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, Crescent Park West, Bonifacio Global City, Taguig City Tel: 757-55-88 / 818-09-45 / 818-09-46

Pre-Eclampsia Case Study

RLE (N- 211)

Submitted By: Adriel Apolinario

Submitted To: Arnold Peralta, R.N.

2nd Semester 2012

A. Nursing History
Ana Santos, 33 y/o, female, R.C., Fil, born in Antipolo, presently residing in #29 Atoside Western Bicutan, Taguig City, was admitted at TPDH on February 26, 2012. On March 1, 2012 at 3:00pm, the patients husband Mr. Ronie Sudaria was interviewed with 100% reliability. General Data: Name: Ana Santos Age: 33 y/o Sex: Female Marital Status: Married Religion: Roman Catholic Race: Filipino Occupation: Housewife Date of Birth: 07/15/1978 Place of Birth: Antepolo Residence: #29 Atoside Western Bicutan, Taguig City Date of Admission: February 26, 2012 Place of Admission: TPDH-ER Number of Admission: 1 Chief Complaint: Blurry Vision History of Present Illness: Informant/Source of Information: Mr. Ronie Sudaria (patients husband). Date of Interview: 03/01/2012 at TPDH-OB WARD The patient was brought to Taguig Pateros District Hospital for the following reason: blurry vision, and headache. Symptoms started 38 days prior to first admission (January 19, 2012) in sudden occurrence. The patient would experience intermittent yellow productive cough with no sign of blood, and headache for one week. The patient took Ambroxol and the cough went away after a week. 7 days prior to admission (February 19, 2012) the patient complained of blurry vision and headache. No medical attention was done. On the day of admission (February 26, 2012) the patient was first admitted to FTI, Manila at the Clinic Ward for the blurry vision. The patient had a blood pressure of 210/100, no medication was given, and the attending physician referred the patient to TPDH-ER. The patient commuted to the referred hospital. Upon admission to TPDH-ER, the patient had a blood pressure of 230/100 and was given 5 grams of Magnesium Sulfate on each buttock to prevent seizure and 0.5 grams of Hydralazine to lower the blood pressure. The patient was placed on a low sodium and low fat

diet. The fetal heart rate was checked and ECG, CBC, Urinalysis was ordered. The patient was then transferred to the OB ward. One day after admission (February 27, 2012) the patient was continually monitored and given medication. The patient vomited 5-8 times throughout the day after eating or medication starting at 5AM. The second day after admission (February 28, 2012) the patient continued to vomit 5-8 times throughout the day after eating or medication. An ultra sound and x-ray was ordered. Three days after submission (February 29, 2012), the patients baby was confirmed as stillbirth at 8AM and was delivered at 11:50PM. The placenta cotyledons were complete and minimal vaginal bleeding. Four days after admission (March 1, 2012) the patient continued experiencing blurry vision, headache and lethargic. Past History: Childhood Illness: The patient had no known childhood illnesses or hospitalization. The patient reported that she was complete of all vaccination as a child. She has no known allergies or any foods or certain days of the season. The only medication she took was Tylenol for fever. Personal And Social History The patient is Roman Catholic living with a family of 4 people. They live in a 2 bedroom single story home. There are no smokers residing in their residence. The patient spends most of the time with house chores such as cleaning and cooking. The patient is a non smoker/alcohol user. During pregnancy the patient did not go out of town. Family History The patients parents did not have any known history of illness. The patients mother is living and the father is deceased of unknown cause. The patient is the youngest and only daughter of six children. The patient does not know of any illness or smoking/alcohol use of her brothers. The patients husbands mother died of a stroke and the father died of unknown cause. The patients husband the eldest. He is a non smoker and drinks beer occasionally with no known illnesses. His brother regularly smokes and drinks alcohol with no known illnesses. The patient has two children, a daughter the eldest and son. The children do not have any known illnesses or complications during delivery.

GENOGRAM

Gordons Functional Health Patterns

Health pattern a. Health Interpretation and Maintenance Past Condition Patient is a 33 years old female. She has no history of high blood pressure and no complication of during in her 2 previews pregnancies. She is a non smoker and alcohol user. The Present Condition Analysis and Interpretation

The patient is lethargic due to I: Clients health poor blood perfusion and blurry perception is not vision. She states that every time altered. she switches position she feel dizzy and sleepy. The patient is afebrile with 35-36 degree temp on the right outer surface axilla arm. Patient continues to experiences blurry vision,

patient and her husband do not allow smoking in the house. She considers herself very healthy. She does not like going to hospitals especially when she is sick.

headache, oriented to time, place and person. She perceived her health is not that well and is aware of her condition. Her long stay at the hospital made her realize the importance of eating healthy by consuming less sodium and fat, especially during her pregnancy. Her husband is more During her first supportive of her health than trimester of pregnancy before. The patient is in complete she only went to the bed rest. health center ones for checkup. She never back because it is too far (30 min. away). She has never had any ultrasound or blood exams during her pregnancy. In addition, she has received her tetanus toxoid vaccines. b. Nutrition and Patient eats on time Metabolic since 3-5 meals a day. pattern She loves to eat fish and chicken which her husband prepares when he is home. During times when her husband is at work she enjoys eating fried foods three times a week and eats salty foods three times a week. The patients favorite dish is adobo. Her husband states Patient is currently on a low salt and low fat diet. She needs assistance in eating every time. She cannot hold her spoon and fork and her husband is the one who feeds her. She eats small meals a day at different times and drinks 2,500ccs of water every day as ordered by the doctor. She is not allowed to drink soda. Most of her diet consists of noodles, fish, vegetables, crackers and rice. The patient displays no appetite to eat. The patient switches position in bed every hour

A: Because of her condition, the client feels that her illness is not severe. She assumes total responsibility for decision-making and self-care.

Reference: Kozier and Erbs Fundamentals of Nursing 8th edition, vol.1, page 295-307.

I: Clients nutrition is hindered because she needs help in eating every time. She cannot do activities of daily living as important as eating.

that she has a stronger because she feels warm all the A: The nutritional taste than him because time. Her skin is moist but cool to metabolic pattern she puts too many salt. touch. focuses on food and fluid intake, She also eats heavy however the client meals with her has problems in husband when he gets eating and that home from work in the might influence evening and sleeps an intake. hour after. She drinks (250cc/8oz/glass) more than 3-4 glasses every day. She enjoys drinking soda with her meals and consumes 1,000 to 2,000cc per day. During pregnancy she took daily vitamins but she cannot recall if she took folic acid. Her weight is stable at 200lbs. She has not experience any increase or decrease in weight. When the patient is sick she usually gets better the next day. c. Elimination pattern Patient has no problem in defecating and urinating. She usually defecates once a day at nighttime and urinates The patient has not defecated since she was admitted. She urinates in approximately 500800cc in 24 hours with small amounts of light yellow urine. The I: Clients elimination pattern is not altered however client needs

Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 120

5-8 times a day with patient does not have any pain or assistance in doing yellow colored urine. difficulty urinating. so. She drinks A: Medications approximately 3-4 of like Methyldopa 250 cc each glass of affects the central water and 1,000nervous system 2,000cc of soda per that interferes day. Clients stool is with the normal brown and loose in urination and consistency. elimination process and may cause retention. In addition, her water intake is regulated at 2,500cc/day. Reference: Kozier and Erbs Fundamentals of Nursing 8th edition, vol.2, page 1288-1289. d. Activity Exercise pattern and Patient does not require any help and is completely independent in performing activities such as feeding, bathing, dressing, toileting and ambulation. She usually walks around outside the house in the morning as a form of her daily exercise. During spare time she Patient is unable to perform activities of daily living due to lethargic and blurry vision. When the patient moves around she feels very dizzy which makes her feels sleepy. She also has difficulty sleeping because her blood pressure is checked every hour. The patient is in complete bad rest. I: The client needs assistance when performing all daily living activities. Her husband is her primary care taker.

A: Because of her Patient is a level 2: Requires condition, the assistance or supervision from client is unable to

walks around the another person, her husband. basketball court outside her house. She states that she has enough energy throughout the day. She has not experienced any musculoskeletal impairment. A week before admission she had difficulty sleeping because of a cough and dizziness.

do her tasks alone such as eating. A problem in the activityexercise pattern may be the primary reason for the patient entering the health-care system or may arise secondary to problems in another functional pattern.

Patient is Level 0: Full self-care.

Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 270 Patient has no difficulty in sleeping and usually sleeps 8-12 hours at night. Throughout the day the patient also takes naps because of the dizziness she feels when she switches position and from her blurry vision. Her rest is disturbed because her vital signs are checked every hour. The patient appears weak because of her slow movements, drowsiness and restlessness from her medications (Metronidazole, Mefenamic acid, Amlodipine, I: The client is having prolonged sleep at night and daytime sleepiness due to her dizziness and blurry vision.

e. Sleep and Rest Patient usually sleeps pattern 5-8 hours at 1AM and wakes up usually at 6AM and does take naps in the morning at usually 6-9AM for 3 hours after the husband leaves for work. During rest time, she usually walks outside at the basketball court. Although most of the time she is at home

A: The patients drowsiness and restlessness maybe due to medications like

doing house work.

Nifedipine and Furosemide.

Furosemide, mefenamic acid, Amlodipine, Nifedipine and metronidazole that may cause excessive daytime sleepiness.

Reference: Kozier and Erbs Fundamentals of Nursing 8th edition, vol.2, page 1171-1172. f. Cognitive and The patient has no Perceptual problem with her pattern hearing and in the past. She use to wear glasses but they were 5 years ago and never worn corrective lenses since. She is lethargic due to her medication yet responds to questions and has no signs of looseness of association or any flights of ideas. I: The client is coherent, cooperative, and alert with no problems with her sensors.

She answers in full sentences when asked questions. She recalls Her memory from her most information about her A: Client manifests past and condition is condition before hospitalization. intact sensory still accurate. She can She does not experience any mechanisms and remember names of chills. perception. most of the drugs she took, and her regiment The patients eyes are round and before hospitalization. symmetrical, reactive to light and She usually learns best pupils constricts. When light is Reference: hands on and has no off, her pupils dilate. Her pupils Kozier and Erbs problems learning new are 5mm dilated because of Fundamentals of things. dizziness and restlessness. The Nursing 8th patient reacts to accommodation edition, vol.2, When she feels sick she

usually uses natural when looking close and far. methods such as herbs. She rarely takes medication because of their financial situation. There are no problems in her senses. g. Self Perception and Self Control pattern The client would then view herself as someone who regards life to the fullest. She rarely worries about her problems. She is a hard worker and is rarely immobilized. During the assessment the patient was responsive yet answered every question with ease and depth. She defined that her hospitalization caused a big impact on her life that changed the way she viewed life. She is more focused on eating less fat and salty foods. She Also realizes She focuses on her that eating late at night and husband and children, sleeping immediately is should be especially when her avoided. husband is at work. The patient feels that she has enough energy throughout the day and rarely rests. She does not believe that she unhealthy since she eat frequently and abundantly since she incorporates vegetable and fruits in her diet. She rarely gets mad or irritated when she is at home. Her relationship

page 981.

I: The client has positive views on her condition. She thinks that her hospitalization only affected her body and lifestyle. She is still calm and positive about things.

A: The patients behavior is affected not only by experiences prior to interactions with the health-care system, but also by interactions with the healthcare system.

Reference: Coxs Clinical Applications of

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with her family and husband is peaceful. She only worries when her husband is at work and her children at school. h. Role and The patient lives with The relationship of her family Relationship her two children and remains strong. They remain firm pattern her husband. and gather strength from each other. They support each other Most of their problems and exude strength to the patient. are financial reasons. They manage by saving Her husband is her main source of money and eating what support. Since the patients they could afford. admission to TPDH, he has not left the hospital for work. He said that The patient would view it is his turn to take care of her. herself as a kind, and responsible mother to The children were sent to the her children and a patients province where her loving wife to her brothers would take care of them husband. When they until she recoveres. have problems in the family they solve it by talking between the members. She has no problems raising her children since they help around the house and are studios at school. The patient does not affiliate or take part in any community organizations. Most of her friends are her

Nursing Diagnosis 5th edition, page 520

I: The clients relationship with her family remains strong.

A: The clients hospitalization made their family become stronger. They used each as a source of energy and hope. Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 606

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neighbors. She involves herself in decision-making for the household and major decisions. Her husband usually has the final say on things. i. Sexual and The patient and her Reproductive husband are into pattern sexual activity when they have time and energy. Most of the time they show love to each other through action and care, such cooking for one another and helping in the house. On the patients menstruation, she not experience problems or pain. cycle is regular. last did any Her Patient and her husband are still intimate with each other. They ensure that they have time with each other since the patient is in complete bed rest. I: The client has sexual activity with her husband when there is time and energy. Usually this is Her husband provides comfort by when her husband hugging and showing care to his comes home from wife, anything to make her feel work. Although at comfortable. their age and schedule, they are not as active as before.

They are not aware or take part in family planning.

A: Sexuality patterns involve sex role behavior, gender identification, physiologic and biologic functioning and the ability to express sexual feelings. Client is able to fulfill sexual needs.

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Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 715 j. Copping-Stress She is not the type of Tolerance mother/wife that gives Pattern up easily. She views stresses as challenges to keep her firm and grounded. According to the patient, she faces stressors of life such as financial crisis, and emotional conflicts by talking with her husband at all times. She does not worry often or use alcohol/drugs for comfort. She deals with her problems as a family and it makes her feel better when her husband is involved is all circumstances. Patient tackles stress by resting. Her husband is her source of outlet. He continues to care and converse with her everyday concern and worry on her well being as well as her children. The patients short-term and Long-term coping strategies is supported by her conversing with her husband. I: The clients coping mechanism is not hindered because of the continued support of her husband. Whenever she experiences stress, the client would take time to rest. A: Her ability to respond to stress is affected by a complex interaction of supportive social and emotional reactions.

Reference: Kozier and Erbs Fundamentals of Nursing 8th edition, vol.2, page 1068.

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k. Values and The patient is satisfied Belief pattern with her life and dreams. She feels that her place and family is where she should be. The client is Roman Catholic and the client believes that she generally gets things she likes out of life. She doesnt go to mass regularly but she makes sure that she says her daily prayers and puts strong faith in God especially during times of conflict or suffering.

During hospitalization the client prays to God every day and believes that God has plans for her and her husband.

I: The patients faith in God is evident in hospitalization. She values her She and her husband view her husbands condition as a sign to eat support. healthier. They both agree that she would lessen the amount of A: The patient salt and fat in her food; also limit finds great solace the amount of soda she drinks. in her spirituality. She is very thankful for her husbands continued support and love. Although they are worried financially since he has not went to work since her hospitalization, they are happy to have each other and they continue to show care and love everyday she is at the hospital. Reference: Coxs Clinical Applications of Nursing Diagnosis 5th edition, page 803

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B. Global city Innovative College College of Nursing and Allied Health Sciences Physical Examination
Name of Client: Ana Santos Unit/Ward: 206 Bed F/ OB WARD Age: 33 y/o Sex: Female Date of Physical Assessment: March 1, 2012 BMI: 37.8, Obese (BMI 30+ = Obese) Height: 5 1 Weight: 200 lbs. Vital Signs: BP: 140/60, regular (right arm) Temp: 35.8, axilla (right outer surface axilla arm) P.R: 68/min, regular (right arm radial pulse) R.R: 17/min, regular General Appearance Appearance: Level of consciousness: Lethargy Oriented, but slowed metal reponses. Speech sluggish, sleeps often, but easily awaken.

Development: Nutritional State: Well Well Developed Nourished

Body Parts

Method of Assessment Inspection

Normal Findings

Actual findings

Analysis and Interpretation Client manifests warm and dry skin due to nausea and vomiting as fluids are lost, most of the

Skin

Uniform skin color with slightly darker exposure areas. No jaundice, cyanosis, pallor, erythema, or hyper/phypopigmentation.

Skin is fair in complexion, cool to touch and moist. No erythma (rash).

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( Kozier and Erbs. techniques in clinical nursing. Physical health examination. P.58)

remaining fluids are drawn to maintain fluids to more vital areas of the body such as the blood and various vital organs requiring fluids. (Deglin, et al. Daviss Drug Guide For Nurses. 9th ed. P. 796)

Palpation

No presence of edema Temperature is uniform Moisture in skin folds and axillae. When pinched, skin springs back to previous state.

No presence of edema Temperature is uniform Moisture in skin folds and axillae. When pinched, skin springs back to previous state.

Client manifests Normal findings

Nails

Palpation

Smooth, firm and nontender

Capillary refill within three to four seconds

When palpated, the nails are smooth, firm and non-tender and its capillary refill is three seconds.

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Eyes

Inspection

Positioned symmetrical to each other

There are no pigmentations, cloudiness or any presence of abnormal discharges in the eyes

Pupils equally rounded and appear normal in size

The eyes of the patient are positioned symmetrically to each other. No pigmentations, cloudiness or any presence of abnormal discharges are seen in the patients eyes. Anicteric sclera Pupillary is 5mm dilated and is reactive to light and accommodation. The parts of the Client manifests head and face are normal findings proportion to each other and are symmetrical. The shape is gently curved with prominences at the frontal and parietal bones. The patient has symmetric facial movements. Smooth uniform consistency; absence of nodules or masses Client manifests normal findings

Pupillary activity appears normal

Head and Face

Inspection

The parts of the head and face is proportion to each other and symmetric

Shape is gently curved with prominences at the frontal and parietal bones

Symmetric facial movements Palpation Smooth uniform consistency; absence of nodules or masses

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Mouth, Throat, Neck

Palpation

There is no significant or palpable mass at the thyroid area

Jugular vein is not distended The lymph nodes are not distended The trachea is palpable at the midline of the neck. Upper Extremities Inspection No venous patterns, varicosities, rashes and ulcers.

No significant or Client manifests palpable mass was normal findings. reported at the thyroid area, jugular vein is not distended. Lymph nodes when palpated were not palpable or significantly distended.

No venous patterns, varicosities, rashes and ulcers

Client manifests normal findings

Thorax and Lungs

Inspection

Chest is symmetric and skin is intact

Quiet, rhythmic, and effortless respirations Palpation Temperature is uniform Chest wall is intact; no tenderness; no masses Auscultation No adventitious breath sounds

Chest is symmetric and skin is intact, the respiratory rate of the patient is 17 cpm. Patient refused to be palpated Unable to assess

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Heart

Inspection

No visible lifts or heaves

Peripheral veins in dependent position, distention and nodular bulges at calves are present Palpation Full Pulsation at 60-100 bpm S1; usually heard at all sites, usually louder at apical area S2; Usually heard at all sites, usually louder at base of heart Systolic; silent interval. Slightly shorter duration than diastole at normal heart rate Diastolic; silent interval. Slightly longer duration than systole at normal heart rates. Abdomen Palpation No tenderness, relax abdomen with smooth, consistent tension, bladder and liver is not palpable. Patient experiences pain in deep palpation in the lower right quadrant. Full Pulsation at 68 bpm Client manifest normal findings

Auscultation

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Lower Extremities

Inspection

No venous pattern, varicosities, rashes, ulcers

No venous pattern, varicosities, rashes, ulcers. Uniform temperature Strong peripheral pulsation.

Client manifests normal findings

Palpation

Uniform temperature

Client manifests normal findings

Inspection Kidneys

Urine color is straw, amber or transparent; urine consistency clear liquid; urine glucose not present. Glasgow coma scale is 15

Urine is light yellow colored, urine consistency is clear liquid.

Neurologic System

Inspection

Glasgow coma scale of the patient was Positive reflexes such as scored as 14 biceps reflex, triceps reflex, wherein the eye brachioradialis, patellar reflex response has the and Achilles reflex score of 3, 5 for verbal response and 6 for motor response. The patient was able to perform all of the said reflexes such as biceps and triceps reflex, brachioradialis, patellar and Achilles reflex.

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Cranial Nerves I Olfactory By asking patient to close his eyes and identify different mild aromas. Identify different mild aromas The patient was able Client manifests such as coffee, vanilla, peanut to determine normal findings butter, orange, lime, different mild chocolate aromas such as alcohol, sweets and water.

II Optic

By asking to Ability to clearly visualize the A snellen chart was Was not able to perform. read snellen snellen chart; check visual not available. chart; check fields by confrontation visual fields by confrontation

III Oculomotor

Able to perform extraocular The nurse will eye movement (EOM); be assessing the movement of sphincter of six ocular pupil; movement of ciliary movements and muscles of lens pupil reaction of a patient

The patient was able Client manifests to perform the six normal findings ocular movements; movement of sphincter of pupil and movement of ciliary muscles of lens. The patient was able Client manifests to perform extra eye normal findings movements, specifically the six ocular movements wherein eyeballs can move downward laterally

IV Trochlear

Able to perform extra eye The nurse will movements specifically be assessing the movements of eyeballs six ocular downward laterally movements of a patient.

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V Trigeminal

The nurse lightly Presence of blink reflex; can touches the feel the sensation of skin of lateral sclera of face and nasal mucosa; able the eye while to feel the sensation of the patient is anterior oral cavity; looking upward. mastication of muscles To test light sensation, have the client close eyes, wipe a wisp of cotton over patients forehead and paranasal sinuses. Ask client to clench teeth.

The patient was able Client manifests to elicit blink reflex; normal findings can feel the sensation of skin of face and nasal mucosa. Patient was able to feel the sensation of anterior oral cavity and was able to clench teeth for mastication.

VI Abducens

The nurse will Ability to move eye balls be assessing the laterally directions of gaze.

Client manifests The patient was able normal findings to move eye balls laterally.

VII Facial

Ability to perform different By asking the patient to smile, facial expressions; able to raise eyebrows, identify different tastes frown, and puff out cheeks, close eyes tightly. Identifying various tastes placed on tip and sides of tongue.

The patient was able Client manifests to perform different normal findings facial expressions by doing the method of assessment and was able to identify various tastes placed on the tongue.

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VIII Auditory

The nurse will Ability to clearly hear spoken be assessing the words and vibrations of patients ability tuning fork to hear spoken word and vibrations of tuning fork.

The patient was able Client manifests to clearly hear normal findings spoken words and vibrations of tuning fork.

IX The nurse will Glossopharyngeal be applying

Able to move the tongue from The patient was able Client manifests side to side and up and down; to move tongue normal findings tastes on no difficulty in swallowing;; from side to side posterior tongue able to identify different taste and up and down. for on posterior tongue The patient did not identification. show any difficulty Asking the in swallowing and patient to move able to identify tongue from different taste on side to side and posterior tongue. up and down.

X Vagus

The nurse will Palpable pharynx and larynx; The pharynx and Client manifests do palpation on presence of gag reflex; no larynx of the patient normal findings the pharynx and presence of hoarseness in the was able to palpate, larynx, assessing clients speech positive gag reflex the gag reflex and no presence of with the use of hoarseness on tongue clients speech. depressor and assess the presence of hoarseness.

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XI Accessory

The nurse will apply pressure on patients shoulders and ask patient to shrug shoulders against resistance and turn head to side against resistance from the nurse hand.

Able to shrug shoulders The patient was able Client manifests against resistance and able to to shrug shoulders normal findings turn to side against resistance against the without any difficulty resistance of the nurse and was able to turn head to side against resistance without having any difficulty.

XII Hypoglossal

Ability to protrude tongue at By asking midline and move up and patient to protrude tongue down and side to side at midline and move it side to side and up and down

The patient was able Client manifests to protrude tongue normal findings at midline without any difficulty and was able to move it up and down and side to side.

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D. LABORATORY STUDY
Examination CBC: WBC Count CBC: Neutrophils CBC: Lymphocytes CBC: Monocytes CBC: Basophils Normal Reference 4,800-10,800 2,000-7,500 1,500-4,000 40-500 10-100 Actual Findings 28,500 mm/3 26,220 1,425 0 0 Analysis & Interpretation (including references)

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