UNIVERSITY OF MAKATI COLLEGE OF ALLIED HEALTH STUDIES J.P. Rizal ext.

,West Rembo, Makati City

A Mini Case Presentation in Maternal and Child Nursing 1

As partial fulfillment in requirement For OB Ward.

2AN1A

I.

INTRODUCTION

Eclampsia, which is considered a complication of severe preeclampsia, is commonly defined as new onset of grand mal seizure activity and/or unexplained coma during pregnancy or postpartum in a woman with signs or symptoms of preeclampsia. Ten percent of all pregnancies are complicated by hypertension. Eclampsia and preeclampsia account for about half of these cases worldwide and have been recognized and described for years despite the general lack of understanding of the disease. We chose this case to present because it is the only available case in the ward, and this is what our seniors suggested we present.

II.

OBJECTIVES

General Objective

The group has chosen to do further study in this case that impacted the interest of each member. More importantly, the focus of this case study shall address questions pertaining to, yet one of the most significant cases in the ward. Lastly the subject matter to be presented will enforce the students ability to apply theoretical knowledge and skills in sensitive procedure done with in the operating room(OR), specially the insertion of the intrajugular catheter.
Specific Objectives:

1. To identify the factors that lead to the development of the problem, 2. To analyze the relationship between factors leading to the development of the problem, 3. To discuss the relevant procedures that were utilized for effective nursing intervention,

4. And to evaluate the patient and familys responsibilities to enface the interventions applied by the student nurse.

III.

NURSING HISTORY BIOGRAPHICAL DATA Name Age Gender Address Nationality Religion
Birthdate Hospital Date of Admission Date of Interview Informant Reliability Source of information Criteria for reliability

: Patient X : 18 : Female : : Filipino : Catholic

: September 30, 1993 : Ospital ng Makati : September 22, 2012 : September 25, 2012 : Patient X and significant others : 95% : Patient :

A. extent of data gathered demographics, history habits = 30% B. Level of consciousness od interviewee condition, willingness to disclose info = 40% C. Completeness of correlating facts Fluidity of transpiring events = 25%

CHIEF COMPLAIN

Pain in Labor

HISTORY OF PRESENT ILLNESS - 6hrs. prior patient was admitted at lying-in due to regular uterine contraction. I.E upon admission was cervix 7cm with Bow. 2 hrs; cervix was fully dilated kindly referred with episodes of exhaustion and loss of consciousness and continue to --- referred to OB PAST MEDICAL HISTORY Hypertension, Diabetes, Asthma, Cancer, Heart Disease FAMILY HISTORY

PATIENT X

MOTHER

FATHER

TITA

GRANDMOTHER

TITA GRAND MOTHER

Legend: = eclampsia = Diabetic IV. GORDONS FUNCTIONAL HEALTH PATTERN FUNCTION HEALTH BEFORE DURING PATTERN HOSPITALIZATION HOSPITALIZATION According to the patient, her condition was good According to the patient, with normal daily activity she is not well. Shes performed every day, experiencing pain on her I. Health before she got right hand, back and in perception and hospitalized. She her vagina due to health maintaining good health episioraphy. management and exercising every pattern morning. When she is Patient didnt have any sick, she is the one taking cough, colds, or fever. care of herself. None of her family smoke, And she drinks alcohol occasionally. The patient consumes 1cup of rice every meal with vegetable and fruit. Before she got hospitalized, she had a good appetite and had no II. Nutrition and problem swallowing food. During her metabolic She also regularly hospitalization, she only consumes 8 glasses (or consumed what kind of pattern more) of water a day. diet the physician orders. According to her, she easily gets well whenever she gets minor illness. She doesnt buy cooked foods outside. Before being hospitalized, She regularly defecates she regularly defecates once a day. During once everymorning hospitalization she is not . -Feces: usually soft. having hard time -Color of the feces: brown. urinating and defecating hypertensive

INTERPRETATION

III.

Elimination pattern

IV.

Activity and exercise pattern

She doesnt have any difficulty in defecating and urinating. -Urine color: clear or yellowish -Odor: usual unnoticed by the patient. -sweat: not too much According to the patient, she regularly finishes her daily routine. She exercises every morning, by doing basic stretching and walking. Before hospitalization, she can perform her daily activities; getting up from bed, sitting, taking a bath, urination, defecation, change of clothes, and any other movement on her own.

Urine color: yellow or amber Odor: usual unnoticed by the patient. -sweat: not too much . -Feces: usually soft. -Color of the feces: brown.

During hospitalization, she can only perform minimal movements and needs assistance for getting up and walking.

V.

Cognitiveperceptual pattern

The patient can hear clearly. Her vision is normal.

During hospitalization, there is no change on her hearing, still normal vision. -Experiencing back pain, pain in the right arm due to IV lines, and swelling of her left arm. During hospitalization, she can only sleep with less than 6 hours. She also states that the only way she can relax in the hospital is when she is in bed.

VI.

Sleep- rest pattern

VII.

Selfperception, Self-concept pattern.

According to the patient she sleeps for 6hrs in the evening and 2hrs for siesta. According to her, she watches TV for her to relax. According to the patient, before hospitalization she was cheerful and her body was strong. According to her and relative, she doesnt easily gets angry or worried on simple thing. She easily gets sad but she doesnt cry.

According to her husband, he noticed that her wife is perplex because she cant still accept what just happened to her baby.

VIII.

Role relationship pattern

She is only living with her husband. According to her, problems can be fixed easily if the two of them talked about it.

Her husband sees her as a good person and hardworking.

IX. Sexuality-reproductive pattern.

Coping stress tolerance pattern Value-belief pattern

Her last menstruation was last December 6 2011. Menarche was when she was 11 yrs old. Never used any contraceptives The client stated that she was okay. Catholic

The client stated that she was okay.

V. Review of Systems
General (+) altered sleep patternhindi ako makatulog ng dire-diretso (+) restlessness Eyes There are no significant findings Nose There are no significant findings Ear There are no significant finding Mouth There are no significant finding Neck There are no significant finding Pain in the upper extremities Integumentary System Due to IV lines

(+)painin perineum (episioraphy) (+) radiating back pain (+) anxiety

Due to IV lines
Bruise in right arm

Gastrointestinal System Pain in the abdomen

Due to surgery(CS)
Respiratory System

There are no significant finding (-) muscle pain (-) shoulder pain (-) standing alone (-) ambulatory Musculoskeletal System (-) joint pain (-) fracture (+) back pain (+) cramps (-) claudication Masakit yung tahi (Episioraphy) (+) numbness and burning sensations (-) Syncope (-) numbness Genito-urinary System amenorrhea Nervous System (+) poor memory (+) drowsiness (+) headache (-) Memory loss (-) tingling sensation

(-) disturbance in balance and coordination (-) dizziness

V. Physical Assessment

CEPHALOCAUDAL EXAMINATION HEAD

TECHNIQUES Inspection

FINDINGS

REFERANCE FINDINGS

(-) lesions
(+)dry and grayish facial skin (-) areas of deformity Symmetric facial features (-) palpable masses or lesions

(-) lesions
(-)dry and grayish facial skin

Palpation

(-) areas of deformity Symmetric facial features (-) palpable masses or lesions Evenly distributed black hair (-) infestations normal texture

HAIR

Inspection

Palpation Evenly distributed black hair (-) infestations Brittle and dry hair in texture Eyebrows symmetrically aligned Eyelashes equally distributed (+) Sunken eyes (+) periorbital edema Whitish red sclera Pale Conjunctivae brown iris (+) PERRLA (2-3 mm diameter of iris) (-) discharge Symmetrically aligned Intact tymphanic membrane (-) masses (-) discharge (-) lesions

EYES

Inspection

Eyebrows symmetrically aligned Eyelashes equally distributed (-) Sunken eyes (+) periorbital edema White sclera Pale Conjunctivae Black iris (+) PERRLA (2-3 mm diameter of iris) (-) discharge Symmetrically aligned Intact tymphanic membrane (-) masses (-) discharge (-) lesions

EARS

Inspection Pinna immediately recoil after it is folded pale nasal mucosa

Pinna immediately recoil after it is folded

Pink nasal mucosa

Palpation

NOSE

Inspection

MOUTH AND THROAT

Inspection

Teeth (+) incomplete dentition Gums and Mucosa (-) swelling (-) bleeding (-) infection Gums are slightly pale normal Pharynx and Tonsillar Fossa grayish and dry oral mucosa (-) swelling and lesions (-) lips are greyish and pale Tongue is yellowish brown, dry and at midline position (-) uremic breath (-) lesions Not supple (+) jugular vein engorgement (+) Right Intrajugular catheter

Teeth (+) complete dentition Gums and Mucosa (-) swelling (-) bleeding (-) infection Gums are pink normal Pharynx and Tonsillar Fossa Pink and moist oral mucosa (-) swelling and lesions (+) lips are pinkish and moist Tongue is pink, moist and at midline position (-) uremic breath (-) lesions Supple (-) vein engorgement

NECK Inspection

Thyroid: nonpalpable Carotid pulses are (-) lymph nodes palpable or lymphadenophaty (-) masses or lesions present Suprasternal Notch: (-) pulsation

Intact

Thyroid: non-palpable (-) lymph nodes palapable or lymphadenophaty (-) masses or lesions present Suprasternal Notch: (-) pulsation (+) symmetrical expansion with respiration (+) Tactile fremitus bilateral

Palpation THORAX AND LUNGS Inspection

(+) symmetrical
expansion with respiration

Palpation

(+) altered Tactile fremitus on the bases of the thorax (+) tympanic sound

Percussion

(-) crackles (-) added or adventitious sound

(+) resonant sound

Auscultation

HEART

Inspection

(+) not visible PMI

(+) regular rhythm Precordium: (-) parasternal impulse (-) thrills PMI- palpable in 5th ICS, apical area S1- heard best at apex, normal intensity S2- heard best at

(+) normal vesicular breathing sounds (-) added or adventitious sound (+) not visible PMI

Palpation

(+) regular rhythm Precordium: (-) parasternal impulse (-) thrills PMI- palpable in 5thICS, apical area

S1- heard best at

Auscultation

base, Extra Sounds- (-) (-)murmurs

ABDOMEN

Inspection

(+) globular
(+) pallor, yellowish gray skin (-) scars, striae (+) skin pinch goes back slowly (+) dry skin (+) Fluid wave technique (determining ascites) Liver: (-) palpable Spleen: (-) palpable Right & left Kidney: (-) palpable

apex, normal intensity S2- heard best at base, Extra Sounds- (-) S3, S4 (-)murmurs (-) globular (-) pallor, yellowish gray skin (-) scars, striae (+) skin pinch goes back rapidly (-) dry skin (-) Fluid wave technique

Palpation

Liver: (-) palpable Spleen: (-) palpable Right & left Kidney: (-) palpable

EXTREMITIES

Inspection

Upper extremities:
(+) pallor, yellowish gray skin (-) cyanosis (-) rashes (+) bruises Palms dry in texture and pale. (-) nails cyanosis and clubbing (+) thick and brittle nails (-) cold to touch (+) dry skin (+) skin pinch goes back

Upper extremities:
(-) pallor (-) cyanosis (-) rashes Palms normal in color and texture (-) nails cyanosis and clubbing (+) thick and brittle nails (-) warm to touch (-) slightly moist (+) skin pinch goes back rapidly

Palpation

slowly Left brachial pulse is bouncing Left AVF has thrill Radial pulses are symmetric but bouncing. (-) delayed capillary refill Left AVF has bruits during auscutation Auscultation Lower Extremities: (+) pallor, yellowish gray skin (-) cyanosis (-) rashes (+) edema (+) dry skin (-) nails cyanosis and Clubbing (+) thick and brittle nails Pulse of Dorsalis pedis and Posterior tibia was symmetric but bounding Pitting edema: +2 (4mm) (-) delayed capillary refill (-)cold & clammy extremities

Left brachial pulse should be normal Radial pulse normal and symmetric

(+) capillary refill within 1-2 secs. left AVF has bruits during auscutation

Inspection

(-) pallor (-) cyanosis (-) rashes (-) edema (-) dry skin (-) nails cyanosis and clubbing (-) thick and brittle nails Pulse of Dorsalis pedis and Posterior tibia was normal and symmetric

Palpation

(-) edema (+) capillary refill within 1-2 secs. (-) cold and clammy extremities

VII. Course in the Ward

VIII. Diagnostics HEMATOLOGY 9/24/12 7:35am Hemoglobin Hematocrit 9/25/12 4:00am Hemoglobin Hematocrit RESULT 7.5 0.23 RESULT 8.6 0.26 NORMAL 12-16g/L 0.37-0.47 NORMAL 12 16 g/L 0.37 0.47

CLINICAL CHEMISTRY 9/24/12 6:39pm 24 hrs urine SI Units protein Total Volume 200.00ml 24 hrs urine 143.40 protein 9/24/12 Examination BUN BUA LDH SGPT SGOT

Conventional Units

143.40 mg/24 hrs.

Result 6.67 515.8 301.6 15.1 21.94

Normal 2.49 - 6.4 mmo/L 148.70 458.0 umol/L 225 450 u/L 0 49 u/L 0 37 u/L

XI. Pathophysiology
In eclampsia, placenta does not form a normal system of arteries [illness( diabetes or high blood pressure), genetic (inherited) factors and the way the mother's immune system reacts to the growing placenta] Placenta does not anchor itself as deeply as expected within the wall of the uterus As the pregnancy progresses, a placenta creates an abnormal balance of enzymes (proteins) called growth factors(VEGF) (placental production and secretion of antiangiogenic factors such as protein like tyrosine kinase 1 and activin A that antagonizes VEGF) ANGIOGENESIS IMPEDANCE Changes the way that arteries in the mother and the placenta functionArteries throughout the body can tighten (become narrower), se BP Become "leaky" allowing protein or fluid to seep through their walls, which causes tissues to swell Edema Also react to the abnormal growth factor balance by forming clots Abnormal cerebral blood flow in the setting of extreme hypertension. Vessels become dilated with increased permeability and cerebral edema occurs and results in ischemia and encephalopathy Seizures Many uterovascular changes occur due to the interaction between fetal and maternal allografts and result in systemic and local vascular changes. These system changes contribute to the brain pathology in eclampsia by inhibiting the regulation of cerebral perfusion.

XII. Surgical Management XIII. Drug Study