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A CASE PRESENTATION
OF
PREECLAMPSIA
Presented by:
Jomari Jones Q. Zapanta
Jokko Jane M. Espinol
Asian Star B. Lago
Diaden M. Morite
Dedication
Acknowledgement
Introduction… … … … … … … … … … … … … … … … … … ...
Review of Related Literature… … … … … …
Nursing Health History
Biographic Data
Admission Data
History of Present Illness
Past Health History
Childhood Illness
Childhood Immunization
History of Hospitalization
Medical History
Surgical History
Accidents and Injuries
Obstetrical History
Sexual History
Allergies
Family Health History
Personal Habits
Diet
Sleep/Rest pattern
Elimination Pattern
Social Data
Family Relationship/Friendship
Educational History
Occupational History
Economic Status
Patterns of Health Care
Review of System
Integumentary System
Respiratory System
Cardiovascular System
Genitourinary System
Gastrointestinal System
Reproductive System
Musculoskeletal System
Endocrine System
Circulatory System
Neurologic System
Physical Examination
Skin
Hair
Nails
Skull and Face
Eyes
Ears
Nose
Mouth and Throat
Clinical Laboratory
Hematology
Urinalysis
Anatomy and Physiology
Ovary
Fallopian Tube
Uterus
Vagina
Vulva
Breast and Mammary Gland
Reproductive Cycle
Oogenesis and Ovulation
Fertilization
Menstruation
Pregnancy
Lactation
Pathophysiology
Drug Study
Nursing Care Plan
Discharge Plan
Definition of Terms
References
DEDICATION
You can also have preeclampsia and not have any symptoms. That's
why it's so important to see your doctor for regular blood
pressure checks and urine tests.
Preeclampsia can prevent the placenta from receiving enough blood,
which can cause your baby to be born very small. It is also one of
the leading causes of premature births, and the complications that
can follow, including learning disabilities, epilepsy, cerebral
palsy, hearing and vision problems.
In moms-to-be, preeclampsia can cause rare but serious
complications that include:
Stroke
Seizure
Water in the lungs
Heart failure
Reversible blindness
Bleeding from the liver
Bleeding after you've given birth
Your doctor also may recommend that you stay in the hospital for
closer monitoring. In the hospital you may be given:
Biographic Data:
Hospital : Caraga Regional Hospital
Case No. : 155073
Ward : OB Ward
Name of Patient : Patient C
Age : 17 yrs old
Sex : Female
Civil Status : Single
Address : Daywan, Claver Surigao del
Norte
Occupation : High School Graduate
Date of Birth : November 12, 2016
Religion : Catholic
Height : 4"5
Weight : 52.6 kg
Fathers name : Mr. Robert Canda
Mother’s name : Mrs. Tessie Canda
Admission Data:
Mode of Transmission : Ambulation
Date and Time of Admission : November 12, 2015
11:21 AM
Vital Signs upon admission
Heart Rate : 66 bpm
Respiratory Rate : 23cpm
Blood Pressure : 160/110 mmHg
Body Temperature : 37 °C
II – Childhood Immunization
Patient was already immunized with DPT and OPV but was
not able to recall the dates when it was given. Her parents told
her that she had received her vaccines.
HISTORY OF HOSPITALIZATION
III- Medical History
IV – Surgical History
VII-Sexual History
VIII-Allergies
X- Personal Habits
XI – Diet
XIII-Elimination Pattern
Before hospitalization, patient usually defecates once a
day and urinates 4 times a day with no difficulties eliminating.
Stool is soft to touch and color brown as stated by the patient
and urine is cloudy and yellowish color.
SOCIAL DATA
XIV-Family Relationship/Friendship
REVIEW OF SYSTEM
INTEGUMENTARY SYSTEM
No history of skin infection as claimed
With history of dandruff
Brown skin complexion
Patient has intact skin with good skin turgor
Slightly swelling on her lower extremities and part of her
faces
Skin is warm to touch
Patient has no lesion
RESPIRATORY SYSTEM
No complaints of weaknesses on simple activity.
No appearance of difficulty in breathing
Has no history of pneumonia, asthma or emphysema.
No abnormality sounds upon auscultation
CARDIOVASCULAR SYSTEM
GENITOURINARY SYSTEM
Urinates 4 times a day as claimed by the patient.
No pain upon voiding.
Color of the urine yellow and the transparency of it is
cloudy as a result of urinalysis
No history of UTI.
GASTROINTESTINAL SYSTEM
With no complaints of constipation as stated by the
patient.
Patient has no abnormality in defecating
No abnormal bowel sounds, as claimed
Patient With no history of hemorrhoids and rectal bleeding.
REPRODUCTIVE SYSTEM
Satisfaction to sex life was experienced as claimed by
her.
With no history of abortion
MUSCULOSKELETAL SYSTEM
With complaints of weakness
With complaints of fatigue
With complaints of lower back pain
No history of fracture or any injury
ENDOCRINE SYSTEM
Patient has no history of thyroid trouble
CIRCULATORY SYSTEM
With no history of painful tonsils during patients early
age
With no history of having nodules on the neck
No history of bleeding problems
No history of hypertension
NEUROLOGIC SYSTEM
Patient is conscious to time, place and people
Has no history of seizure
PHYSICAL EXAMINATION
Skin
Inspection
Has a brown complexion
Has closed intact skin
No lesions
Slightly swelling in the lower extremities and past of her
face
Palpation
Skin is warm to touch
Has a good skin turgor
Hair
Inspection
Color of hair is black
No infestation of parasites
With dandruff
Has a long and straight hair
Nails
Inspection
Pink nail bed
Nails are completely distributed in her fingers
Patient has no cracked or nail injuries
Eyes
Inspection
Both eyes were symmetrical
Eyelashes equally distributed, curled slightly outward
Pupils are equally rounded
The pupil was brown in color with white conjunctiva
Blinking reflex was normal and functional
Peripheral reflexes are normal and functional
Vision acuity is in normal range and can read the Snellen
chart
Patient is not using any glasses and contact lenses as
visional aid
Ears
Inspection
Auricles same color as facial skin, symmetrical and are
aligned with outer canthus of eye
Pinna recoils after it is folded
No cerumen
Able to hear spoken words clearly
No discharges
Nose
Inspection
Has the same color as facial skin
Not tender, no lesion
No discharges
Straight and symmetrical
Able to identify odors like alcohol, cologne and coffee
HEMATOLOGY SECTION
During labor
HEART:
The heart is a muscular organ found in all vertebrates that is
responsible for pumping blood throughout the blood vessels by
repeated, rhythmic contractions.
The heart is enclosed in a double-walled sac called the
pericardium. The superficial part of this sac is called the
fibrous pericardium. This sac protects the heart, anchors its
surrounding structures, and prevents overfilling of the heart
with blood. It is located anterior to the vertebral column and
posterior to the sternum. The size of the heart is about the
size of a fist and has a mass of between 250 grams and 350
grams. The heart is composed of three layers, all of which are
rich with blood vessels. The superficial layer, called the
visceral layer, the middle layer, called the myocardium, and the
third layer which is called the endocardium. The heart has four
chambers, two superior atria and two inferior ventricles. The
atria are the receiving chambers and the ventricles are the
discharging chambers. The pathway of blood through the heart
consists of a pulmonary circuit and a systemic circuit. Blood
flows through the heart in one direction, from the atrias to the
ventricles, and out of the great arteries, or the aorta for
example. This is done by four valves which are the tricuspid
atrioventicular valve, the mitral atrioventicular valve, the
aortic semilunar valve, and the pulmonary semilunar valve.
Systemic circulation is the portion of the cardiovascular system
which carries oxygenated blood away from the heart, to the body,
and returns deoxygenated blood back to the heart. The term is
contrasted with pulmonary circulation.
Functions
Nutrition
Pathophysiology
of Preeclampsia
Predisposing Factor: Precipitating Factor:
Vasospasm
Kidney effect
Interstitial effect
Vascular effect
Decreased glomeruli filtration rate
and increased permeability of
glomeruli membranes.
Vasoconstriction
Diffusion of fluid from
blood stream into
Increased blood scrum urea, nitrogen,
interstitial tissue
uric, acid, and creatinine
Poor organ perfusion
PRE-ECLAMPSIA
Drug Study
Timing: 3x a day
Classification: Antibiotic
Adverse effect:
Contraindication:
Classification: NSAID
Adverse effect:
Nursing consideration:
Dosage: None
Timing: Once a day
Indication:
Mechanism of Actions:
Adverse effect:
Contraindication:
Nursing consideration:
Assessment:
Subjective Cues:
Objective Cues:
Nursing Diagnosis:
Interventions:
- Assess the patients pain (location, severity of pain,
characteristics, onset and duration, frequency and
precipitating factors)
- Provide/ teach patient in pin management, such as listening
to music or other entertainment media.
-
Evaluation:
- After 3 hrs of nursing interventions the patient will be
relieved from pain and discomfort.
NURSING CARE PLAN 2
Assessment:
Subjective Cues:
“Satisfy ako nagpasuso sa ako baby.” As verbalized by the
patient.
Objective Cues:
- The patient is able to do right position during
breastfeeding.
- The baby is able to suck/swallow the nipple correctly.
- The patient talks to her baby during breastfeeding.
Nursing Diagnosis
Interventions:
- Assess the patients knowledge and previous experience with
breastfeeding.
- Teach the patient about the benefits of breastfeeding.
- Demonstrate how to support and position the infant.
- Encourage the patient skin to skin contact.
- Discuss/demonstrate breastfeeding aids.
- Instruct SO to encourage patient to breastfeed infant.
Evaluation:
Assessment:
Objective Cues:
- Patient’s age is 17 years old
- High school undergraduate
- Patient’s lacks interest to express and convey role as a
mother.
Nursing Diagnosis:
Independent:
Evaluation:
Assessment:
Objective Cues:
- Vaginal laceration
- Postpartum for 2 days
- Meconium stained uterus
Nursing Diagnosis:
Interventions:
Collaborative:
- Administer 500mg cefuroxime capsules 3x a day
- Plain NSS 1000ml.
IVF SHEET
VITAL SIGNS
http://www.mdedge.com/clinicianreviews/article/79478/cardiology/
pregnancy-induced-hypertension
https://www.scribd.com/doc/66170616/Pregnancy-Induced-
Hypertension
http://www.webmd.com/baby/guide/preeclampsia-eclampsia#1