I. INTRODUCTION
Description of the Disease
Preeclampsia, also referred to as toxemia, is a condition that pregnant women can
get. It is marked by high blood pressure accompanied with a high level of protein in the
urine. Women with preeclampsia will often also have swelling in the feet, legs, and
hands. Preeclampsia, when present, usually appears during the second half of pregnancy,
generally in the latter part of the second or in the third trimesters, although it can occur
earlier.
In addition symptoms of preeclampsia can include:
Rapid weight gain caused by a significant increase in bodily fluid
Abdominal pain
Severe headaches
A change in reflexes
Reduced output of urine or no urine
Dizziness
Excessive vomiting and nausea
The exact causes of preeclampsia are not known, although some researchers
suspect poor nutrition, high body fat, or insufficient blood flow to the uterus as possible
causes.
The only real cure for preeclampsia and eclampsia is the birth of the baby. Mild
preeclampsia (blood pressure greater than 140/90) that occurs after 20 weeks of gestation
in a woman who did not have hypertension before; and/or having a small amount of
protein in the urine can be managed with careful hospital or in-home observation along
with activity restriction.
The group chose the case for the reason that they wanted to show the readers the
process on how pre-eclampsia occurs and for them to fully understand and be reminded
on one of the complications associated with pregnancy.
In developing countries: preeclampsia/eclampsia impact 4.4% of all deliveries (1)
and may be as high as 18% in some settings in Africa (2) If the rate of life threatening
eclamptic convulsions (0.1% of all deliveries) is applied to all deliveries from countries
considered to be the least developed, 50,000 cases of women experiencing this serious
complication can be expected each year. According to Safe Motherhood.org of the
585,000 maternal annually (3), 13%, or 76,050, are due to eclampsia.
Nurse-Centered Objectives
Upon completion of this case study, the student nurse should be able to:
1. Identify the risk factor contributing to the occurrence of the disease.
2. Formulate significant nursing diagnosis, with the significantly related nursing care
plan.
3. Identify the different medications administered for this disease their indications,
contraindications, side effect, and specific responsibility .
4. Identify the laboratory and diagnostic procedure done with the pre-eclamptic
patient, their indication and purposes, and specific nursing responsibilities.
Client-Centered Objectives
Upon completion of this case study, the client should be able to:
1. Understand awareness of her disease.
2. Know the possible causes of the disease.
3. Learn and understand why such laboratory examinations are being done.
II. NURSING HISTORY
a.) Demographic Data
Mrs. Ob, a 39 years old housewife and first time mother, who currently
resides at Guagua Pampanga with her husband Mr. Gyne. She was born a Filipina
on November 9, 1969 in Sta. Rita Guagua Pampanga. The patient was admitted at
a Regional Hospital with a chief complaint of abdominal pain, last November 15,
2008 at around 3:00 p.m.
b.) Socio-Economic and Cultural Factors
Mrs. Ob is plain housewife and her husband is an extra laborer on a
construction site. She graduated at a Public High School. And she didn’t continue
her college level due to financial problem.
Mrs. Ob was raised as a Roman Catholic, were she learned about religious
values but she still believes in super natural forces and superstitious beliefs. When
it comes in health matters, she seeks the help of a albularyo and uses herbal
medicines to treat any member of the family who has an ailment. But when
serious matters arise she still refers to medical professionals for help.
c.) Environmental factors
Ms. Ob resides at Guagua Pampanga and occupies the ancestry house of
her family. The location of their house is not easily accessible to hospitals, health
centers and other government institutions. Mrs. Ob did not report any problems
regarding her environment which interfered to her pregnancy.
Maternal-child Health History
a.) Maternal – Obstetric record (for OB cases)
Mrs. Ob was married to Mrs. Gyne at the age of 33 years old. She has a
record of T1P0A0L1M0 at her 39th week of gestation. She underwent low
transverse ceasarian section under a certain obstetrician at the regional hospital
last November 18, 2008 at around 10:00 in the evening, she delivered her 1st child
who is term baby with hyperbilirubinemia.
b.) Antepartal/ Prenatal Preparation
When Mrs. Ob was still pregnant, she only consulted once in a district
hospital all throughout.
c.) Significant Trimestral Changes (1st to 3rd trimester)
Mrs. Ob rxperienced some changes in her pregnancy, such as striae
gravidarum, linea nigra, and melasma. She also experienced nausea and vomiting,
dizziness, and headache.
Family Health Illness History
Legend:
hypertension
died of old age
pneumonia asthma deceased pre eclampsia
*pink border – mother side*blue border – father side*violet border - patient
Grandmother
Grandfather
Mother
Grandmother
Grandfather
Father
Patient
Both the grandparents from the mother’s side died from old age. From the father’s
side, the grandmother died from Hypertension and the father was died from Pneumonia.
The mother is not experiencing any health problems but the father has hypertension and
asthma. The patient, upon admission has elevated blood pressure and is suffering from
aggravating factors like anxiety, nervousness and fear.
PHYSICAL ASSESSMENT
November 27, 2008
SKIN
brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (37°C)
when pinched, skin readily springs back to previous state
moist skin folds
nails with smooth texture
nail beds pink
prompt capillary refill time (2 seconds)
bipedal non-pitting edema
HEAD
absence of nodules or masses
symmetric facial features and movements
symmetric nasolabial folds
evenly distributed black hair
no infestations
EYES
eyebrows symmetrically aligned with equal movement
eyelashes equally distributed and curled slightly outward
skin of eyelids intact with no discoloration
lids close symmetrically
bilateral blinking exhibited
no discharge, edema or tearing
white sclera
pink palpebral conjunctiva
iris black in color
pupils equal in size with smooth borders
illuminated pupils constricts
pupils converge when near object is moved toward the nose
when looking straight ahead, the client can see objects in the periphery
both eyes coordinated, move in unison with parallel alignment
EARS
color same as facial skin
symmetrically aligned
pinna immediately recoils after it is folded
pinna is not tender
no lesions or discoloration
dry cerumen, grayish-tan color
normal voice tones audible
able to hear ticking of a watch in both ears
NOSE
symmetric and straight
no discharge or flaring
absence of lesions and tenderness
nasal septum intact and in the midline
MOUTH AND THROAT
outer lips uniform pink color with symmetric contour, soft and moist
buccal mucosa is of uniform pink color
gums are pink
tongue pink, moist, at central position
NECK
head centered
lymph nodes not palpable
BREAST
firm
generally symmetric in size
CARDIOVASCULAR
BP 180/100 mmHg
PR 114
reported palpitations
symmetric pulse strength
RESPIRATORY/CHEST
chest symmetric
chest wall intact, no tenderness, no masses
symmetric chest expansion and excursion
RR: 29 breaths per minute
GASTROINTESTINAL/ABDOMEN
striae present at hypogastric and iliac regions
linea nigra present
no tenderness
presence of surgical incision
URINARY
absence of nocturia, dysuria, urgency, hesitancy,
light yellow urine
REPRODUCTIVE
regular menstrual cycle
G1P1
MUSCULOSKELETAL/EXTREMITIES
muscle equal size on both sides of the body
no bone deformities
no tenderness
PHYSICAL ASSESSMENT
November 28, 2008
SKIN
brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (37°C)
good skin turgor
moist skin folds
nails with smooth texture
nail beds pink
prompt capillary refill time
bipedal non-pitting edema
HEAD
rounded
smooth skull contour
symmetric facial features
symmetric nasolabial folds
symmetric facial movements
HAIR
thick black hair
evenly distributed
no infestations
EYES
eyebrows symmetrically aligned
eyelashes curled slightly outward
exhibited bilateral blinking
both eyes coordinated, move in unison and with parallel alignment
white sclera
pink palpebral conjunctiva
pupils equally round and reactive to light and accommodation
iris black in color
pupils equal in size with smooth borders
illuminated pupils constricts
no discharge
EARS
color same as facial skin
symmetrically aligned
pinna immediately recoils after it is folded
pinna is not tender
no lesions or discoloration
dry cerumen, grayish-tan color
normal voice tones audible
NOSE AND SINUSES
symmetric and straight
no discharge
absence of lesions and tenderness
nasal septum intact and in the midline
sinuses not tender
MOUTH AND THROAT
outer lips uniform pink color
symmetric contour
buccal mucosa is of uniform pink color
no abrasions and ulcerations
gums are pink
tongue pink, moist, at central position
tongue moves freely with no tenderness
palate surface intact
uvula positioned in midline
palatine tonsils pink and smooth and not swollen
NECK
head centered
head movement coordinated and smooth with no discomfort
lymph nodes not palpable
BREAST AND AXILLAE
rounded, generally symmetric
areola rounded and the same shape
nipples round, everted and equal in size
milk letdown
CARDIOVASCULAR
BP 160/100 mmHg
PR 106
prompt capillary refill time (less than 1 second)
symmetric pulse strength
RESPIRATORY/CHEST
chest symmetric
chest wall intact, no tenderness, no masses
full symmetric chest expansion and excursion
respiratory rate of 22 breaths per minute
GASTROINTESTINAL/ABDOMEN
striae present at hypogastric and iliac regions
symmetric movement caused by respiration
tender because of suture from cesarean operation
URINARY
yellowish urine
REPRODUCTIVE
regular menstrual cycle
G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
muscle equal size on both sides of the body
equal strength
no bone deformities
no tenderness
no tenderness on calf muscle when dorsiflexed
NEUROLOGIC
can respond to verbal commands
oriented
conscious
PHYSICAL ASSESSMENT
November 29, 2008
SKIN
brown skin generally uniform in color except in areas exposed to the sun
skin temperature uniform and within the normal range (37.2°C)
when pinched, skin readily springs back to previous state
moist skin folds
nails with smooth texture
nail beds pink
nail plate angle about 160°
prompt capillary refill time
bipedal non-pitting edema
HEAD
rounded
smooth skull contour
no masses, tenderness in the scalp
symmetric facial features
symmetric nasolabial folds
symmetric facial movements
HAIR
thick, evenly districbuted black hair
no infestations
EYES
eyebrows symmetrically aligned
exhibited bilateral blinking
anicteric sclera
pink palpebral conjunctiva
pupils equally round and reactive to light and accommodation
no discharge
EARS
symmetrically aligned
pinna not tender and immediately recoils after folded
no lesions or discoloration
dry cerumen, grayish-tan color
normal voice tones audible
able to hear ticking of a watch in both ears
NOSE AND SINUSES
symmetric and straight
no discharge or flaring
absence of lesions and tenderness
nasal septum intact and in the midline
both nares patent
MOUTH AND THROAT
outer lips uniform pink color
symmetric contour
buccal mucosa is of uniform pink color
gums are pink
tongue pink, moist, at central position
palate surface intact
uvula positioned in midline
palatine tonsils pink and smooth and not swollen
gag reflex present
30 adult teeth, 2 molars missing, 1 with black discoloration of the enamel
NECK
neck muscles equal in size, head centered
head movement coordinated and smooth with no discomfort
lymph nodes not palpable
BREAST AND AXILLAE
areola rounded and the same shape
nipples round, everted and equal in size
milk letdown
CARDIOVASCULAR
BP 150/100 mmHg
PR 96
strong, regular rhythm
prompt capillary refill time (less than 1 second)
RESPIRATORY/CHEST
chest symmetric
right and left shoulders and right and left hips are at the same height
chest wall intact, no tenderness, no masses
full symmetric chest expansion and excursion
respiratory rate is 28 breaths per minute
GASTROINTESTINAL/ABDOMEN
striae present at hypogastric and iliac regions
rounded contour
symmetric movement caused by respiration
tender because of suture form cesarean operation
URINARY
yellowish urine
REPRODUCTIVE
regular menstrual cycle
G1P1 (1-0-0-1-0)
MUSCULOSKELETAL/EXTREMITIES
muscle equal size on both sides of the body
smooth coordinated movements
equal strength
no tenderness
walks aided to maintains balance
no tenderness on calf muscle when dorsiflexed
NEUROLOGIC
can respond to verbal commands
oriented
conscious
DIAGNOSTIC AND LABORATORY PROCEDURES
Diagnostic or Laboratory Procedure
Indication or Purpose
Date Ordered and
Date Results were
released
ResultsNormal Values
Analysis and Interpretation
of Results
WBC Count To determine
infection or
inflammation
Pre-operation
assessment of
the patient.
November
16, 2008
8.0 5-10 x
109/L
No infection
or
inflammation
is present.
RBC Count Pre-operation
assessment of
the patient.
November
16, 2008
3.3 4.2-5.4 x
1012 /L
Decreased
RBC count on
pregnant is
normal
because of the
increase in
plasma volume
during
pregnancy.
Hemoglobin Pre-operation
assessment of
the patient.
November
16, 2008
96 120-
160g/L
The result
indicates that a
1000 ml
sample of
blood contains
96 g of
hemoglobin.
Decreased
hemoglobin on
pregnant is
normal
because of
their increase
in plasma
volume.
Hematocrit
(%)
Pre-operation
assessment of
the patient.
November
16, 2008
0.29 0.37-0.47
g/L
The result
indicates that a
1000 ml
sample of
blood contains
.29 g of
hemoglobin.
Decreased
hematocrit on
pregnant is
normal
because of
their increase
in plasma
volume.
Nursing Responsibilities During Different Laboratory Procedures
White Blood Cell Count
Before
Explain to the patient that the WBC test is used to detect an infection or
inflammation.
Tell the patient that the test requires a blood sample. Explain who will perform
the venipuncture and when.
Explain to the patient that he may experience slight discomfort from the needle
puncture and the tourniquet.
Inform the patient that he should avoid strenuous exercise for 24 hours before the
test. Also tell him that he should avoid eating a heavy meal before the test.
If the patient is being treated for an infection, advise him that this test will be
repeated to monitor his progress.
Notify the laboratory and physician of medications the patient is taking that may
affect test results: they may need to be restricted.
During
Ensure subdermal bleeding has stopped before removing pressure.
After
If a hematoma develops at the venipuncture site, apply warm soaks. If the
hematoma is large, monitor pulses distal the venipuncture site.
Inform the patient that he may resume his usual diet, activity and medications
discontinued before the test, as ordered.
A patient with severe leucopenia, they have little or no resistance to infection and
requires protective isolation.
Red Blood Cell Count
Before
Explain to the patient that RBC count is used to evaluate the number of RBCs and
to detect possible blood disorders.
Tell the patient that the test requires a blood sample. Explain who will perform
the venipuncture and when.
Explain to the patient that he may experience slight discomfort from the needle
puncture and the tourniquet.
Inform the patients that he need not restrict foods and fluids
During
Ensure subdermal bleeding has stopped before removing pressure.
After
If a hematoma develops at the venipuncture site, apply warm soaks.
Hemoglobin
Before
Explain to the patient that the hbg test is used to detect anemia or polycythemia or
to assess his response to treatment.
Tell the patient that the test requires a blood sample. Explain who will perform
the venipuncture and when.
Explain to the patient that he may experience slight discomfort from the needle
puncture and the tourniquet.
During
Ensure subdermal bleeding has stopped before removing pressure.
After
If a hematoma develops at the venipuncture site, apply warm soaks.
Hematocrit
Before
Explain to the patient that hct is tested to detect anemia and other abnormal
conditions
Tell the patient that the test requires a blood sample. Explain who will perform
the venipuncture and when.
Explain to the patient that he may experience slight discomfort from the needle
puncture and the tourniquet.
Inform the patients that he need not restrict foods and fluids
During
Ensure subdermal bleeding has stopped before removing pressure.
After
If a hematoma develops at the venipuncture site, apply warm soaks.
III. THE PATIENT AND HIS ILLNESS
Efforts to unravel the pathogenesis of pre-eclampsia have been hampered by the
lack of clear diagnostic criteria for the disease and its subtypes. Consequently, several
studies have included a variety of other conditions that do not necessarily reflect an
adverse pregnancy outcome.
Abnormal placentation (stage 1), particularly lack of dilatation of the uterine
spiral arterioles, is the common starting point in the genesis of pre-eclampsia, which
compromises blood flow to the maternal–fetal interface. Reduced placental perfusion
activates placental factors and induces systemic hemodynamic changes. The maternal
syndrome (stage 2) is a function of the circulatory disturbance caused by systemic
maternal endothelial cell dysfunction resulting in vascular reactivity, activation of
coagulation cascade and loss of vascular integrity. Pre-eclampsia has effects on most
maternal organ systems, but predominantly on the vasculature of the kidneys, liver and
brain.
V. THE PATIENT AND HIS CARE
1. Medical Management
a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy
Medical
Management
Date Ordered General
Description
Indication &
Purpose
Client
Response to
Treatment
IVF
D5LRS 1L
30gtts/min
Date Ordered
November 15,
2008
Date d/c
November 20,
2008
5% dextrose in
lactated ringers
solution
(Osmolarity of
527-hyprtonic,
pH of 4.9) -
provides
calories and free
water, provides
electrolytes.
Also contains
sodium lactate
which is used in
treating mild to
moderate
metabolic
acidosis.
D5NM is
administered by
intravenous
infusion for
parenteral
maintenance of
routine daily
fluid and
electrolyte
requirement with
minimal
carbohydrates
calories and to
correct or replace
fluid losses due
to change in the
patient’s diet
(NPO) and
during the
cesarean
The patient
responded well
with no signs of
irritation and
adverse
reactions.
operation.
Nursing Responsibilities:
Check the doctor’s order
Explain the procedure to the patient
Tell the patient that she might feel a discomfort from the tourniquet and the IV
insertion
Check and monitor IVF regulation and level of fluid
Check if there is a need for removal and replacement of fluid
Check if the tube is in the vein and signs of edema
Check if there is a back-flow of blood
Check if there is bubbles present in the tube
Always Monitor V/S.
b. Pharmacotherapy
Brand name and
Generic name
Date ordered/
Date started/
Date changed/
Route of
Administration,
Dosage and
Frequency of
Administration
General action Client response
Mefenamic
Acid
11-19-08 P.O., 500mg,
TID for pain
Inhibits
prostaglandin
synthesis by
decreasing the
activity of the
enzyme,
cyclooxygenase,
which results in
Patient was
relieved from
pain.
decreased
formation of
prostaglandin
precursors
Cephalosporin
Cefuroxime
sodium
11-19-08 I.V., 750mg, q8 Inhibits bacterial
cell wall
synthesis by
binding to one or
more of the
penicillin-
binding proteins
(PBPs) which in
turn inhibits the
final
transpeptidation
step of
peptidoglycan
synthesis in
bacterial cell
walls, thus
inhibiting cell
wall
biosynthesis.
Bacteria
eventually lyse
due to ongoing
activity of cell
wall autolytic
enzymes
The patient did
not acquire
infection and
did not
experience any
adverse
reaction.
(autolysins and
murein
hydrolases)
while cell wall
assembly is
arrested.
Ferrous Sulfate 11-19-08 P.O., O.D. Replaces iron,
found in
hemoglobin,
myoglobin, and
other enzymes;
allows the
transportation of
oxygen via
hemoglobin.
The patient
responded well
to treatment
and did not
experience any
adverse
reaction.
Nifedipine 11-19-08 P.O., 10mg, BID Inhibits calcium
ion from
entering the
"slow channels"
or select
voltage-sensitive
areas of vascular
smooth muscle
and myocardium
during
depolarization,
producing a
relaxation of
The patient
responded well
to treatment
and did not
experience any
adverse
reaction.
coronary
vascular smooth
muscle and
coronary
vasodilation;
increases
myocardial
oxygen delivery
in patients with
vasospastic
angina
c. Diet
Type of Diet Date Ordered,
Date Performed,
Date Administer
General
Description
Indication &
Purpose
Client
Response to
Treatment
NPO 11-17-08
11-19-08
The patient is not
allowed to take
any oral food or
liquid
This is done to
prevent
alteration of the
result of the
fasting blood
sugar.bcs intake
of food can
increase
glucose level
The patient
complied with
the prescribed
diet.
Clear Liquid
Diet
11-19-08 A diet of clear
liquids maintains
This diet reduce
stimulation of
The patient
complied with
11-20-08 vital body fluids,
salts, and
minerals; and also
gives some energy
for patients when
normal food intake
must be
interrupted. Clear
liquids are easily
absorbed by the
body. by mouth
(NPO) for a long
time. This diet is
also used in
preparation for
medical tests such
as sigmoidoscopy,
colonoscopy, or
certain x-rays.
the digestive
system, and
leave no residue
in the intestinal
tract. This is
why a clear
liquid diet is
often prescribed
in preparation
for surgery, and
is generally the
first diet given
by mouth after
surgery. Clear
liquids are
given when a
person has been
without food by
mouth (NPO)
for a long time.
the prescribed
diet.
d. Exercise
Activity General Purpose Date Order Client
Description Response
Complete Bed
Rest
Prescribed
maternal
complication of
pregnancy
To provide
adequate rest
11-18-08 The client
adhered to the
order without
complaints.
VI. NURSING CARE PLAN
Cues Nursing diagnoses
Scientific Explanation
Objective Nursing intervention
Rationale Expected outcomes
S-“sumasakit
nga daw ung
tahi niya at
sumusigaw siya”
as the SO
verbalized
O- facial
grimaces
Rated pain as 8
in a pain scale of
1-10, 10 being
the highest
Acute pain
related to
postparum
Unpleasant
sensory
experience
arising from post
surgical incision
from cesarean
section.
After 2-4 hr of
nursing
intervention, the
pt rate the pain
from 8 to 3 in a
pain scale of 1-
10
- Provide quite
environment
-Encouraged to
do deep
breathing
exercise
- Encouraged
adequate rest
period
-to promote pain
management.
-to reduce tension
-to prevent
fatigue
-to reduce
pressure on the
Goal Partially
met AEB pt
rated the pain
from 8 to 5 in a
pain scale of 1-
10
Guarding
behavior
- Encouraged to
support the
affected area
upon movement
affected area
Cues Nursing diagnoses
Scientific Explanation
Objective Nursing intervention
Rationale Expected outcomes
S-“ayoko na
muna dapat
mabuntis kc
papangit ung
katawan ko
tsaka bat ang
itim ng pek-pek
ko” as pt
verbalized
Disturbed body
image related to
pregnancy AEB
changes in
appearance
Severity of the
abdominal
wound due to
surgery, a new
type of tissues
develops that
eventually will
causes scar
formation
After 2-4 hrs of
nursing
intervention, the
patient will able
to understand the
change of body
image.
-Encouraged
client to looked/
touch the
affected body
area
-Encourage the
client to have a
daily exercise.
-to begin to
incorporate
changes into
body image.
-to bring back
the usual
physical images.
Goal met the
patient
recognized and
verbalized
understanding of
body changes.
O-presence of
melasma
-presence of
bipedal edema
-Advised the SO
to give support
to the pt
(especially
emotional
feelings)
-Assist pt to
identify positive
behavior
-to feel that the
patient still
worthy.
-to aid in
recovery.
Cues Nursing diagnoses
Scientific Explanation
Objective Nursing intervention
Rationale Expected outcomes
S: “bumibilis
nga tibok ng
puso ko”
verbalized by
the patient
O: -with the
tenderness of
abdominal are
-facial grimaces
-BP= 160/100
mmhg
Decreased
cardiac output
related to altered
heart rate (111
bpm) AEB
tachycardia, pt’s
report of
palpations;
(r/t) decreased
venous return
AEB edema
(ankle), SOB
(28)
Pregnancy
Induced
Hypertension is a
condition in
which
vasospasms
occur. It is caused
by altered cardiac
output that injures
endothelial cells
of the arteries.
Blood vessels
become less
resistant to
After 4 hrs of
nursing
intervention, the
patient will
display
hemodynamic
stability (heart
rate will decrease
from 111 bpm to
100 bpm, BP
from 140/100 to
120/80)
-Keep client on
bed and in
position of
comfort
-decrease
stimuli; provide
quiet env’t
-Encouraged
deep breathing
exercise
-Encouraged
- decreases
oxygen
consumption
-to promote
adequate rest
-to reduce
anxiety
-to reduce risk for
orthostatic
Goal Met AEB
within 4 hrs. of
nursing
intervention the
pt. HR
decreased from
111 bpm to 100
bpm, BP from
140/100 to
120/80 (Normal
BP)
RR= 28 cycles
per min.
PR= 111 bpm
pressor
substances. This
results to
vasoconstriction
and increases BP
dramatically
changing
positions slowly
-give
information
about positive
signs of
improvement
-Instruct client to
avoid or limit
activities that
may stimulate
valsalva
response (rectal
stimulation,
hypotension
-to provide
encouragement
-to prevent in
changes in
cardiac pressures
or impede blow
flow
bearing down
B.M)
Cues Nursing diagnoses
Scientific Explanation
Objective Nursing intervention
Rationale Expected outcomes
S- Risk for Constipation After 4 hrs of - Educate - Information Goal Met AEB
O- decreased
ambulation of
the patient bcs
of pain and the
complete bed
rest ordered of
the physician.
constipation
related to post
CS delivery.
may happen due
to disturbance of
normal bowel
movements
because
intestines were
displaced during
surgical
procedure.
nursing
intervention, the
patient will
verbalize
understanding
the etiology and
appropriate
intervention if
constipation may
occur.
patient/ SO
about safe and
risky practices
for managing
constipation.
- Instruct balance
fiber and bulk in
diet and fiber
supplements.
- Promote
adequate fluid
intake, also
suggest drinking
warm fluids.
can help client to
make beneficial
choices when
need arises.
- To improve
consistency of
stool and
facilitate passage
through colon.
- To promote
soft stool and
stimulate bowel
the patient
verbalized
understanding
about
constipation and
gained
knowledge of
appropriate
intervention.
- Encourage
activity within
limits of
individual
ability.
activity.
-To stimulate
constrictions of
the intestines
Cues Nursing diagnoses
Scientific Explanation
Objective Nursing intervention
Rationale Expected outcomes
O- postpartum
surgery
Impaired Skin
Integrity related
The incision
from the
After 2-4 hrs of
nursing
-stress proper - to control the
spread of
Goal Met AEB
the patient was
to surgery cesarean section
altered the skin
integrity making
it more
susceptible to
pathogens and
even the pt’s
normal flora
intervention, the
patient will able
to know the
preventive
measures of
wound healing
hand hygiene.
-Encouraged to
increase foods
that are rich in
protein
-Encouraged
proper clothing
-Apply
appropriate
dressing
infection.
- to aid in tissue
repair
-to maintained the
proper skin
moisture.
-to help in wound
healing
able to knew
the preventive
measures of
wound healing
VIII. Discharge Plan
General Condition of client upon discharge
During nurse-patient interaction upon discharge, the patient was wearing a
comfortable pair of white shirt and white pajama and a pair of flat slip-ons while being
sealed on a chair cuddling her baby boy. Her hair was untidy and up in a ponytail with
visible infestations. She was oriented enough to follow instructions and answers
questions asked by the student nurse.
Methods
M- Instructed the patient to take the following home medication as ordered by the
physician:
Mefenamic Acid 500mg PRN
Ferrous Sulfate OD
Nifedipine 10mg BID
E- Instructed patient to avoid strenuous activities. And practice deep breathing
exercise.
T- n/a
H- Instructed patient to take a bath everyday. Emphasize the importance of breast
feeding.
O- Advice to visit or have a follow up check-up with her attending physician.
D- Low fat, Low salt diet.
IX. Conclusion
Nurses can help the nation achieve National Health Goals. These goals speak
directly to both fetus and the mother because pregnancy is a high risk factor for them.
Close monitoring in pregnant women and health teaching as much as possible about
pregnancy could definitely reduce life threatening complications.
Studies shows that there is no certain facts that will give us the idea where pre-
eclampsia arise. But there so many factors that could prevent this complication such as
diet modifications, proper compliance with the health care providers, proper exercise.
And if the complication is already present, proper monitoring, proper diet and drug
compliance should be ruled in.
X. Recommendations
With this study, the student nurses were able to gain more knowledge and wider
view and perspective of the complication of pregnancy which is pre-eclampsia. Thus, the
student nurses would like recommend and share some pointers on how to deal with
different diseases with pregnancy specifically pre-eclampsia.
To the government, primarily they should allocate sufficient budget to sustain and
provide better facilities. They must be responsible enough to create awareness program
for care and management for all the Filipino people.
To the health care team, they should righteously implementing basic and ideal
procedures regardless of the health care facilities where they belong. They must observe
and always remember to keep in line with their duties towards both the mother and the
child during the pregnancy.
To the community and the family, that they must be insufficient coordination with
the government and the health care team regarding promotion of health before, during,
and after the delivery of the baby.
XI. BIBLIOGRAPHY
http:// www.nursingcrib.com
http:// www.medicinenet.com
http:// www.wrongdiagnosis.com
http:// www.umm.edu.com
http:// www.doh.gov.ph