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Our Lady of Fatima University College of Nursing Regalado, Quezon City

A Case Study on Pregnancy-Induced Hypertension

In Partial Fulfillment of the Requirements in Nursing Care Management Related Learning Experience

Presented by: BSN 2A1-2 Group 10

Espellogo, Leizel Y. Falle, Mery Ann M. Gianchand, Olivia E. Hinanay, Ely John Maglaoy, Manuel David B. Manuel, Janine M. Mateo, Donna Marie

First Semester S.Y 2011-2012

I. Introduction

Hypertensive disorders of pregnancy also known as Pregnancy Induced Hypertension are high blood pressure disorders of pregnancy which is one of the major problem for mother in pregnancy.PIH is common in pregnant teens and in women over age 40 but it also develops during the second half of the pregnancy and usually after the 20th week of gestation.PIH is usually present to those person with a previous history of PIH, chronic hypertension, lupus, alcohol, drug or tobacco abuse, presence of diabetes, underweight or overweight, kidney disease and expected twins or triplets. The warning signs of PIH those people are rapid weight gain, 4-5 lbs in a single week, a rise in blood pressure, protein in urine, severe headaches, blurry visions, severe pain over the stomach under the ribs of the mother who have PIH and decrease in amount of urine. PIH can prevent prematurity and death of the baby through the following closely by the medical professional and attending pre-natal checkup. PIH can cause low birth weight of the baby.

Therefore, it is necessary to all health worker engaged on themselves all about clinical knowledge and skills and to develop their values to be able to become an efficient and effective competent individual when it comes health assessment in performing their duties and responsibilities when it comes to health assessments.

II. Objectives

General: This study aims to improve our skills, knowledge and attitude in performing our duties and responsibilities to give an efficient and effective outcome especially to the health of the patients.

Specific: 1. To identify factors if having pregnancy induced hypertension.

2. To develop a teaching program that will educate patients specially those who are susceptible of pregnancy induced hypertension.

3. To understand the disease process, its etiology, signs and symptoms, pathophysiology and diagnostic procedure.

4. To promote awareness to individual by imparting knowledge so they could learn and understand more about pregnancy induced hypertension.

5. To discuss and describe interventions for health promotion, prevention and treatment of patient pregnancy induced hypertension.

III. Patients Profile A. Biographical Data

1. Name: 2. Address: 3. Age: 4. Birthdate: 5. Sex: 6. Race: 7. Marital status: 8. Occupation: 9. Religion:

Mrs. R.E.R. Sto. Nino 1 Sapang Palay, SJDM 30 June 19,1981 Female Filipino Married Housewife Catholic

10. Health Care financing and usual source of Medical Care: Supported by the patients parents since the patient and his husband doesnt have source of income

A. Working Diagnosis Postpartum Hypertension (pre-eclampsia)

B. Chief Complaint and Reason for Visit: Hypertension

C. History of Present Illness: Our patient had 3 pregnancies; all children were born at right gestational age. She had no history of abortion and multiple births. All children are living. According to the patient she has been experiencing intrapartal and PIH every time she gets pregnant. She got complete pre-natal check-ups from the health center. Her blood pressure started to get elevated on the 3rd trimesters of each pregnancy and continues even after she gave birth. After she gave birth to her youngest son at home, the attending midwife decided to bring her to the hospital for referral since her blood pressure went up to 200/140 mmHg. This was her first time to be admitted to the hospital due to postpartum hypertension.

D. Past History: Mrs. R.E.R. already gave birth to 3 boys. Her first child was born April 23, 2003 and the next child was born March 14, 2008 and just on September 25, 2011 she gave birth to another baby boy. All children were born full term. She gave birth to her children at home by normal delivery and was attended by a midwife.

E. Family History of Illness: The patient has a family history of hypertension. According to her, both of her parents have hypertension.

IV. Physical Assessment Assessment Body Build, Height & Weight Posture And Gait Body And Breath Odor Signs Of Distress Attitude Affect Or Mood Normal Findings Proportionate Varies With Lifestyle Stands normally Actual Findings Proportionate Varies With Lifestyle Stands normally Interpretation Proportionate body there is no evidence of physical problems Relaxed, erect posture; coordinated movement Proper hygiene maintenance Because of lack of sleep, distress noted Thinks normally, proper to the situation She acts and think normally appropriate to the situation Can speak normally, with normal voice tone

No Body Or Breath No Body Or Breath Odor Odor No Distress Noted distress noted Cooperative Appropriate To The Situation Understandable, Moderate Pace, Thought Association Logical Sequence Make Sense, Has Sense Of Reality Cooperative Appropriate To The Situation Understandable, Moderate Pace, Thought Association Logical Sequence Make Sense, Has Sense Of Reality

Quantity, Quality And Organization Of Speech Relevance And Association Thought Exhibits

Talking with sense means she thinking normally

Assessment Uniformity Of Skin Color

Normal Findings Uniformity Except In Areas Expose To The Sun

Skin Actual Findings Uniformity Except In Areas Expose To The Sun

Edema

No Presence Of Edema Freckles, some birthmarks, some flat and raised nevi;no abraisions or other lesions Moisture In Skin Folds & Axillae Uniform, Within Normal Range Skin Springs Back To Previous State When Pinched

Presence of edema on feet 1+ Freckles,some birthmarks,some flat and raised nevi;no abraisions or other lesions Moisture In Skin Folds & Axillae Uniform, Within Normal Range Skin Springs Back To Previous State When Pinched, except the part with edema

Skin Lesion

Interpretation Uniformity of skin, except areas expose to light and some areas of lighter pigmentation(conjunctivas , palms, lips, nail beds) Swollen, shiny and taut and tends to blanch the skin color No lesion noted in the body

Skin Moisture

Skin Temperature Skin Turgor

Some body parts that having sebaceous glands are moisture Normal temperature uniformity Skin stays pinched or tented or moves back slowly

Assessment Head

Normal Findings Rounded And Symmetrical, Smooth Skull Contour, No Nodules

Skull and Face Actual findings Rounded And Symmetrical, Smooth Skull Contour, No Nodules

Interpretation Normal, no signs of any deformities and signs of skull contour and nodules

Eyebrows

Eyelids

Eyelashes

Conjunctiva

Eyes and Vision Evenly Distributed, Evenly Distributed, Symmetrical, Skin Symmetrical, Skin Intact Intact Skin Intact, No Skin Intact, No Discharges, No Discharges, No Discoloration, Discoloration, Symmetrical Symmetrical Equally Equally Distributed, Distributed, Slightly Curved Slightly Curved Outward Outward Shiny, Smooth Pale conjunctiva

Properly distributed, equal

Can blink normally

Turned outward, equally distributed, muscle normally contract Pale, possible anemia

Lacrimal Gland Cornea

Pupils Eyes(Visual Acuity)

,Sometimes Appear Red Or Pink No Edema Or Tearing Transparent, Shiny, Smooth, Blinks When Cornea Is Touched Black Color,smooth border,PERRLA Can see without using eyeglasses

No Edema Or Tearing Transparent, Shiny, Smooth, Blinks When Cornea Is Touched Black Color, smooth border,PERRLA Cant see without eyeglasses

Normal no evidence of any swelling or tenderness Corneal sensitivity test active,trigeminal nerve is intact,cornea clarity and texture normal. Pupils are equal,constrict to light dilate in the dark Nearsightedness, can see only when objects are near

Auricles

Response To Normal Voice Tone

Ears and Hearing Color Is Uniform, Color Is Uniform, Symmetric, Mobile, Symmetric, Mobile, Firm pinna Recoils Firm pinna Recoils When Folded When Folded Normal Voice Tone Cannot hear Normal Audible Voice Tone

Color same as facial skin,auricle aligned with outer canthus of the eye. Abnormal cannot hear Normal voice, normal voice tones

Nares

Lining Of Nose

Nose and Sinuses Symmetric, Symmetric, Straight, Straight, No No Discharges, Non Discharges, Non Swelling, Uniform Swelling, Uniform Color, Not Tender Color, Not Tender Nasal Septum In Nasal Septum In Midline Midline Mouth Pale lips and buccal mucosa Complete

No presence of lesions,air moves freely as the client breaths

Normal and in midline

Lips And Buccal Mucosa Teeth And Gums

Pink, Soft, Symmetrical Complete

Tongue

In Midline, Freely Movable, Pink

In Midline, Freely Movable, Pink

Palates And Uvula, Tonsils

Light Pink, No Discharges, Present Gag Reflex

Light Pink, No Discharges, Present Gag Reflex

Abnormal, possible anemia No tooth decay,smooth shiny tooth enamel,no dentures In Central position,moist,slightly rough ;thin whitish coating,normal,can move freely No discoloration, palates are lighter pink hard palate

Shape And Symmetry Spinal Deformities Inspect Neck Muscles

Neck and Musculoskeletal System Symmetrical Symmetrical Vertically Aligned Symmetrical With Head Centered Vertically Aligned Symmetrical With Head Centered

Positioned in midline Normal, no deformities No swelling or masses,coordinated,smoot h movements with no discomfort No discomfort, can hyper extends, laterally flexes and rotates

Observe Head Movement

Muscle

Bones

Coordinated, Smooth, Movement With No Discomfort, Equal Strength Size Is Symmetrical, No Contracture, Normally Firm No Deformities, No Swelling Or Tenderness No Swelling, No Tenderness Varies To Some Degrees

Coordinated, Smooth, Movement With No Discomfort, Equal Strength Size Is Symmetrical, No Contracture, Normally Firm No Deformities, No Swelling Or Tenderness No Swelling, No Tenderness Limited range of motionin one or more joints

Equal strength, symmetrical, normal

Normal, can move freely, no swelling, deformities or tenderness Normal, no signs of swelling in area, no tenderness Can stand and walk, but limited range of motions.

Joints

Range Of Motion

V. Activities of Daily Living

Functional Health Pattern Health Perception and Health Management

Before her present condition Complies easily with health care providers suggestion. Practices health promotion activities such as healthy diet and breastfeeding Visits the health center for check-up when sick.

During her present Interpretation condition Same perception about The patient has a health good health perception and Complies with practices proper medications health management

Follows the nurses or

doctors suggestion Does not have traditional health beliefs and Eats 3 times daily. The usual food intake would be composed of fish and vegetables, seldom eats meat Drinks 5 glasses of water and 2 cups of coffee a day Takes vitamins as a supplement Skin color was fair, height proportional to body weight

Nutritional and Metabolic

Same amount and quality of food is taken

Patients diet had no change so it cant be directly inferred that skin pallor was due to diet.

Coffee was eliminated

Discontinued taking vitamins Pale color of skin, height still proportional to body weight Same bowel movement frequency

Elimination

Moves bowel once a day without difficulty

Soft firm stool Difficulty moving Voids fair amount of urine bowels although stool without difficulty in normal quality is soft and firm frequency Clear, yellow urine More frequency in voiding urine in the lesser amount and same quality No exercise done due to confinement Leisure time spent by chatting with husband

Bowel movement was affected because patient cant exert enough effort to expel stool.

Activity Exercise

Considers doing household chores as an exercise Leisure time spent by chatting with friends and playing with kids

Exercise was eliminated since she cannot do household chores while in the hospital and she didnt replace it by another form of exercise.

Sleep-Rest

Has 6 - 8 hours of sleep everyday Deep, uninterrupted sleep Gets enough energy from sleep Doesnt need any sleep aids

Has maximum of 3 hours of interrupted sleep Takes nap in the afternoon to compensate lost sleeping hours Asks to repeat the questions during the interview Eyeglasses left at home Had worried about her childs nutrition since the newborn was left at home but now feels better because the newborn is already with her

Inadequate sleep due to noisy environment,

CognitivePerceptual

Normal hearing acuity and does not use hearing aid

Comprehension has changed because patient cant hear clearly.

Uses eyeglasses Able to comprehend easily Feels good about herself Has ability to do normal activities without help Doesnt have anything that causes anger, anxiety and depression

Self-Perception and Self-Concept Pattern

Anxiety is no longer an issue since her baby is already with her.

VI. Development Tasks Generativity vs. Stagnation

At the age of 30, the significant task of the patient is to perpetuate culture and transmit values of culture through the family and working to establish a stable environment. In her age, success is achieved by contributing to the world by being active in their home and community or society. Mrs. R.E.R. is a full time housewife since she got married so she only had continued to build her life focusing on her family. Although she shows self fulfillment in terms of being a mother and wife, she manifested the feeling of lack of accomplishment because she mentioned that she also wants to play a different role in the society by having a career or job someday.

VII. Laboratory/Diagnostic Findings Date September 25, 2011 Procedure Hemoglobin Norms 115-155 Result 95 Analysis Due to blood loss which causes decreased RBC resulting to low Hgb Due to blood loss which causes decreased RBC resulting to low Hgb Urinary tract infection No viral or chronic bacterial infection Interpretation Decreased

Hematocrit

0.40-0.48

0.30

Decreased

WBC Count Lymphocytes

5.0-10.0 0.2-0.4

12.9 0.25

Increased Normal

Gabriel J. Cruz , MD, DPSP PATHOLOGIST

ROUTINE URINALYSIS Urine Color Transparency Reaction Result Amber Turbid Acidic Analysis Normal urine concentration Bacterial Infection Due to the amount of sodium and excess acid retained by the body Normal urine concentration Hypertension affects filtration that can cause excessive protein in urine No diabetes No bleeding in urinary system Bacterial infection in urinary tract
Inflammation within urinary tract

September 25, 2011 Interpretation Normal Abnormal Abnormal

Specific Gravity Protein

1.02 ++++

Normal Abnormal

Sugar RBC Pus Cells Epithelial Cells Bacteria Mucus Threads Amorphous Urates

Negative 3-5/HPF 8-10/HPF + + + +

Normal Normal Abnormal Abnormal Abnormal Abnormal Abnormal

Infection on urinary tract


Inflammation within urinary tract

Uric acid crystals

Gabriel J. Cruz , MD, DPSP PATHOLOGIST

VIII. Anatomy and Physiology (Affected Organ)

HEART The heart is responsible for maintaining adequate circulation of oxygenated blood around the vascular network of the body. It is a four-chamber pump, with right side receiving deoxygenated blood from the body at low pressure and pumping it to the lungs. And at the left side receiving oxygenated blood form the lungs and pumping I at the high pressure around the body. The myocardium is a specialized form of muscle, consisting of individual cells joined by electrical connections. The contraction of each cell is produced by a rise in intracellular leading to spontaneous depolarization, and as each cell electrically connected to its neighbor, contraction of one cell leads to wave of depolarization and contraction across the myocardium. This depolarization and contraction of the heart is controlled by a specialized group of cells localized in the sino-atrial node in the right atrium pacemaker cells.

KIDNEY The kidney is the responsible for the volume and concentration of fluids in the body by producing urine. Urine is produce in a process called glomerular filtration, which remove as the waste products, minerals and water from the blood. The kidney maintains the volume of the fluid in the body and also the concentration of urine by filtering the waste product and reabsorbing useful substances and water from the blood. The kidney also performs detoxification of harmful substances increase absorption of calcium by producing calcitrol (form of vitamin D) and also secretes rennin (hormone that regulates blood pressure and electrolyte.)

IX. Pathophysiology (Flowchart)

(Predisposing)

(Precipitating)

Age: 30

Lifestyle: drinks occasionally Stress (Financial needs of the family)

Gender: F Eating habits Race: Filipino

Family History: both parents have hypertension.

VASOSPASM

VASCULAR EFFECT

KIDNEY

INTERSTITIAL EFFECT

VASOCONSTRICTION

KIDNEY EFFECT

EDEMA

DECREASE URINE INCREASE OF BP (160/120) OUTPUT AND PROTENURIA (150ml)

Who is at risk for Pregnancy induced hypertension? -PIH is more common during a womans first pregnancy and in women whose mothers or sisters had PIH. The risk of PIH is higher in women carrying multiple babies, in teenage mothers and in women older than 40 years of age. Other women at risk include those who had high blood pressure or kidney disease before they became pregnant.

How does vasospasm affects the Heart? Vasospasm happens by increased cardiac output that injures the endothelial cells of the arteries. The blood vessels during pregnancy are resistant to the effects of pressors substances such as angiotensin and norepinephrine, so blood pressure remain normal during pregnancy.

How does vasospasm affects the Kidney? Vasospasm in the kidney increases blood flow resistance. Degenerative changes develop in the kidney glomeruli because of back-pressure. This leads to increased permeability of the glomerular membrane, allowing the serum proteins albumin and globulin to escape into the urine the degenerative changes also results in decreased glomerular filtration, so there is a decrease urine output and clearance of creatinine.

X. Course in the Ward

Mrs. R.E.R. a 30 year old postpartum who gave birth to her baby at home attended by a midwife was suspected to have a postpartum hypertension was admitted to the Ospital ng Lungsod ng San Jose Del Monte.

DAY 1 (Sept. 25 2011, 7pm-7am) As the client admitted by Dr. Roberto Enriquez to the OB ward, she was given a liter of intravenous fluid of D5LR solution at 20 gtts/min. She was inserted a Foley catheter connected to the urine bag and Vital signs were taken. She was instructed for NPO. And as of 4pm she was given an initial dose of MgSO4, 4grams infused 250ml 5% of dextrose solution, her blood pressure was monitored 200/100. At 5pm she had given MgSO4 5grams diluted in 10ml of sodium chloride in each buttock deep intramuscular and she was asked by the nurse if she didnt experience abdominal pain, nausea or vomiting before the medication was administered. After that her Blood pressure was 170/100, and after 30 minutes she had given Hydralizine 5ml every 6 hours intravenous, it was administered slowly. And as of 2am she was given Amlodipine 5mg twice a day as ordered by the physician.

DAY 2 (Sept. 26 2011, 7am-7pm) Her Blood pressure was 140/100 and had continued MgSO4. As ordered by the physician the dose of Amlodipine increased to 10mg twice a day. And once she completed the MgSO4 , the nurse may remove the inserted Foley catheter. Her hemoglobin count was 95, and urinalysis result was +4 as seen and examined by Dra. Garza who ordered to discontinue antibiotics and to start Cephalexine 500mg/cap every 6 hours in 7 days and FeSO4 twice a day . and the patient was told she may go home if she completed MgSO4 and was controlled her Blood pressure with Amlodipine . She was also instructed to take Diazepam 5g twice a day in 1 week continuously even shes at home.

DAY 3 (Sept. 27 2011, 7pm-7am) Her blood pressure was150/100 and was referred to Dra. Comia, then her oral medications were given and then were referred to OB.

DAY 4 (Sept. 28 2011, 7am-7pm) She walked slowly with an intravenous fluid and was referred to MS-OB and vital signs were taken. Her medications were given; her Blood pressure was monitored and was referred to Dr. Nieto.

DAY 5(Sept. 29 2011, 7pm-7am) She was taken a low sodium low fat diet and still taking her medication, vital signs were taken. Her Blood was monitored. Clonidine 5g was given sublingual as instructed by the physician. Then her blood pressure became 150/90 after an hour. She was referred to Dr. Gonzales with orders in and carried out.

DAY 6 (Sept. 30 2011, 7am-7pm) Oral medications were given, uterus was firm and contracted, her vital signs were taken and blood pressure was monitored 150/100. She was advised to breastfeed.

XI. Nursing Care Plans ASSESSMENT Subjective: None Objective: Pitting Edema:3 seconds Lower extremities: Bipedal Edema UO:150 cc per hour VS: BP: 160/120 BT: 36.4 PR: 104 RR: 18 Long Term Goal: After 2 days of nursing intervention, the patient will have stabilized fluid volume as evidenced by balanced input/output, vital signs within clients normal limits and free of signs of edema DIAGNOSIS Excessive fluid volume related to increased fluid retention as manifested by the presence of edema in the feet. PLANNING Short Term Goal: After 8 hours of nursing intervention the patients edema will be decreased as evidenced by pitting edema (12 seconds) INTERVENTION Independent >Monitor urine output RATIONALE >Kidney function is directly correlated to circulatory fluid volume, so that if fluid is trapped in third spaces, output decreases and specific gravity increases. >Changed parameters may indicate altered fluid or electrolyte status. >Helps to increase urine output thus decreases fluid retention Long Term Goal: After 2 days of nursing intervention, the patient had stabilized fluid volume as evidenced by balanced input/output, vital signs within clients normal limits and free of signs of edema EVALUATION Short Term Goal: After 8 hours of nursing intervention the patients edema was decreased as evidenced by pitting edema (1-2 seconds

>Monitor BP

>Encourage the patient to eat fruits and vegetables that has high diuretic property >Elevate edematous extremities, change in position frequently >Discuss the importance of fluid restrictions Dependent: >Insert indwelling urinary catheter as per doctors order

>Helps to reduce tissue pressure and risk of skin breakdown. to increase venous blood return >Helps the client to understand the relationship of food restriction to her condition >Provides accurate hourly totals of urine output, and monitors client for developing renal problems or oliguria.

>Restrict sodium and fluid >Restricting the sodium in the diet will intake as indicated favor the renal excretion of excess fluid. Fluid restriction may decrease intravascular volume and myocardial workload

ASSESSMENT Subjective: Di ko alam kung bakit nakaconfine pa ako, mataas nga ang bp ko pero feeling ko okay naman ako dahil wala naman akong masakit na nararamdaman as verbalized by the client. Objective: >Observed confusion when patient was asked about her condition >Lack of information source ( no television and radio at home)

DIAGNOSIS Knowledge regarding condition, prognosis Related to lack of exposure/unfamili arity with information as manifested by statement of misconceptions

PLANNING Short Term Goal: After 4 hours of nursing intervention, client will identify signs/symptoms requiring medical evaluation.

INTERVENTION Independent: >Assess clients knowledge of the disease process.

>Provide information about the disease and the complications that it can cause. Long Term Goal: After 1 day of nursing intervention, the client will verbalize understanding of disease and appropriate treatment plan.

>Provide information about signs/symptoms, and instruct client when to notify healthcare provider.

EVALUATION Short Term Goal: >Establishes data base After 4 hours of and provides information nursing about areas in which intervention, client learning is needed. was able to identify signs/symptoms requiring medical >Makes the client know evaluation. the importance of treatment and management of her condition. Long Term Goal: After 1 day of >Helps ensure that client nursing intervention, seeks timely treatment the verbalized indicating worsening of understanding of condition or additional disease process and complications. appropriate treatment plan.

RATIONALE

>Keep client informed >Fears and anxieties can of health status, results be compounded when of tests. client does not have adequate information about the state of the disease process.

ASSESSMENT Subjective: > "Hindi ako makatulog ng maayos, halos tatlong oras lang na deretsong tulog sa isang araw tapos putolputol na". As verbalized by the client. Objective: >Pale conjunctiva, lips, palm and skin >Frequent yawning >Dark circles under the eyes VS: BP: 160/120 BT: 36.4 PR: 104 RR: 18

DIAGNOSIS >Disturbed sleep pattern related to uncomfortable environment as manifested by pale conjunctiva, lips, palm and skin frequent yawning and dark circles under the eyes.

PLANNING Short Term Goal: >After 4 hours of nursing intervention the client will demonstrate relaxation skills and other methods to promote sleep.

INTERVENTION Independent: >advise to establish regular bedtime and wakeup time and a short daytime nap. >Advise to take warm bath before bedtime.

RATIONALE >To promote good sleeping pattern

EVALUATION Short Term Goal: >After 4 hours of nursing intervention the client was able to demonstrate relaxation skills and other methods to promote sleep.

>To promote feeling of freshness before sleeping. >To promote comfort while sleeping.

>Advise to wear loosefitting shirts. Long Term Goal: >After 1 day of nursing intervention the client will be able to sleep at least 8 hours a day.

>Advise to drink 1 glass of warm milk before sleeping.

>Milk contains tryptophan, a precursor of serotonin, which is thought to induce and maintain sleep. >To avoid interruption in the middle of sleep. >To reduce noise destruction for the comfortable sleep of the patients.

Long Term Goal: >After 1 day of nursing intervention the client was able to sleep at least 8 hours a day.

>encourage voiding before going to sleep. Collaborate: >Advise the roommates to lower their voices and prevent noise at bedtime.

XII. Drug Study Name of Drug Classification Mechanism of Actions Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; inhibits transmembrane calcium flow, which result in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of myocardial contractility , and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption, and in patients with vasospastic (Prinzmetals) angina,increased delivery of oxygen to cardiac cells. Indication Contraindication Contraindicate d with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree), and lactation. Use cautiously with heart failure, pregnancy. Adverse Effect CNS: Dizziness,li ghtheadedness, headache, asthenia, fatigue,letha rgy CV: Peripheral edema, arrhythmias Dermatologi c: Flushing, rash GI: Nausea, abdominal discomfort Drug to Drug Interaction Nursing Consideration y Monitor BP very carefully if patient is also on nitrates. Monitor cardiac rhythm regularly during stabilization of dosage and periodically during longterm therapy. Administer drug without regard to meals.

Amlodipine Antianginal Antihypertens ive Calcium Channel Blocker

Angina pectoris due y to coronary artery spasm (Prinzmetals variant angina) Chronic stable angina, alone or in combination with other drugs To reduce the risk of hospitalization due to angina and y to reduce the need for coronary revascularization procedures in patients with angiographically documented CAD without heart failure or ejection fraction less than 40% Essential hypertension, alone or in combination with other antihypertensives

Name of Drug Cephalexin

Classification Antibiotic

Mechanism of Actions y

Indication

Contraindication Contraindicat ed with allergy to cephalosporin s or penicillins. Use cautiously with renal failure, lactation, pregnancy. y y

Adverse Effect CNS: Headache, dizziness, lethargy, paresthesia GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembrano us colitis, hepatotoxicity GI: Nephrotoxicity Hematologic: Bone marrow depression Hypersensitivity: Ranging from rash to fever to anaphylaxis; serum sickness reaction Other: Super infections

Drug to Drug Interaction y

Nursing Consideration Arrange for culture and sensitivity tests of infection before and during therapy if infection does not resolve. Give drug with meals; arrange for small, frequent meals if GI complication s occur. Refrigerate suspension, discard after 14 days.

Bactericidal: Inhibits synthesis Cephalosporin of bacterial cell (first wall, causing cell generation) death.

Respiratory tract y infections caused by Streptococcus pneumonia, group A beta hemolytic streptococci. Skin and skin structure infections y caused by staphylococcus, streptococcus Otitis media caused by S. pneumonia, Haemophilusinflue nzae, streptococcus, staphylococcus, Moraxella catarrhalis Bone infections caused by staphylococcus, Proteus mirabilis GU infections caused by Escherichia coli, P. mirabilis, Klebsiella

Increased y nephrotoxici ty with amino glycosides Increased bleeding effects with oral anticoagula nts Disulfiramli y ke reaction may occur if alcohol is taken within 72 hr after cephalexin administrati y on

Name of Drug

Classification

Mechanism of Actions y

Indication

Contra indication Contrain dicated with allergy to cephalos porins or penicilli ns. Use cautious ly with renal failure, lactation , pregnan cy y

Adverse Effect

Drug to Drug Interaction Increased nephrotoxi city with amino glycosides Increased bleeding effects with oral anticoagul ant Risk of disulfiram -like reaction with alcohol; avoid this combinati on during and for 3 days after completio n of therapy y

Nursing Consideration Culture infection site, and arrange for sensitivity test before and during therapy if expected response is not seen. Give oral drug with food to decreased GI upset and enhance absorption. Give oral tablets to children who can swallow tablets; crushing the drug results in a bitter, unpleasant taste. Use solution for children who cannot swallow tablets. Have vitamin K available in case hypoprothrombin emia occurs. Discontinue if hypersensitivity reaction occurs.

Cefuroxime Antibiotic

Bactericidal : Inhibits Cephalosporin synthesis of bacterial cell wall, causing cell death.

Pharyngitis, tonsillitis, y caused by Streptococcus pyogenes Otitis media caused by Stretococcus pneumonia, S.pyogenes, Haemophilus influenza, Moraxella catarrhalis Acute bacterial maxillary y sinusitis caused by S. pneumonia, H. influenza Lower respiratory infections caused by S. pneumonia, Haemophilus parainfluenza, H. influenza UTIs caused by Escherichia coli, Klebsiella pneumonia Uncomplicated gonorrhea (urethral and endocervical) Skin and skin structure infections, including impetigo caused by Streptococcus aureus, S. pyogenes Treatment of early Lyme disease

y y y

CNS: Headache, y dizziness, lethargy, paresthesias GI: Nausea, vomiting, diarrhea, anorexia, y abdominal pain, flatulence, pseudomembranous colitis, hepatotoxicity GU: Nephrotoxicity y Hematologic: Bone marrow depression Hypersensitivity: Ranging from rash to fever to anaphylaxis; serum sickness reaction Local: Pain, abscess at injection site, phlebitis, inflammation at IV site Other: Super infections, disulfiram-like reaction with alcohol

Name of Drug Clonidine

Classification Antihypertensive

Mechanism of Actions y

Indication

Contraindication Contraindicat y ed with hypersensitivi ty to clonidine or any adhesive layer components of the transdermal system. Use y cautiously with severe coronary insufficiency, recent IM, cerebrovascul ar disease; chronic renal y failure; pregnancy, lactation.

Adverse Effect

Drug to Drug Interaction

Nursing Consideration Do not discontinue transdermal therapy prior to surgery; monitor BP carefully during surgery; have other BP controlling drugs readily available. Continue oral clonidine therapy to within 4 hr of surgery then resume as soon as possible thereafter.

Stimulates CNS Central analgesic alpha2adrenergic Sympatholytic receptors, inhibits sympathetic cardioaccele rator and vasoconstric tor centers, and decreases sympathetic out flow from the CNS.

Hypertension, y used alone as part of combination therapy Treatment of severe pain in cancer patients in combination with opiates; epidural more effective with neuropathic y pain (Duralcon) Unable uses: tourette syndrome; migraine, decreases severity and frequency; menopausal flushing, decreases severity and frequency of episodes; chronic methadone detoxification; rapid opiate detoxification (in doses up to 17 mcg/kg/day); alcohol and benzodiazepine withdrawal

CNS: Drowsiness, y sedation, dizziness, headache, fatigue that tend to diminish within 4-6 wks, dreams, nightmares, insomnia, hallucination,delirium, y nervousness, restlessness, anxiety, depression, retinal degeneration CV: Heart failure, orthostatic hypotension, palpitations, tachycardia, bradycardia, Raynauds phenomenon, ECG abnormalities manifested as Wenckebach period or ventricular trigeminy Dermatologic: Rash, angioneurotic edema, hives, urticaria, hair thinning and alopecia, pruritis, dryness, itching or burning of the eyes, pallor y GI: Dry mouth, constipation, anorexia, malaise, nausea, vomiting, parotid pain, paroritis, mild transient abnormalities in LFTs GU: Impotence, sexual dysfunction, nocturia,

Decreased y antihyperte nsive effect with TCAs (imipramin e) Paradoxical hypertensio n with propranolol ; also greater withdrawal hypertensio n when abruptly discontinue y d and patient is taking betaadrenergic blocking agents Additive sedation with CNS depressants , alcohol

treatment; management of hypertensive urgencies (oral clonidine loading is used; initial dose of 0.2 mg then 0.1 mg every hour until a dose of 0.7 mg is reached or until BP is controlled); atrial fibrillation; attention deficit hyperactivity disorder; postherpetic neuralgia, smoking cessation (transdermal)

difficulty in micturition, urinary retention Other: Weight gain, transient hyperglycemia or elevated serum creatine phosphokinase level, gynecomastia, weakness, muscle or joint pain, cramps of the lower limbs, dryness of the nasal mucosa, fever

Name of Drug Ferrous sulfate

Classification Iron preparation

Mechanism of Actions Elevates the y serum iron concentration, and is then converted to y Hgb or trapped in the reticuloendothe y lial cells for storage and eventual conversion to a usable form of iron.

Indication

Contraindication Contraindicate d with allergy to any ingredient; sulfite allergy; hemochromato sis, hemosiderosis, hemolytic anemia. Use cautiously with normal iron balance; peptic ulcer, regional enteritis, ulcerative colitis.

Adverse Effect y CNS: CNS toxicity, acidosis, coma and death with overdose GI: GI upset, anorexia, nausea, vomiting, constipatio n, diarrhea, dark stools, temporary staining of the teeth(liquid preparation s) y

Drug to Drug Interaction Decreased anti-infective response to ciprofloxacin, norfloxacin, ofloxacin; separate doses by at least 2 hr Decreased absorption with antacids, cimetidine Decreased effects of levodopa if taken with iron Increased serum iron levels with chloramphenic ol Decreased absorption of levothyroxine; separate doses by at least 2 hr

Nursing Consideration Confirm that patient does have iron deficiency anemia before treatment. Give drug with meals (avoiding milk, eggs, coffee, and tea) if GI discomfort is severe; slowly increase to build up tolerance. Administer liquid preparations in water or juice to mask the taste and prevent staining of teeth; have the patient drink solution with a straw. Warm patient that stool may be dark or green. Arrange for periodic monitoring of Hct and Hgb levels.

Prevention y and treatment of iron deficiency anemia Dietary supplement for iron Unlabeled use: Supplementa y l use during epoetin therapy to ensure proper hematologic response to epoetin

Name of Drug Hydralazine

Classification Antihypertensive Vasodilator

Mechanism of Actions Acts directly on vascular smooth muscle to cause Vasodilatio n, primarily arteriolar, decreasing peripheral resistance; maintains or increases renal and cerebral blood flow. y

Indication

Contraindication Contraindicate d with hypersensitive ty to hydralazine, tartrazine (in 100-mg tablets marketed as Apresoline); CAD, mitral valvular rheumatic heart disease (implicated in MI). Use cautiously with CVAs; increased in tracranial pressure (druginduced BP decrease increases risk of cerebral ischemia); severe hypertensionwi th uremia; advanced renal damage; slow

Adverse Effect CNS: Headache, peripheral neuritis, dizziness, tremors, psychotic reactions characterized by depression, disorientation, or anxiety CV: Palpitation, tachycardia, angina pectoris, hypotension, paradoxical pressor response, orthostatic hypotension GI: Anorexia, nausea, vomiting, diarrhea, constipation, paralytic ileus GU: Difficult micturition, impotence Hematologic: Blood dyscrasias Hypersensitivity: Rash, urticaria, pruritis; fever, chills, arthralgia,

Drug to Drug Interaction y Increased y pharmacolo gic effects of betaadrenergic blockers and hydralazine when given concomitant y ly; dosage of beta blocker may need adjustment

Nursing Consideration Give oral drug with food to increase bioavailability (drug should be given in a consistent relationship to ingestion of food for consistent response to therapy). Drug may cause a syndrome resembling SLE. Arrange for CBC, lupus erythematosus (LE) cell preparations, and ANA titers before and periodically during prolonged therapy, even in the asymptomatic patient. Discontinue if blood dyscrasias occur. Reevaluate therapy if ANA or LE tests are positive. Arrange for pyridoxine therapy if patient develops symptoms of peripheral neuritis. Monitor patient for

Oral: y Essential hypertens ion alone or in combinat ion with other drugs Parentera l: Severe essential hypertens ion when drug cannot be y given orally or when need to lower BP is urgent Unlabele d uses: Reducing afterload in the treatment of heart failure,

y y

severe aortic insufficie ncy, and after valve replacem ent (doses up to 800 mg tid)

acetylators (higher plasma levels may be achieved; lower dosage may be adequate); lactation, pregnancy,pul monary hypertension.

eosinophilia; rarely, hepatitis, obstructive jaundice Other: Nasal congestion, flushing, edema, muscle cramps, lymphadenopathy, splenomegaly, dyspnea, lupus-like syndrome, possible carcinogenesis, lacrimation, conjunctivitis

orthostatic hypotension, which is most marked in the morning and in hot weather, and with alcohol or exercise

Name of Drug Magnesium Sulfate

Classification

Mechanism of Actions Cofactor of many enzyme systems involved in neurochemical transmission and muscular excitability; prevents or controls seizures by blocking neuromuscular transmission; attracts and retains water in the intestinal lumen and distends the bowel to promote mass movement and relieve constipation. y

Indication

Contraindication

Adverse Effect

Drug to Drug Interaction y Potentiation of neuromuscula r blockade produced by nondepolarizing neuromuscula r relaxants

Nursing Consideration

Antiepileptic Electrolyte Laxative

Acute nephritis (children), to control hypertension IV: Hypomagnese mia, replacement therapy IV or IM: Preeclampsia or eclampsia PO: Shortterm treatment of constipation PO: Evacuation of the colon for rectal and bowel examinations To correct or prevent hypomagnese mia in patients on parenteral nutrition

Contraindicat ed with allergy to magnesium products; heart block, myocardial damage; abdominal pain, nausea, vomiting, or other symptoms of appendicitis; acute surgical abdomen, fecal impaction, intestinal and biliary tract obstruction, hepatitis. Do not give during 2 hr preceding delivery because of risk of magnesium toxicity in the

y y

CNS: Weakness, dizziness, fainting, sweating (PO) CV: Palpitations GI: Excessive bowel activity, perianal irritation (PO) Metabolic: Magnesium intoxication(fl ushing, sweating, hypotension, depressed reflexes, flaccid paralysis, hypothermia, circulatory collapse, cardiac and CNS depressionparenteral); hypocalcemia

Reserve IV use in eclampsia for immediate lifethreatening situations Give IM route by deep IM injection of the undiluted (50%) solution for adults; dilute to a 20% solution for children. Give oral magnesium sulfate as a laxative only as a temporary measure. Arrange for dietary measures (fiber, fluids), exercise, and environmental control to return to normal bowel activity. Do not give oral magnesium sulfate with abdominal pain, nausea, or vomiting. Monitor bowel function; if diarrhea and cramping occur, discontinue oral drug. Maintain uterine

Unlabeled uses: Inhibition of premature labor (parenteral), adjust treatment of exacerbations of acute asthma; treatment torsades de pointes, atypical ventricular arrhythmias

neonate. Use cautiously with renal insufficiency.

with tetany (secondary to treatment of eclampsiaparenteral)

output at a level of 100 ml every 4 hr during parenteral administration.

Name of Drug Methyldopa

Classification

Mechanism of Actions

Indication

Contraindication Contraindicat ed with hypersensitivi ty to methyldopa, active hepatic disease, previous methyldopa therapy associated with liver disorders. Use cautiously with previous liver disease, renal failure, dialysis, bilateral cerebrovascul ar disease, pregnancy, RR lactation.

Adverse Effect CNS: Sedation, headache ,asthenia, weakness (usually early and transient), dizziness, lightheaded symptoms of cerebrovascular insufficiency, paresthesias, parkinsonism, Bells palsy,decreased mental acuity, involuntary choreoathetotic movements, psychic disturbances CV: Bradycardia, prlonged carotid anus hypersensitivity, aggravation of angina pectoris,paradoxical pressor response, pericarditis, myocarditis, orthostatic hypotension, edema Dermatologic: Rash seen as eczema or lichenoid eruption, toxic epidermal necrolysis fever, lupus like syndrome Endocrine: Breast enlargement,

Drug to Drug Interaction y

Nursing Consideration Administer IV slowly over 30-60 min; monitor injection site Add athiazide to drug regimen or increase dosage if methyldopa tolerance occurs

Antihypertensive Mechanism y of action not y Sympatholytic conclusively demonstrated ; probably due to drugs metabolism, which lower arterial BP by y stimulating CNS alpha2adrenergic receptors, which in turn decreases sympathetic outflow from the CNS,

Hypertension y IV methyldopate : Acute hypertensive crisis; not drug of choice because of slow onset of action Unlabeled uses: Hypertension y of pregnancy

Potentiatio y n of the pressor effect of sympathom imetic amines Increased y hypotensio n with levodopa Risk of hypotensio n during surgery with central anesthetic; monitor patient carefully

gynecomastia, lactation, hyperprolactinemia, amenorrhea, galactorrhea, impotence, failure to ejaculate, decreased libido y GI: Nausea, vomiting, distention, constipation, flatus, diarrhea, colitis, dry mouth, sore or black tongue, pancreatitis, sialadenitis, abnormal liver function tests, jaundice, hepatitis, hepatic necrosis. Hematologic: Positive Coombs test, hemolytic anemia, bone marrow depression leucopenia, granulocytopenia, thrombocytopenia, positive tests for antinuclear antibody, lupus like syndrome, and rheumatoid factor

XIII. Discharge Planning MEDICATION EXERCISE/ENVIRONMENT y y y y y y y y y y HEALTH TEACHING y y y y y y Advise patient not to skip the medication that the doctor ordered Enough rest Elevate feet several times a day during the day Use of drugs Catheterization Obtaining labs(CBC,PLATELETS COUNT,LIVER FUNCTION) Encourage patient for sodium restriction Encourage to avoid foods rich in oils and fats Encourage patient to limit her daily activities and exercise Encourage to avoid Salty, high fat diet, instead eat healthy foods. Advise to continue medicine as prescribed Separate utensils for the mother and other things that will be used for the whole family Encourage eat high protein foods, calcium, magnesium, zinc, vitamin c and e Health teachings for symptoms mild and severe preeclampsia Observe carefully for symptoms Give instruction about what symptoms to watch for so she can alert clinician if additional symptoms occur between visits Provide information about how to control the disease Low fats and sodium diet, restriction if possible High in protein, calcium and iron Adequate fluid intake Eat fresh green healthy leafy vegetables and fresh fruits Limit sexual activity Provide spiritual and emotional support

TREATMENT

OPD FOLLOW UP

y y y y y y y

DIET

SPIRITUAL/SEX