I.

IntroductionIt was my first week of hospital exposure at OB ward of East Avenue Medical Center when I found

my prospect patient my case study.For the purpose of confidentiality I will call my prospect, Mrs. Rosanna. She is 23 years of age and presently residing at old capitol with her husband Luis.

Mrs. Rosanna was admitted on February 9, 2011 at 10:30 in the morning complaining of epigastric and labor pains. On admission, she was diagnosed with preeclampsia at 39 5/7 weeks AOG and a BP of 150/90.Definition

Preeclampsia is a complication of pregnancy. In preeclampsia, the woman has dangerously high blood pressure, swelling (edema) and protein in the urine (proteinuria). Blood pressure rises from 140/90 mm Hg to 160/110 mm Hg. High blood pressure is first noted sometime after week 20 of pregnancy and isaccompanied by protein in the urine (2g of protein in 24 hour urine or 2+ to 3+ on qualitative examination)Risk Factors

Preeclampsia is most common among women who have never given birth to a baby (called nulliparas). About 7% of all nulliparas develop preeclampsia.The disease is most common in mothers under the age of 20 or over the age of 35. Other risk factors include poverty, multiple pregnancies (twins, triplets, etc.), pre-existing chronic hypertension or kidney disease, diabetes, excess amniotic fluid, and a condition of the fetus called nonimmune hydrops. The tendency to develop preeclampsia appears to run in families.The daughters and sisters of women who have had preeclampsia are more likely to develop the condition.Causes and symptoms

Experts are still trying to understand the exact causes of preeclampsia and eclampsia. It is generally accepted that preeclampsia and eclampsia in general are problematic because these conditions cause blood vessels to leak. The effects are seen throughout the body.• General body tissues.When blood vessels leak, they allow fluid to flow out into the tissues of the body. The result is swelling in the hands, feet, legs, arms, and face. While many pregnant women experience swelling in their feet, and sometimes in their hands, swelling of the upper limbs and face is a sign of a more serious problem. As fluid is retained in these tissues, the woman may experience significant weight gain (two or more pounds per week).• Brain. Leaky vessels can cause damage within the brain, resulting in seizures orcoma.• Eyes. The woman may experience problems seeing, and may have blurry vision or may see spots. The retina may become detached.• Lungs. Fluid may leak into the tissues of the lungs, resulting in shortness of breath.• Liver. Leaky vessels within the liver may cause it to swell. The liver may be involved in a serious complication of preeclampsia, called the HELLP syndrome. In this syndrome, red blood cells are abnormally destroyed, chemicals called liver enzymes are abnormally high, and cells involved inthe clotting of blood (platelets) are low.

• Kidneys. The small capillaries within the kidneys can leak. Normally, the filtration system within the kidney is too fine to allow protein (which is relatively large) to leave the bloodstream and enter the urine. Inpreeclampsia, however, the leaky capillaries allow protein to be dumped into the urine. The development of protein in the urine is very serious, and often results in a low birth weight baby. These babies have a higher risk of complications, including death.• Blood pressure. In preeclampsia, the volume of circulating blood is lower than normal because fluid is leaking into other parts of the body. The heart tries to make up for this by pumping a larger quantity of blood with each contraction. Blood vessels usually expand in diameter (dilate) in this situation to decrease the work load on the heart. In preeclampsia, however, the blood vessels are abnormally constricted, causing the heart to work even harder to pump against the small diameters of the vessels.This causes an increase in blood pressure.

The most serious consequences of preeclampsia and eclampsia include brain damage in the mother due to brain swelling and oxygen deprivation during seizures. Mothers can also experience blindness, kidney failure, liver rupture, and placental abruption. Babies born to preeclamptic mothers are often smallerthan normal, which makes them more susceptible to complications during labor, delivery, and in early infancy. Babies of preeclamptic mothers are also at risk of being born prematurely, and can suffer the complications associated with prematurity.Prognosis

The prognosis in pre eclampsia (and eclampsia) depends on how carefully a patient is monitored. Very careful, consistent monitoring allows quick decisions to be made, and improves the woman’s prognosis. Still, the most common causes of death in pregnant women are related to high blood pressure.About 33% of all patients with preeclampsia will have the condition again with later pregnancies. Eclampsia occurs in about 1 out of every 200 women with preeclampsia. If not treated, eclampsia is almost always fatal.II.

Objectives

a. Establish rapport and gain the trust and cooperation of the patient and immediate family members. b. Perform and obtain thorough and complete physical assessment using the assessment techniques

following the cephalocaudal approach; obtain complete medical, socio-cultural, and family history related to the patient’s current health condition.c. Analyze and prioritize problems based from the gathered pertinent data to come up with the correct nursing diagnoses.

d. Plan the appropriate nursing interventions to address the patient’s health needs. The interventions should address not only the physical well being of the patient but also her emotional, social, and mental welfare.e. Implement the planned nursing interventions to meet the desired outcomes and help improve patient’s condition.

f. Impart useful health teachings to the patient and immediate family members to prevent further development of the patient’s condition and other related complications, and for the patient to be able to adjust well and continue with her normal life after being discharged from the hospital.

III. Nursing health history

a. Biographical informationSurname: X First name: Rosanna Middle name: ZAge: 39Nationality: FilipinoAddress: Old Capitol, Quezon, City

b.Reasons For seeking Health CareMrs. X seeks for health care because of the chief complains of labor pain

c. Client ExpectationMrs. X has expectation in the following areas:1. Information needed about his disease process and involvement indecision making.2 . Caring and compassion expressed by care providers.3. Timelines of caregiver’s response to client request.4. Relief of pain and symptoms.5 . Deliver the neonate safely.

d. Present IllnessMrs. X came to the emergency room last Wednesday, February 9, 2011 after her client meeting and subsequently complaining of severe epigastric and laborpain.

e.Past Health HistoryMrs. X has only been hospitalized on her first born delivery.

f. Family HistoryMrs. X has verbalized that the only heredo-familial disease that they have was hypertension on her mother side.

g. ImmunizationShe verbalized that she had a complete vaccination.h. Nutrition

She verbalized that she primarily eats vegetable and meat.

i. Environment HistoryMrs. X leaves at Old Capitol, Quezon City. Their concrete type of house is located in a residential area with good ventilation. Their water source was on water pump but they buy drinking water and their garbage was being burn.j. Psychosocial History

Mrs. X stated that she has a lot of support system coming from her family and relatives.k. Spiritual HealthMrs. X is a Roman Catholic and makes it a point to visit and attended amass every Sunday with her husband. Their beliefs about life. Their source for guidance in acting their beliefs, and the relationship they have in exercising their faith is truly God centered manner.

IV. Assessment

V. Anatomy and physiology Renal system

The excretory system consists of the kidneys, the ureters, the urinary bladders, and the urethra. The kidneys are the major excretory organs of the body. The skin, liver, lungs, and intestines eliminate some waste products, but if the kidneys fail to function, these other excretory organs cannot adequately compensate. The Urinary system eliminates waste, regulates blood volume, ion concentration and pH; and it is involve with red blood cell production.

1. Approximately 180 L of filtrate enters the nephrons each day; of that volume 65% is reabsorbed in the proximal tubule. In the proximal tubule, solute molecules move by active transport and cotransport from the lumen of the tubule into the interstitial fluid. Water moves by osmosis because the cells of the tubule wall are permeable to water.

2. Approximately 15% of the filtrate volume is reabsorbed in this segment of the descending limb of the loop of Henle. The concentrated interstitial fluid of the medulla. Because the wall of the descending limb is permeable to water, water moves by osmosis from the tubule into the more concentrated interstitial fluid. By the time the filtrate reaches the tip of the renal pyramid, the concentration of the filtrate is equal to

the concentration of the interstitial fluid. 3. The descending limb into the loop of Henle is not permeable to water. Solutes diffuse out of the thin segment.4. Na+, K+, and Cl- are cotransported across the apical membrane of the thick segment. Na+ is actively

transported and K+ and Cl- diffuse across the basal membrane of the epithelial cells of the thick segment into the interstitial fluid.

5. The volume of the filtrate doesn’t change as it passes through the ascending limb, but the concentration is greatly reduced. By the time the filtrate reaches the cortex of the kidney, the concentration is approximately 100 mOsm/L, which less concentrated than interstitial fluid of the cortex.

6. The distal tubule and collecting are permeable to water if ADH is present. If ADH is present, water moves by osmosis from the less concentrated filtrate into the more concentrated fluid. By the time the filtrate reaches the tip of the renal pyramid an additional 19% of the filtrate is reabsorbed.

7. One percent or less remains as urine.

Vascular System

The heart provides the major force that causes blood to circulate, and the peripheral circulation functions to carry blood, exchange nutrients, waste products, and gases, transport hormones, components of the immune system, molecules required for coagulation, enzymes, nutrients, gases, waste products,and other substances are transported in the blood to all areas of the body, regulate blood pressure, and direct blood flow. Blood flows from the heart through elastic arteries, muscular arteries, and arterioles to the capillaries. Blood returns to the heart from the capillaries through venules, small veins, and large vein. Layers of blood vessels The tunica intima consists of endothelium, a delicate connective tissue basement membrane, a thin layer of connective tissue called the lamina propia, and a fenestrated layer of elastic fibers call the internal elastic membrane. The internal elastic membrane separates the tunica intimafrom the next layer, the tunica media. The tunica media, or middle layer, consists of smooth muscle cells arranged circularly around the blood vessel. The amount of blood flowing through a blood vessel can be regulated by contraction or relaxation of the smooth muscle in the tunica media. A decrease in blood flowresults from vasoconstriction, an increase in blood vessel diameter because of smooth muscle relaxation. The tunica adventitia is composed of connective tissue, which varies from the dense connective tissue near

the tunica media to loose connective tissue that merges with the connective tissue surrounding the blood vessels.Reproductive System

The vagina is a muscular, hollow tube that extends from the vaginal opening to the uterus. The vagina is about 3 to 5 inches (8 to 12 centimeters) long in a grown woman. Because it has muscular walls it can expand and contract. This ability to become wider or narrower allows the vagina to accommodate something as slim as a tampon and as wide as a baby. The vagina's muscular walls are lined with mucous membranes, which keep it protected and moist. The vagina has several functions: for sexual intercourse, as the pathway that a baby takes out of a woman's body during childbirth, and as the route for the menstrual blood (the period) to leave the body from the uterus. The vagina connects with the uterus, or womb, at the cervix. The cervix has strong, thick walls. The opening of the cervix is very small (no wider than a straw), which is why a tampon can never get lost inside a girl's body. During childbirth, the cervix can expand to allow a baby to pass.The uterus is shaped like an upside-down pear, with a thick lining and muscular walls - in fact, the uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. When a woman isn't pregnant, the uterus is only about 3 inches (7.5 centimeters) long and 2 inches (5 centimeters) wide. At the upper corners of the uterus, the fallopian tubes connect the uterus to the ovaries. The ovaries are two oval-shaped organs that lie to the upper right and left of the uterus. They produce, store, and release eggs into the fallopian tubes in the process called ovulation.Each ovary measures about 1 1/2 to 2 inches

(4 to 5 centimeters) in a grown woman. There are two fallopian tubes, each attached to a side of the uterus. The fallopian tubes are about 4 inches (10 centimeters) long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area wraps around the ovary but doesn't completely attach to it. When an egg pops out of an ovary, it enters the fallopian tube. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus. The ovaries are also part of the endocrine system because they produce female sex hormones such as estrogen and progesterone.

Placenta

n humans, the placenta averages 22 cm (9 in.) in length and 2-2.5 cm (0.8-1 in.) in thickness. It typically weighs approximately 500 grams (1 lb). It has a dark reddish/blue or maroon color. It connects to the fetus by an umbilical cord of approximately 55-60 cm (22-24 in.) in length that contains two arteries and one vein. The umbilical cord inserts into the chorionic plate. Vessels branch out over the surface of the placenta and further divide to form a network covered by a thin layer of cells. This results in the formation of villous tree structures. On the maternal side, these villous tree structures are grouped into lobules called cotelydons. In humans the placenta usually has a disc shape but different mammalian species have widely varying shapes..

VI. Pathophysiology

VII. Medical management

Doctor’s orders

Post partum order

On Februay 9, 2011, 7:00 pm, the doctor ordered to ward and IVF to consume DAT. He also ordered to follow up lab results. Medications prescribed are cefalexin TID, FeSO4 OD, Mefinamic Acid TID. Also ordered is to put ice pack over fundus, massage uterus as needed, perineal hygiene and to watch out for profuse vaginal bleeding, refer.

On February 10, 2011 at 3:50pm the doctor ordered to admit patient to OB service charity ward and to secure consent. He also ordered to monitor and record TPR every shift. The patient is also under a DAT diet.The patient is for diagnostic for CBC, U/A, blood typing, and HBsAg, with IVF of D5LRS 1L for 8 hours.

Medications prescribed are HNBB 1 amp, for IVP every 4 hours, MgSO4 5g deep IM in each buttocks and Hydralazine 5mg IVP. To Labor Room, for perenial prep, monitor Vital signs FHT POL and record, to refer accordingly.

Last February 11, 2011 the doctor ordered NPO at 10pm, for blood chem. tomorrow. February 12, 2011, the doctor ordered to continue medications, start nefedipine 30g stat then OD, carry out blood chem. then refer. With BP of 150/90, negative fever, negative haldz, negative profuse vaginal bleeding, negative pain C/L CBS

February 14, 2011 the doctor ordered continue meds with low, salt low fat diet. Follow up blood chem.

Drug study