Universidad de Manila

College of Health Sciences

Department of Nursing

A Case Study
On
Chronic Hypertension with
Superimposed Pre-Eclampsia on a
Repeat Cesarian Section Delivery with
Bilateral Tubal Ligation

Submitted by:
Group 6 NR41
Sapiandante, Sherina Brenda R.
Tuazon, Jennah Ricci J.
Submitted to:
Maam Rosalinda I. Morales
Clinical Instructor

INTRODUCTION
Cesarian Section
Commonly reffered to as C-section, a cesarian section is a method of delivery by
abdominal and uterine incisions. Cesarian delivery may take place in the labor and delivery
department or in the OR. Pregnancy and labor produce many physioogic alterations. Both the
mother and the newborn have specific needs requiring comprehensive care. To promote a
positive experience, the perioperative team should be cognizant of these physiological needs and
of the reasons for transabdominal delivery. During a C-section, mothers are given regional
anesthesia and are usually awake.
The frequency of cesarian delivery is attributed maily to diagnosis and management of
uterine dystocia (ineffective labor), falure to progress, and fetal distress detected by fetal
monitoring. A C-section is performed when safe vaginal delivery is questionable or immediate
delivery is crucial because he well being of the mother or fetus is threatened. Indications may
include hemorrhage, placenta previa, abruptio placenta, toxemia, fetal malpresentation,
cephalopelvic disproportion, chorioamnionitis, genital herpes in the mother within 6 weeks of
delivery, fetal distress, or prolapsed umbilical cord.
Bilateral Tubal Ligation (BTL)
A Bilateral Tubal Ligation (BTL) is a surgical procedure that involves blocking the
fallopian tubes to prevent the ovum from being fertilized. It can be done by cutting, burning or
removing sections of the fallopian tubes or by placing clips on each tube.
A BTL is used when a woman wants to prevent pregnancy. It is considered a permanent
form of birth control, although in some cases it can be reversed. There can be damage to the
tubes after reversal, so this decision should not be made quickly.
Pre-Eclampsia
Formerly called toxemia, preeclampsia is a condition that pregnant women develop. It is
marked by high blood pressure and a high level of protein in the urine. Preeclamptic women will
often also have swelling in the feet, legs, and hands. This condition usually appears during the
second half of pregnancy, often in the latter part of the second or in the third trimesters, although
it can occur earlier.
If undiagnosed, preeclampsia can lead to eclampsia, a serious condition that can put you
and your baby at risk, and in rare cases, cause death. Women with preeclampsia who have
seizures are considered to have eclampsia.
There's no way to cure preeclampsia, and that can be a scary prospect for moms-to-be.
But you can help protect yourself by learning the symptoms of preeclampsia and by seeing your
doctor for regular prenatal care. When preeclampsia is caught early, it's easier to manage.

The exact causes of preeclampsia and eclampsia -- a result of a placenta that doesn't
function properly -- are not known, although some researchers suspect poor nutrition, high body
fat, or insufficient blood flow to the uterus as possible causes. Genetics plays a role, as well.
Preeclampsia is most often seen in first-time pregnancies, in pregnant teens, and in
women over 40 years old. Other risk factors include

A history of high blood pressure prior to pregnancy

A history of preeclampsia
Having a mother or sister who had preeclampsia
A history of obesity
Carrying more than one baby
History of diabetes, kidney disease, lupus, or rheumatoid arthritis

In addition to swelling, protein in the urine, and high blood pressure , preeclampsia
symptoms can include:

Rapid weight gain caused by a significant increase in bodily fluid

Abdominal pain
Severe headaches
Change in reflexes
Reduced urine or no urine output
Dizziness
Excessive vomiting and nausea
Vision changes
Sudden and new swelling in your face, hands, and eyes (some feet and ankle swelling is
normal during pregnancy.)
Blood pressure greater than 140/90.
Sudden weight gain over 1 or 2 days
Abdominal pain, especially in the upper right side
Severe headaches
A decrease in urine
Blurry vision , flashing lights, and floaters

PATIENTS PROFILE

Personal Data
This is a case of patient A.S., 31 years old female, a Roman Catholic, married, currently
residing at Quiapo, Manila. She was admitted for the first time at Ospital ng Maynila Medical
Center last January 11, 2016 at 11:55 am. She is conscious and ambulatory and is accompanied
by her husband.
Chief Complaint/History of Present Illness
Patient came in for prenatal checkup at OB-OPD. She was transffered to ER due to BP of
220/140 mmhg.
Pre-Operative Diagnosis
G5P4 (4004) pregnancy uterine 32 weeks 1 day AOG, cephalic not in labor, chronic
hypertension with superimposed pre-eclampsia; s/p primary LTCS G4 for non reassuring fetal
status.
Operation Performed
Repeat Low Transverse Cesarian Section for uncontrolled hypertension with Bilateral
Tubal Ligation.
Post-Operative Diagnosis
G5P5 (4105) pregnancy uterine delivered pre-term, cephalic livebirth; chronic
hypertension with superimposed pre-eclampsia; s/p 2 LTCS G4 for non reassuring fetal status,
G5 for uncontrolled hypertension with bilateral tubal ligation (OMMC 2016)

PATHOPHYSIOLOGY

NURSING CARE PLAN

Actual
ASSESSMENT

DIAGNOSIS

Objective:
Teary eyed
(+) guarding
behavior
(+) facial grimace
Pale palpebral
conjunctiva
Skin warm to
touch

Acute pain related

to disruption of
skin, tissue, and
muscle integrity
secondary to
cesarian section

V/S taken as
follows:
T: 36.7
P: 90bpm
RR: 20cpm
BP: 180/120

PLANNING
After 4-6 hours of
nursing intervention,
patient will verbalize
decrease intensity of
pain.

INTERVENTION

RATIONALE

Independent:
Evaluate pain
regularly noting
characteristics,
location, intensity
(0-10 scale).

Provides
information about
need for or
effectiveness of
interventions.

Identify specific
Prevents undue
activity limitations. strain on operative
site.
Recommend
planned or
progressive
exercise.

Promotes return
of normal function
and enhances
feelings of general
wellbeing.

Schedule
adequate rest
periods.

Prevents fatigue
and conserves
energy for healing.

Review

Provides elements
necessary for

EXPECTED
OUTCOME
After 6 hours of
nursing intervention,
the patient verbalized
decreased pain as
evidenced by (-) facial
grimace, (-) guarding
behavior.

importance of
nutritious diets and
adequate fluid
intake.
Reposition as
indicated.
Provide additional
comfort measures
like back rub

tissue regeneration
or healing.

May relieve pain

and enhance
circulation.
Improves
circulation reduces
muscle tension and
anxiety associated
with pain.

Encourage use of Relieves muscle

relaxation
and emotional
technique like deep tension.
breathing
exercises.
Dependent:
Administer
analgesics or
nonsteroidal antiinflammatory
drugs as
prescribed.
.

To relieve mild or
moderate pain.

ASSESSMENT
Objective:
Discomfort in
moving
Less ROM
activities
V/S taken as
follows:
T: 36.7
P: 90bpm
RR: 20cpm
BP: 180/120

DIAGNOSIS

PLANNING

Activity
Intolerance related
to immobility
postoperatively as
evidenced by
discomfort in
moving and less
ROM activities

After 8 hours of
nursing
intervention, the
patient will be able
to show ease in
movement

INTERVENTION

RATIONALE

Independent:
Evaluate current
limitations/degree
of deficit in light
of usual status

This provides
comparative
baseline

Plan care with

rest periods

To reduce fatigue
and regain strength

Assist client with

activities

To prevent
injuries

Dependent:
Plan activities
with patient

To teach the
patient what
activities can and
cannot be done
yet.

EXPECTED
OUTCOME
After 8 hours of
nursing
intervention, the
patient showed
ease in movement
and more ROM
activities

ASSESSMENT
Objective:
V/S taken as
follows:
T: 36.7
P: 90bpm
RR: 20cpm
BP: 180/120

DIAGNOSIS

PLANNING

Impaired skin
integrity related to
surgery

After 4 hours of
nursing
intervention, the
patient will show
participation in the
treatment
programs

INTERVENTION

RATIONALE

Independent:
Assess the
affected area

To note for
further problems
or complications

EXPECTED
OUTCOME
After 4 hours of
nursing
intervention, the
patient showed
participation in the
treatment
programs by
asking the nurse on
duty the proper
care for her suture

Potential
ASSESSMENT

DIAGNOSIS

PLANNING

Objective:
Dressing dry and
intact
V/S taken as
follows:
T: 36.7
P: 90bpm
RR: 20cpm
BP: 180/120

Risk for infection

related to
inadequate primary
defenses secondary
to surgical incision

After 4 hours of
nursing
intervention,
patient will be able
to understand
causative factors,
identify signs of
infection and
report them to

INTERVENTION

RATIONALE

Independent:
Monitor vital
signs

To establish a
baseline data

Inspect dressing
and perform
wound care

Moist from
drainage can be a
source of infection

EXPECTED
OUTCOME
Patient is expected
to be free of
infection, as
evidenced by
normal vital signs
and absence of
purulent drainage
from wounds,
incisions, and

health care
provider
accordingly.

tubes.
Monitor WBC
count

Rising WBC
indicates bodys
efforts to combat
pathogens.

Monitor elevated
temperature,
redness, swelling,
increased pain, or
purulent drainage
at incisions

These are signs

of infection.

Wash hands and

teach other
caregivers to wash
hands before
contact with
patient and
between
procedures with
patient.

Friction and
running water
effectively remove
microorganisms
from hands.
Washing between
procedures reduces
the risk of
transmitting
pathogens from
one area of the
body to another.

Encourage fluid
intake of 2000ml
to 3000ml of water
per day (unless
contraindicated).

Fluids promote
diluted urine and
frequent emptying
of bladder;
reducing stasis of

urine, in turn
reduces risk of
bladder infection
or UTI.
Encourage
coughing and deep
breathing; consider
use of incentive
spirometer.

Dependent
Administer
antibiotics

This measures
reduces stasis of
secretions in the
lungs and
bronchial tree.
When stasis
occurs, pathogens
can cause upper
respiratory
infections,
including
pneumonia.

Antibiotics have
bactericidal effect
that combats
pathogens.

DRUG STUDY

GENERIC
NAME,
BRAND
NAME,
DRUG
CLASS,
INDICATION
Generic Name:
Tramadol
Brand name:
Dolotral,
Milador
Drug Class:
Analgesic
Indication:
Used for
moderate to
severe pain

ROUTE,
DOSAGE,
FREQUENCY

MECHANISM OF
ACTION

Route: IV

Centrally
acting
Dosage: 500
analgesic not
mg
chemically
related to
Frequency: q6 opioids but
x 4 doses if BP binds to mu<90/60 mmHg, opioid
HR <60 bpm
receptors and
inhibits
reuptake of
norepinephrine
and serotonin

SIDE
EFFECTS,
ADVERSE
REACTIONS

NURSING
RESPONSIBILITIES

Nausea,
diarrhea,
constipation,
vomiting,
dyspepsia,
abdominal pain,
anorexia,
flatulence

> Assess patients

pain (location,
type, character)
before and after
therapy
>Assess for
hypersensitivity
reactions
> Monitor for
possible drug
induced adverse
reactions
> Monitor I/O
> Assess changes
on bowel pattern.
Increase diet bulk
and oral fluids to
prevent
constipation

GENERIC
NAME,

ROUTE,
DOSAGE,

MECHANISM OF

SIDE
EFFECTS,

NURSING
RESPONSI-

BRAND
NAME,
DRUG
CLASS,
INDICATION
Generic name:
Ketorolac

FREQUENCY

Route: IV
Dosage: 30mg

Brand name :
Toradol
Drug class :
Nonsteroidal
antiinflammatory
agents, no
opioid
analgesics
Indication:
Short term
management of
pain (not to
exceed 5 days
total for all
routes
combined)

Frequency: q8
x 3 doses

ACTION

ADVERSE
REACTIONS

BILITIES

Inhibits
prostaglandin
synthesis,
producing
peripherally
mediated
analgesia

Hypersensitivity,
cross-sensitivity
with other
NSAIDs may
exist, pre- or
perioperative
use, use
cautiously in:
1) History of GI
bleeding
2) Renal
impair-ment
(dosage
reduction may
be required)
3)
Cardiovascular
disease

> Patients who

have asthma,
aspirin-induced
allergy, and nasal
polyps are at
increased risk for
developing
hypersensitivity
reactions.

Also have
antipyretic and
antiinflammatory
properties.
Therapeutic
effect:
Decreased pain

> Assess for

rhinitis, asthma,
and urticaria.
> Assess pain
prior to and 1-2 hr
following
administration.
> Caution patient
to avoid
concurrent use of
alcohol, aspirin,
NSAIDs,
acetaminophen, or
other OTC
medications
without consulting
health care
professional.
> Advise patient
to consult if rash,
itching, visual
disturbances,
tinnitus, weight
gain, edema, black
stools, persistent

headache, or
influenza-like
syndromes (chills,
fever, muscles
aches, and pain)
occur.
GENERIC
NAME,
BRAND
NAME,
DRUG
CLASS,
INDICATION
Generic name :
Ranitidine

ROUTE,
DOSAGE,
FREQUENCY

Route: IV
Dosage: 50mg

Brand name :
Zantac

Drug class :
Therapeutic:
Anti-ulcer
agents
Pharmacologic
:
Histamine H2
antagonists
Indication:
Treatment and
prevention of
heartburn, acid
indigestion,
and sour
stomach.

Frequency: q8
while NPO

MECHANISM OF
ACTION

Inhibits the
action of
histamine at
the H2 receptor
site located
primarily in
gastric parietal
cells, resulting
in inhibition of
gastric acid
secretion.
In
addition, raniti
dine bismuth
citrate has
some
antibacterial
action against
H. pylori.

SIDE
EFFECTS,
ADVERSE
REACTIONS

Altered taste,
black tongue,
constipation,
dark stools,
diarrhea, druginduced
hepatitis,
nausea

NURSING
RESPONSIBILITIES

> Assess patient

for epigastric or
abdominal pain
and frank or
occult blood in the
stool, emesis, or
gastric aspirate.
> Inform patient
that it may cause
drowsiness or
dizziness.
> Inform patient
that increased
fluid and fiber
intake may
minimize
constipation.
> Advise patient
to report onset of
black, tarry stools;
fever, sore throat;
diarrhea;
dizziness; rash;
confusion; or
hallucinations to
health care
professional
promptly.

> Inform patient

that medication
may temporarily
cause stools and
tongue to appear
gray black.

GENERIC
NAME,
BRAND
NAME,
DRUG
CLASS,
INDICATION
Generic
Name:
Paracetamol
Brand name:
Biogesic
Classification:
Anti-pyretic,
analgesic

ROUTE,
DOSAGE,
FREQUENCY

MECHANISM OF
ACTION

Route: IV

> Decreases
fever by a
Dosage: 60 mg hypothalamic
effect leading
Frequency: q6 to sweating and
x 4 doses
vasodilation
> Inhibits
pyrogen effect
on the
hypothalamicheat-regulating
center

SIDE
EFFECTS,
ADVERSE
REACTIONS

NURSING
RESPONSIBILITIES

Nausea,
stomach upset,
skin rash, acute
toxicity may
result in liver
failure

> Check that the

patient is not
taking any other
medication
containing
paracetamol
> There are no
known harmful
effects when used
during pregnancy
> Alcohol
increases the risk
of liver damage
that can occur if
an overdose of
paracetamol is
taken. The hazards
of paracetamol
overdose are
greater in
persistent heavy
drinkers and in
people with
alcoholic liver
disease

GENERIC
NAME,
BRAND
NAME,
DRUG
CLASS,
INDICATION
Generic Name:
Cefuroxime
Brand name:
Ceftin
Drug Class:
Semisynthetic
cephalosporin
antibiotic

ROUTE,
DOSAGE,
FREQUENCY

Route: IV
Dosage:
750mg
Frequency: q8
x 3 doses

MECHANISM OF
ACTION

SIDE
EFFECTS,
ADVERSE
REACTIONS

NURSING
RESPONSIBILITIES

Inhibits cellwall synthesis,

promoting
osmoticinstabil
ity; usually
bactericidal

Pseudomembra
nous colitis,
nausea,
vomiting,
anorexia,
diarrhea

> Ask patient if

he/she is allergic
to penicillins or
cephalosporins

MECHANISM OF
ACTION

SIDE
EFFECTS,
ADVERSE
REACTIONS

NURSING
RESPONSIBILITIES

Stimulates
central alphaadrenergic
receptors to
inhibit
sympathetic
cardioaccelerat
or and
vasoconstrictor
centers

Local skin
irritation,
allergic contact
dermatitis,
drowsiness, dry
mouth, nausea,
constipation,
anxiety, fatigue

> Perform blood

studies

Indication:
Perioperative
prevention
GENERIC
NAME,
BRAND
NAME,
DRUG
CLASS,
INDICATION
Generic Name:
Clonidine

ROUTE,
DOSAGE,
FREQUENCY

Route: SL
Dosage: 75mg

Brand name:
Catapres,
Duraclon,
Melzin
Drug Class:
Alpha-agonist
hypotensive
agents

Frequency: if
BP >160/100

> Perform renal

studies
> Assess BP and
apical pulse
before initial dose
> Check for
edema in feet

Indication:
Management
of all grades of
hypertension

> Note allergic

reactions