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A Case Study on Pre-eclampsia
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INTRODUCTION
A serious, statistically important disorder characterized by the development after
the twentieth week of gestation of hypertension, with proteinuria or edema or both. These
symptoms should be progressive in severity to actually make the diagnosis of pregnancy-
induced hypertension. If coma or convulsion–not caused by coincidental neurologic
disease–complicates the course of the illness, it is then called eclampsia.
Guided by our enlarging view of Severe preeclampsia, nurses are in a prime
position for aiding in promoting the optimal level of wellness in our patients. This begins
with thorough assessments. Blood pressure measurements should be accurate, and never
be treated as trivial. Other objective assessment data may include monitoring pertinent
laboratory values, proteinuria, and fetal surveillance. Subjective data such as visual
disturbances and headaches, which may be precursors to seizures, should also be
assessed. All of these assessments are important.
Nurses also should relish their role as patient advocates and patient educators. As patient
advocates, and armed with the knowledge of recent research, nurses are in a position to
promote care that is both evidence-based and appropriate. As patient educators, nurses
are able to increase their patients' ability to understand and participate in their own care to
achieve the optimal level of wellness.
A database of hospital discharge data from approximately 300,000 deliveries in
the United States found the overall incidence of severe preeclampsia was about 1 percent
of pregnancies. Studies of preeclampsia report about 5 percent of nulliparous women
develop preeclampsia and 40 to 50 percent of these women develop severe disease. Chief
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causes of the maternal death are aspiration (pneumonia), cerebral hemorrhage, cardiac
failure with pulmonary edema, or obstetrical hemorrhage associated with premature
separation of the placenta.
In the Philippines, according to Department of Health, Maternal Mortality Rate
(MMR) is 162 out of 10,000 live births (Family Planning Survey 2006). Maternal deaths
account for 14% of deaths among women. For the past five years all of the causes of
maternal deaths exhibited an upward trend. Preeclampsia showed an increasing trend of
6.89%; 20%; 40%; and 100%. Ten women die everyday in the Philippines from
pregnancy and childbirth related causes but for every mother who dies, roughly 20 more
suffer serious disease and disability. The UNFPA office in the Philippines declared that
family planning can help prevent maternal deaths by 35%. (http://hb4110.net/wp-
content/uploads/KIT_MATERNAL%20HEALTH_BASIC%20STATS.doc.)
Treatment of preeclampsia depends on the severity of the symptoms encountered, the
philosophy of the physician, and the understanding of the compliance of the client. She
and her family deserve careful teaching regarding her problem, its observation, and its
treatment. Regular, adequate prenatal care is the best insurance for control of the
complication. Magnesium sulfate is the first-line treatment of prevention of primary and
recurrent eclamptic seizures. It reduces transmission of nerve impulses from brain to
muscles.
We decided to use this as a subject for our case study because as what we all know this
kind of illness is said to be a silent killer if prompt medical attention is unmet. That is
why we want to know the root cause of such disease in order for us to know how we
could intervene and play our role as a nurse. We believe that by studying this case we
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will gain more information and knowledge about the disease and will lead us to a certain
perception as to how we will manage and care if ever we will experience again patients
with the same disease.
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OBJECTIVES
General Objectives:
This study done by group 3 of BSN 3E aims to present all the details about Severe
Preeclampsia; its causative factors, its damage to the human physiology, and its
underlying complications if left untreated. This can be achieved through research, with
the use of the patient’s hospital records, article references and other materials, and
through interviewing the patient during hospitalization; also, to formulate a complete and
comprehensive definition of the diagnosis.
This study also aims to understand the medical principles that accompany
Preeclampsia. With this, we hope this will lead to insights on appropriate nursing care
and management that a patient with the same such ailments will need in the future.
Specific Objectives:
The specific aims of this study are:
Establish a good interpersonal therapeutic relationship with the patient as well as
her family and significant others;
Formulate an introduction related to the condition being studied, which includes
implication to nursing practice, research and education;
Obtain patient’s data of the patient’s physical condition as wel as her overall body
system functioning;
Assess patient’s background, such as medical history and family structure as well
as its function that could have affected that patient’s current health status;
Assess the condition of the client through physical examination using
cephalocaudal approach;
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Define the complete diagnosis of the patient coming from the different references
Discuss the human anatomy and physiology of the systems involves in the disease
process of our client;
Trace the pathophysiology of the disease from the possible cause
Identify the symptoms, predisposing and precipitating factors that contribute to
the present illness of the client;
Determine various laboratory and diagnostic examination used in relation to the
disease with its corresponding nursing intervention;
Research the medications administered to the patient;
Identify the different medical and nursing management that was carried out to the
patient.
Make appropriate nursing care plans for the patient
Health teachings that must be given to the patient
Determine client’s prognosis on the disease
Present all the references used in the case study
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PATIENT’S DATA
Name:Mrs. X
Address:Cateel, Davao Oriental
Age:35 y.o.
Sex: Female
Civil Status:Married
Nationality:Filipino
Religion:Roman Catholic
Occupation:Physical therapist and housewife Birthplace: Davao Oriental
Birth date: April 11, 1973
Educational Attainment: College graduate
Family Data:
Spouse: Mr. Y
Age: 34 y.o.
Occupation: Resigned airforce
Father's Name: Mr. A
Mother's Name: Mrs. B
Number of Children: 1
Clinical Data:
Patient's Name: Mrs. X
Age/Sex: 35 y.o./Female
Date of Admission: Sept. 3,2008
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Hospital: Davao Medical Hospital (DMC)
Ward: OB
Admitting Physician: Dr. Herera-Chua
Attending Physician: Dr. Orinello Mautilla
VS on Admission:
Temp: 36 BP: 110/70 mm Hg PR: 80 bpm RR: 20 bpm
Surgical Procedure: Stat. CS with BTL
Date of Operation: Sept.6,08
Anesthesiologist: Dr. Ongkingco
Surgeon: Dr. Dribello
Time of Operation: 10:25am- NA
Address: Cateel, Davao Oriental
Final Diagnosis: Pregnancy Uterine delivered by repeat low segment transverse CS 32 weeks by billiard score. Cephalic delivered to live birth baby girl felt heart rate by auscultation. Pre-ecclampsia severe Stat. LSS with uncontrolled BP. Operation LS TCS with BTL (Bilateral Tubal Ligation).
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FAMILY BACKGROUND
Health History
Mrs. X was born on April.11,1973. And she’s the 2nd among the 5 siblings of Mr. A and
Mrs. B. Both of her parents are living. Mrs. X is currently living with her husband and
has been blessed with 1 child. Mrs. X was born and raised in Cateel, Davao Oriental
where she lived and went to school. She took up Physical Therapy but since she had been
pregnant she stopped working and considered herself as a housewife. She has no vices,
does not drink nor smoke. The familial disease that runs in their family is hypertension.
They also have their business which is a small restaurant and sells meat and fishes too.
She gave priority on the food and the everyday fare of her daughter. Their family income
which is 1,500/week is enough to support their needs.
Past Health History
The patient experienced her first hospitalization and was admitted on 1998 at
Davao Medical Center to deliver her 1st baby. Aside from hypertension which is
hereditary in their family, she only experienced illnesses such as colds, cough and fever.
She also said that she experience migraine because of stress. She self medicates
whenever her condition is not that serious and only entertains the thought of seeking
consultation whenever her condition cannot be relieved by home meds. She had
completed her immunizations that have been given during her younger years.
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Menstrual History:
Her menarche occurred at the aged of 14 years old. She has regular monthly cycles and
lasts about 5-6 days. Sometimes she experienced primary dysmenorrhea, pain that occurs
typically in the lower abdomen and is crampy. Her last menstrual period was on Dec.29,
2007.
Contraceptive History
She didn’t experience to take any of those contraceptives.
History of Present Illness
Mrs. X had a Normal Spontaneous Vaginal Delivery (NSVD) on her first
pregnancy. On her 2nd,3rd,and 4th pregnancy was through Cesarean operation, her babies
died because of premature delivery. Her last menstrual period was on Dec.29, 2007. Her
estimated time on confinement is Oct. 6, 2008. Her age of gestation is 36weeks and 2/7
days. On her 5th pregnancy she was then given a shot of Tetanus Toxoid at Jan 7,2008
and completed her 5 shots in 9mos. And was told to have a cesarean section due to her
previous CS delivery and she had also decided to undergo Bilateral Tubal Ligation. On
Sept.3, 9:30a.m of this year, a days prior to patient’s admission, she complained of labor
pain. She was admitted at Davao Medical Center for further evaluation and tests. After
being seen and examined by her attending physician, high blood pressure, proteinuria,
migraine and pitting edema of about 2mm by 8mos. prior to her admission were noted
and diagnosed to have a severe preeclampsia.
The patient was willing to submit herself for the said procedure and voluntarily
signed her consent on Sept.6 ,08 at 10:30 am. In Davao Medical Center.
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Effects of Illness to self and family
The patient remains to be positive regarding her condition. They planned their
last pregnancy because their 2nd,3rd and 4th child died. And since their last baby died, she
decided to have a bilateral tubal ligation because she feared that her future pregnancy
might have the same condition. She said that she would want a speedy recovery so that
she would be able to work and manage her business again.
Her family members are supportive and taking turns in staying with her at the
hospital. Financially speaking, they are not bothered because they are able to support the
patient’s medical needs.
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DEVELOPMENTAL DATA
Development implies a progressive and continuous process of change leading to a state of organized and specialized functional capacity. These changes can be measured quantitatively but more distinctly measured in qualitative changes. Development is the behavioral aspect of growth and these proceeds from simple to complex, or from single acts to integrated acts.
Theorist
Robert
Havighurst’s
Developmental
Milestones Theory
Theory
Robert
Havighurst
believed that
learning is basic
to life and that
people continue
to learn
throughout life.
A
developmental
task is a “task
which arises at
or about certain
period in the life
of an individual,
successful
Stage
Mrs. X, is 35 years old
and belongs to the early
adulthood (20-40) and the
following are the tasks
that the person must
achieve during this stage.
Developmental
task
1. Selecting a
mate
√
2. Learning to
live with a
partner
√
Result and
Justification
Mrs. X has
achieved the first
developmental
task which is
selecting a mate
because she
already found
someone to
become his partner
in life in the
person of her
husband.
She has achieved
the second
developmental
task which is
learning to live
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achievement of
which leads to
happiness and to
success with
later tasks, while
failure leads to
unhappiness in
the individual,
disapproval in
the society, and
difficulty with
later tasks.
3. Starting a
family
√
4. Rearing
children
√
5. Managing a
home
√
6. Getting started
in an occupation
√
7. Taking on
civic
responsibility
√
8. Finding a
congenial social
group
√
with a partner
because she has
been married for
fourteen years and
in spite of their
marital problems
they were able to
adjust throughout
their marriage and
accepted each
others differences.
Starting a family is
the third task
which was also
achieved by our
patient. She got
married and had 5
children but only
one survive.
The fourth task is
rearing children.
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She achieved this
by taking care of
her child. Her 1st
child is already 10
years old and has
been going to
school. She
teaches her child
good values and
instill to them
discipline even at
their young age.
The fifth task is
managing a home.
She has achieved
this task because
she is able to take
care of their home.
She is a physical
therapist but she
makes sure that
she is able to do
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household chores
as well as
budgeting for her
husband’s income
to meet their
needs.
Getting started in
an occupation is
the sixth task. She
has achieved this
because she was
working before
she got married.
When she got
pregnant she
stopped working
but immediately
when back after a
few months of
giving birth. She
became a part-
time housewife so
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she can take care
of her family. She
chose this
occupation
because she felt
that her family
needs her.
Our patient has
achieved the
seventh
developmental
task which is
taking on civic
responsibility. She
exercises her right
to vote and she is
also concern with
the present
condition of our
country.
The last task for
this stage is
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finding a
congenial social
group. Our
patient achieved
this task because
she is active in
their community
such as joining the
GKK group. She
tries to participate
in their
community’s
activities if she
finds time.
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Psychosocial
Theory of
Development by
Erik Erikson.
Erikson envisions
life as a sequence of
levels of
achievement. Each
stage signals a task
that must be
achieved. The
resolution of a task
can be complete,
partial, or
unsuccessful.
Erikson believes
that the greater the
task achievement,
the healthier the
personality of the
person; failure to
achieve a task
influences the
person’s ability to
achieve the next
task. Erikson’s
eight stages reflect
Mrs. X belongs to the
stage of generativity
versus stagnation
(25-65 years old).
The syntonic quality
of adulthood is
generativity., defined
as “the generation of
new beings as well as
new products and new
ideas”. It is
concerned with
establishing and
guiding the next
generation, includes
the procreation of
children, production
of work, and the
creation of new things
and ideas that
contribute to the
building of a better
world. The anisthesis
Our patient has
partially achieved
this stage of
development.
Though still at 35
years of age she
has showed
positive indicators
that she can
achieve this task
successfully. She
plays significant
roles in her
business and
households as well
as in her
community. She
has one child and
raised her to be a
good individual.
Being a mother
and a wife she does
her best to
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both positive and
negative aspects of
the critical life
periods. The
resolution of the
conflicts at each
stage enables the
person to function
effectively in the
society.
of generativity is
stagnation. It
happens when people
become too absorbed
in themselves, too
self-indulgent. The
emphasis of the
developmental task is
on maintaining
intimate relationships.
The self is more
altruistic, and
concepts of service to
others and love and
compassion gain
prominence.
continue learning
by being active in
the community
activities. She
learns from other
mothers and
practices it to her
own family. Mrs.
X also shares her
skills and
knowledge to other
parents.
Cognitive Theory
of Development by
Jean Piaget
Jean Piaget
proposed a sequence
of cognitive
development that
emphasized the
relationship
Mrs. X belongs to the
Formal Operational
Stage (11 years old-
adulthood). The
formal operational
stage is characterized
Our patient has
achieved the task
of formal
operational stage
because she and
her husband have
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between action and
thought. He also
proposed that each
serves as a
precursor to all
succeeding stages so
that reasoning
develops
sequentially, always
from less effective
to the more
effective stage.
This progression is
not necessarily at
the same rate for
every person, and
people do not
progress through the
stages exhibiting all
the reasoning
characteristics of a
particular stage.
by formal reasoning.
A person becomes
better at organizing
and structuring data
with the methods of
concrete operational
thought. They
become aware that
such methods do not
lead a logically
exhaustive solution to
their problems. They
can reflect on their
own reasoning to look
for inconsistencies.
They can check their
results in numerical
calculations against
order-of-magnitude
estimates. In this
stage, a person uses
rational thinking.
Reasoning is
decided to have
achild and raise a
family. Even
though she has
good educational
background she
also developed
formal reasoning
from the
experiences and
the lessons life
taught her. She
was able to answer
in a consistent
manner and
without hesitation
in every question
we asked her.
Moreover, she has
learned to develop
rational thinking,
reasoning and
decision.
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deductive and
futuristic.
DEFINITION OF COMPLETE DIAGNOSIS
Complete: Pregnancy Uterine delivered by repeat low segment transverse CS 32 weeks
by billiard score. Cephalic delivered to live birth baby girl felt heart rate by auscultation.
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Pre-ecclampsia severe Stat. LSS with uncontrolled BP. Operation LS TCS with BTL
(Bilateral Tubal Ligation).
UTERINE PREGNANCY
A normal pregnancy occurs when a fertilized egg is implanted in the uterus
(womb) and an embryo grows.
Source: http://www.emedicinehealth.com/pregnancy/article_em.htm
CAESAREAN SECTION DELIVERY
Caesarean delivery is the delivery of a fetus through a transabdominal incision of
the uterus. The basic purpose or use of caesarean delivery is to preserve the life and
health of the mother and her fetus. It is based on evidence of maternal or fetal stress.
Source: Essentials of Maternity Nursing, 3rd Edition, Bobak and Jensen
LOW SEGMENT CS DELIVERY
Lower segment caesarean delivery can be performed through a vertical or
transverse incision. It is more popular because it is easier to perform, is associated with
less blood loss and fewer postoperative infections, and is less likely to rupture in
subsequent pregnancies.
Source: Essentials of Maternity Nursing, 3rd Edition, Bobak and Jensen
CEPHALIC
Presentation of any part of the fetal head, usually the upper and back part as a
result of flexion such that the chin is in contact with the thorax in vertex presentation.
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There may be degrees of flexion so that the presenting part is the large fontanel in
sincipital presentation, the brow in brow presentation, or the face in face presentation.
Source: http://cancerweb.ncl.ac.uk/cgi-bin/omd?cephalic+presentation
SEVERE PRE-ECLAMPSIA
A woman when her blood pressure has risen to 160 mm Hg systolic and 110 mm
Hg diastolic or above on at least two occasions 6 hours apart at bed rest or her diastolic
blood pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+
on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are
also present. With severe preeclampsia, the extreme edema will be noticeable as puffiness
in a woman's face and hands. It is most readily palpated over bony surfaces, such as over
the tibia on the anterior leg, the ulnar surface of the forearm, and the cheekbones, where
the sponginess of fluid-filled tissue can be palpated against bone. If there is swelling or
puffiness at these points to a palpating finger but the swelling cannot be indented with
finger pressure, the edema is nonpitting. If the tissue can be indented slightly, this is 1+
pitting edema; moderate indentation is 2+; deep indentation is 3+; and indentation so
deep it remains after removal of the finger is 4+ pitting edema.
Source:MCN pp.427-428 by Adele Pilliteri
The patient’s blood pressure rises to 160/110 mmHg or more on two separate
occasions 6 hours apart with pregnant woman on bed rest. Presence of proteinuria of 5-10
g/L in 24 hours or 2+ or more protein on dipstick, generalized edema, noticeable
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puffiness of eyes, face, and fingers, pulmonary edema, hyperreflexia 3+ or more, ankle
clonus, oliguria (less than 100 ml/4 hr output), severe headache, blurred vision,
photophobia, blind spots on funduscopy, severe irritability, elevated serum creatinine,
and presence of thrombocytopenia.
Source: Essentials of Maternity Nursing, 3rd Edition by Bobak, Jensen
BILATERAL TUBAL LIGATION (BTL)
Tubal ligation for women seeking out a safe, effective, permanent and convenient
form of contraception, may be a good option. The most common form of surgical
sterilization procedure used for women today is called a tubal ligation, often referred to
as "having your tubes tied". A tubal ligation procedure prevents the egg and sperm from
meeting and you from becoming pregnant. It is a permanent and highly effective form of
birth control. A tubal ligation typically is performed via a small incision in your belly
button . It can either be performed after delivery or at a latter time. When a tubal ligation
is performed after delivery it is called a post-partum tubal ligation and does not require
laparoscopy. If you have a tubal ligation and you are not pregnant, it is usually performed
by laparoscopic surgery. All forms of tubal ligation require either burning, cutting,
clamping or tying the mid section of your fallopian tubes.
Source: http://www.womenshealthcaretopics.com/surgical_sterilization.htm
PHYSICAL ASSESSMENT
General Survey:
Our patient, Mrs. X, 35 years old was assessed on September 7, 2008. She was
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admitted at Obstetrical ward, Davao Medical Center on September 3, 2008. He weighs 67
kg. and a height of 5’0”. Patient was received lying on bed conscious, coherent and
responsive. She cooperates and participates in our physical assessment. She has 1 child.
The patient’s body structure is endomorphic.
Vital signs:
12:00 am 4:00 am
BP - 140/100 BP -120/90
PR - 71 bpm PR - 77 bpm
RR - 20 bpm RR - 23 bpm
Temp. - 36 ۫ C Temp. – 36.2 ۫ C
Skin
Our patient has a brown complexion. She has cold clammy skin. She has a poor
skin turgor as skin slowly goes back to its previous state after being pinched and with
capillary refill of 3 seconds. Dry skin and has a rough texture. Presence of hairs noted in
the head and in the upper and lower extremities. Lesions, bleeding and bruises were not
seen upon observation. Nails are not properly trimmed and traces of dirt noted.
Hair
Hair is black in color and evenly distributed. No signs of dandruff and lice noted.
No swelling, laceration, bruises and tenderness were seen upon inspection.
Eyes
Eyes are symmetrical with each other. The cornea is moist and white in color. The
iris appears to be black on both eyes. Pupils are equally round and reactive to light
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accommodation with a papillary size of 2-3 mm. She does not have any problem in her
eyesight. Eyebrows are thin and eyelashes are evenly distributed along the margin of the
eyelids; both eyes move in unison; no signs of scratches on both eyes and no discharges
noted.
Ears
The shape of the pinnaes are oval and with no discharges noted. Upper margin of
the pinnaes is in line with the outer canthus of the eyes. Ears are firm and non-tender.
Patient can hear voices properly. Signs of lesions, lacerations, swelling and bruises were
not seen upon inspection.
Nose
External surface of the nose is smooth and oily. Nasal septum is in midline of the
head. Nasal mucosa is moist and nasal hairs present. Lesions and inflammation are not
present. No discharges noted.
Mouth
Lips are dry with minimal cracks. Teeth are not complete and there is a presence
of cavities noted. Gums and buccal mucosa are pinkish in color. Tongue is in the midline
of the mouth. Tonsils are not inflamed. No signs of inflammation and laceration on the
uvula. Bleeding, ulceration and swelling were not seen upon inspection. Patient has fair
dental hygiene.
Neck
The neck of our patient can move easily without any discomfort, which includes
right and left lateral, right and left rotation, flexion and hyperextension. Neck can
properly support the head. No signs of enlargement, masses on the thyroid. Carotid pulse
25
is palpable. No signs of swelling or enlargement of the lymph nodes. No deformities
noted.
Chest and lungs
Chest expansion is symmetrical. Normal respiratory rate of 13 breathes per
minute with regular rhythm. No signs of productive cough and difficulty in breathing.
The patient has a clear breath sound. Crackles and wheezing sound are not present upon
auscultation. No lesion and bruises were seen upon inspection.
Abdomen
Patient’s abdomen is soft, flabby, nontender with bilaterally symmetric umbilicus
inverted at midline. She has normoactive bowel sound upon auscultation. With lateral
surgical incision on the abdomen.
Genito-urinary
Presence of pubic hair on mons pubis noted. The client has normal menstrual
cycles before she was pregnant. Normal discharges of urine were present as stated by the
patient. There was no presence of any unusual vaginal secretions as stated by the patient.
Upper extremities
Both arms can stretch, flex, rotate and extend without difficulty. No signs of
lesion and bruises noted. Fingernails are not properly trimmed and traces of dirt noted.
Lower extremities
Both legs can stretch, flex, rotate, extend and bend without any difficulty. Legs
cannot properly support. She needs assistance in walking. Signs of edema were observed
on the patient’s lower extremities. When poked the pitting of the edema was 2mm.
26
Toenails are trimmed and there are no traces of dirt noted. No signs of deformities,
lesions, lacerations, and bruises, bleeding were seen upon observation.
ANATOMY AND PHYSIOLOGY
CARDIOVASCULAR SYSTEM
The Heart
27
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) and back
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
28
the vessel wall 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 in Latin 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 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
29
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
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
30
plasma or out of the plasma. Most of the mechanisms that accomplish such changes in
plasma volume operate by altering the body’s 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 rennin-
angiotensin 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 renin-
angiotensin 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 volume
control contributes to the precision in controlling venous return, which in return yields to
the precise overall control of blood circulation
31
EXOCRINE SYSTEM
The exocrine system’s 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
32
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.
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, Bowman’s capsule, proximal convulted tubule, Loop of Henle,
distal convoluted tubule and the collecting tube. The Bowman’s 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 be processed in the
nephron to form urine.
The Glomerulus is the body’s well-known capillary network and is surely one of
the most important ones for survival. Glomerulus and Bowman’s 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
33
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
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.
34
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.
35
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.
ETIOLOGY
Predisposing
Factors
Actual Rationale Justification
Sex Pre-eclampsia is a disease of women The patient is
exposed to this
36
condition since she
is a female.
Age Some of the more common chronic
diseases that may be present in women
over 35, and which may affect a
pregnancy, are arthritis, hypertension,
and diabetes
(http://
www.expectantmothersguide.com/
library/stlouis/
ESLadv_maternal_age.htm)
This is a
contributing factor
to the patient’s
condition since she
is already 35 years
old.
Family history Pre-eclampsia is also more common in
women who have preexisting
hypertension, diabetes, autoimmune
diseases like lupus, various inherited
thrombophilias like Factor V Leiden, or
renal disease, in women with a family
history of pre-eclampsia, obese women,
and in women with a multiple gestation
(twins, triplets, and more).
Genetic predisposition may present as
an immunologic factor in determining
This is evident in
our patient since
she has relatives
having high blood
pressure. Since
hypertension is a
hereditary factor, it
predisposes the
patient to develop
hypertension and
can result to the
progress of
37
the development of preeclampsia
among women. Research has shown a
greater frequency of preeclampsia
among daughters and granddaughters
of women with a history of eclampsia,
which suggests an autosomal recessive
gene controlling the maternal immune
response. A history of chronic
hypertension in the family may also
increase the risk of developing
preeclampsia during pregnancy.
(http://en.wikipedia.org/wiki/Pre-
eclampsia)
(Lowdermilk and Perry.Maternity
Nursing 7th Ed. Mosby Year Book
Publishing, St.Louis. Missouri, USA.)
preeclampsia
during her
pregnancy.
Primigravida X It is much more common in women
who are pregnant for the first time and
its frequency drops significantly in
second pregnancies.
Our patient already
had her previous
pregnancies
(multigravida).
38
(http://en.wikipedia.org/wiki/Pre-
eclampsia)
Race X Maternal race also influences the rate
of pregnancy-associated hypertension.
Asian or Pacific Islander women have
the lowest rate for hypertension
complicating pregnancy with a rate of
19.6 per 1000.
(Lowdermilk and Perry.Maternity
Nursing 7th Ed. Mosby Year Book
Publishing, St.Louis. Missouri, USA.)
This is not evident
in our patient since
she is an Asian.
Precipitating
Factors
Actual Rationale Justification
Preeclampsia
in previous
pregnancy
The single most significant risk for
developing pre-eclampsia is having had
pre-eclampsia in a previous pregnancy.
This is evident in
our patient because
during her
previous
39
(http://en.wikipedia.org/wiki/Pre-
eclampsia)
pregnancies she
was also diagnosed
with pre-
eclampsia.
Multiple
pregnancies
Mothers who are pregnant with
multiples are at extremely high risk for
preeclampsia, also known as Toxemia
or Pregnancy Induced Hypertension
(PIH).
Women who are pregnant with more
than one child, compared with those
expecting one child, are 2-4 times as
likely to experience complications of
childbirth.
(http://multiples.about.com/cs/
medicalissues/a/preeclampsia.htm)
(Pathophysiology Adaptations and
Alterations in Function, 4th Edition by
Barbara L. Bullock)
This can be
considered a factor
to the patient’s
condition since she
already had her
previous
pregnancies
(multigravida).
40
Diet and
Nutrition
X Some studies indicate that poorly
nourished women develop
preeclampsia more often. Studies of
calcium supplementation for preventing
preeclampsia have had mixed results
with some recent studies showing no
effect. Pregnant women should make
sure their diet is adequate in food
sources of these vitamins and take only
the supplements prescribed by their
prenatal care provider.
(http://parenting.ivillage.com/
pregnancy/pcomplications/
0,,4b0,00.html)
This is not a factor
in our patient since
she knows that she
needs to watch the
foods that she is
eating. She is
aware that her
baby needs
sufficient
nutrients.
SYMPTOMATOLOGY
SYMPTOMS Actual Rationale Justification
Hypertension The systolic blood pressure is the
pressure of the blood as a result of
The client had a
systolic BP of
41
contraction of the ventricles, that is, the
pressure of the height of the blood
valve and the diastolic blood pressure
is the pressure when the ventricles are
at rest. This happens because the heart
is forced to pump against the rising
peripheral vascular resistance due to
vasospasm, therefore increasing the
blood pressure. A pregnant woman
with severe preeclampsia who is
experiencing hypertension has a blood
pressure of 160/110 mm Hg.
140 mmHg and
a diastolic BP of
100 mmHg
therefore this
symptom is
present in our
client.
Proteinuria Proteinuria is a condition in which
protein is present in the urine. It is
normally confined to the blood, spilling
into the urine because the small blood
vessels in the kidneys become damaged
due to hypertension. A patient is
considered to be experiencing
proteinuria if the urine sample results
show 3+ or 4+.
(Maternal & Child Health Nursing, 4th
Edition by Pillitteri)
Based on the
patient’s
laboratory
tests, the client
had traces of
protein (3+)
upon
undergoing
urinalysis.
42
Edema Edema develops because of the protein
loss, sodium and water retention due to
lowered glomerular filtration rate. It is
noticeable in the woman’s face and
hands as puffiness. It is most readily
palpated over the bony surfaces, such
as over the tibia on the anterior leg, the
ulnar surface of the forearm, and on the
cheekbones, where the sponginess of
the fluid tissue.
(Maternal & Child Health Nursing, 4th
Edition by Pillitteri)
Signs of edema
were observed
on the patient’s
lower
extremities.
The pitting of
the edema was
2mm.
Oliguria X Increased water retention due to the
decreased release of ADH stimulated by
angiotensin II. It is a condition in which
a person has a total urine output of less
than 500ml over 24 hours.
This is not
evident in our
patient because
her urine
output is more
than 500 ml
per 24 hours.
Based on her I
and O records
43
she had a urine
output of 725
ml.
Scotomata or
Blurred vision
X Blurring of vision is caused by
vasoconstriction which can be related to
hypoxia of the vessels of the head. It
can damage the cerebral cortex which is
the visual center in the brain
The patient
stated that she
did not have
any problem
with her
eyesight during
the course of
her pregnancy.
She can also
see clearly
without the use
of any
correctional
eyeglasses or
aid.
Hemolysis
Due to the
increased blood
pressure, the blood
Hemoly
sis
X Due to the
increased
blood pressure,
the blood
vessels will
44
vessels will rupture
that will lead to
RBC
fragmentation.
rupture that
will lead to
RBC
fragmentation.
Based on the
patient’s
laboratory results,
the patient has a
normal RBC
count.Headache
Due to increased blood pressure there
is cerebral hypertension.
The patient
stated that she
experienced
episodes
headache.
Seizures X Due to too much pressure exerted by
the blood cranial blood vessels may be
affected resulting to seizures.
The patient
verbalized that
she was not
able to
experience any
episodes of
seizure.
PATHOPHYSIOLOGY
45
Whereas all hypertensive disorders in pregnancy (pre-eclampsia, essential
hypertension, 'secondary' hypertension) share high blood pressure as a common theme
(probably mediated by inappropriate vasoconstriction), pre-eclampsia is the only disorder
with multisystem abnormalities.
The triad of physiological derangements in pre-eclampsia is:
1. Intense vasospasm,
2. Local or disseminated intravascular coagulation,
3. Plasma volume contraction.
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 placental mass, ex. Twins, or abnormal placenta. Current hypotheses propose
release of a toxic factor from the placenta which alters maternal endothelial cell
functions, though this is unproven.
Vasospasm follows due to excess production or sensitivity to vasoconstrictors
(angiotensin II, serotonin and endothelin are the most popular candidates) and/or
decreased production or 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 pressures. There is redistribution of fluid from
46
the intravascular to interstitial fluid spaces so that total extra cellular fluid volume
remains unaltered. These are important considerations 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.
Systems most commonly affected are the kidney (manifested by reduced GFR,
proteinuria, hyperuricaemia and occasionally oliguria), the liver (manifested by elevated
aspartate transaminase with or without epigastric and right upper quadrant pain), the
brain (manifested most commonly by transient visual scotomata due to occipital lobe
ischemia, severe headaches and rarely convulsions, ex. eclampsia) and the placenta
(manifested by intrauterine fetal growth retardation and less commonly placental
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.
DOCTOR’S ORDER
Date Ordered Doctor’s Order Rationale Remarks
47
PRE OP ORDERSeptember
3,2008
@8:30 am
Admitting physicianDr. Isip
Secure consent for legal purposeDONE
On NPOFor preparation for surgery, to avoid efflux of food that will cause aspiration with anesthesia
DONE
VS q 4° Check the BP for any changes because the patient has hypertension
DONE
Labs: CBC, BT, PC, CTBT, W/A, SGPT, Serum Creatinine, HBSOG
Measures and evaluate the cellular components of bloods and its function. It also helps in diagnosing the client’s condition.
DONE
Start venoclysis D5water 500cc @ KVO rate Helps expand intravascular volume, corrects an underlying imbalance in fluids and electrolytes and compensates the loss in the body
DONE
Meds: Hydralazine 5mg IVTT now, then for DPB ≥ 110 mmHg
An antihypertensive that relaxes the smooth muscle in the anterial wall.
DONE
MgSO4 in 100cc D5water Slow IVTT5gm MgSO4 IM in each buttock.Start MgSO4 drip after 4 hours loading doseD5water 80cc+20cc MgSO4 via soluset to run @ 25 gtts/min in 4 hours x 6 cycles with toxicity precautions
To increase water in the intestines, this may induce defecation.
DONE
Insert Foley Catheter and attach to urobagTo monitor the intake and output of the patient.
DONE
48
Baseline EFM For close monitoring of the fetal status and serves as a baseline data.
DONE
I & O q Shift To monitor the intake and output
DONE
9:30 am Dexamethasone 6mg q 12° IVTT x 4 doses Anti-inflammatory DONE
10:00 am schedule stat CS (fetal distress) with BTL Cesarean delivery DONE secure consent For legal purposes. DONE inform OR/AROD/PRON For preparation. DONE cefazolin 1gram q 8° IVTT antibacterial DONE
Refer
POST OP ORDERS@
11:00 am
post LSTCS with BTL under spinal anesthesia DONE to PACU then to ward once stable DONE NPO temporarily Assess peristaltic
movementDONE
VS q 15 mins until stable then hourly Check the BP for any changes because the patient has hypertension
DONE
IVF: D5LR 1 L to run @ 120cc/hour Meds:1. cont. MgSO4 drip as ordered
To increase water in the intestines, this may induce defecation.
DONE
2. Tramadol 50mg IVTT q 6° To manage mild/severe pain
DONE
3. Ketorolac 30mg IVTT q 8° Non-steroidal anti-inflammatory drug
DONE
4. Metoclopramide 10mg IVTT q 8° Gastrointestinal stimulant
DONE
5. Ranitidine 50mg IVTT q 6° while on NPO Histamine antagonist
DONE
6. Cont. IV antibiotics as ordered DONE
Oxygen by mask to supply sufficient DONE
49
amount of oxygen Keep patient warm To maintain body
temperature in the normal range.
DONE
Keep uterus well contracted always Prevent hemorrhage DONE I & O q hourly Monitor intake and
outputDONE
Watch out for any unusualities DONE Refer DONE
DONE
September4
2008@
7:30 am
continue cefazolin IVTT x 3 days antibacterialDONE
continue gentamycin 240mg OD Antibiotic DONE Remove FBC and refer if unable to void in 4-6
hours after.DONE
September6
2008@
7:30 am
please comply with antibiotic medsDONE
may have clear liquid mgt. diet once with flatus
start • mefenamic acid 500mg/cap TID • Ferrous Sulfate
Treatment for pain.
Treatment for anemia
DONE
continue gentamycin 240mg IVTT q 24 hrs OD antibiotic DONE continue cefazolin IVTT q 8° Antimicrobial and
antiparasitic agentsDONE
encourage ambulation DONE
increase oral fluid intake
To avoid dehydration
DONE
10:00 amUnder the service of
DR. Mantilla
Amlodipine 10mg OD Anti-hypertensive DONE
Metoprolol 100mg BID (6am-6pm) Antihypertensive DONE Low fat, low salt diet DONE VS q 4° Check the BP for
any changes because the patient has hypertension
DONE
Cont. IVF @ same rate & PO meds DONE D/C IVTT meds DONE
50
Start PO meds – kindly transcribe to medication sheet about :
1. FeSO4 1 tab OD
Antianemic-iron DONE
2. Ascorbic acid 1 tab OD Vitamins and Minerals
DONE
DIAGNOSTIC EXAM
51
IPD HEMATOLOGYCBC + BLT
TEST RESULT UNIT REF. RANGES
Hemoglobin
- To identify the amount
of O2 carrying protein
contained within the
RBC.
- Decreased Hgb indi-
cates anemia from
blood loss, dietary de-
fiency, and malnutrition
and kidney disease.
128.0 g/L 115 – 155
Hematocrit
- To identify the percent-
age of the blood volume
occupied by red blood
cells.
- Decreased Hct indicates
blood loss, anemia,
blood replacement ther-
apy, and fluid balance,
and screens red blood
cell status.
0.38 0.36 – 0.48
52
RBC Count
- To know the amount of
RBC in the blood. Rule
out anemia due to nutri-
tional deficiencies,
blood loss.
4.89 X10^6/uL 4.20 – 6.10
WBC Count
- To determine infection
or inflammation in the
body and monitor its re-
sponses to specific ther-
apies. Explain to the pa-
tient the necessity of
undergoing the test that
it helps detect occur-
rence of anemia and
polycythemia.
20.27 X10^3/uL 5.0 – 10.0
DIFFERENTIAL COUNT
TEST RESULT UNIT REF. RANGES
Neutrophil
- To indicate the presence
of bacterial infection and
81 55-75
53
amount of Leukocyte
Lymphocytes
- To identify if there is an
abnormal amount of
lymphocyte that may
indicate viral infection
such as HIV. A decreased
number of lymphocytes in
the peripheral circulation,
occurring as a primary
hematologic disorder or
in association with
nutritional deficiency,
malignancy or infection
mononucleosis.
15 20-35
Monocytes
- Increase of these may re-
spond to corticosteroid,
with pus conditions, hem-
orrhage.
4 2-10
Eosinophil
- High percentage of
eosinophil, may indicate
0 1-8
54
bacterial infestation or al-
lergies
Basophil
- Increase of basophil may
indicate parasite, hyper-
sensitiveness and heart-
worm causing endocrine
disease, chronic liver dis-
ease
0 0-1
Platelet count
- The smallest cells in the
blood are the platelets,
which are designed for a
single purpose—to begin
the process of
coagulation, or forming a
clot, whenever a blood
vessel is broken.
436 X10³/uL 150-400
BLOOD TYPE (ABO + Rh)
TEST RESULT UNIT REF. RANGES
Blood type B
55
Blood type Rh
- In forward typing, if
there’s agglutination,
the patient’s RBC’s
are mixed with anti-A
and anti-B serum, the A
and B antigen is
present, thus blood type
is O. This is to check
compatibility of the
donor and the patient
before transfusion
+
IMMUNOLOGY
TEST RESULT UNIT REF. RANGES
HBsAg qualitative
- to determine the
existence of hep B
antigen.
-
CHEMISTRY RESULT UNIT REF. RANGES
SGPT 27 U/L 30-65
CREATININE 61.40 Umol/L 53.00-115
56
HBSAG
QUALITATIVE
NEGATIVE
CLINICAL MICROSCOPY
A) P.E.
Color Dark yellow
Appearance Cloudy
Reaction 7.0
Specific Gravity 1.015
B) Chem. E.
Albumin
Sugar Negative
MICROSCOPIC EXAMINATION
Epithelial Cells:Squamous CastRenal Hyaline
57
Pus cells 0-3 hpf Fine granular >20 lpf
RBC >100 hpf Course granular 1-20 lpf
Mucous threadsBacteriaYeast cellsOil globulesSpermatozoa
INTERPRETATION:
Pregnancy alters urinary tract function and increases the risk of infection.
Asymptomatic bacteriuria frequently precedes symptomatic UTI, and it is important to
screen for this entity, as treatment during the first trimester has been shown to reduce the
incidence of pyelonephritis and possibly that of low birth weight.
The examination of urine provides information regarding the diseases involving
the kidney and lower urinary tract. The result of yellow color urine is due largely to the
pigment urochrome and to small amounts of urobilins and uroerythrin. Urochrome
excretion is thought to be proportional to the metabolic rate and is increased during fever,
thyrotoxicosis, and starvation. The uroerythrin may be deposited in uric acid or urate
crystals (brick dust deposit), and should not be confused with blood.
NURSING RESPONSIBLITIES
Blood Typing:
Inform the patient that the test determines her blood group.
58
Check the patient’s history for recent administration of blood, dextran or
I.V.
After the procedure, apply direct pressure to the venipuncture to the site
until bleeding stops.
Hematology:
Explain that the test measures the amount, size and content of red blood
cells, and can help in identifying problems such as anemia.
Observe the client for signs and symptoms of anemia including pallor,
dyspnea, chest pain and fatigue.
Encourage rest period for client that is experiencing fatigue related to
anemia. Severe anemia may produce these symptoms from tissue hypoxia.
Protect client from exposure to potential sources of infection such as
proper nutrition, hand washing.
Watch out for signs and symptoms of infection such as fever, jaundice,
flashed skin, redness and swelling.
Assess the client for unusual bruising, or prolonged bleeding from
venipuncture site.
Immunology:
59
Explain that the test identifies the presence of HBsAg in the blood, which
can help in identifying problems such as infection with Hepatitis B or
chronic infection.
Protect client from exposure to potential sources of infection such as
proper hand washing.
Determine if the patient is reactive or nonreactive for Hepatitis B Surface
Antigen
Assess client for unusual bruising, or prolonged bleeding from
venipuncture site.
Urinalysis:
Ensure that urinalysis to be performed should be a clean catch specimen ,
midstream specimen, fresh urine specimen, frist morning specimen,12 or
24hour collection, multiple bottle voidings or a specimen obtained with a
catheter.
Instruct female patients to separate the labia and uncircumcised male to
retract the foreskin.
For a catheterized patient, collect urine from the port on the tubing, not the
urinary drainage bag, because this may be contaminated. Use a drip
method to collect urine from a urostoma.
Evaluate client ability to perform ADL.
60
Date Ordered: September 3, 2008 @ 8:30am
Generic Name
Brand Name
Classification Dosage & frequency Mechanism of actions
Indications
Hydrazaline Hydrochloride
Alazine, Apresoline,
Novohylazin, Supres
Antihypertensive Adults: initially, 10 mg P.O. q.i.d.; gradually increased to 50 mg q.i.d.Maximum recommended dosage is 200 mg daily, but some patients may require 300 to 400 mg daily. Can be given b.i.d. for CHF.I.V. - 10-20 mg given slowly and repeated as necessary, generally q 4 to 6 hours. Switch to oral antihypertensive as soon as possible.I.M.- 20 to 40 mg repeated as necessary, generally q 4 to 6 hours. Switch to oral antihypertensive as soon as possible.Children: initially, 0.75 mg/kg P.O. daily in four divided doses (25 mg/m² daily). May increase gradually to 10 times this dosage if necessary.I.V.- gives slowly 1.7 to 3.5 mg/kg daily or 50 to 100 mg/m² daily in four to six divided doses.I.M.- 1.7 to 3.5 mg/kg daily or 50 to 100 mg/m² daily in four to six divided doses.
Directly relaxes arteriolar smooth muscle.
Essential Hypertension (oral, alone or in combination with other antihypertensive); to reduce after load in severe CHF ( with nitrates); and severe essential hypertension (parenteral to lower blood pressure quickly)
61
Contraindications Side Effects Adverse Reactions
Nursing Responsibilities
Breast-feeding—Hydralazine passes into breast milk. Although most medicines pass into breast milk in small amounts, many of them may be used safely while breast-feeding. Mothers who are taking this medicine and who wish to breast-feed should discuss this with their doctor.
Children—Although there is no specific information comparing use of hydralazine in children with use in other age groups, this medicine is not expected to cause different side effects or problems in children than it does in adults. However, the oral solution contains aspartame, which is converted to phenylalanine in the body. Children with phenylketonuria cannot process phenylalanine and high levels of this substance in body fluids may cause brain damage.
Older adults—Many medicines have not been studied specifically in older people. Therefore, it may not be known whether they work exactly the same way they do in younger adults. Although there is no specific information comparing use of hydralazine in the elderly with use in other age groups, this medicine is not expected to cause different side effects or problems in older people than it does in younger adults.
Less common
Blisters on skin; chest pain; general feeling of discomfort or illness or weakness; joint pain; muscle pain; numbness, tingling, pain, or weakness in hands or feet; skin rash or itching; sore throat and fever; swelling of feet or lower legs; swelling of lymph glands
Rare
Fever; general feeling of discomfort or illness; sore throat; weakness
Other side effects may occur that usually do not need medical attention. These side effects may go away during treatment
Blood: neutropenia, leukemia.
CNS: peripheral neuritis, headache, dizziness.
CV: orthostatic hypotension, tachycardia, arrhythmias, angina, palpitations, sodium retention.
GI: nausea, vomiting, diarrhea, anorexia.
Use cautiously in cardiac diseases, CVA, or severe renal impairment and in those taking other hypertensive.
Monitor patient’s Vital signs and body weight frequently. Some clinicians combine hydralazine therapy with diuretics and beta-adrenergic blocking agents to decrease sodium retention and tachycardia, and to prevent anginal attacks.
Watch patient closely for signs of lupus erythematosus-like syndrome (sore throat, fever, muscle and joint aches, skin rash). Call doctor immediately if any of these develops.
Teach patient about his disease and therapy. Explain the importance of taking this drug as prescribed, even when he’s feeling well. Tell outpatient not to discontinue this drug suddenly, but to call the doctor if unpleasant adverse reactions
62
Other medicines—Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. When you are taking hydralazine, it is especially important that your health care professional know if you are taking the following:
Diazoxide (e.g., Proglycem)—Effect on blood pressure may be increased
Other medical problems—The presence of other medical problems may affect the use of hydralazine. Make sure you tell your doctor if you have any other medical problems, especially:
Heart or blood vessel disease or Stroke—Lowering blood pressure may make
problems resulting from these conditions worse
Kidney disease—Effects may be increased because of slower removal of hydralazine from the body
Phenylketonuria—The oral solution of hydralazine contains aspartame, which is converted to phenylalanine in the body. Patients with phenylketonuria cannot process phenylalanine and high levels of this substance
as your body adjusts to the medicine. However, check with your doctor if any of the following side effects continue or are bothersome:
More common
Diarrhea; fast heartbeat; headache; loss of appetite; nausea or vomiting; pounding heartbeat
Less common
Constipation; dizziness or lightheadedness; redness or flushing of face; shortness of breath; stuffy nose; watery eyes
Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your doctor.
Skin: Rash.
Other: lupus erythematosus-like syndrome (especially with high doses), weight gain.
occurs. Instruct patient to check with
doctor or pharmacistbefore taking OTC medications.
Elderly patients maybe more sensitive to hypotensive effects.
Inform the patient that orthostatic hypotension can be minimized by rising slowly and avoiding sudden position changes
Give this drug with meals to increase absorption.
Compliance may be improved by administering this drug b.i.d. check with the doctor.
CBC, lupus erythematosus cell preparation, and antinuclear antibody titer determinations should be done before therapy and periodically during long term therapy.
Has been prescribed during pregnancy for treatment of eclampsia. Administered I.V.
I.V. use: give slowly and repeat as necessary, generally q4 to 6 hours. Switch to oral antihypertensive as soon as possible.
63
in body fluids may cause brain damage
Generic Name
Brand Name
Classification Dosage & frequency Mechanism of actions
Indications
Magnesium Sulfate
(mag NEE see um SUL fate)
Epsom Salt, Sulfamag
Anticonvusant, miscellaneous;
and laxative saline
IM Anticonvulsant.
Adults: 1-5 g of a 25-50% solution up to 6 times/day. Pediatric: 20-40 mg/kg using the 20% solution (may be repeated if necessary)
IV Anticonvulsant.
Adults: 1-4 g using 10-20% solution, not to exceed 1.5 ml/min of the 10% solution.
Hypomagnesenia, mild. Adult: 1 g as a 50% solution q 6 hr for 4 times (or total of 32.5 mEq/24hr)
Hypomagnesenia, severe Adults up to 2 mEq/kg over 4 hr.
IV INFUSION
May decrease acetylcholine released by nerve impulses, but its anticonvulsant mechanism is unknown.
For Hypomagnesemic seizures.Seizures secondary to hypomagnesemia in acute nephritis.Prevention or control of seizures in preeclampsia or eclampsia
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Anticonvulsant.Adults: 4-5 g in 250 ml d5w @ a rate not to exceed 3 ml/min.
Hypomagnesenia, severe Adults: 5 g (40 mEq) in 1000 ml D5W or sodium chloride solution by slow infusion over period of 3 hr.
Hyperalimentation.Adults: 8-24 mEq/day; infants: 2-10 mEq/day
ORAL SOLUTIONLaxative
Adults: 10-15g; pediatrics: 5-10 g.
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
In the presence of heart block or myocardial damage. In toxemia of pregnancy during the 2 hr prior to delivery.
Stop taking magnesium sulfate and seek emergency medical attention if you experience an allergic reaction (difficulty breathing; closing of your throat; swelling of your lips, tongue, or face; or hives).
CNS: sweating, drowsiness, depressed reflexes, flaccid paralysis, hypothermia.
CV: hypotension, flushinh, circulatory collapse, depressed cardiac function,
Use cautiously in impaired renal function, myocardial damage, and heart block, and in women in labor.
Drug can decrease the frequency and the force of uterine contraction.
Keep I.V. calcium glucanate available to reverse magnesium intoxication; however, use
65
Other, less serious side effects may be more likely to occur. Continue to take magnesium sulfate and talk to your doctor if you experience diarrhea or upset stomach.
heart block.
OTHER: respiratory paralysis, hypocalcemia.
cautiously in patients undergoing digitalization due to danger of arrhythmias.
I.V. use: Monitor vital signs every 15 mins. When giving drug I.V.
Watch for respiratory depression and signs of heart block. Respirations should should be approximately 16/mins before each dose given.
Monitor I & O. urine output should be 100ml or more in 4 hr period before each dose.
Check blood magnesium levels after repeated doses. Disappearance of knee-jerk and patellar reflexes is a sign of pending magnesium toxicity.
Maximum infusion rate is 150mg/min. rapid drip will induce uncomfortable feeling of heat.
Especially when given I.V. to toxemic mothers within 24 hrs before delivery,observe neonates for signs of magnesium toxicity, including neuromuscular or respiratory depression.
Signs of hypermagnesemia begin to appear at blood levels of 4 mEq/L.
Has been used as a tocolytic agent (suppresses uterine contractions) to inhibit premature labor.
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Ordered @ 9:30 am
Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
Dexamethasone Decadron, deronil, dexone, hexadrol, mymethasone.
Anti-inflammatory
Shock: 4 to 8 mg intravenously initially, repeat if necessary to a total dose of 24 mg.
Autoimmune diseases and inflammations: long-term therapy with 0.5 to 1.5 mg oral per day. Avoid more than 1.5 mg daily, because serious side effects are more frequently encountered with higher doses.
Adjuvant to or part of chemotherapy: individual schedule
Diagnostic purposes: special schedule
Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes. Also suppresses the immune response, stimulates bone marrow and influences protein, fat, and carbohydrate metabolism.
For Cerebral edema, Infalammatory conditions, allergic reactions, neoplasias.
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Contraindications Side Effects Adverse Reactions
Nursing Responsibilities
Some of these contraindications are relative:
Existing gastrointestinal ulceration
Cushing's syndrome Severe forms of
heart insufficiency Severe
hypertension Uncontrolled
diabetes mellitus Systemic
tuberculosis Severe systemic
viral, bacterial, and fungal infections
Preexisting wide angle glaucoma
Osteoporosis
If dexamethasone is given orally or by injection (parenteral) over a period of more than a few days, side-effects common to systemic glucocorticoids may occur. These may include:
Stomach upset, increased sensitivity to stomach acid to the point of ulceration of esophagus, stomach, and duodenum
Increased appetite leading to significant weight gain
A latent diabetes mellitus often becomes manifest. Glucose intolerance is worsened in patients with preexisting diabetes.
Immunsuppressant action, particularly if given together with other immunosuppressants such as ciclosporine. Bacterial, viral, and fungal disease may progress more easily and can become life-threatening. Fever as a warning symptom is often suppressed.
CNS: euphoria, insomia, psychotic behavior.
CV: CHF, hypertension, edema.
EENT: cataracts, glaucoma.
GI: peptic ulcer, GI irritation, increased appetite.
Metablic: possible hypokalemia, hyperglycemia and carbohydrates intolerance.
Skin: delayed wound healing, acne, various skin eruptions.
Local: atrophy at I.M. injection site.
Contraindicated to fungal infections and for alternate day theraphy. Also contraindicated in patients hypertensive to any component of the drug.
Use cautiously in GI ulceration or renal disease, hypertension, osteoporosis, varicella, vaccinia, exsanthema, diabetis mellitus, cushing’s syndrome, thromboembolic disorders, seizures, CHF, tuberculosis, hypoalbuminemia, emotional instability.
Gradually reduce drug dosage after long-term therapy. Tell patient not to discontinue drug abruptly or without doctor’s consent.
Always titrate to lowest effective dose. Monitor patient’s weight, blood pressure,
serum electrolytes. Instruct patient to carry a card indicating his
need for supplemental systemic glucocorticoids during stress, especially as dosage is decreased.
Give a daily dosage in the morning for better results and toxicity.
Teach patient’s signs of early adrenal insufficiency: fatigue, muscular weakness, joint pain, fever, anorexia, nausea, dyspnea, dizziness, and fainting.
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Psychiatric disturbances, including personality changes, irritability, euphoria, mania
Osteoporosis under long term treatment, pathologic fractures (e.g., hip)
Muscle atrophy, negative protein balance (catabolism)
Elevated liver enzymes, fatty liver degeneration (usually reversible)
Cushingoid (syndrome resembling hyperactive adrenal cortex with increase in adiposity, hypertension, bone demineralization, etc.)
Depression of the adrenal gland is usually seen, if more than 1.5 mg daily are given for more than three weeks to a month.
Hypertension, fluid and sodium retention, edema, worsening of heart insufficiency (due to mineral corticoid activity)
Dependence with withdrawal syndrome is frequently seen.
Increased intraocular pressure, certain types of glaucoma, cataract (serious clouding of eye lenses)
Dermatologic: Acne, allergic
May mask or exacerbate infections, including latent amebiasis.
Watch for depression or psychotic episodes, especially in high dose therapy.
Inspect patient’s skin for peteciae. Warn patients about easy bruising.
Patients with diabetes may need increased in insulin; monitor blood glucose.
Monitor growth in infants and children on long term theraphy.
Gve P.O. dose with food when possible.
69
dermatitis, dry scaly skin, ecchymoses and petechiae, erythema, impaired wound-healing, increased sweating, rash, striae, suppression of reactions to skin tests, thin fragile skin, thinning scalp hair, urticaria.
Allergic reactions (though infrequently): Anaphylactoid reaction, anaphylaxis, angioedema. (Highly unlikely, since dexamethasone is given to prevent anaphylactoid reactions.)
Other side-effects have been noted, and should cause concern if they are more than mild.
The short time treatment for allergic reaction, shock, and diagnostic purposes usually does not cause serious side effects
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Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
CefazolinAncef, Cefacidal, Cefamezin, Cefrina, Elzogram, Faxilen, Gramaxin, Kefazol, Kefol, Kefzol, Kefzolan, Kezolin, Novaporin, and Zolicef.
Antimicrobial and antiparasitic agents
Adults: 250 mg I.M. or I.V. Q 8 hrs to 1 g 6 hrs. maximum 12 g/day in life-threatening situations.
Children over 1 month: 25 to 100 mg/kg/day I.M. or I.V.in three or four divided doses.
Inhibits cell wall synthesis, promoting osmotic instability. Usually bactericidal.
Cefazolin is mainly used to treat bacterial infections of the skin. It can also be used to treat moderately severe bacterial infections involving the lung, bone, joint, stomach, blood, heart valve, and urinary tract. It is clinically effective against infections caused by staphylococci and streptococci species of Gram positive bacteria. These organisms are common on normal human skin. Resistance to cefazolin is seen in several species of bacteria.
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Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Do not use this medication if you are allergic to cefazolin, any type of penicillin, or to other cephalosporin antibiotics, such as:
cefaclor (Ceclor); cefadroxil
(Duricef);
cefdinir (Omnicef);
cefditoren (Spectracef);
cefixime (Suprax);
cefotaxime (Claforan;
cefprozil (Cefzil);
ceftazidime (Fortaz);
Side effects from cefazolin are not common. Possible side effects include:
diarrhea stomach pain upset stomach vomiting rash
Blood: transient neutropenia, leucopenia, eosinophilia, anemia.
CNS: dizziness, headache, malaise, paresthesia.
GI: pseudomembranous colitis, nausea, anorexia, vomiting, diarrhea, glossitis, dyspepsia, abdominal cramps, anal pruritus, tenesmus, oral candidiasis (trush).
GU: genital pruritus and moniliasis, vaginitis.
Skin: musculopapular and erythematous rashes, urticaria.
Local: @ injection site- pain, induration, sterile abscesses, tissue sloughing; phlebitis
Use cautiously in impaired renal function and in those with history of sensitivity to penicillin. Ask patient if he’s ever had any reaction to cephalosporin or penicillin therapy before administering first dose
Avoid doses greater than 4 g daily in patients with severe renal impairment.
Obtain specimen for culture and sensitivity test before first dose. Therapy may begin pending test results.
Because of long duration of effect, most infections can be treated with dose q 8 hrs.
Not as painful as other cephalosporin when given I.M.
I.V. use: alternate injection sites if I.V. therapy last longer that 3 days
Considered the first-generation cephalosporin of choice by most authorities.
With large doses or prolonged therapy, monitor for superinfection, especially in high risk patients.
Reconstituted cefazolin sodium is stable for 24 hrs at room temp. or 96 hours under refrigerator.
About 40% - 70% of patients receiving cephalosporin shows a false positive direct
72
cefuroxime (Ceftin);
cephalexin (Keflex); and others.
Before using cefazolin, tell your doctor if you are allergic to any drugs (especially penicillins), or if you have:
kidney disease; liver disease; or
a stomach or intestinal disorder such as colitis.
and thrombophlebitis with I>V> injection.
Coombs’ test; only a few of these indicate hemolytic anemia.
73
ORDERED during Post OP. .September 3, 2008 @ 11:00 am
Generic Name
Brand Name
Classification Dosage & frequency Mechanism of actions Indications
Tramadol ultram Analgesics, central acting
Doses range from 50–400 mg daily, maximum dose of 400 mg a day (webmed), with up to 600 mg daily when given IV/IM. The formulation containing APAP contains 37.5 mg of tramadol and 325 mg of paracetamol, intended for oral administration with a common dosing recommendation of one or two tabs every four to six hours.
The mode of action of tramadol has yet to be fully understood, but it is believed to work through modulation of the noradrenergic and serotonergic systems in addition to its mild agonism of the μ-opioid receptor. The contribution of non-opioid activity is demonstrated by the analgesic effects of tramadol not being fully antagonised by the μ-opioid receptor antagonist naloxone.
Tramadol is marketed as a racemic mixture with a weak affinity for the μ-opioid receptor (approximately
is used to treat moderate and severe pain and most types of neuralgia, including trigeminal neuralgia. It has been suggested that tramadol could be effective for alleviating symptoms of depression and anxiety because of its action on the noradrenergic and serotonergic systems, the involvement of which appear to play a part in its ability to alleviate the perception of pain.
74
1/6000th that of morphine; Gutstein & Akil, 2006). The (+)-enantiomer is approximately four times more potent than the (-)-enantiomer in terms of μ-opioid receptor affinity and 5-HT reuptake, whereas the (-)-enantiomer is responsible for noradrenaline reuptake effects (Shipton, 2000). These actions appear to produce a synergistic analgesic effect, with (+)-tramadol exhibiting 10-fold higher analgesic activity than (-)-tramadol (Goeringer et al., 1997).
The serotonergic modulating properties of tramadol mean that it has the potential to interact with other serotonergic agents. There is an increased risk of serotonin syndrome when tramadol is taken in combination with serotonin reuptake inhibitors (e.g. SSRIs) or with use of a light box, since these agents not only potentiate the effect of 5-HT but also inhibit tramadol metabolism. Tramadol is also thought to have some NMDA-type antagonist effects which has given it a potential application in neuropathic pain states
75
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Hypersensitivity to tramadol. In acute intoxication with alcohol, hypnotics, centrally acting analgesics,opiates, or psychotropic drug. Use for preoperative medication or for postdelivery analgesia in nursing mothers.
Nausea, vomiting, sweating and constipation. Drowsiness.
Stomach upset, increased sensitivity to stomach acid to the point of ulceration of esophagus, stomach, and duodenum
Vasodilation, liver failure, speech disorder.Dermatologic problems.
The most commonly reported adverse drug reactions are nausea, vomiting, sweating and constipation. Drowsiness is reported, although it is less of an issue than for other opioids. Respiratory depression, a common side effect of most opioids, is not clinically significant in normal doses. By itself, it can decrease the seizure threshold. When combined with SSRIs, tricyclic antidepressants, or in patients with epilepsy, the seizure threshold is further decreased. Seizures have been reported in humans receiving excessive single oral doses (700 mg) or large intravenous doses (300 mg). An Australian study found that of 97 confirmed new-onset seizures, eight were associated with Tramadol, and that in the authors' First Seizure Clinic, "Tramadol is the most frequently suspected cause of provoked seizure. Seizures caused by tramadol are most often tonic-clonic seizures. Dosages of coumadin/warfarin may need to be reduced for anticoagulated
Document indications for therapy, location, onset, and characteristics of symptoms. Use a pain rating scale.
Assess for history of drug addiction, allergy to opiates or codeine, or seizures; drug may increase the risk of convulsions.
Monitor VS, I & O, liver and renal function studies; reduce dose with dysfunction and if over 75 yrs. Old.
CLIENT/FAMILY TEACHING
Take only as directed. May be taken without regard to meals. Do not exceed single or daily doses of tramadol; do not share meds, store safely out of reach of child.
Do not perform activities that require mental alertness; drug may cause drowsiness and impair mental or physical performance. Alcohol may intensify drug effect.
Report lack of response. Review list side effects (nausea, dizziness, constipation, somnolence, and pruritus) that one may experience and report if persistent or
76
patients to avoid bleeding complications. Constipation can be severe especially in the elderly requiring manual evacuation of the bowel.
intolerable. May mask abdominal pathology and obscure
intracranial pathology due to abnormal pupil contraction.
Generic Name
Brand Name
Classification Dosage & frequency Mechanism of actions Indications
Ketorolac Toradol and Acular
non-steroidal anti-inflammatory drug
For oral dosage form (tablets):
For pain:
Adults (patients 16 years of age and older)—One 10-milligram (mg) tablet four times a day, four to six hours apart. Some people may be directed to take two tablets for the first dose only.
The primary mechanism of action responsible for ketorolac's anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the the enzyme cyclooxygenase (COX). Like most NSAIDs, ketorolac is a non-selective COX inhibitor.
As with other NSAIDs, the mechanism of the drug is associated with the chiral S form. Conversion of
Ketorolac is indicated for short-term management of pain (up to five days maximum).
77
Children up to 16 years of age—Use and dose must be determined by your doctor.
For injection dosage form:
For pain:
Adults (patients 16 years of age and older)—15 or 30 mg, injected into a muscle or a vein four times a day, at least 6 hours apart. This amount of medicine may be contained in 1 mL or in one-half (0.5) mL of the injection, depending on the strength. Some people who do not need more than one injection may receive one dose of 60 mg, injected into a muscle.
Children up to 16 years of age—Use and dose must be determined by your doctor.
the R enantiomer into the S enantiomer has been shown to occur in the metabolism of ibuprofen; it is unknown whether it occurs in the metabolism of ketorolac.
78
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Ketorolac is contraindicated in patients with a previously demonstrated hypersensitivity to ketorolac, and in patients with the complete or partial syndrome of nasal polyps, angioedema, bronchospastic reactivity or other allergic manifestations to aspirin or other non-steroidal anti-inflammatory drugs (due to possibility of severe anaphylaxis). As with all NSAIDs, ketorolac should be avoided in patients with renal (kidney) dysfunction.
Rare Bleeding from the rectum or
bloody or black, tarry stools Bleeding or crusting sores on
lips Blue lips and fingernails Chest pain Convulsions Fainting Shortness of breath, fast,
irregular, noisy, or troubled breathing, tightness in chest, and/or wheezing
Vomiting of blood or material that looks like coffee grounds
More common Swelling of face, fingers,
lower legs, ankles, and/or feet Weight gain (unusual)
Less common Bruising (not at place of
injection) High blood pressure
Ketorolac may cause some people to become dizzy or drowsy. If either of these side effects occurs, do not drive, use machines, or do anything else that could be dangerous if you are not alert.
Serious side effects can occur during treatment with this medicine. Sometimes serious side effects can occur without any warning. However, possible warning signs often occur, including swelling of the face, fingers, feet, and/or lower legs; severe stomach pain, black, tarry stools, and/or vomiting of blood or material that looks like coffee grounds; unusual weight gain; and/or skin
Use as a part of a regular analgesic schedule rather than on an as needed basis.
If given on p.r.n. basis, base the size of a repeat dose on duration of pain relief from previous dose. If the pain returns within 3-5 hours, the next dose can be increased by up to 50% (as long as the total daily dose is not exceeded). If the pain does not return for 8-12 hr, the next dose can be decreased by as much as 50% or the dosing interval can be increased to q 8-12 hr.
Shortening the dosing intervals recommended will lead to an increased frequency and duration of side effects.
Correct hypovolemia prior to administering.
Protect the injection from light Document indications for therapy, onset,
location, pain intensity/level, and characteristics of the symptoms.
Note any previous experience with NSAIDs and the results.
Determine any renal or liver
79
Skin rash or itching Small, red spots on skin Sores, ulcers, or white spots on
lips or in mouth
Rare Abdominal or stomach pain,
cramping, or burning (severe) Bloody or cloudy urine Blurred vision of other vision
change Burning, red, tender, thick,
scaly, or peeling skin Cough or hoarseness Dark urine Decrease in amount of urine
(sudden) Fever with severe headache,
drowsiness, confusion, and stiff neck or back
Fever with or without chills or sore throat
General feeling of illness Hallucinations (seeing,
hearing, or feeling things that are not there)
Hearing loss Hives Increase in amount of urine or
urinating often Light-colored stools
rash. Also, signs of serious heart problems could occur such as chest pain, tightness in chest, fast or irregular heartbeat, or unusual flushing or warmth of skin. Stop taking this medicine and check with your doctor immediately if you notice any of these warning signs.
dysfunction; assess hydration. Avoid alcohol, ASA, and all OTC
agents without approval. Report any unusual bruising/bleeding,
weight gain, swelling of feet and ankle, increased joint pain, change in urine patterns or lack of response.
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Loss of appetite Low blood pressure Mood changes or unusual
behavior Muscle cramps or pain Nausea, heartburn, and/or
indigestion (severe and continuing)
Nosebleeds Pain in lower back and/or side Pain, tenderness, and/or
swelling in the upper abdominal area
Painful or difficult urination Pale skin Puffiness or swelling of the
eyelids or around the eyes Ringing or buzzing in ears Runny nose Severe restlessness Swollen and/or painful glands Swollen tongue Thirst (continuing) Unusual tiredness or weakness Yellow eyes or skin
Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care
81
professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:
More common Abdominal or stomach pain
(mild or moderate) Bruising at place of injection Diarrhea Dizziness Drowsiness Headache Indigestion Nausea
Less common or rare Bloating or gas Burning or pain at place of
injection Constipation Feeling of fullness in
abdominal or stomach area Increased sweating Vomiting
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Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
Metoclopramide Metoclopramide Hydrochloride Intensol®. Reglan®Reglan® Syrup
Gastro intestinal stimulant
Tablets, syrup, concentration
Diabetic gastroparesis
Adults: 10 mg 30 min before meals and bedtime for 2-8 weeks(therapy should be reinstituted if symptoms recur).
IM, IV Prophylaxis of vomiting due to chemotherapy.Initial: 1-2 mg/kg IV q 2 hr for two doses, with the
It appears to bind to dopamine D2 receptors where it is a receptor antagonist, and is also a mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist.
The anti-emetic action of metoclopramide is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone (CTZ) in the central nervous system (CNS)—this action prevents nausea and vomiting triggered by most stimuli.[2] At higher doses, 5-HT3
By inhibiting the action of prolactin-inhibiting hormone (i.e., dopamine), metoclopramide has sometimes been used to stimulate lactation. Metoclopramide increases peristalsis of the jejunum and duodenum, increases tone and amplitude of gastric contractions, and relaxes the pyloric sphincter and duodenal bulb. These prokinetic effects make metoclopramide useful in the treatment of gastric stasis
83
first dose 30 mins before chemotherapy.
PROPHYLAXIS of POSTOPERATIVE N&V.Adults: 10-20 mg IM near the end of surgery.
antagonist activity may also contribute to the anti-emetic effect.
The prokinetic activity of metoclopramide is mediated by muscarinic activity, D2 receptor antagonist activity and 5-HT4 receptor agonist activity.[3][4] The prokinetic effect itself may also contribute to the anti-emetic effect.
(e.g. after gastric surgery or diabetic gastroparesis), as an aid in gastrointestinal radiology by increasing transit in barium studies, and as an aid in difficult small intestinal intubation. It is also used in gastroesophageal reflux disease (GERD/GORD).
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Metoclopramide is contraindicated in phaeochromocytoma. It should be used with caution in Parkinson's disease since, as a dopamine antagonist, it may worsen symptoms. Long-term use should be avoided in patients with clinical depression as it
drowsiness restlessness fatigue constipation diarrhea
If you experience any of the following symptoms, call your doctor immediately:
involuntary movements of
Common adverse drug reactions (ADRs) associated with metoclopramide therapy include: restlessness, drowsiness, dizziness, lassitude, and/or dystonic reactions. Infrequent ADRs include: headache, extrapyramidal effects (EPSE) such as oculogyric crisis, hypertension,
Document indications for therapy, onset, location, pain intensity/level, and characteristics of the symptoms.
Determine any renal or liver dysfunction; assess hydration.
Avoid alcohol, ASA, and all OTC agents without approval.
Report any unusual bruising/bleeding, weight gain, swelling of feet and ankle, increased joint pain, change in urine patterns or lack of response
84
may worsen mental state. Also contraindicated with a suspected bowel obstruction.
the limbs or eyes spasm of the neck, face, and
jaw muscles change in mood (depression)
hypotension, hyperprolactinaemia leading to galactorrhoea, diarrhoea, constipation, and/or depression. Rare but serious ADRs associated with metoclopramide therapy include: agranulocytosis, supraventricular tachycardia, hyperaldosteronism, neuroleptic malignant syndrome and/or tardive dyskinesia.
The risk of EPSEs is increased in young adults (<20 years) and children. Such dystonic reactions are usually treated with benztropine or procyclidine. The risk of tardive dyskinesia and EPSE is increased with high-dose therapy and prolonged use. Tardive dyskinesias may be persistent and irreversible in some patients.
Metoclopramide is physically and/or chemically incompatible with a number of drugs.
Report any persistent side effects so they can be properly evaluated and counteracted.
After PO use, absorption of certain drugs from the GI tract may be affected.
Inject slowly IV over 1-2 min to prevent transient feelings or anxiety and restlessness.
Assess abdomen for bowel sounds and distention; note any N&V.
Do not operate car hazardous machinery until drug effects realized; drug has a sedative effect.
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Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
Ranitidine Zantac, Zantac 150, Zantac 300, Zantac 75, Zantac EFFERdose
Histamine H 2 antagonist
Duodenal Ulcer (Active)Adults
PO 150 mg twice daily or 300 mg at bedtime. Maintenance dose is 150 mg at bedtime. IM/IV/Intermittent IV 50 mg every 6 to 8 h.
Treatment of Duodenal and Gastric UlcersChildren 1 mo to 16 yr of age
PO 2 to 4 mg/kg twice daily (max, 300 mg/day).
Completitively inhibits the action of histamine (H2) at receptors sites of the parietal cells, decreasing gastric acid secretion.
Treatment and maintenance therapy of duodenal ulcer; management of gastroesophageal reflux disease (GERD; including erosive or ulcerative disease); short-term treatment of benign gastric ulcer; treatment of pathologic hypersecretory conditions (Zollinger-Ellison); maintenance therapy for gastric ulcer patients at reduced dosage after healing of acute ulcers; treatment of endoscopically diagnosed erosive esophagitis; maintenance of healing of
86
Maintenance of Healing of Duodenal and Gastric UlcersChildren 1 mo to 16 yr of age
PO 2 to 4 mg/kg daily (max, 150 mg/day).
Acute Benign Gastric Ulcer and GERDAdults
PO 150 mg twice daily. IM/IV/Intermittent IV 50 mg every 6 to 8 h.
Treatment of GERD and Erosive EsophagitisChildren 1 mo to 16 yr of age
PO 5 to 10 mg/kg daily usually given in 2 divided doses.
Pathologic Hypersecretory ConditionsAdults
erosive esophagitis.
87
PO 150 mg twice daily. Individualize.
Erosive EsophagitisAdults
PO 150 mg 4 times daily. IM/IV/Intermittent IV 50 mg every 6 to 8 h. Continuous IV 6.25 mg/h. For patients with Zollinger-Ellison, start infusion at rate of 1 mg/kg/h and adjust upward in 0.5 mg/kg/h increments according to gastric acid output (max, 2.5 mg/kg/h; infusion rate 220 mg/h).
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
88
Standard considerations. chest pain, fever, feeling short of breath, coughing up green or yellow mucus;
easy bruising or bleeding, unusual weakness;
fast or slow heart rate;
problems with your vision;
fever, sore throat, and headache with a severe blistering, peeling, and red skin rash; or
nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes).
Less serious side effects may include:
headache (may be severe); drowsiness, dizziness;
Cardiovascular
AV block; bradycardia; cardiac arrhythmias; premature ventricular beats.
CNS
Agitation; confusion; depression; dizziness; fatigue; hallucinations; headache; insomnia; malaise; motor disturbances; somnolence; vertigo.
Dermatologic
Alopecia; erythema multiforme; rash; vasculitis.
EENT
Blurred vision.
GI
Abdominal discomfort; constipation; diarrhea; nausea; pancreatitis; vomiting.
Hematologic
No known contraindications
Drug is minimally absorbed. Incidence of adverse reaction is low.
Tell patient for best results to take sucralfate on an empty stomach (1 hour before each meal and at bed time)
Pain and ulcer symptoms may subside within the first few weeks of therapy. However, for complete healing, be sure patient continues on prescribed regimen.
Monitor for severe, persistent constipation.
Studies suggest that drug is as effective as cimetidine in healing duodenal ulcers.
Drug has been used to treat gastric ulcers, but effectiveness of this use is still under investigation.
89
sleep problems (insomnia);
decreased sex drive, impotence, or difficulty having an orgasm; or
swollen or tender breasts (in men);
nausea, vomiting, stomach pain; or
diarrhea or constipation.
Acquired immune hemolytic anemia; agranulocytosis; autoimmune hemolytic or aplastic anemia; granulocytopenia; leukopenia; pancytopenia; thrombocytopenia.
Hepatic
Cholestatic or hepatocellular effects.
Musculoskeletal
Arthralgias; myalgias.
Miscellaneous
Anaphylaxis; angioneurotic edema; hypersensitivity reactions.
Precautions
Pregnancy
Category B .
Lactation
Drugs contains aluminum but isn’t classified as antacid.
Urge patient to avoid smoking, as this may increase gastric acid secretion and worsen disease.
90
Excreted in breast milk.
Children
Safety and efficacy of ranitidine have been established in children 1 mo to 16 yr of age for the treatment of duodenal and gastric ulcers, GERD and erosive esophagitis, and the maintenance of healed duodenal and gastric ulcer. Safety and efficacy have not been established for the treatment of pathological hypersecretory conditions or the maintenance of healing of erosive esophagitis in children or in neonates less than 1 mo of age.
Elderly
May have reduced renal function; therefore, decreased drug Cl may be more common.
Hypersensitivity
Rare cases of anaphylaxis have occurred as well as rare episodes of hypersensitivity.
91
Renal Function
Decreased Cl may occur; dosage reduction may be needed. Hemodialysis reduces level of ranitidine-dosage; timing must be adjusted so that scheduled dose coincides with end of hemodialysis.
Hepatic Function
Use drug with caution; decreased Cl may occur.
Hepatocellular injury
May occur, manifested as reversible hepatitis, hepatocellular or hepatocanalicular or mixed, with or without jaundice.
Rapid IV administration
May rarely result in bradycardia, tachycardia, or premature ventricular beats, usually in patients predisposed to cardiac rhythm disturbances.
92
Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
Gentamiin Gentacidin Antibiotic, aminoglycoside
Adults and children: instill 1 – 2 drops in eye q 4 hrs. in severe infections, may use up to 2 drops q 1 hr. apply ointment to lowe conjunctival sac B.I.D. or T.I.D.
Inhibits protein synthesis None significant
93
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Opthalmic use to treat dendritic keratitis, vaccinia, varicella, mycobacterial infections of the eye, use with steroids after uncomplicated removal of a corneal foreign body. Concurrent use with nephrotoxic drug or diuretics. Lactation.
azotemia, cylindruria, dizziness, hearing loss, hyposthenuria, injection site reaction, interstitial nephritis, myasthenia, proteinuria, pyuria, renal tubular acidosis, renal tubular necrosis, tinnitus, vertigo,
Eyes: burning, stinging or blurred vision (with ointment), transient irritation (from solution).
Other: hypersensitivity, over growth of non susceptible organisms with long term use.
Contraindicated in aminoglycoside hypersensitivity. Use cautiously in impaired renal function.
Solution is not for injection. In conjunctiva or in anterior chamber of the eye.
Have cultured taken before giving drug.
If ophthalmic gentamicin is administered, be sure to carefully monitor serum gentamicin concentration level.
Stress importance of following recommended therapy. Pseudomonas in infections can cause complete vision loss within 24 hrs if infection is not controlled.
Warn patient to avoid sharing wash clothes and towels with family members during infection.
Always wash hands before
94
and after applying ointment. Cleanse eye area of
excessive exudates before application.
Tell patient to watch signs for sensitivity such as itching lids, swelling, or constant burning.
Teach patient on how to instill. Advice him to wash hands before and after administering ointment or solution, and not to touch tip of tube to eye.
Store away from heat. Tell patient not to share eye
medications to members.
95
Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
mefenamic acid ponstan Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Oral MILD TO MODERATE PAIN Adult: 250-500 mg tid. Child: >6 mth: 25 mg/kg daily in divided doses for up to 7 days. DENTAL PAIN Adult: 250-500 mg tid. Child: >6 mth: 25 mg/kg daily in divided doses for up to 7 days. POSTOPERATIVE PAIN Adult: 250-500 mg tid. Child: >6 mth: 25 mg/kg daily in divided doses for up to 7 days. DYSMENORRHOEA Adult: 250-500 mg tid. Child: >6 mth: 25 mg/kg daily in divided doses for up to 7 days. OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS
Mefenamic acid inhibits the enzymes cyclooxygenase (COX)-1 and COX-2 and reduces the formation of prostaglandins and leukotrienes. It also acts as an antagonist at prostaglandin receptor sites. It has analgesic and antipyretic properties with minor anti-inflammatory activity.
Mild to moderate pain, dysmenorrheal.
96
Adult: 250-500 mg tid. Child: >6 mth: 25 mg/kg daily in divided doses for up to 7 days. MENORRHAGIA Adult: 250-500 mg tid. Child: >6 mth: 25 mg/kg daily in divided
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Inflammatory bowel disease; peptic ulcer; neonates; pregnancy (3rd trimester), lactation. Coronary artery bypass graft surgery, severe renal impairment, and severe heart failure.
None significantAbdominal pain, dyspepsia, constipation, diarrhoea, nausea, GI ulcers; oedema; bronchospasm; headache, drowsiness, insomnia, visual disturbances; CHF, hypertension, tachycardia, syncope; urticaria, rash; thrombocytopenia, aplastic anaemia, agranulocytosis; tinnitus; elevated liver enzymes; abnormal renal function.
Contraindicated in GI ulceration or inflammation.
Use cautiously in hepatic or renal disease, cardiovascular disease, blood dyscrasia, diabetes mellitus, and a history of peptic ulcer disease, and in asthmatics with nasal polyps.
Serious GI toxicity can occur at any time in patient’s chronic NSAIDs therapy. Teach patients signs and symptoms of GI bleeding, and tell patient to report these to the doctor immediately.
Concomitant use with aspirin, alcohol, or steroids may increase the risk of GI adverse
97
reactions. Warn patient against hazardous
activities that require alertness until CNS effects of the drug are known
Severe hemolytic anemia may occur with prolong use. Monitor CBC every 4 to 6 months or as indicated.
Stop drug if rash visual disturbances or diarrhea develops.
Should not be administered for more than one week at a time, because risk of toxicity increases.
Administered with food to minimize GI adverse reactions.
False-positive reactions for urine bilirubin using the diazo tablet test have been reported.
98
Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
99
Ferrous sulfate Chem-Sol, Fe 50, Feosol, Fer-Gen-Sol, Fer-in-Sol, Feratab, Fero-Gradumet Filmtab, FeroSul, Ferra T.D. Caps, Ferra-TD, Ferro-Bob, Ferro-Time, Ferrospace, Mol-Iron, Slow Fe, Yieronia
Antianemic, iron Adults: 325 mg P.O. t.i.d or q.i.d. alternatively, give 1 delayed release capsule (160 or 525 mg) P.O. twice daily
Children: 4 to 6 mg/kg daily in 3 divided doses.
Pregnant Women: 150 mg P.O. daily during the last 2 trimesters.
Premature and undernourished infants: 1 to 2 mg/kg P.O. daily (as elemental iron) in divided doses.
Provides elemental iron, an essential component in the formation of hemoglobin
For iron deficiency, prophylaxis for iron deficiency anemia.
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Hemosidersis, hemochromatosis, peptic ulcer, regional enteritis, and ulcerative
Less serious side effects may include:
constipation; upset stomach;
GI: nausea, vomiting, constipation, black stools.
Others: elixir may stain your teeth.
For infants and young children, administer liquid preparation with a dropper. Deposit liquid well back against the cheek. Eggs and milk or coffee and tea consumed with a meal or one hour after may
100
colitis. Hemolytic anemia, pyridoxine-responsive anemia, and cirrhosis of the liver. Use in those which normal iron balance.
black or dark-colored stools; or
Temporary staining of the teeth.
significantly inhibit absorption of dietary iron. Ingestion of calcium and iron supplements with food can decrese iron absorption by 1/3 ; iron absorption is not decrease if calcium carbonate is use and taken between meals. Do not crash or chew sustained releases products. Take a drug history including:1. antacid use; any other drugs that may
interact.2. OTC drugs, i.e., iron compounds or
vitamin E use.3. allergy to sulfites or tartrazines. note any GI bleeding; tarry stools or
bright blood in stool. assess for thalassemia; obtain
hemoglobin, electrophoresis, as iron administration could be lethal.
note any complains and fatigue, pallor, poor skin turgor, or change in mental status, especially in the elderly.
assess nutritional status and diet history through questioning and intake if possible.
review pregnancies and menstruation history; note frequency, amounts, and heavy bleeding. Pregnancy is an indication for iron prophylactically.
Monitor VS,CBC,CHEM profile, stool
101
for occult blood, reticulocytes, serum trasferine , and iron panel results.
Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
Amlodipine Norvasc Calcium channel blocker
Antianginal Antihyperte
nsive
Hypertension and angina: 5 mg daily (single dose).
The dose may be increased to 10 mg daily if necessary
Amlodipine inhibits the transmembrane calcium influx with greater effects on vascular smooth muscle than on cardiac muscle. Its main action is to cause peripheral arterial vasodilatation and therapy a reduction in after load and blood pressure. Hence, it reduces myocardial oxygen demand more by an indirect effect than direct on cardiac muscle. Reflex tachycarida does not occur due to slow onset of action.
Angina pectoris due to coronary artery spasm.
Chronic stable angina, alone or in combination with other drugs.
Essential hypertension alone or in combination with other antihypertensives.
102
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Known hypersensitivity.Cardiogenic shock.Unstable angina.Significant aortic stenosis
Pregnancy and lactation
Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.
Check with your doctor as soon as possible if any of the following side effects occur:
More common
Swelling of ankles or feet
Less common
Dizziness
Flushing, palpitations and peripheral edema.
Dizziness, headache, hypotension.Rare effects:Prutins, rashes, urtocardia.Nausea, abdominal pain.Muscle pain, weakness, paraesthesias etc.Gum hyperplasic.Importance increased urinary frequency.Altered Liver functions elevateIon of serum liver Enzymes jaundice.Gynaecomastia.
Monitor patient carefully (BP cardiac rhythm and output) while adjusting drug to therapeutic dose; use special caution if patient has CHF.
Monitor BP carefully if patient is also on nitrates
Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy.
Administer drugs without regard to meals Take with meals if upset stomach occurs Tell patient to report irregular heart beat,
shortness of breath, swelling of the hands or feet, pronounce dizziness, & constipation.
103
Pounding heartbeat
Rare
Chest pain
Dark yellow urine
Dizziness or lightheadedness when getting up from a lying or sitting position
Slow heartbeat
Yellow eyes or skin
Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have
104
any questions about them:
More common
Abdominal pain
Flushing
Headache
Sleepiness or unusual drowsiness
Less common Nausea
Unusual tiredness or weakness
105
Generic Name
Brand Name Classification Dosage & frequency Mechanism of actions Indications
Metoprolol Apo-Metoprolol
(CAN), Betaloc
(CAN), Lopressor,
Novometoprol
(CAN), Nu-Metop
(CAN)
Beta1 –
selective
adrenergic
blocker
Antihypertensive
Hypertension:
initially, 100 mg/
day PO in single
or divided doses,
gradually increase
dosage at weekly
intervals. Usual
maintenance dose
is 100-450
mg/day.
Angina pectoris:
initially, 100
mg/day PO in two
divided doses;
maybe increased
gradually,
effective range,
100-400 mg/day.
Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing in the influence of the symphathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of rennin, and lowering BP; acts in the CNS to reduce symphathetic outflow and vasoconstrictor tone.
Essential hypertension
Tachycardia
Coronary heart
disease (prevention of
angina attacks)
Secondary prevention
after a myocardial
infarction
Treatment of heart
failure.
Migraine prophylaxis
Adjunct in treatment
of hyperthyroidism
106
MI early
treatment: three
IV bolus doses of
5 mg each at 2-
min intervals with
careful
monitoring. If
these are
tolerated, give 50
mg PO 15 min
after the last IV
dose and q 6 hr
for 48 hr.
thereafter, give
maintenance dose
of 100 mg PO
Bid. Reduce
initial PO doses
to 25 mg, or
discontinue in
patients who do
107
not tolerate the IV
doses.
MI, late
treatment: 100 mg
PO bid as soon as
possible after
infarct,
continuing for at
least 3 mo and
possibly for 1-3
yrs.
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Contraindicated
with sinus
bradycardia (HR <
45 beats/min),
second or third-
degree heart block
Slow heart rate, Tiredness, Dizziness,
Diarrhea, Itching or unexplained rash,
Shortness of breath
Fatigue, lethargy, dizziness, bradycardia, hypotension, CHF, peripheral vascular disease. Nausea, vomiting, diarrhea, skin rash, dyspnea, bronchospasm, fever,
Do not discontinue drug abruptly after
long-term therapy.
Taper drug gradually 2 week with
monitoring.
Ensure the patient swallows the ER
tablets whole; do not cut, crush, or
108
(PR interval > 0.24
sec), cardiogenic
shock, CHF,
systolic BP < 100
mm Hg; lactation.
Use cautiously with
diabetes or
thyrotoxicosis;
asthma or COPD;
pregnancy
arthralgias.chew. Toprol XL tablets may be divided
at the score; divided tablets should be
swallowed whole, not crushed or
chewed.
Advice the patient to consult the
physician about withdrawing drug if
patient is to undergo surgery.
Give oral drug with food to facilitate
absorption.
Provide continual cardiac monitoring for
patients receiving metoprolol
Do not stop taking this drug unless
instructed to do so by your health care
provider.
Swallow the extended-release tablets
whole; do not cut, crush or chew if
using Troplol XL, you can divide the
tablets at the score.
109
Generic Name
Brand Name
Classification Dosage & frequency Mechanism of actions Indications
Ascorbic acid Ascorbic acid antioxidant Dietary sources: citric juices, fresh vegetables and fruit, potatoes
Toxicodynamics Hyperoxaluria may result after
Ascorbic acid is recommended for prevention and treatment of scurvy
110
(Vitamin C) Administered orally or IV
Dietary supplementation (RDA: recommended daily allowance):
Adults: 60mg per day
Scurvy: 100-300mg per day over several days will reverse scurvy effects
Infants:
preventive: 30mg per day
treatment: 100-300mg per day
Premature infants: 75-100mg per day
Enhanced wound healing: 300-500mg per day for 7-10 days pre- and post-operatively
Burn patients: 1-2 grams per day
administration of ascorbic acid Ascorbic acid may cause acidification of the urine, occassionally leading to precipitation of urate, cystine, or oxalate stones, or other drugs in the urinary tract. Urinary calcium may increase, and urinary sodium may decrease after 3 to 6 g of ascorbic acid daily. Ascorbic acid reportedly may affect glycogenolysis and may be diabetogenic but this is controversial.
Pharmacodynamics In humans, an exogenous source of ascorbic acid is required for collagen formation and tissue repair. Vitamin C is a co-factor in many biological processes including the conversion of dopamine to noradrenaline, in the hydroxylation steps in the synthesis of adrenal steroid hormones, in tyrosine metabolism, in the conversion of folic acid to folinic acid, in carbohydrate metabolism, in the synthesis of lipids and proteins,
(disorder caused by lack of vitamin C). Its parenteral administration is desirable for patients with an acute deficiency or for those absorption of orally ingested ascorbic acid uncertain.
Symptoms of mild deficiency may include faulty bone and tooth development, gingivitis, bleeding gums, and loosened teeth. Febrile states, chronic illness and infection (pneumonia, whooping cough, tuberculosis, diphtheria, sinusitis, rheumatic fever, etc.) increase the need for ascorbic.
111
in iron metabolism, in resistance to infection, and in cellular respiration. Vitamin C may act as a free oxygen radical scavenger. The usefulness of the antioxidant properties of vitamin C in reducing coronary heart disease were found not to be significant.
Contraindications Side Effects Adverse Reactions Nursing Responsibilities
Ascorbic acid is contraindicated in patients with hyperoxaluria and G-6-PD deficiency
Stomach upset, diarrhea, mouth sores, frequent urination, kidney stones develop, such as: abdominal/back pain, painful urination.
Faintness, dizziness with fast I.V. administration.
Nausea, vomiting, diarrhea, epigastric burning.
Use cautiously in G6PD deficiency. I.V. use: administer I.V. infusion
cautiously in patients with renal insufficiency.
Avoid rapid I.V.administration. When administering for urine
acidification, check urine pH to ensure efficacy.
Protect solution from light
112
113
SURGICAL PROCEDURE
CAESAREAN SECTION
A caesarean section (or cesarean section in American English), also known as c-
section, is a form of childbirth in which a surgical incision is made through a mother's
abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is
usually performed when a vaginal delivery would put the baby's or mother's life or health
at risk; although in recent times it has been also performed upon request for births that
would otherwise have been natural. The surgery is relatively safe for mother and baby.
Still, it is major surgery and carries risks. It also takes longer to recover from a C-section
than from vaginal birth. After healing, the incision may leave a weak spot in the wall of
the uterus. This could cause problems with an attempted vaginal birth later. However,
114
more than half of women who have a C-section can give vaginal birth later. C-sections
are also more common among women carrying more than one baby.
Types
There are several types of caesarean sections (CS). The differences between them
primarily lie in the deep incision made on the uterus, below the skin and subcutaneous
tissue, and should be differentiated from the skin incision, such as a Pfannenstiel incision.
The classical caesarean section involves a midline longitudinal incision which
allows a larger space to deliver the baby. However, it is rarely performed today as
it is more prone to complications.
The lower uterine segment section is the procedure most commonly used today; it
involves a transverse cut just above the edge of the bladder and results in less
blood loss and is easier to repair.
An emergency caesarean section is a caesarean performed once labour has
commenced.
A crash caesarean section is a caesarean performed in an obstetrical emergency,
where complications of pregnancy onset suddenly during the process of labor, and
swift action is required to prevent the deaths of mother, child(ren) or both.
A caesarean hysterectomy consists of a caesarean section followed by the
removal of the uterus. This may be done in cases of intractable bleeding or when
the placenta cannot be separated from the uterus.
Traditionally other forms of CS have been used, such as extraperitoneal CS or
Porro CS.
115
a repeat caesarean section is done when a patient had a previous section.
Typically it is performed through the old scar.
Indications
Caesarean section is recommended when vaginal delivery might pose a risk to the mother
or baby. Reasons for caesarean delivery include:
precious (High Risk) Fetus
prolonged labour or a failure to progress (dystocia)
apparent fetal distress
apparent maternal distress
complications (pre-eclampsia, active herpes)
catastrophes such as cord prolapse or uterine rupture
multiple births
abnormal presentation (breech or transverse positions)
failed induction of labour
failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of
forceps/ventouse' is tried out - This means a forceps/ventouse delivery is
attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched
to a caesarean section. This takes place in the operating theatre.
the baby is too large (macrosomia)
placental problems (placenta praevia, placental abruption or placenta accreta)
umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and
succenturiate-lobed placentas, velamentous insertion)
116
contracted pelvis
Sexually transmitted infections such as genital herpes (which can be passed on to
the baby if the baby is born vaginally, but can usually be treated in with
medication and do not require a c-section)
previous caesarean section (though this is controversial – see discussion below)
prior problems with the healing of the perineum (from previous childbirth or
Crohn's Disease)
BILATERAL TUBAL LIGATION (BTL)
Tubal ligation (informally known as getting one's "tubes tied") is a permanent form of
female sterilization, in which the fallopian tubes are severed and sealed or "pinched shut",
in order to prevent fertilization. Hormone production, libido, and the menstrual cycle can
be affected by a tubal ligation.
A tubal ligation can be done in many forms; through a vaginal approach, through
laparoscopy, a minilaparotomy ("minilap"), or through regular laparotomy. Also, a
distinction is made between postpartum tubal ligation and interval tubal ligation, the
latter not being done after a recent delivery. There are a variety of tubal ligation
techniques; the most noteworthy are the Pomeroy type that was described by Ralph
Pomeroy in 1930, the Falope ring that can easily be applied via laparoscopy, and tubal
cauterization done usually via laparoscopy. In addition, a bilateral salpingectomy is
effective as a tubal ligation procedure. A tubal ligation can be performed as a secondary
procedure when a laparotomy is done; i.e. a cesarean section. Any of these procedures
may be referred to as having one's "tubes tied."
117
Tubal ligation can be performed under either general anesthesia or local anesthesia
(spinal or epidural, often supplemented witha tranquilizer to calm the patient during the
procedure). The default in tubal ligations following on from cesarean birth is usually
spinal/epidural, while the default in non-childbirth related situations may be general
anesthesia as a matter of doctor preference. However, tubal ligations under local
anesthesia, either inpatient or outpatient, may be performed under patient request.
Less commonly performed is the Essure procedure, in use since 2002. In this procedure
micro-inserts are placed within the fallopian tubes by means of catheter and
Hysteroscopy. The micro-inserts produce eventual occlusion of the fallopian tubes by
causing the in-growth of tissue.
Nursing Responsibilities
1. Facilitation of the patient’s and family understands of anesthesia, surgery, and
procedures
2. Relieving the patient’s and the family’s anxiety about the outcome with reasonable
information
3. Encourage patient to commence deep breathing, coughing and leg exercises.
4. Encouragement of good dietary and fluid intake during hospital stays prior to surgery.
5. Advice patient to comply with health regimen
118
NURSING THEORY
Dorothea E. Orem (Self-Care Deficit Theory
Orem explicated self-care as a human need and nursing as a human service; she
emphasized nursing’s special concern for a person’s need for self-care actions on a
continuous basis to sustain life and health or to recover from disease or injury. She
formalized the Self-Care Deficit Theory of nursing as a general theory composed of the
following three related theories: (1) the Theory of Self-Care, (2) the Theory of Self-Care
Deficit, and (3) The Theory of Nursing Systems. Her work identifies three types of
nursing systems: (1) wholly compensatory (doing for the patient), (2) partly
compensatory (helping the patient do for himself or herself), and (3) supportive-educative
(helping the patient learn to do for himself or herself and emphasizing the important role
of the nurse in designing nursing care).
We, as nurses require a continuous and practical action to our patient to enable
them to know and meet therapeutic self-care demands to let them be aware of certain
limitations that could help them develop independence towards their needs necessary for
their living. When we had our interview to Mrs. X first, we were able to developed trust
towards the patient which is very important. And as we go through our interaction we
had provided guided teachings to help them resolve their problems but with limitations.
Limitations in which we only give some alternatives and they will be the one to help
theirselves function on the things they need to work with. Through a good therapeutic
communication Mrs. X was able to gain a lot of information in which it made her think to
make some changes with regards to her life style
119
Imogene King (Goal Attainment Theory)
King’s theory of goal attainment focuses on the interpersonal system and the
interactions that take place between individuals, specifically in the nurse-patient
relationship. In the nursing process, each member in the dyad perceives the other, makes
judgements, and takes actions. Together this activities culminate in reaction. Interaction
results and, if perceptual congruence exist and disturbances are conquered, transactions
occur. The system is open to permit feedback because each phase of the activity
potentially influences perception.
It is very much important that we establish rapport to our patient so that we could
extract some information available from research in nursing and related fields. In this
case, we have gained enough information about the client’s background. We have made
an appropriate approach because the patient was able to verbalize her own feelings of
her condition. And as much as possible we were being careful of the questions being
asked to the patient, because we might hurt her feelings and later on she might not gave
us the appropriate answers. We have also provided some individualized plan of care that
encouraged the patient to participate in the decision-making.
Jean Watson (Human Caring Relationship Theory)
Jean Watson proposed that the ultimate aim of nursing is caring with the purpose
of preserving the dignity and wholeness of humans. She emphasizes that caring may
occur without curing, but curing cannot occur without caring. Nursing as a discipline is
devoted to caring, to health, and to healing in their many meanings and interpretations.
120
Nursing occurs in caring occasions or moment through the use of ten carative factors in a
nurse-patient relationship known as transpersonal caring. The practice of nursing is both
a science and an art and focuses on the goals of growth, meaning, and self-healing rather
than the problem solving seen in the use of the nursing process.
As a student nurse our goal is to help the patient gain a higher degree of harmony
within the mind, body, and soul which generates self-knowledge, self reverence, self-
healing, and self-care. During our interview to our patient with regards to her condition,
we were able to gain her trust through the aspect of caring. We were able to develop the
helping-trust relationship that is why the patient was able to voice out his positive and
negative feelings about her condition. There was an effective communication because we
were able to get the trust of the patient and we showed some concern and care towards
her state of condition.
121
Ineffective Peripheral Tissue Perfusion
Date Cues Needs Nsg. Diagnosis Objective Intervention Evaluation
September
07,
2008
@ 11pm
S/O:
- Edema noted
on lower
extremities
- cold, clammy
skin noted.
- BP: 140/100
A
C
T
I
V
I
T
Y
-
E
X
E
R
C
I
S
E
Ineffective Tissue
Perfusion related to
vasoconstriction of
blood vessels.
R: Decreased in
oxygen resulting in
the failure to
nourish the tissues
at the capillary level
source: page 565,
Nurse's Pocket
Guide, Marilynn E.
Doenges, Mary
Frances Moorhouse,
Alice C. Murr
Within the span of
care, client will be
able to
- verbalizes
understanding of
condition and
therapy regimen.
- increased
perfusion as
evidenced by
normal range of BP.
- extremities warm
to touch
1. Monitored blood
pressure every
4hours.
® This will serve as
the baseline data.
2. Instructed to
have enough rest
on
semi fowlers
position.
® Sodium tends
to be excreted
at a faster rate.
3. Instructed to eat
low fat and low salt
diet.
® To reduce
edema that may
September 08,
2008 @ 7am
GOAL MET
- client was
able to
demonstrate
increased
perfusion.
demonstrat
e increased
perfusion as
evidenced
by palpable
peripheral
pulse
122
P
A
T
T
E
R
N
activate renin
angiotensinaldoster
one
system.
4. Administer
anti- hypertensive
drug as ordered.
® To control the
BP and to avoid
other
complications.
5. Determine the
factors related to
individual situation.
® Diseases and
post-op conditions
may help contribute
to the client’s
present state.
- BP: 120/90
123
6. Identify changes
related to systemic
and peripheral
alterations in
circulation.
® Altered vital
signs or pain may
be signs of change.
7. Note customary
baseline data.
® This provides
comparison with
current findings.
8. Measure
circumference of
extremities as
indicated.
® This will be
useful in identifying
edema in involved
124
extremity.
9. Check for calf
tenderness
(Homans' sign),
swelling and
redness.
® This may indicate
thrombus
formation.
10. Review
laboratory results.
® Results may
show client’s
Hb/Hct and clotting
times.
11. Encourage early
ambulation when
possible.
® This enhances
venous return.
125
12. Provide
comfortable bed.
® This may provide
comfort and protect
the extremities.
13. Encourage use
of relaxation
techniques.
® This will
decrease tension
level.
126
Activity Intolerance
Date Cues Needs Nsg. Diagnosis Objective Intervention Evaluation
September
08,
2008
@ 11pm
S/O:
- client
required
assistance in
transferring
from one bed
to another
- Swelling on
her feet was
A
C
T
I
V
I
T
Y
-
E
Activity intolerance
related to edema on
the lower
extremities.
R: Insufficient
physiological or
psychological
energy to endure or
complete required
Within the span of
care, client will be
able to:
- verbalize
understanding of
situation and safety
measures.
1. Monitor client VS.
® This will serve as
the baseline data.
2. Identify
condition/diagnoses
that contribute to
difficulty walking.
® Diseases, post-
op conditions, and
age may affect
September 09,
2008 @ 7am
GOAL MET
- client was
able to
verbalize
understanding
of situation and
safety
127
noted. X
E
R
C
I
S
E
P
A
T
T
E
R
N
or desired daily
activities
source: page 65,
Nurse's pocket
Guide, Marilynn E.
Doenges, Mary
Frances Moorhouse,
Alice C. Murr
capability to walk
properly.
3. Consult with
patient or
significant other.
® This is to develop
individual mobility.
4. Discuss of
demonstrate use of
adjunctive devices.
® This is to provide
information vital to
patient.
5. Provide safety
measures as
indicated.
® Providing a safe
environment for
client may decrease
risk of injury.
measures.
128
6. Involve client and
SO in care.
® This is to
enhance safety for
client and SO.
7. Reassess client if
she has internalized
the previous
teachings well.
® Reassurance
means client has
fully understood
what was taught.
129
Self-care Deficit
Date/time Cues Needs Nursing
Diagnosis
Objectives/Goals Nursing
Intervention
Evaluation
130
September
08, 2008
@
11PM
S/O:
>halitosis
noted
>strong body
odor noted
>poor skin
turgor noted
>fingernails
noted
> dandruffs
noted
A
C
T
I
V
I
T
Y
E
X
E
R
C
I
S
E
P
A
Self-Care Deficit
related to pain or
discomfort as
evidenced by
halitosis, strong
body odor, poor
skin turgor, dirty
and untrimmed
fingernails
® Inability to
maintain proper
hygiene
source: Nurse's
Pocket Guide,
Marilynn E.
Doenges, Mary
Frances Moorhouse,
Alice C. Murr
Within my span of
care, client will be
able to:
>Perform self-care
activities within
level of own ability.
>Identify individual
areas of weakness
or needs.
> Demonstrate
techniques or
lifestyle changes to
meet self-care
needs.
>Verbalize
knowledge of
healthcare
practices.
1.Determine age or
developmental
issues affecting
ability of individual
to practice in own
care.
® This might be an
effect that causes
the client not to
perform proper
hygiene and self-
care.
2. Determine
client’s ability to
participate in self-
care activities.
(scale of 0-5)
® Underlying
condition dictates
Goal Met
>Client was
able to clean
her body
through
cleansing bed
bath.
>halitosis and
strong odor
were absent.
>Nails were
trimmed and
cleaned.
>Hair was
properly tied.
>Client
verbalize the
importance of
proper
131
T
T
E
R
N
>Identify personal
resources that can
provide assistance.
level of deficit
needs affecting
choice of
interventions.
NOTE:
Psychological
factors (eg.
Depression,
motivation, and
degree of support)
also have a major
impact on the
client’s abilities.
3. Provide
assistance with
activities as
necessary.
® Meet needs
while supporting
hygiene.
132
client participation
and dependence.
4. Encourage or use
energy-saving
techniques; eg.
Using bath towels
or tepid sponge
bath: doing tasks in
small increments.
5. Recommend
scheduling
activities to allow
client sufficient
time to accomplish
tasks to fullest
extent of ability.
® Unhurried
approach reduces
frustration,
promotes client
133
participation,
enhancing self-
esteem.
Risk for Infection
Date/ Time Cues Needs Nursing Diagnosis Objectives/ Goal Intervention Evaluation
September
09,
2008
@ 11pm
Subjective:
“lisod kaayo
mag atiman sa
akon tahi basin
ma infect” as
verbalized by
the pt.
Objectives:
Weak
looking
H
E
A
L
T
H
P
E
R
C
E
Risk for infection
related breakage in
continuity of skin
secondary to surgical
incision.
® At increased risk
for being invaded by
pathogenic organisms
source: Page 322,
Nurse's Pocket Guide
Within my 8 hours
span of care the
patient will be able
to:
- Verbalize
understanding of
individual
causative/risk factor
- Identify
intervention to
1. Monitor vital signs
® to serve as
baseline data.
2. Encourage fluid
intake of 2000 ml to
3000 ml of water per
day (unless
contraindicated).
® Fluids promote
diluted urine and
frequent emptying
September 10,
2008 @ 7am
Within my shift
GOAL MET
The client able
to:
- Verbalize
understanding of
individual
causative/risk
factor
134
restlessn
ess
Restless
noted
Stitches
in the
abdomen
noted,
dressing
is dry
and
intact
P
T
I
O
N
-
H
E
A
L
T
H
M
A
N
A
G
E
by Marilyn E.
Doenges, Mary
Frances Moorhouse,
Alice C. Murr
prevent/reduce risk
of infection
of bladder; reducing
stasis of urine, in
turn, reduces risk of
bladder infection or
urinary tract
infection (UTI).
3. Observe for
localized signs of
infection at insertion
sites of invasive
lines, sutures,
surgical incision.
® Signs of infection
should be dealt with
immediately.
4. Stress proper
hand washing
technique.
® A first line of
- Identify
intervention to
prevent/reduce
risk of infection
135
M
E
N
T
P
A
T
T
E
R
N
defense against
nosocomial
infections., hand
washing is the single
most effective way
of preventing the
spread of
microorganisms
5. Encourage early
ambulation, deep
breathing, coughing,
positions change.
® This is to
mobilize respiratory
secretions.
6. Maintain
adequate hydration.
® This is to avoid
136
bladder distention.
7. Emphasize
necessity of taking
antibiotics as
directed.
® Premature
discontinuation of
treatment when
client begins to feel
well may result in
return of infection.
8. Involve in
appropriate
community
education programs.
® This is to
increase awareness
of spread/
137
prevention of
communicable
diseases.
9. Discuss
importance of not
taking antibiotics /
using “leftover” drug
unless specifically
instructed by
healthcare provider
® Inappropriate use
can lead to
development of
drug-restrains/
secondary infections
10. Encourage
balance diet,
emphasizing
138
proteins, fatty acids
and vitamins
® Immunity that
affected by
deficiencies in one
or more of these
nutrients
11. Teach the client
risk factors
contributing to
surgical wound
infection, smoking,
and higher body
mass index
® Theses are some
of the factors
associated with risk
of surgical wound
infection
139
12. Instruct the
client about the
need for good
nutrition
® Optimal good
nutritional status
contributes to health
maintenance and
the prevention of
infection.
140
Acute Pain
Date/ Time Cues Needs Nursing Diagnosis Objectives/ Goal Intervention Evaluation
September
09,
2008
@ 11pm
Subjective:
“sakit akong
tahi gihapon”
as verbalized
by the patient
Objectives:
Grimace
d face
noted
with
moderat
e pain
scale of
6
S/P
cesarean
C
O
G
N
I
T
V
E
P
E
R
C
E
P
T
U
A
Acute pain related
surgical incision
secondary to
cesarean delivery
® Unpleasant
sensory and
emotional experience
arising from actual or
potential tissue
damage or described
in terms of such
damage; sudden or
slow onset of any
intensity form mild to
severe with an
anticipated or
predictable end and a
within 2-3 hours
span of care the
patient will:
- Patients pain will
no longer be noted
as evidence by
patients pain scale
will reduce from
moderate six to mild
three
- Demonstrate use
of relaxation
techniques and
diversional activities
1. Administer
analgesics or non
steroidal
antiinflammatory
drugs as
prescribed.
® To relieve mild
or moderate
pain.
2. Reposition as
indicated.
® May relieve
pain and
enhance
circulation.
3. Provide additional
September 10,
2008 @ 7am
Goal met as
evidence by
patient:
- Patients pain
will no longer be
noted as
evidence by
patients pain
scale will reduce
from moderate
six to mild three
- Demonstrate
use of relaxation
141
section L
P
A
T
T
E
R
N
duration of less than
6 months
source: page 388,
Nurse's Pocket Guide,
Marilynn E. Doenges,
Mary Frances
Moorhouse, Alice C.
Murr
comfort
measures like
back rub.
® Improves
circulation,
reduces muscle
tension and
anxiety
associated with
pain.
4. Encourage use of
relaxation
technique like
deep breathing
exercises.
® Relieves
muscle and
emotional
tension.
techniques and
diversional
activities
142
5. Provide a
comfortable
environment.
® comfortable
environment aids in
relaxation and
minimize distraction
6. Encourage
patients to verbalize
feelings and
concern.
® to alleviate
anxiety.
7. Asses for verbal
and non-verbal
indicators of pain
and evaluate
143
response to
technique used.
® follow up
assessment provides
information about
effectiveness of
comfort measures
used and need for
additional relief
measures.
8. Explain to the
client the pain
management
approach that has
been ordered,
including therapies,
medication
administration, side
144
effect, and
complications.
® one of the most
important steps
towards improved
control of pain is a
better client
understanding of the
nature of pain, it's
treatment and the
role the client needs
to play in pain
control
9. Provide comfort
measures
® to provide
nonpharmacological
pain management
145
10. Encourage
diversional activities
® to divert his/her
attention to other
activities and to
relief
11. Encourage
adequate rest
® to prevent fatigue
12. Reinforce the
importance of taking
pain medications to
keep pain under
control.
® teaching clients to
stay on top of their
pain and prevent it
146
from getting out of
control will improve
the ability to
accomplish the goals
of recovery
147
DISCHARGE PLAN
M E T H O D
- Instruct the pa-
tient or signifi-
cant others re-
garding the
compliance of
medications to
hasten healing.
- Instruct to take
medications
with meal to
prevent GI up-
set.
- Inform patient
and significant
- Strenuous activ-
ities are given
precautions to
prevent increase
of blood pres-
sure.
- Patient should
have adequate
rest periods
- Discuss to the
patient and sig-
nificant others
regarding the
purpose of the
medicines being
given.
- Family should
encourage pa-
tient to take rec-
ommended
medications and
other therapeu-
- Inform patient
the importance
of proper
sanitation and
hygiene.
- Encourage
client to have
adequate rest
periods in order
to avoid stress.
- Inform the pa-
tient to return
for follow up
check-up as
scheduled En-
courage to co-
operate well
with home med-
ications.
- Instruct patient
to follow a low
salt, low fat
diet. Fatty de-
posits are pre-
cipitating fac-
tors in hyper-
tension due to
deposits in the
blood constrict-
ing blood ves-
sels. Low
sodium to pre-
vent water re-
148
others regarding
the proper stor-
age of medica-
tions.
tic regimen. tention.
149
POOR(1) FAIR(2) GOOD(3) JustificationOnset of illness
Patient’s onset of illness is gradual because she was able to comply all the medications that were given to her. She is always given an immediate care and proper actions are done.
Duration of illness
If there are any problems that occur in her body they immediately seek for medical attention to avoid it from worsening.
Precipitating factor
One factor which contributed to the patient’s condition is her pregnancy.
Presdisposing factor
Since the patient is 35 years old his age and gender would tell that she is prone to Preeclampsia.
Willingness to follow treatment
regimen We rated are patient as such because she is willingly complying to her medications. She is very cooperative to some tests that were performed. She puts on effort on her process of curing so that she could easily recover with her condition.
Family support
Her family is financially, emotionally and spiritually supportive. As what we have observed her husband was always with her at the bedside. They’ve been making ways to help her cope up with her condition.
TALLY:
150
PROGNOSIS
Poor (1 x 2) = 2
Fair (2 x 1) = 2
Good (3 x 4) = 12
Overall: 16/ 6 = 2. 7
Impression:
Patient’s prognosis shows a good outcome. They are justified to the following
data that we had gathered. Patient is very cooperative in her ongoing treatment. Her
family was very much supportive in any ways. They immediately seek for medical
attention if ever problems occur. Since the patient is female and is now at the age of 35
years old, there is no doubt that she is prone to such kind of disease.
151
RECOMMENDATION
For the family:
We recommend that the family will still continue to give the patient love and
support even though they lack support on their financial needs. It could still help the
patient survive when there is a strong bond of relationship within the family. The family
must learn to understand the patient’s situation. They must also be aware of some
medications that are really needed for the patient. They must find ways and means to
comply with such certain meds, because if patient is left untreated then it will lead to
certain complications that will even more add up to the expected amount.
For the patient:
The patient should be aware with her condition. She must be well oriented of the
facts about the things that she should be alarmed of. We recommend that the patient will
be complying all the medications given to her by the physician. And as a patient she must
follow all the doctor’s guidelines to her. She must discipline herself to all the things that
must be avoided. Also, patient must learn the importance of proper hygiene in order to
lessen other possible infections. Since the patient has hypertension we recommend her to
lessen strenuous activities.
For the community:
Pre-eclampsia is not always preventable for those at risk, however, steps can be
taken to lower the chance to develop and to delay the possible outcome. That’s why we
want to recommend all the pregnant women to stay healthy as much as possible. Women
152
who start their pregnancy at a normal body weight, are well nourished, those who don't
smoke are less likely to develop pre-eclampsia. If you are at higher risk, be sure to follow
all prenatal care advise and keep all the medical appointments.
153
REFERENCES
Nurse’s Pocket Guide by Marilyn Doenges, Mary Frances Moorhouse, and Alice
C. Murr
Blackwell’s Nursing Dictionary
Essentials of Maternity Nursing 3rd Edition by Bobak and Jensen
Mosby’s Pocket Dictionary
Nursing ’93 Drug Handbook
2005 Edition PDR, Nurses Drug Handbook
Medical – Surgical Nursing by Black J. and Hawk J.H.
http://hb4110.net/wp-content/uploads/KIT_MATERNAL%20HEALTH_BASIC
%20STATS.doc.
http://www.emedicinehealth.com/pregnancy/article_em.htm
http://cancerweb.ncl.ac.uk/cgi-bin/omd?cephalic+presentation
MCN pp.427-428 by Adele Pilliteri
http://www.womenshealthcaretopics.com/surgical_sterilization.htm
http://www.expectantmothersguide.com/library/stlouis/
ESLadv_maternal_age.htm
http://en.wikipedia.org/wiki/Pre-eclampsia
Lowdermilk and Perry.Maternity Nursing 7th Ed. Mosby Year Book Publishing,
St.Louis. Missouri, USA
http://multiples.about.com/cs/medicalissues/a/preeclampsia.htm
Pathophysiology Adaptations and Alterations in Function, 4th Edition by Barbara
L. Bullock
154
http://parenting.ivillage.com/pregnancy/pcomplications/0,,4b0,00.html
Maternal & Child Health Nursing, 4th Edition by Pillitteri
155
![Pre Eclampsia Eclampsia[1]](https://img.dokumen.tips/doc/110x75/577cc41f1a28aba711982f27/pre-eclampsia-eclampsia1.jpg)
