at home, a baby boy
born last November 13, 2007. The first three children were born in Villanueva, Misamis
Oriental, even when they already moved to Gingoog. She stated that whenever shes
pregnant, her mother would always want her to go back to Villanueva and have her
baby delivered there because her mother wants to take care of her.
The fourth son was delivered at home last March 31, 2011 in Gingoog City with
the help of a midwife. Her fifth child, a baby boy was born last January 19, 2015 in
Misamis Oriental Provincial Hospital Gingoog in which she experienced high blood
pressure during the onset of the third trimester. According to her, during the prenatal
check-up her blood pressures are normal ranging from 110/ 80 to 120/90. But as we
checked her records, we found out that there was a significant increase of the blood
pressure on her third visit. She usually has her prenatal check-up at the Barangay
Health Center of Brgy. 16. Moreover, she stated that this is the first pregnancy that she
experienced high blood pressure.

DISEASE HISTORY
During the interview, Ms. EQ admitted that in her family, hypertension is
common, especially to her mothers side. However, with her previous pregnancies
according to her, she did not experience hypertension. She has no history of
hospitalization aside from when she delivered her first baby.

HISTORY OF PRESENT ILLNESS

Ms. EQ was admitted to the hospitals emergency room at 11:35 AM last January
19, 2015, with chief complaint of labor pain. Patients blood pressure is 140/90 mmHg,
fundal height of 29 cm, weighed 49 kilos, G5 P4 with doctors initial diagnosis of preeclampsia.
Her last menstrual period was April 9, 2014, with an expected date of
confinement on January 16, 2015. She is on her 40 th week gestation.
Her laboratory results show a +1 protienuria. However, we were not able to have
a copy of her lab results. A mild edema was noted by the barangay midwife during her
prenatal visits.
PRENATAL CHECK-UP
FIRST VISIT
Ms. EQs prenatal record reveals that her first prenatal check up was on
September 17, 2014. Blood pressure of 120/80, AOG is 23 weeks, weighed 43 kg. The

midwife gave her 30 tablets of ferrous sulfate and multivitamins with iron. She was
advised to drink plenty of water, have enough rest, eat vegetables, and avoid salty
foods and spicy foods. She was advised to get a urinalysis and CBC laboratory but was
unable to comply.
The ferrous sulfate is necessary to supplement or help in the production of blood
cells and avoid anemia, as physiologically, a pregnant woman will have 30 50%
increase in blood volume. Multivitamins is necessary to supplement and prevent
micronutrient deficiency that may happen during pregnancy, especially that Ms. EQ has
a very low weight. It is important to avoid salty food because it may cause UTI during
pregnancy which is very dangerous to the fetus inside. The fetus might get the illness.
Another important reason is that, too much salt will attract water that may lead to water
retention causing edema. Spicy foods are not good because it will cause hemorrhoids.
SECOND VISIT
Ms. EQs second prenatal check-up was on Nov. 26, 2014 at 33 weeks gestation
with a blood pressure of 120/80 and weighs 45 kg. We see no significant change in her
vital signs. She was given the same recommendations; however, she admitted that it is
very hard for her to comply in terms of the diet because she is so fund of eating bulad,
ginamos and instant noodles.
THIRD VISIT
On the third visit on Dec. 19, 2014 at 36 weeks AOG, Ms. EQ had a significant
increase in her blood pressure. Her BP was 140/90 which alarmed the midwife. She
weighed 47 kg with the FH of 28 cm.
10

PHYSICAL AND VITAL SIGNS ASSESSMENT

HOME VISITATION ASSESSMENT

MOTHER
TIME
First Visit
Feb. 5, 3025
Second Visit
March 1, 2015
Third Visit
March 3, 2015

T
36.6C

P
84bpm

R
24cpm

BP
140/90mmHg

37.0C

84bpm

23cpm

160/120mmHg

36.4C

86bpm

23cpm

160/120mmHg

BABY
TIME
First Visit
Feb. 5, 3025
Second Visit
Macrh 1, 2015
Third Visit
March 3, 2015

T
36.4C

P
157bpm

R
45RR

36.4C

156bpm

46RR

36.5C

158bpm

44RR

11

GORDONS FUNCTIONAL ASSESSMENT

PATTERNS
1.Health Pattern and Health Management

-Client completed her prenatal check-up in

the Barangay 16 Health Center. According
to her, the vital signs are normal but when
we checked her records, we noticed her
vital signs during her prenatal are not
normal. The patient had completed her
immunization, and she was given Ferrous

2.Nutritional/Metabolic

Sulfate at their barangay.

-The client eats 3 times daily and her food
preferences

3.Elimination

are

instant

noodles,

vegetables and fish.

-During her pregnancy, she has a good
elimination pattern. She voids according
approximately 5-6 times daily.

4.Activity-Exercise

She

defecates daily also.

-Prior to hospitalization, she does not have
any special activities. Her exercise was
only when shes moving around the house
doing

household

hospitalization
5.Sleep-Rest

she

chores.
was

During

instructed

to

complete bed rest due to her condition.

-She experienced disturbance in her sleep
because

of

discomfort

during

her

pregnancy, like difficulty breathing.

12

6.Cognitive-Perceptual

-Client answers questions according to

what was asked to her. She was oriented
to place, time and person. However, we
can say that her willingness to learn on

7.Self-PerceptionSelf-Concept

what to do still needs further motivations.

-Although shes willing to listen to what we
have to say, she seemed to be passive

8.Role-Relationship

concerning her condition.

-As a mother, she seemed to be struggling
with the nutritional intake of her children
because she has 2 malnourished kids.
However,she

9.Sexuality-Reproductive

is

able

to

do

all

the

household chores,
-According to Ms. EQ, now that there is a
new baby, they find it hard to engage in
sexual activities because the baby is
sleeping in the bed with them. She also
said that her partner usually comes home
tired and there is no more interest in doing
sexual activities.
-However, she said that normally they
would engage in such activities at least

10.Coping-Stress Tolerance

twice a week.
-Knowing her

condition

during

her

hospitalization stresses her because she

13

was shocked. But she told us that, she

can no longer prevent it because its there
11.Value-Belief

already.
-Ms. EQ is a devout Roman Catholic. She
is a member of the BEC and believes that
having faith in God will help us to get
through challenges.

14

DOCTORS ORDER AND INTERPRETATION

1. TPR q4
-

To monitor the patients vital signs as the baseline of her health status.

To monitor her blood pressure if theres abnormalities and can be given easily
the prescribed medicines ordered by the doctor.

2. Stat IVF D5LR 1L @ 20gtt

-

forsequential administration since her BP is high, it has to be monitored so

that medications will infused through IVTT.

Its a maintenance fluid.

3. NPO in active labor

-

To avoid altering the descent of the baby.

To avoid defecation during delivery.

To avoid full stomach.

15

VI

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) andback 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
16

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 inLatin 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

17

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
18

total volume of blood, the 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
19

volume control contributes to the precision in controlling venous return, which in return
yields to the precise overall control of blood circulation.
EXOCRINE SYSTEM
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 from the heart goes to the kidneys. The kidneys process blood plasma and
form urine from waste to be excreted and removed 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.

20

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 products that pass through the porous glomerular capillaries and
enter the space that constitute the glomerular filtrate, which will beprocessed 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

21

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
by increasing 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.

22

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.

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.
23

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.

24

VII

PATHOPHYSIOLOGY

25

DISCUSSION OF THE PATHOPHYSIOLOGY

Whereas all hypertensive disorder in pregnancy (pre-eclampsia. Essential

hypertension, secondary hypertension) share high blood pressure as a common theme
(probably mediated inappropriate vasoconstriction) pre- eclampsia is the only disorder
with multisystem abnormalities.
The triad of physiological derangement in pre-eclampsia is:
1.

Intensive vasospasm

2.

Local or disseminated intravascular coagulation

3.

Plasma volume contraction.

With the case of Ms. EQ, history of hypertension in the family plays a very big

factor. Another factor was that, she is now in her fifth pregnancy at the age of 29 which
may cause disruptions in placental formation. Her diet is also of great influence. As
stated by her, she enjoys eating bulad, ginamos and instant noodles. This diet could
influence the kidney infiltration causing the protein specifically albumin to be excreted.
Although the cause of pre- eclampsia is unknown the placenta appears to be the
culprit- delivery of the placenta is the only known cure and the disorder is more frequent
with large placenta mass,ex. Twins, or abnormal placenta. Current hypotheses propose
release of a toxic factor from the placenta which alters maternal endothetial cell
functions, though this is unproven.

26

Vasospasm follows due to excess production or sensitivity to vasoconstrictions

(antigiotensis II. Serotonin and endothelin are the most popular candidates) and
decreased production sensitivity to vasodilators.(prostacyclin and nitric oxide are the
current candidates here). This issue is by no means resolved.

Intravascular coagulation is associated with platelet activation, thrombocytopenia

and, often reduced production of anti- thrombin III.
Plasma volume contraction follows vasospasm, capillary leakage and, in more
severe cases, reduction in plasma osmotic pressure. There is redistribution of fluid from
the intravascular to interstitial fluid spaces so that total extra cellular volume remains
unaltered. These are important consideration as intravascular volume correction may
result in pulmonary edema when capillary permeability is high and plasma osmotic
pressure low.
The net result of this triad of abnormal physiology is organ hypoperfusion system
most commonly affected are the kidney (manifested by reduced GFR, proteinuria
,hyperuriceamia and occasionally oliguria), the liver (manifested by elevated aspartate
transaminase with or without epigastric and upper quadrant pain), the brain (manifested
by intrauterine fetal growth retardation and less commonly placenta abruption or fetal
death in utero). Peripheral edema is common but is not a useful clinical sign. Pulmonary
edema is rare and when it occurs is usually teratogenic.

27

VIII

NURSING CARE PLAN

ANTE-PARTUM
FEAR

Cues and
evidences
Subjective
data:
Nahadlokl
agekona
ma
cesarean
kokaydako
dawakongti
yan.;
verbalized
by the
patient.
Objective
Data:
>Increase
alertness
>Sad facial
expression

Nursing
Diagno
sis

Fear
related
to past
history
as
evidenc
ed by
increas
es
alertne
ss.

Definition
Responses
to
perceived
threat
isconscious
ly
recognized
as a
danger.

Nursing Goals
At the end of 30
minutes the mother
will be able to:
Acknowledge
and discuss
fears with
others.
Display
emotion of
confidence
throughout the
course of her
pregnancy.

Intervention

Rationale

Therapeutic:
1. Support the
mother
emotionally to
have a positive
outlook
throughout her
pregnancy by
staying with
the client.

>Providing
client with
usual or
desired
support
person can
diminish
feeling of
fear.

Educative:
2. Discuss clients
perceptions/fea
rful feeling and
listen clients
concern.

>Promotes
atmosphere
of caring
and permits
explanation/
correction of
mispercepti
on.
>Provides a
healthy
outlet for
energy
generated
by fearful
and
promotes
relaxzation.

Collaborative:
3. Refer to the
physical
therapist to
develop
exercise
program.

Evaluation: After our series of intervention the patient acknowledged and discuss fear
with others and display emotion of confidence throughout the coarse of her pregnancy.

28

 Goals met.

29

ANTE-PARTUM
INEFFECTIVE BREATHING PATTERN
CUES
SUBJECTIVE:
maglisodlagek
oogginhawalabi
nainighigdanak
u, as
verbalized by
the patient.

Objective:
Alteration
in depth
breathing
Dyspnea

NURSING
DIAGNOSIS
Ineffective
breathing
pattern
related to
pain as
manifested
by alteration
in depth of
breathing.

DEFINATI
ON
Inspiration
and/or
expiration
that does
not provide
adequate
ventilation.

NURSING
GOAL
At the end of
30mins. The
mother will be
able to:
Establish a
normal
effective
respiratory
pattern
Verbalizes
relief for
shortness of
breath.

INTERVENTION

RATIONA
LE

Therapeutic:
Encourage
mother to use
pillows behind the
head and
shoulders at
night.

For her to
breathe
properly at
night.

Educative:
Educate the
mother to
assume proper
and positioning
every time she
sits and sleep.

To have
effective
breathing
pattern.

Collaborative:
Refer to general
exercise program
as indicated.

To
maximize
clients
level
functioning
.

Evaluation: After our series of intervention the patient established normal effective
respiratory pattern, and verbalized relieved for shortness of breath.

> Goal met

30

POST PARTUM
SLEEP DEPRIVATION
Assessment
SUBJECTIVE:
Dilikomakatulogka
ypuronalangsakits
alawasakogibati.
As client
verbalized.
OBJECTIVE:
>1 hr. at sleep per
day PTA
> 30 mins at sleep
per day upon
admission

Nursing
Diagnosis

Analysis

Goals

Rationale

Intervention

SHORT TERM:
Sleep
deprivation
R/T discomfort
on perineum
secondary to
labor and
delivery.

Prolonged
periods at
time w/out
sleep

After 3 hrs. at
nursing
intervention, the
client will
>report
decreased
feeling at
discomfort as
manifested by
verbalizing
feeling at
comfort.
> achieved at
least 5-6 hrs. at
continuous sleep
per day
>show signs
decreased
yawning at
daytime.
> report
decreased body
malaise
LONG TERM:
After 3 days of
nursing
Intervention the
client will
> be able to
reestablish and
maintain normal
sleep pattern
> achieve 7-8
hrs. at
continuous sleep
per day.
> report absence
of body malaise

INDEPENDENT
identify
presence of
related factors
that can
continue to
sleep
deprivation

>to identify
Causatives
contributing
factors

position client
in a
comfortable
position

to alleviance
discomfort

-to distract
attention on
pain,reduce
tension and
promote
nonpharmac
ological pain
managemen
t

to help in
providing
better

provide
comfort
measures

assess sleep
pattern

Evaluation: After series of interventions the client knew the importance of sleep in her
condition and adjusted lifestyle to accommodate genuine changes.

31

> Goal partially met

IX

DRUG STUDY
Ante Partum

Name
of Drug

Indicatio
n

Mechanism
of Action

Generic
Name:
Tetanus
Toxoid

Provide
passive
immunity
to
tetanus

Promotes
immunity to
tetanus by
inducing
production
of antitoxin

Adverse
effects
SYST:
Anaphylax
is

Side Effects
GI:
Nausea,
vomiting,
anorexia,
Integumentary
skin abscess,
urticaria, itching,
swelling
CV:
Tachycardia
Hypotension
SYST:
Lymphadenitis
CNS:

Crying,
fretfulness,
fever
drowsiness

Special Nursing
Responsibility
Determine date of
last tetanus
immunization
Dont use hot or
cold compresses
may increase
severity of local
reaction
Obtain history of
allergies and
reaction to
immunization
Contraindication in
immunosuppresion
and
immunoglobulin
abnormalities
Assess for skin
reaction: swelling,
rash, urticaria

32

Intra Partum

Name of Drug
Generic Name:
Oxytocin

Indication
Induction or
Stimulation of
labor

Mechanism of
Action
Chemical effect:
Causes potent and
selective stimulation
of uterine and
mammary gland
smooth muscle.

Adverse Effects
Maternal

Maternal

CNS:
Subarachnoid,
hemorrhage, seizures,
coma

GI:
Nausea, vomiting,
constipation

CV:
Hypertension,
arrhythmias

CV:
Increased heart rate,
systematic venous
return, and cardiac
output.

Other:

Integumentary:

Hypersensitivity
abruption placenta,
impaired uterine blood
flow, increased uterine
motility, anaphylaxis

Rash

Brand Name:
Syntocinon

Classification:
Oxytocin

Dosage
10 u oxytocin
infused
at D5LR 1L

Side Effects

Other:
Titanic contractions,
Pelvic hematoma
Fetal
Blood hyperbilirubin

Post-Partum
Name of
drug

Generic
Name:
Ferrous
Sulfate

Indication

Iron
deficiency
Prophylax
is for iron
deficiency

Mechanism of
Action

Provide
elemental iron,
an essential
component in the
formation of
hemoglobin

Adverse
Effects

CNS:
Seizure
MSC:
Anaphylaxis

Side
Effect

Special Nursing
Responsibility

GI:
Nausea,
constipati
on black
and red
tools,

Check for
constipation
record color
and amount
of stool.
Teach dietary
33

anemia

epigastric
pain,
diarrhea

Brand Name:

CNS:
dizziness,
headache

Classification
:
Hematinics

Other:
temporary
staining
teeth

Dosage:
1 cap PO,
OD

measures for
preventing
constipation.
To avoid
staining
teeth, give
elixir iron
preparations
with straw
Administer
between
meals for
best
absorption
may give
juice, do not
give with
antacids.
Administer at
least 1 hour
since
corrosion
may occur in
the stomach.

Post-Partum
Name of
drug

Indication

Mechanism
of Action

Adverse
Effects

Side Effects

Special Nursing
Responsibility

34

Generic
Name:
Mefenamic
Acid

Brand
Name:
Postan,
Pontel

Relief of
moderate
pain when
therapy
will not
exceed
one week.
Treatment
of primary
dysmenorr
hea

Antiinflammatory
analgesic,
and
antipyretic
activities
related to
inhibition of
prostaglandin
synthesis;
exact
mechanism
of action are
not known

Give milk or
GI:
cholestatic,
hepatitis,
peptic
ulceration
GU:
Nephrotoxicity
HEMA: Blood
dyscrasis
Hepatic:
hepatotoxicity

GI: Nausea,
anorexia,
vomiting,
diarrhea,
jaundice,
constipation,
flatulence,
cramps, dry
mouth
CNS:
Dizziness,
drowsiness,
anxiety,
insomnia
CV:
Tachycardia,
Palpitations
Integumentary:
Rash,
sweating

food to
decrease GI
upset.
Arrange for
periodic
ophthalmologic
examination
during longterm therapy
Contraindicated
in GI ulceration
or inflammation
Stop drug if
rash, visual
disturbances or
diarrhea
develops
Should not
administer for
more than 1
week at a time,
because of risk
of toxicity
increases
Warm patient
against
hazardous
activities that
require
alertness until
CNS effects of
the known drug
Evaluate
therapeutic
response:
Decreased
pain, stiffness,
swelling in joint,
ability to move
more easily.

Post- Partum
Name of
drug

Indication

Mechanism

Adverse
Effects

Side
Effects

Special Nursing
Responsibility
35

Generic
Name:
Amoxicillin
trihydrate

Infection due to Bacterial:

susceptible
strains of
Haemophilis
influenza,
Escherichia
coli, protues
mirabilis,
Brand
Neisseria
Name:
gonorhoeae,
Amoxil
streptococcus
pneumonia,
nonpenicillinaseproduang
Classificatio
staphylococcus
n:
Helicobacter
Antipylori infection
infective
in combination
with other
agents.
Post- exposure
Dosage
prophylaxis
500mg
against bacillus
T.I.P.O
antraris.

inhibits
synthesis of
cell wall of
sensitive
organism,
causing cell
death.

CNS: Seizure
GI: Pseudo
membranes
MISC:
Anaphylaxis,
Serum
sickness
HEMA: Bone
marrow
depression,
granulocytope
nia

GI:
Culture
Diarrhea,
infected area
nausea,
prior to
vomiting
treatment;
reculture area
response is
Derm:
not expected.
Rashes Give in oral
preparations
only,
amoxicillin is
not affected
by food.
Continue
therapy for at
least 2 days
after signs of
infection have
disappeared;
is
recommended
.
Use
corticosteroids
or
antihistamines
for skin
reaction

Post- Partum
Name of
Drug

Indication

Mechanism of
Action

Adverse
Effects

Side Effects

Special Nursing
Responsibility
36

Brand
Name:
Terramycin

Generic
Name:

Classificati
on:
Ophthalmic
antiinvectives

Dosage:
Neonates1 drop of
1% solution

Prevention
of
gonorrheal
ophthalmic
neoraturom

Causes of
protein
denaturation,
which prevents
gonorrheal
ophalmianeon
atorum,.
Bacteriostatic,
germicidal and
astringent.

Eye:
Periorbita,
edema,
temporary
staining of
lids and
surrounding
the tissue,
conjunction
s (with
concentration
of 1% or
greater)

Integumentary: Dont use

Irritation,
repeatedly
discoloration of
tissue
Always wash
hands before
instilling
solution
Dont irritate
eye after
installation

Store wax
ampule from
lightand heat
Solution may
stral the skin
and utensils
Handle carefully

37

DISCHARGE PLAN

Exercise
1.

Encourage patients on deep breathing exercises.

2.

Move extremities when lying.

3.

Elevate the head part when sleeping, to promote increase peripheral circulation

4.

Encourage overall passive and active exercises program during pregnancy to

prevent need for cesarean birth.

5.

Exercises like tailor sitting, squatting, Kegel exercise, pelvic rocking, and

abdominal muscle contraction will promote easy delivery.

Treatment:
1.

Use of drugs

2.

Catheterization

3.

Obtaining labs. (CBC, platelets count, liver function, BUN and creatinine,

Health Teaching:
1.

Encourage patient foe sodium restriction.

2.

Encourage to avoid foods rich in oil and fats.

3.

Encourage patient to limit her daily activities and exercises.

Ongoing Assessment:
38

1.

Observe carefully for symptoms at prenatal visit.

2.

Give instruction about what symptoms to watch for so she can alert her clinician

if additional symptoms occur between visits.

Diet:
1.

Low fats and sodium diet, restriction if possible.

2.

High in protein, calcium and iron.

3.

Adequate fluid intake

Sex:
1.

limit sexual activity

39