Embed Size (px)
Citation preview
I. INTRODUCTION
Pregnancy-induced hypertension is a condition in which vasospasm occurs during
pregnancy. Signs of hypertension, proteinuria, and edema develop.
PIH, a condition separate from chronic hypertension tends to occur most frequently in
primiparas younger than age 20 years or older than 40 years, women who have had five or more
pregnancies, women of color, women with a multiple pregnancy, women with hydramnios and
women with underlying disease such as heart disease, diabetes with vessel or renal involvement
and essential hypertension. The condition may be associated with poor calcium or magnesium
intake.
A woman has passed from mild to Severe Preeclampsia when her blood pressure has
risen to 160mmHg systolic and 110mmHg diastolic or above on at least two occasions 6 hours
apart at bed rest or her diastolic pressure is 30mmHg above the prepregnancy level. Marked
proteinuria, 3+ or 4+ on a random urine sample, or more than 5g in a 24 hours sample, and
extensive edema are also present.
The hypertension, albuminuria and edema of preeclampsia, usually arise 32 weeks into a
first pregnancy, and are often accompanied by headache and disruptions of vision. Preeclampsia
seems to originate from an implantation abnormality that affects placental blood vessels. The
resulting placental ischemia may be severe enough to produce placental infarcts.
Complications of hypertension are the third leading cause of pregnancy-related deaths,
superseded only by hemorrhage and embolism. Preeclampsia is associated with increased risks
of placental abruption, acute renal failure, cerebrovascular and cardiovascular complications,
disseminated intravascular coagulation, and maternal death.
Pre-eclampsia is a medical condition where hypertension arises in pregnancy in association
with significant amounts of protein in the urine. Because pre-eclampsia refers to a set of
symptoms rather than any causative factor, it is established that there are many different causes
for the syndrome. With the elevation of blood pressure, it is the most visible sign of the disease,
it involves generalized damage to the maternal endothelium, kidneys and liver, with the release
of vasopressive factors only secondary to the original damage.
1
Pre-eclampsia may develop from 20 weeks gestation and its progress differs among
patients. And most cases are diagnosed pre-term. Apart from abortion, Caesarean section, or
induction of labor, and therefore delivery of the placenta, there is no known cure. And if no
interventions where made, iIt could lead up to six weeks post-partum
As of 2010, preeclampsia in the Philippines is the 3rd maternal mortality cause. And
according to internet sources, out of 86, 241. 6972 estimated population, there are 46,392
mothers who were or are affected with preeclampsia. And in all over the world, India got the
highest incidence rate which is 572, 945 mothers. While on the other hand, Monaco got the
lowest which is 17 mothers only.
Current trends in preeclampsia and pregnancy induced hypertension is about adding
calcium supplement to the mothers nutrition to prevent preganancy induced hypertension and
preeclampsia. Pregnancy-induced hypertension and preeclampsia are important causes of
maternal and fetal morbidity in the US. Epidemiology. And intervention studies have shown an
inverse relationship between calcium intake and the risk of these complications of pregnancy.
A small meta-analysis has also supported this association. This report, from McMaster
University in Hamilton, Ontario, describes the findings of a new, larger meta-analysis of
previously published randomized trials of calcium supplementation during pregnancy.
Fourteen randomized trials involving 2,459 women were included in the meta-analysis;
most involved calcium supplementation at a dose of 1500-2000 mg/ day. The pooled analysis
showed significant reductions in systolic and diastolic blood pressures, by 5.40 and 3.44 mm
Hg, respectively, in women who received calcium supplemetation. The odds ratio for
preeclampsia in women with calcium supplementation was 0.38 (95% CI 0.22-0.65).
Nonsignificant trends toward reductions in adverse outcomes of pregnancy, including preterm
delivery, caesarean delivery, intrauterine growth retardation, and intrauterine or neonatal death,
were observed in women receiving calcium supplementation.
The results of this meta-analysis support the conclusion that calcium supplementation
during pregnancy leads to important reductions in blood pressure and the risk of preeclampsia.
However, a beneficial effect of calcium on serious morbidity resulting from preeclampsia has
2
not been established. The possibility that calcium supplementation may merely correct mild
preeclampsia, without affecting the risk of more serious complications, cannot be ruled out.
The authors conclude that "the current, limited evidence supports a policy of offering
calcium supplementation to all pregnant women in whom there is a concern about the
development of preeclampsia.
Preeclampsia is usually diagnosed late in pregnancy although it can occur earlier. When it
is diagnosed, the patient has to be very carefully monitored because of the risk of seizures in
the mother or other problems that can affect the baby, often leading to a premature delivery of
the baby. When preeclampsia occurs in a patient, it can progress and become severe enough to
require delivery of the baby, even if it is premature, in order to save the life of the mother.
Usually, delivery of the baby will treat the condition and prevent progress of the disorder. If
pre eclampsia does get worse before the delivery of the baby, it can lead to bleeding disorders
in addition to seizures, and is thus considered as a potentially life threatening condition. This
type of severe hypertension is called Eclampsia.
Objectives of the Study
Short- Term Objectives:
In completing the study, the nurse researcher shall have:
1. Explained the anatomy and physiology of the Circulatory system.
2. Identify the factors that cause Severe Pre-Eclampsia.
3. Describe this disease condition.
4. Describe the clinical symptoms of this kind of disease.
5. Identified the diagnostic tools use for Severe Pre-Eclampsia.
6. Familiarized the procedure needed for the correction of Severe Pre-Eclampsia.
7. Formulated nursing care plan related to the potential and existing problems effective for
the improvement of the patient’s condition.
3
Long- Term Objectives:
1. Develop plan of care for the client who Severe Pre-Eclampsia.
2. Provided documentation of the case that will serve as a reading source of information for
the other nurses on matter related to this case.
II. NURSING HISTORY
a. BIOGRAPHIC DATA
Mrs. JC (a pseudo name given by the student nurses) currently lives on the
city of San Fernando. She is 37 years old and was born on October 15, 1975. She is
married with 4 male children residing with them. She is a native Capampangan. She is
currently just a plain housewife. She speaks Kapampangan and Tagalog. She and her
family are Roman Catholics. She was admitted to JBL with a chief complain of dizziness,
elevated blood pressure with sudden abdominal cramps. (01/29/13, 4:30pm).
b. PAST MEDICAL HISTORY
Mrs. JC was completely immunized before her first birthday. According to her,
she never had a chicken pox or any childhood diseases. She was never admitted to
hospital before. Even the first 4 pregnancies she had, she never went to hospital. She had
a miscarriage on her 4th pregnancy. According to her, she never had any difficulties on
that miscarriage. She did not felt any abnormalities during that pregnancy nor any
accidents. The only physical complaint she uttered was her abdominal cramps which
according to her was quite common to their family.
c. HISTORY OF PRESENT ILLNESS
January 29, 2013, 4:30 pm, Mrs. JC felt sudden dizziness and abdominal cramps
while doing her usual day to day routine. Her husband took her to the nearby clinic in
their residence but transferred to JBL right away due to abnormal elevation of her blood
pressure reaching the 200/110 mmHg level. She is in her 38 weeks of gestation and
starting to labor.
4
l. LIFESTYLE
Mrs. JC usually wakes up around 5:30 in the morning. She usually drink coffee
for her breakfast. She prepares her children to school- cook their breakfast and other
stuffs. She help her husband too in preparing for work and usually went to their
destination around 7:00 in the morning with their children. During the day, she just play
bingo with her neighborhood until afternoon. She do manicure and pedicure service as
her part-time job. Before, they have their own sari sari store but they stopped it due to
financial difficulties. According to her, their usual menu includes fish, vegetables and
meat. They are not fond in eating preserved foods as well as meat also. Soft drinks are
something she likes to drink every day. She consumed around 2-3 bottles of it every day.
She does not smoke ever since but has a sedentary lifestyle in general. During evening
they just usually watch televisions with her family and go to bed usually at 10:00 in the
evening.
5
E. FAMILY HISTORY OF ILLNESS
Legends:
6
According to the patient, her family has no history of any serious illnesses. Her parents died at old age (her father at 76 years old and mother at 82 years old). Her husband’s parents also died at old age. She does not remember her parents having any diseases at all. The only thing she remembered is that her father is a smoker. They are eight siblings in their family and she is the 3rd among them. She, together with her mother, oldest sister and her younger sister experience abdominal cramping which is for her is somewhat normal to them. According to her, she already consulted a physician regarding this, had an UTZ and there is nothing they found out.
Last 2011, she had a miscarriage on her 3 month child supposedly. According to her, she cannot remember a thing that may contributed to the miscarriage. Well, except for the fact that she never delivered her babies in a hospital or clinic. Her newly born child is the first one she delivered in a hospital. She usually deliver her babies from a “hilot” only. Her family relies on “herbolaryos” in their place for the treatment of their diseases.
Admitting Assessment and Diagnosis
January 29, 2013 at exactly 4:30 in the afternoon
SKIN: (-) rash
HEAD- EENT: pp1-Ar
LYMPHNODES: (-) CLAD
CHEST AND LUNGS: SCF CBS Cardiovascular AP NRRR (-) murmur
ABDOMEN: FH- 30
FHT-140
IE- CX 8cm dilated, fully effaced (+) BOW, Vx, ST-2
ADMITTING IMPRESSION: G5P3 (3013) PU 38 6/7 wk AOG vx, 1L
PE Severe
ADMISSION DIAGNOSIS: G5P3 (3013) PU 38 6/7 wk AOG vx, 1L
PE Severe
7
OTHER DIAGNOSIS: Severe Pre Eclampsia
FINAL DIAGNOSIS: G5P4 (4014) PU Delivered to a live term boy, cephalic AS, 8,9, AOG via
NSD – PE Severe
HEAD: N
NECK: N
EYES: N
EARS: N
NOSE: N
BREAST: N- not tender, symmetrical
ARMS: N
LEGS: N
BACK: N
PADS: 2 per day, soaked, red
First Day (February 5, 2013)
a. General Survey
At 9:00 am, physical assessment was done during the actual nurse-patient
interaction. She was lying on bed, conscious and coherent with an ongoing
D5LRS 1L X 30-31 gtts/min infusing well on his left hand. The client has
a large stature body. The client is observed to be kempt and well-groomed.
The patient is observed to be quite but cooperative.
b. Vitals Signs
Blood Pressure – 110/80 mmHg
Pulse rate – 78 bpm
Respiratory rate – 20 cpm
8
Temperature – 37 C
c. IPPA (Cephalocaudal)
SKIN
Upon inspection, the skin was observed to have a fair complexion, with
uniform pigmentation. Upon palpation, the client’s skin feels smooth and
warm. It is relatively dry, without excessive perspiration or red, flaky
areas. Slight edema has been observed on her extremities..
HEAD
Skull size was normocephalic. Skull and face were symmetrical with an
equal distribution of hair. Hair was black in color with fair amount of
white and gray strands, short, dry, and fine. There was no dandruff or
infestation present. No lesions, lacerations, tenderness, masses and
depressions noted.
FACE
Face portrayed emotions with symmetrical movements. No masses or
involuntary movement. The face was round, with no edema, lesions,
discolorations present.
EYES
Upon inspection, the client’s eye is non-edematous, without scaling or
lesions on eyelids. Eyelids completely cover the corneas when closed and
its color is the same as surrounding skin color. Eyelashes are evenly
distributed and curved outward. Eyebrows are of equal size, color, and
distribution. Conjunctiva of both eyes is pale. Pupils are equal and respond
to light spontaneously. Lacrimal structures are free from exudate,
swelling, and excessive tearing. Eyes are properly aligned. Upon
palpation, eyelids show no evidence of swelling or tenderness.
9
EARS
Ears were symmetrical with same size bilaterally and color consistent
with face. Pinnas were free from lesions, masses, swelling, redness,
tenderness, and discharges and were in line with the eyes. External canals
were clear with no cerumen seen. No inflammation, masses, discharges
and foreign bodies noted. Gross hearing acuity was good. No pain on the
mastoid process was reported upon palpation.
NOSE
The nose was symmetrical with no deformities, skin lesions, masses
present. Nasal septum is intact and in midline. No nasal flaring was
observed. No discharges were present. No tenderness in his sinuses upon
palpation.
MOUTH
Mouth was proportional and symmetrical. Lips were rust colored and were
dry with no presence of ulcerations, sores or lesions. Teeth were yellowish
in color with some dental caries noted. Right upper first premolar tooth
was absent. Tongue was in central position and moves freely with no
swelling or ulcerations observed. Gag reflex was present as evidenced by
patient swallowing. Tonsils were not inflamed. Halitosis was not noted.
NECK
Neck was symmetrical with no masses or swelling noted. No jugular vein
distention was noted. Range of motion was normal and moves easily
without discomfort upon rotation, flexion, extension and hyperextension.
10
Thyroid was not enlarged has no nodules, masses, and irregularities upon
palpation. Trachea is symmetrical and in midline without deviation.
CHEST and LUNGS
No thorax deformity observed. Respiratory rate was 20 cycles per minute
with regular breathing pattern. Symmetrical chest expansion was observed
during respiration. No use of accessory muscles during breathing
observed. Chest wall was intact; no tenderness and masses noted. Uniform
temperature also noted. No adventitious breath sounds heard upon
auscultation. No cough present. No dyspnea, hemoptysis, hiccups noted.
HEART
Apical heart beat was present upon auscultation with a point of maximal
impulse at the 5th intercostal space left midclavicular line; with cardiac
rate of 78 beats per minute with a regular rhythm. No abnormal beats,
palpitations, thrills or murmurs present upon auscultation.
ABDOMEN
Abdomen was slightly enlarged and globular when patient was in supine
position. Pulsations were not visible. The abdomen had hypoactive bowel
sounds of two bowel sounds per minute.
BACK & EXTREMITIES
Symmetrical shoulder movement observed during respiration. Spine was
located at the midline with no discrepancies noted. Shoulders, arms,
elbows and forearms were free from nodules, deformities and atrophy.
Range of motion was not limited. Neither pallor nor bone enlargements
were noted upon inspection of the upper extremities. Upper and lower
extremities were slightly edematous. Radial and brachial pulses were
11
present. Hip joint and thighs were symmetrical with no deformities
present.. No inflammation noted in the lower extremities. Range of motion
was active and not limited.
12
IV. DIAGNOSTIC AND LABORATORY PROCEDURES
HEMATOLOGY
Diagnostic/
Laboratory
Procedures
Indications or
purpose
Date Ordered Date
Results were
released
Normal Values Results Analysis and
Interpretation of
results
Complete Blood
Count (CBC)
or
Hematology Test
It is an important
screening test that
includes RBC
count, hemoglobin,
hematocrit, RBC
induces, WBC
count, with or
without differential
count and platelet
count
Blood Typing The process of
identifying an
individual's blood
group by serologic
testing of a sample
of blood.
Jan. 29, 2013 O +
Hemoglobin Hemoglobin is the
13
main component of
a red blood cell.
Each RBC contains
250 million
molecules of
Hb. Therefore, Hb
concentration
correlates closely
with the RBC
count. HB level is a
good indicator of
anemia.
Jan. 29, 2013 F: 115-155g/L 126g/L Hemoglobin count
is within the normal
range.
Hematocrit Routine for
screening of CBC.
Diagnosis suspected
anemia and
monitors treatment
in blood loss. It is
the percentage of
the volume of a
blood sample
occupied by cells.
F: 0.38- 0.48 .37 Hematocirt level is
below the normal
range which may
indicate decrease in
plasma level and/or
increase in the
blood concentration.
14
WBC A WBC count can
be useful in
diagnosing infection
and inflammation
5-10x 10g/L 10.7g/L WBC count is
within the normal
level which is an
indicator of
nonexistence of an
inflammation or
infection.
Neutrophils This respond more
rapidly during
inflammatory and
tissue damage. May
indicate bacterial
infection and also
may be raised in
acute viral
infections.
0.45- 0.65 .75g/L Neutrophils count is
above the normal
level which is an
indicator of an
existence of an
inflammation.
Lymphocytes A white blood cell
formed in lymphatic
tissue throughout
the body (e.g.,
lymph nodes,
spleen, thymus,
0.20-0.35 .25 Lymphocytes count
is within the normal
range.
15
tonsils, Peyer
patches) from
precursor cells
originating in bone
marrow and in
normal adults
making up
approximately 22–
28% of the total
number of
leukocytes in the
circulating blood.
They plays a major
role in immune
system response.
Platelet This was order for
the patient in order
to measures the
number of platelet
per mm3 of blood.
-assess the severity
of
150-400x109/L 231 Platelet count is
within the normal
range.
16
thrombocytopenia,
which can result in
spontaneous
bleeding, as wll as
thrombocytosis
Nursing Responsibilities
Explain to the client that this test detects anemia and other abnormal conditions of the blood.
This test also indicates if the individual has infection.
Inform the client that she needs not restrict food or fluids before the test.
Maintain aseptic technique when performing this procedure.
URINALYSIS
Diagnostic/ Indications or Date Ordered Date Normal Values Results Analysis and
17
Laboratory
Procedures
purpose Results were
released
Interpretation of
results
Color This was order for
the patient in order
to screen for renal
or urinary tract
diseases and to
determine metabolic
or systemic disease
related to renal
disorder.
Jan. 29, 2013
Pale yellow to deep
amber
Yellow Urine is in normal
color.
Transparency Clear Slightly turbid Slightly turbid urine
means that there is
protein traced in the
urine.
Albumin negative + 2 Albumin is
increased which
signifies protenuria.
Specific gravity 1.001-1.025 1.020 Specific gravity is
within the normal
range.
pH 5.5-6.5 acidic Urine is has been
detected to be acidic
Pus Cells 0-1 hpf 8.10 hpf Pus cells level is
increased which
indicates
inflammation or
infection in the
18
patient.
Epithelial Cells Few few Epithelial cells are
within the normal
range.
Nursing Responsibilities:
Before
Check the doctor’s order.
Inform the patient that urine specimen is needed. Explain to the patient the procedure and its significance.
Explain to the patient how the procedure is done.
Fill up request form properly.
Provide a clean container for collection of urine.
During:
Instruct to collect a clean catch, mid-stream urine.
Send the specimen to the laboratory properly labeled together with laboratory slip.
After:
Chart time of collection of urine.
Attach results to the chart as soon as they are available.
19
V. THE PATIENT AND HIS ILLNESS
A. Anatomy and Physiology
CARDIOVASCULAR SYSTEM
THE HEART
The human heart, through rhythmic contraction, provides the pressure necessary to propel
blood through the body. Blood flow is essential to deliver nutrients to the tissues of the body and
to transport metabolic wastes, including heat, to removal sites. The presence of an arterial pulse
caused by the beating of the heart is appropriately designated as a vital sign.
The heart weighs about 300 g and is located within the mediastinum, it is cone-shaped and
tilted forward and to the left. Because of its orientation during fetal development, the apex of the
heart (tip of the cone) is at its bottom and lies left of the midline. The base is at the top, where the
great vessels enter the heart and lies posterior to the sternum. The heart consists of four
20
chambers: two smaller atria at the top (the base) of the heart and two larger ventricles at the
apex. A band of fibrous tissue separates the atria from the ventricles and seats the four cardiac
valves. A muscular septum separates the right from the left atrium and the right from the left
ventricle.
Functionally, the heart is actually two pumps working simultaneously. The right atrium and
right ventricle generate the pressure to propel the oxygen-poor blood through the pulmonic
circulation; the left atrium and left ventricle propel oxygen-rich blood to the remainder of the
body through the systemic circulation. At rest, each side of the heart pumps approximately 5000
ml of blood per minute (cardiac output). This is accomplished by a contraction frequency (heart
rate) of 72 beats/min, with each contraction ejecting a volume of 70 lm (stroke volume) into the
arterial system. Cardiac output can increase five-fold during exercise as a result of increases in
both heart rate and stroke volume.
STRUCTURES OF THE HEART
LAYERS OF THE HEART
The heart consists of three distinct layers of tissue: endocardium, myocardium and
epicardium. The endocardium (innermost layer) consists of thin endothelial tissue lining the
inner cahmbers and the heart valves. The myocardium (middle layer) consists of striated muscle
fibers froming interlaced bundles and is the actual contracting muscle of the heart. The
epicardium or visceral pericardium covers the outer surface of the heart. It closely adheres to
the heart and to the first several centimeters of the pulmonary artery and aorta.
The visceral pericardium is encased by the parietal pericardium, a tough, loose-fitting,
fibrous outer membrane that is attached anteriorly to the lower half of the sternum, posteriorly to
the thoracic vertebrae and inferiorly to the diaphragm. Between the visceral pericardium and the
parietal pericardium is the pericardial space, which holds 5 to 20 ml of pericardial fluid. This
fluid lubricates the pericardial surfaces as they slide over each other when the heart beats.
CHAMBERS OF THE HEART
21
The heart consists of four chambers: two upper collecting chambers (atria) and two lower
pumping chambers (ventricles). A muscular wall (septum) separates the chambers of the right
side from those of the left side. The right atrium receives deoxygenated blood from the body.
The blood moves to the right ventricle, which pumps it to the lungs against low resistance. The
left atrium receives oxygenated blood from the lungs. The blood flows into the left ventricle
(the heart’s largest, most muscular chamber), which pumps it against high resistance into the
systemic circulation.
CARDIAC VALVES
The cardiac valves are delicate, flexible structures that consist of endothelium covered by
fibrous tissue. They permit only unidirectional blood flow through the heart. The valves open
and close passively, determined by pressure gradients between the cardiac chambers. “Leaky”
valves that do not seal when closed are called regurgitant or insufficient. “Stiff” valves that
cannot open completely are called stenotic.
Cardiac valves are of two types: (1) atrioventricular (AV) and (2) semilunar.
Atrioventricular valves lie between the atria and ventricles. The tricuspid valve, on the right
side, is composed of three leaflets. The mitral (bicuspid) valve, on the left is composed of two.
Attached to the edges of the AV valves are strong, fibrous filaments called chordae tendineae,
which arise from papillary muscles on the ventricular walls. The papillary muscles and chordae
tendineae work together to prevent the AV valves from bulging back into the atria during
ventricular contraction.
The semilunar valves consist of three cup-like cusps that open during ventricular contraction
and close to prevent backflow of blood into the ventricles during relaxation. Unlike the AV
valves, the semilunar valves open during ventricular contraction. The pulmonic semilunar valve
(right ventricle to pulmonary artery) and the aortic semilunar valve (left ventricle to aorta) do
not have papillary muscles.
CARDIAC BLOOD SUPPLY
22
The heart muscle requires a rich oxygen supply to meet its own metabolic needs. The
coronary arteries (right and left) branch off the aorta just above the aortic valve, encircle the
heart and penetrate the myocardium. Coronary vessel distribution can vary greatly.
Contraction of the muscle of the left ventricle generates enough extravascular pressure to
occlude the coronary blood vessels and prevent blood flow to the muscle of the heart during
ventricular systole. Thus 75 % of the coronary artery blood flow occurs during diastole, when the
heart is relaxed and resistance is low. For adequate blood flow through the coronary arteries, the
diastolic blood pressure must be atleast 60 mmHg. Coronary blood flow increases with increased
heart work load. The coronary veins return blood from most of the myocardium to the coronary
sinus of the right atrium. Some areas, particularly on the right side of the heart, drain directly into
the cardiac chambers.
CORONARY ARTERIES
The heart, just like all other muscles in the body, needs its own supply of oxygen in order
to function properly. Although its chambers contain blood, the heart receives no nourishment
from the blood inside the chambers. The heart gets its blood supply from the coronary arteries.
The two major coronary arteries, the right coronary artery and the left main coronary artery,
branch off the aorta, and then divide into many smaller arteries that lie in the heart muscle and
feed the heart.
FUNCTIONS OF THE HEART
ELECTROPHYSIOLOGIC PROPERTIES
The electrophysiologic properties of cardiac muscle regulate the heart rate and rhythm. These
properties include excitability, automaticity, contractility, refractoriness and conductivity.
EXCITABILITY
The ability of cardiac muscle cells to depolarize in response to a stimulus, excitability, is
influenced by hormones, electrolytes, nutrition, oxygen supply, medications, infection and
autonomic nerve activity.
23
In myocardial cell, as in other types of muscle and neurons, differences in intracellular and
extracellular ion concentrations create electrical and concentration gradients for ionic movement
across the semipermeable cell membrane. At rest, the inside of a myocardial cell is more
negative than the outside. This resting membrane potential results primarily from the
differences in concentrations of potassium and sodium. Although both ions are present on either
side of the cell membrane, potassium has a greater extracellular concentration. Selective
channels can increase membrane permeability for specific ions, allowing the ion to move down
the electrochemical gradient and to alter the resting membrane potential.
When the cardiac cell is stimulated to a certain threshold, a sequence of ion permeability
changes cause a dramatic change in the transmembrane potential, this is known as action
potential. The action potential consists of depolarization and repolarization phases. The
electrocardiogram (ECG) reflects currents generated during the depolarization and repolarization
of regions of the heart.
Depolarization is caused by an increase in cell membrane permeability to sodium. The cell
returns to its resting (relaxed) state during repolarization. Sodium permeability drops sharply and
potassium permeability increases, returning the membrane to the negative resting potential. In
the process of depolarization and repolarization, small amounts of sodium leak into the cell and
potassium leaks outward. The cell compensates for this by actively pumping sodium back out
and potassium inward.
Other ions, such as calcium and chloride, also play a role in the action potential and the
contraction it causes. For the heart, calcium is especially important because it initiates
contraction. During depolarization, myocardial cell membrane permeability to calcium increases
and calcium moves into the cell. This inward calcium triggers the release of more calcium stored
in the sarcoplasmic reticulum. As the intracellular concentration of calcium increases, calcium
reacts with contractile elements and myocardial muscle fibers contract.
AUTOMATICITY (RHYTHMICITY)
The ability of cardiac pacemaker cells to initiate an impulse spontaneously and repetitively,
without external neurohormonal control, is known as automaticity or rhythmicity. Given the
24
proper conditions, the heart can continue to beat outside the body. In contrast, skeletal muscle
must be stimulated by a nerve to depolarize and contract. The sinoatrial (SA) node pacemaker
cells have the highest rate of automaticity of all cardiac cells. The conduction tissue area with the
highest automaticity, or rate of spontaneous depolarization, assumes the role of pacemaker. SA
node cell automaticity is due to changes in ionic permeability of the membrane. Even at rest, a
decreasing potassium permeability and increasing slow channel permeability. Move the cell
membrane potential more positively toward threshold voltage. When threshold is reached, the
cell initiates an action potential. Norepinephrine and acetylcholine cause heart rate to increase
and decrease, respectively. The rate of spontaneous depolarization can also be affected by other
hormones, body temperature, drugs and disease.
CONTRACTILITY
The heart muscle is composed of long, narrow cells or fibers. Cardiac muscle fibers, like
striated skeletal muscle contain myofibrils, Z bands, sarcomeres, sarcolemmas, sarcoplasm and
sarcoplasmic reticulum. Contraction results from the same sliding filament mechanism described
for skeletal muscle.
The action potential initiates the muscle contraction by releasing calcium through the T-tubules
of the cell membrane. The calcium reaches the sarcoplasmic reticulum causing additional
calcium release. The intracellular calcium diffuses to myofibrils, where it binds with troponin.
When the actin filaments become activated by calcium, the heads of the cross-bridges from the
myosin filaments immediately become attracted to the active sites of the actin. Contraction then
occurs by power stroke repetition. After contraction, free calcium ions are actively pumped back
into the sarcoplasmic reticulum and muscle relaxation begins.
One important difference between cardiac and skeletal muscle is that cardiac muscle needs
extracellular calcium. All the calcium involved in skeletal muscle comes from the sarcoplasmic
reticulum. In cardiac muscle, however, extracellular calcium enters through the T tubules and
triggers the release of more calcium from the sarcoplasmic reticulum. Because of this, calcium
channel blockers can alter contraction of the heart, but not the contraction of skeletal muscle.
REFRACTORINESS
25
Refractoriness is the heart’s inability to respond to a new stimulus while still in a state of
depolarization from an earlier stimulus. Refractoriness develops when the sodium channels of
the cardiac cell membrane become inactivated and unexcitable during an action potential. Thus
the heart muscle does not respond to restimulation, preventing the possibility of titanic
contractions that are seen in skeletal muscle.
Refractoriness occurs in two periods. The absolute refractory period occurs during
depolarization and the first part of repolarization. During this period, cardiac cells do not respond
to any stimuli, however strong. The relative refractory period occurs in the final stages of
repolarization; refractoriness diminishes and a stronger-than-normal stimulus can excite the heart
muscle to contract. At the end of the refractory period, there is transient hyperexcitability. The
sodium channels are rest and the cardiac cells can again conduct action potentials.
Normally, the ventricles have an absolute refractory period of 0.25 to 0.3 seconds, which
approximates the duration of the action potential. The relative refractory period for the ventricles
lasts about 0.05 seconds. The atria have a refractory period of about 0.15 seconds, and they can
therefore contract rhythmically much more quickly than the ventricles. The duration of the action
potential and the refractory period are not fixed, however; both can shorten as heart rate
increases.
CONDUCTIVITY
Conductivity is the ability of heart muscle fibers to propagate electrical impulses along and
across cell membranes. The heart muscle must conduct the action potential from its origin
throughout the heart both rapidly and smoothly so that the atria and ventricles contract as a unit.
Intercalated disks join adjacent myocardial cells, allowing the action potential to travel over the
entire muscle mass. However, the fibrous band of tissue that separates the atria and ventricles
lack intercalated disks. Thus the atria are isolated electrically from the ventricles except for the
only normal conduction pathway, the atrioventricular node. The conduction system consists of
the following major parts:
1. The Sinoatrial (SA) node, or pacemaker, is located at the junction of the superior vena
cava and the right atrium. Under normal circumstances, the SA node initiates electrical
26
impulses (heartbeats) approximately 60 to 100 times per minute, but it can adjust its rate.
Three internodal and one interatrial tract carry the wave of depolarization through the
right atrium to the AV node and to the left atrium, respectively. The sympathetic and
parasympathetic nervous systems regulate the SA node. Any myocardial tissue that
generates impulses at a higher rate than the SA node can become an abnormal
pacemaker.
2. The atrioventricular (AV) node, or AV junction, is located in the lower aspect of the
atrial septum. The AV node can be secondary cardiac pacemaker, but it normally receives
electrical impulses from the SA node and is the only pathway for conducting impulses
from the atria to the ventricles. Within the AV node, the impulse is delayed 0.07 seconds
whikle the atria contract. This delay enables atrial contraction to be completed before the
ventricles contract.
3. The common bundle of His in the interventricular septum is relatively short, branching
into the right and left segments. The right bundle branch (RBB) courses down the right
side of the interventricular septum. The left bundle branch (LBB) bifurcates into anterior
and posterior fascicles, both of which extend into the left ventricle. The right and left
bundle branches terminate in Purkinje fibers.
4. Purkinje fibers are a diffuse network of conducting strands beneath the ventricular
endocardium; they rapidly spread the wave of depolarization through the ventricles.
Activation of the ventricles begins in the septum and then moves from the apex of the
heart upward. Within the ventricular walls, depolarization proceeds from the
endocardium to epicardium. Repolarization occurs in each cell and does not involve the
conduction system. Repolarization occurs in reverse order, so that the last cells to
depolarize are the first to repolarize. The action potentials of Purkinje fibers have the
longest duration and their repolarization is occasionally seen as a U wave of the
electrocardiogram (ECG).
27
B. Pathophysiology
a. Book based
i. Schematic Diagram
28
ii. Synthesis of the Disease
IV. Synthesis of the disease
1. Definition of Severe preeclampsia (book based)
Preeclampsia is a condition in which vasospasm occurs during pregnancy in which it leads to
an increase in blood pressure. Its concern is about the hypertension that develops as direct result
of pregnancy and is characterized by hypertension with proteinuria and edema that develops after
20th week of gestation.
2. Predisposing or precipatory factors
Predisposing (Non – modifiable) factors
Sex – Female
Age of Pregnancy below 20 y/o - due to their lifestyle
Age above 35 y/o- chances of giving birth to babies with genetic defects
Primiparas
Familial history of Hypertension- higher chances of acquiring
hypertension
Familial history of heart disease- higher possibility of acquiring heart
disease
Multigravida
heart disease- the heart might not meet the demand for the heart during
pregnancy
diabetes- could lead to gestational diabetes and lead to complications like
PTL and preeclampsia
renal/kidney malfunction- can lead to an increased glomerular filtration
rate
29
Precipitating Factors – Modifiable
Diet / Nutrition- poor nutrition can weaken the body’s deffenses
Weight(overweight)- are linked to conditions like preeclampsia
Lack of Exercise- may increase blood pressure and pulse rate
3. Signs and symptoms with rationale
A. Hypertension or increased blood pressure- due to an increase in the resistance of blood
vessels. This may hinder blood flow in many organ systems in the expectant mother
including the liver, kidneys, brain, uterus, and placenta.
B. protein in the urine – because of damaged blood vessels that may lead to kidney failure
C. Edema (swelling) – due to the large increase in body fluids, or because of the growing
uterus pressing on the pelvic veins and thus slightly obstructing blood flow.
D. Blurring of vision - caused by an increase in blood pressure during pregnancy
E. Continuous headache- may signal cerebral edema
F. Nausea and vomiting –could be because of the combination of the many physical changes
taking place in your body such as the higher levels of hormones
G. changes in liver or kidney function tests- due to protein in the urine
4. Health promotion and preventive aspect of the disease
• Consult the physician regularly- to prevent further complications
• Place patient in a lateral recumbent position- to reduce pressure in the vena cava
• Elevate lower extremities- to facilitate venous return
•Dangle the feet of the patient at the edge of the bed before letting her stand- to prevent
orthostatic hypotension.
• Provide a low salt and low fat diet – to Provide adequate nutrition
• Advice patient to drink at least 8 glasses of fluid per day- to replace fluid loss
• Advice patient to add fiber to her diet- to prevent constipation
30
• If allowed, advice patient to do gentle stretching exercises of her legs, feet, arms and hand-
to improve circulation and increase muscle tone.
• Provide emotional support- for the patient to feel better
b. Patient Centered
i. schematic diagram
31
32
PREDISPOSING FACTORS
Sex- Female Age > 35 years old Multigravida
PRECIPITATING FACTORS
Diet Overweight Lack of exercise Sedentary life style
Cerebral Vasospasm Vascular Effects Kidney Effects Interstitial Effects Increased Plasma Volume
Headache and Peripheral
vasoconstriction
vasoconstriction
Increase glomeruli infiltration rate and
increases permeability of
glomeruli membranes
Diffusion of fluid from the blood
stream into interstitial tissue
Edema
33
Poor organ Perfusion
Circulatory Compensation
Mechanism
Increased Blood Pressure
200/110 mmHg
Increased blood urea nitrogen, uric acid
and creatinine
Increased urine output and protenuria
1. Definition of Severe Preeclampsia
Preeclampsia’s progress differs among patients. It was diagnosed on the later part of
pregnancy wherein the patient manifested hypertension, preinuria and edema on the lower
extremities.
2. Predisposing or precipatory factors
Predisposing (Non – modifiable) factors
Sex – Female
Age – Pregnancy 38 years old
Multigravida
Precipitating Factors – Modifiable
Diet / Nutrition – poor nutrition can weaken the body’s deffenses
Weight(overweight)- are linked to conditions like preeclampsia
Lack of Exercise/sedentary lifestyle- may increase blood pressure and
pulse rate
3. Signs and symptoms with rationale
A. Hypertension or increased blood pressure- due to an increase in the resistance of blood
vessels. This may hinder blood flow in many organ systems in the expectant mother
including the liver, kidneys, brain, uterus, and placenta.
B. +2 Proteinuria (protein in the urine) – because of damaged blood vessels that may lead to
kidney failure
C. Edema (swelling) – due to the large increase in body fluids, or because of the growing
uterus pressing on the pelvic veins and thus slightly obstructing blood flow.
34
4. Health promotion and preventive aspect of the disease
• Patient Consulted the Physician- to prevent further complications
• Monitored vital sign esp. the pt.’s blood pressure- to determine if there are alterations in the
blood pressure
• Provided complete bed rest- it can help reduce high readings of blood pressure
• Instructed the pt. to increase oral fluid intake- to replace fluid loss
• Low salt and low fat diet- to prevent further edema
• Delivery of the baby- to cure pre-eclampsia
35
VI. THE PATIENT AND HIS CARE
1. Medical Management
a. IVFs, BT, NGT feeding, Nebulizations, TPN, Oxygen Therapy, etc
Medical
Management
General Description Indications/ Purpose Date ordered, date
preformed, date
changed or D/C
Client’s response to
treatment
Nursing
Responsibilities
D5LRS 1L 5% Dextrose in
Lactated Ringers
solution is used to
supply the patient
with glucose in
order to sustain
nourishment.
Indicated to Patients
who are unable to
maintain adequate
fluid balance and need
replacement fluid. To
supply nutrients
directly into the
bloodstream
January 30, 2013
There were no
signs and
symptoms noted
upon administration
of fluid such as
pain – swelling and
tenderness at the
insertion site,
patient didn’t
manifest S/SX of
fluid overload.
PNSS 1L + 20 g
MgSO4
It contains 0.9 NaCl
to provide the
patient fluid and
electrolyte
replacement. It has
the same plasma
concentration with
To provide
fluid and
electrolyte
replacement.
MgSO4 to
lower patient’s
BP and
January 29, 2013
36
the blood.
MgSO4 relaxes
smooth muscles of
the uterus through
Calcium
displacement, thus,
decreasing uterine
motility. Better to
use than
sympathomimetics
because it has fewer
side effects. MgSO4
is also a CNS
depressant which
prevents
convulsions
increase
perfusion to
the uterus
which has a
therapeutic
effect to the
fetus.
Prophylaxis for
seizures in
severe
preeclampsia
without
producing
deleterious
CNS
depression in
mother or
infant.
Indwelling Foley
Catheter
An indwelling, or
foley catheter is a
thin, flexible
To closely
monitor
patient’s urine
The catheter was
placed and
successfully
37
drainage tube that
drains urine when a
person is unable to
empty his /her
bladder
independently..
Once inserted, a
small balloon inside
the catheter is then
inflated to anchor
the catheter in
place. The catheter
is attached to a
drainage bag ,
which collects the
urine.
output to
determine fluid
balance
between intake
and output.
inserted at the pt’s
urethra, intact and
patent.
NURSING RESPONSIBILITIES
Check for the doctor’s order for oxygen therapy
Acquaint the patient with requirement and need for oxygen therapy.
Check the patency of the equipments use in oxygen therapy.
Regulate well the oxygen being given to the client.
38
b. Drugs
Generic Name
and Brand Name
General Action Indications/ Purpose Date ordered,
date
preformed,
date changed
or D/C
Client’s
response to
medication
with actual
side effects
Nursing Responsibilities
Generic Name:
cefuroxime
Sodium
Brand Name:
Kefox
(500mg/cap BID)
Second Generation
cephalo sporins-
Inhibits bacterial
Cellwall Synthesis
Promoting Osmotic
instability
-Treatment of UTI
- Peri-operative
Prevention
January
29,2011
The patient
did not
develop
allergy to the
drug.
-Before administering, make sure
patient is not allergic to
penicillins or cephalosporins.
- Absorption of cefuroxime is
enhanced by food.
- may be crushed if swallowing is
a difficulty
-may be dissolved in small
amounts of apple, orange or
grape juice, even chocolate milk.
However, drug’s bitter taste is
difficult to mask even with food.
-High-fat meals increased drug
bioavailability
-If large doses are given, therapy
is prolonged, or patient is at high
39
risk, monitor patient for signs
and symptoms of superinfection
-Unlike other second generation
cephalosporins, cefuroxime can
cross the blood-brain-barrier.
Generic Name:
Metronidazole
Brand Name:
Flagyl
(500mg/cap TID)
Antibiotics-
Metronidazole is
converted to reduction
products that interact
with DNA to cause
destruction of helical
DNA structure and
strand leading to a
protein synthesis
inhibition and cell
death in susceptible
organisms. It is
effective against a
wide range of
organisms including E.
histolytica, T.
vaginalis, Giardia,
-amoebic hepatic
abscess
-bacterial infection
caused by anaerobic
microorganisms
-to prevent post
operative infection
in contaminated
colorectal surgery
-pelvic
inflammatory
disease
January
29,2011
Dizziness
was
experience
by the
patient.
-watch carefully for edema
because it may cause sodium
retention
-Tab: Should be taken with food.
Susp: Should be taken on an
empty stomach. (Take at least 1
hr before meals.)
- metallic taste and dark or red
brown urine may occur
40
anaerobes
e.g. Bacterioides
sp, Fusobacterium
sp, Clostridium
sp,Peptococcus sp
and Peptostreptococcus
sp
Generic Name:
FESO4
Brand Name:
Iron Sulfate
(350mg tab OD)
Antianemic, Iron-
absorbed from the
duodenum and
upper jejunum by an
active mechanism
through the mucosal
cells where it combines
with the protein
transferrin.
-Prophylaxis and
treatment of iron
deficiency and iron-
deficiency anemia.
-Dietary supplement
for iron. Optimum
therapeutic
responses are
usually noted within
2-4 weeks.
January
29,2011
Patient’s
stool turned
black.
-best taken n an empty stomach/
with full glass of water/ orange
juice
-remind patient that stool may
turn black
-do not crush or chew
Generic Name:
Mefenamic acid
Brand Name:
Ponstel (500mg/
non-steroidal anti-
inflammatory drug
(NSAID)-
exhibits anti-
inflammatory,
-for mild to
moderate pain and
inflammation
January
29,2011
Dizziness
was
experience
by the
patient.
-should be taken with food
- Discontinue drug promptly if
diarrhea, dark stools, hematemesis,
ecchymoses, epistaxis, or rash occur
and do not use again. Contact
41
cap TID) analgesic, and
antipyretic
activities in animal
models. The
mechanism of
action of
MEFENAMIC
ACID, like that of
other NSAIDs, is
not completely
understood but may
be related to
prostaglandin
synthetase
inhibition.
physician.
-Do not breast feed while taking this
drug without consulting physician.
Generic Name:
Nifedipine
Brand Name:
Apo- Nifed
(10mg/ tab BID)
Anti-hypertensive,
Anti-hypertensive,
Calcium Channel
Blockers
-inhibits the
movement of
calcium ions across
- To lower high
blood pressure. This
reduces the
possibility of having
an angina pectoris
attack.
January
29,2011
Blood
pressure of
patient went
from 200/110
to 130/80
-Assess the history of allergies to
nifedipine and also pregnancy and
lactation
-Monitor patient’s Blood Pressure
and cardiac input and output
carefully.
-Ensure that patient does not chew
42
the membranes
of cardiac and
arterial muscle
cells, inhibition of
transmembrane
calcium flow
results in the
depression
of impulse
formation in
specialized cardiac
pacemaker cells, in
slowing of the
velocity of the
conduction of the
cardiac muscle
impulse, in the
depression of the
of myocardial
contractility and in
the dilation
of coronary
or divide sustained-release of tablet
43
arteries, arterioles.
These effects lead
to decreased
cardiac work,
decreased cardiac
energy
consumption, and
increased delivery
of oxygen to
myocardial cells.
Generic Name:
Spironolactone
Brand Name:
Aldazide
(25mg/tab BID)
Diuretic-
competes with
aldosterone for
receptor sites in the
distal renal tubules,
increasing sodium
chloride and water
excretion while
conserving
potassium and
hydrogen ions, may
block the effect of
-for essential
hypertension
January
29,2011
Patient
experienced
increased
urinary
output
-Take with meals or milk; avoid
excessive ingestion of food high in
potassium or use of salt substitutes
-Diuretic effect may be delayed 2-3
days and maximum hypertensive
may be delayed 2-3weeks
-monitor I and O ratios and daily
weight, BP, serum electrolytes (K,
Na) and renal function
44
aldosterone on
arteriolar smooth
muscle as well
c. Diet
Type of Diet General Description Indications/ Purpose Date ordered, date
preformed, date
changed or D/C
Client’s response
and/or reaction to
diet
Nursing
Responsibilities
Low salt, low fat
diet
The average adult
intake of salt is 5 to
15 g/day, the
therapeutic effect of
sodium reduction on
blood pressure does
not occur until salt
intake is reduced
below 5g/day.
Cholesterol is
contained in animal
fats and dairy
products. Saturated
fat occurs
predominantly in
For body’s
resistance
For muscle strength
For regular
functioning of the
body
To reduce or
decrease cholesterol
levels
To maintain a
normal blood
pressure
Jan 30, 2013 At first the client is
not use to eat bland
food. She had a
hard time in
modifying her diet.
Reinforcement of
instruction that he
needs to eat low salt
and low fat was
done. The client
complied with the
instruction but with
not much
enthusiasm.
Educate client
about his diet
Avoid client
from aspirating by
proper positioning
Instruct to
increase fruit juices
and low fat milk in
diet for nourishment
Avoid food rich
in sodium like
processed food,
dried food and can
good food.
Read label of
45
animal fats and
tropical oils.
Unsaturated fats
predominate in most
plant derived fats.
food carefully for
the amount of
sodium in it.
Encourage
significant others
not to prepare food
rich in sodium.
Avoid too much
saturated fat and
cooking using
animal oil, instead
use vegetable oil
d. Activity
Type of Activity General Description Indications/ Purpose Date ordered, date
preformed, date
changed or D/C
Client’s response
and/or reaction to
activity
Nursing
Responsibilities
Bed Rest The client ordered
to stay on bed due
to the risk of blood
pressure elevation
To conserve
strength and energy
and to avoid
physical exertion to
January 29, 2013 Client obediently
follow the activity
restrictions
Educate client
regarding her
activity
Assisting client
46
the client to her bathroom
privileges
Explain the
purpose of
restrictions in
activity and position
in bed as ordered.
Assist the
patient to maintain
the prescribed
position.
Encourage the
patient to adhere to
ordered activity.
Accomplish
necessary
documentation of
patient’s reaction to
the ordered activity
restrictions.
47
VII. NURSING MANAGEMENT
A. Nursing Care Plans
Assessment Nursing Diagnosis Scientific
Explanation
Objectives Intervention Rationale Expected Outcome
The pt may
verbalize:
Discomfort
In the
Lower
Abdomen
Intolerance
to some
activities
constant pain
in the post-
surgical site
Acute pain Pain is a
subjective
unpleasant
sensation
resulting from
stimulation of
sensory nerve
endings by
injury, or
other harmful
factors. Pain is
activated when
a pt’s pain
threshold is
reached. Pain
threshold is the
point at which
SHORT-TERM:
After 3 hrs of
nursing inter-
ven
tions,
the pt’s pain scale
will be re-
duced
to 4/10
LONG TERM:
After
> Establish
rapport
>Monitor and
assess VS
>Assess the pt’s
general physical
condition
>Perform a
comprehensive
assessment of
pain noting its
location,
intensity, and
provocation.
To gain pt’s trust
and cooperation
To obtain baseline
To determine
presence of
abnormality
To determine
precipitating or
aggravating factors.
The pt’s pain scale
shall havel re-
duced
from 6/10 to 4/10.
The pt shall have
demonstrated use of
relaxation skills and
48
The pt
manifested:
Facial
grimaces
Sharp stabbing
pain that
radiates from
the incision site
with a pain
scale of 5/10.
Guarding
behavior
Narrowed
focus
The pt may
manifest:
Restlessness
Listlessness
a stimulus
activates pain
receptors to
produce a
feeling of pain.
Pain usually
accompanies
inflammation.
It results from
the synthesis
of
prostaglandins,
which are
hormones
produced
during the
inflammatory
process.
3 days
of nsg
inter-
ventions,
the pt will
demonstrate use of
relaxation skills
and divers ional
activities as
indicated for
individual
situation.
>Perform pain
assesment
everytime each
time pain occurs
Accept client’s
description of
pain
Instruct client to
report pain as
soon as it begins
Provide quiet
environment and
To rule out
worsening of
underlying
condition/
development of
complications.
Pain is a subjective
experience and
cannot be felt by
others.
Timely
interventions are
more likely to be
successful in
alleviating pain
To lessen
discomfort felt by
divers ional activities
as indicated for
individual situation.
49
Sleep
disturbance
Reduced
interaction
with people
and
environment
Panic
Worry
regarding the
duration of
pain
calm activities
Provide comfort
measure (change
of position)
Encourage use of
relaxation
exercise such as
deep breathing
technique
Encourage
diversional
activities such as
socializing with
others
Review
procedures/
expectations and
the client
To provide
nonpharmacological
pain management
To divert pt’s
attention away from
the pain sensation
To reduce concern
of the unknown and
associated muscle
tension
To reduce fatigue to
reduce pain
50
tell client whet
treatment will
hurt
Encourage
adequate rest
periods
Administer
prescribed meds
51
Assessment Nursing Diagnosis Scientific
Explanation
Objectives Intervention Rationale Expected Outcome
The pt may
verbalize:
Palpitations
Fatigue
Shortness of
breath/dyspnea
anxiety
The pt
manifested:
Weight gain
Edema
Variations in
BP reading
Restlessness
Decreased Cardiac output
r/t decreased venous
return secondary to
severe preeclampsia AEB
altered BP and edema
Inadequate
blood is
pumped by the
heart to meet
the metabolic
demands of the
body. It
resulted from a
systemic vaso
constriction in
the body
caused by
preeclampsia.
Vasoconstricti
on is the
decrease in the
diameter of the
blood vessels
which occur in
diseases like
SHORT-TERM:
After 3 hrs of
nursing
interventions, the
pt will display
hemodynamic
stability (blood
pressure within
closer range)
LONG TERM:
After 3 days of
nursing
interventions, the
pt will demonstrate
activities that
reduce the
workload of the
> Establish
rapport
>Monitor and
assess VS
>Assess the pt’s
general physical
condition
Determine
baseline vital
signs/hemodyna
mic parameters
including
peripheral pulses.
Review signs of
impending failure
/shock.
To gain pt’s trust
and cooperation
To obtain baseline
To determine
presence of
abnormality
Provides
opportunities to
track changes
To prevent
hypovolemic shock
The pt shall have
displayed
hemodynamic
stability (blood
pressure within closer
range)
The pt shall have
demonstrated
activities that reduce
the workload of the
heart (stress
management,
therapeutic
medication regimen
52
The pt may
manifest:
Jugular vein
distention
Cold clammy
skin
Arrhythmaia
crackles
Prolonged
capillary refill
pregnancy-
induced
hypertension.
Decreased
blood supply
leads to a
decrease in
venous return,
thus there is a
relatively
smaller
amount of
blood expelled
by the
ventricles of
the heart.
heart (stress
management,
therapeutic
medication
regimen program,
balanced activity/
rest plan)
Position with
HOB flat or keep
trunk horizontal
while raising legs
20 to 30 degrees
(contraindicated
in congestive
state in which
semi-fowler’s
position is
preferred)
Promote adequate
rest, by
decreasing
stimuli, providing
quiet
environment
Maintain patency
of invasive
To increase venous
return
To maximize sleep
periods
To prevent air
embolus and/or
program, balanced
activity/ rest plan)
53
intravascular
monitoring and
infusion lines.
Tape
connections.
Avoid activities
such as isometric
exercises, rectal
stimulation,
vomiting, and
spasmodic
coughing.
Administer stool
softener as
indicated.
Encourage pt to
to breathe deeply
in/out during
activities that
increase risk for
exsanguination.
May stimulate a
valsalva response
This prevents
exertion of too
much workload to
the heart.
54
valsalva effect.
Provide
psychological
support. Maintain
calm attitude but
admit concerns if
questioned by the
client.
Encourage
relaxation
techniques.
Elevate
edematous
extremities and
avoid restrictive
clothing.
Provide for diet
restrictions.
Honesty can be
reassuring when so
much activity and
“worry” are
apparent to the
patient.
To reduce anxiety
To promote comfort
To enhance pt’s
therapeutic regimen
55
Monitor intake
and output.
Discuss
significant signs
and symptoms
that need to be
reported to the
healthcare
provider
( e.g. muscle
cramps, d/a,
dizziness, skin
rashes).
Encourage
changing
positions slowly,
To determine fluid
balance
May be sign of drug
toxicity and/or
mineral loss ,
especially
potassium.
To reduce risk of
orthostatic
hypotension
56
dangling legs
before standing.
Give information
about positive
signs of
improvement
such as decreased
edema, improved
vital signs /
circulation).
Administer
supplemental
oxygen as
indicated.
Administer due
meds.
To provide
encouragement.
To increase oxygen
available to tissues.
57
Assessment Nursing Diagnosis Scientific
Explanation
Objectives Intervention Rationale Expected Outcome
The patient
may verbalize:
fatigue
weakne
ss
lack of
interest
in
activity
The patient
manifested:
prolong
ed
hours in
a
supine /
lying
position
Activity Intolerance
secondary to severe pre
eclampsia AEB
prolonged hours in a
supine / lying position
In severe pre
eclampsia the
cardiac
system can
become
overwhelmed
because the
heart is forced
to pump
against
peripheral
resistance.
Avoiding
strenuous
and/or
unnecessary
activities may
reduce
workload of
SHORT-TERM:
After 3 hrs of
nursing
interventions, the
patient will
demonstrate a
decrease in
physiologic signs
of intolerance
(decrease in BP)
LONG TERM:
After 3 days of
nursing
interventions, the
patient will report
measurable
increase in activity
> Establish
rapport
>Monitor and
assess VS
>Assess the pt’s
general physical
condition
Evaluate current
limitations /
degree of deficit
in light of visual
status
Assess
cardiopulmonary
response to
physical activity,
To gain pt’s trust
and cooperation
To obtain baseline
To determine
presence of
abnormality
Provides
comparative
baseline
To note for
prgression/
accelerating degree
The patient shall have
demonstrated a
decrease in
physiologic signs of
intolerance (decrease
in BP)
The patient shall have
reported a measurable
increase in activity
tolerance.
58
appears
weak
and
restless
The patient
may manifest:
Abnormal
heart rate or
blood pressure
in rsponse to
activity
the heart
Bed rest,
which resulted
to activity
intolerance, is
the best
method to aid
in the
evacuatioevac
uation of
excess sodium
and in the
promotion of
diuresis that
will result to a
decrease in
BP. When the
body is in a
recumbent
position,
sodium tends
to be excreted
tolerance. including VS,
before, during
and after activity.
Assess
emotional/psycho
logical factors
affecting the
current situation
Adjust activities,
reduce intensity
levels or
discontinue
activities that
cause undeserved
physiological
changes
of fatigue
Stress and/or
depression may be
increasing the
effects of an illness,
or depression may
be the result of
being forcec into
inactivity
To prevent
overexertion
59
at a faster rate
than during
activityIncrease
activity/exercise
level gradually,
teach methods
such as stopping
for rest during a
ten minute walk,
sitting down
instead of
standing to brush
hair
Plan care with
rest periods
Provide positive
atmosphere while
acknowledging
difficulty of the
situation for the
client
To conserve energy
To reduce fatigue
Helps to minimize
frustration
60
Assist client
Promote comfort
measures and
provide pain
relief
Check and
regulate IVF
Give due meds
To protect pt from
injury
To enhance pt
ability to participate
in activities
To obtain the
desired rate
To treat
abnormalities
61
Assessment Nursing Diagnosis Scientific
Explanation
Objectives Intervention Rationale Expected Outcome
The patient
may verbalize:
Shortness of
breath
orthopnea
The patient
manifested:
pitting edema
in lower
extremities
restlessness
The patient
may manifest:
oliguria
dyspnea
Excess fluid volume r/t
compromised regulatory
mechanism secondary to
severe preeclampsia
In PIH,
vasospasm
occurs in the
kidney which
increases
blood flow
resistance.
Degenerative
changes
develop in
kidney
glomeruli
because of
back pressure.
These
degenerative
changes result
in decreased
glomeruli
filtration, so
SHORT TERM:
After 3 hrs of
nursing
interventions, the
patient’s fluid
volume will
stabilize AEB
balanced I/O.
LONG-TERM:
After 3 days of
nursing
interventions, the
patient will
demonstrate
behaviors to
monitor fluid
status and reduce
recurrence of fluid
> Establish
rapport
>Monitor and
assess VS
>Assess the pt’s
general physical
condition
>Monitor I/O
>Review pt’s
sodium intake
>Compare
current weight
To gain pt’s trust
and cooperation
To obtain baseline
To determine
presence of
abnormality
To calculate fluid
balance
Sodium attracts
water
To determine rate
of weight gainTp
the patient’s fluid
volume shall have
stabilized AEB
balanced I/O.
The patient shall have
demonstrated
behaviors to monitor
fluid status and
reduce recurrence of
fluid excess
62
azotemi
a
there is a
lkowered urine
output and
clearance of
creatinine.
Increased
kidney tubular
reabsorption of
sodium occurs.
Because
sodium retains
fluid, edema
results.
excess. with admission
and/or previously
stated weight
>Auscultate
breath sounds
>Measure
abdominal girth
for changes
>Note patterns
and amount of
urination
>Restrict fluid
and sodium
intake as
determine presence
of crackles or
congestion
May indicate
increasing fluid or
edema
To detect
impoairment in
urinary elimination
Sodium and add’l
fluid intake may
aggravate edema
To reduce tissue
pressure and risk of
skin breakdown
63
indicated
>Evaluate
edematous
extremities,
change position
frequently
>Place the pt in a
semi-fowler’s
position as
appropriate
>Discuss
importance of
fluid restrictions
and “hidden
sources” of intake
(such as foode
high in h20
content
>Set appropriate
To facilitate
movement of
diaphragm to
improve respiratory
effort
Reinforces the need
for sodium and
water intake
restriction
To prevent peaks /
valleys in fluid
level
To obtain desired
64
rate of fluid
intake / infusion
>Administer due
meds
>Check and
regulate IVF
>Attend to pt’s
needs
rate
To facilitate faster
recovery
Assessment Nursing Diagnosis Scientific
Explanation
Objectives Intervention Rationale Expected Outcome
65
The pt
manifested:
A systemic
vasoconstrictio
n
The pt (fetus)
may manifest:
Meconium
staining
Increased
pulse rate
Risk for fetal injury r/t
maternal regulatory
dysfunction
With severe
preeclampsia,
the cardiac
system can
become
overwhelmed
because the
heart is forced
to pump
against rising
peripheral
resistance.This
reduces blood
supply to
organs, most
markedly in
the kidneys,
pancreas, liver,
brain, and
PLACENTA.
Poor placental
perfusion may
SHORT-TERM:
After 3 hrs of
nursing
interventions, the
pt’s placental
persfusion will
increase.
LONG-TERM:
After 3 days of
nursing
interventions, the
pt will demonstrate
a decrease in
systemic
vasoconstriction to
increase
uteroplacental
circulation
Establish rapport
>Monitor and
assess VS
>Assess the pt’s
general physical
condition
Instruct mother to
assume a left
lateral position.
Promote bed rest
To gain pt’s trust
and cooperation
To obtain baseline
To determine
presence of
abnormality
To avoid putting
pressure on the
inferior vena cava.
To increase
uteroplacental
circulation and
prevent too much
workload on the
The pt’s placental
persfusion shall have
increased.
The pt shall have
demonstrated a
decrease in systemic
vasoconstriction to
increase
uteroplacental
circulation
66
reduce the
fetal nutrient
and Oxygen
supply.
Encourage
relaxation
techniques such
as deep breathing.
Avoid
constipation.
Instruct mother
heart.
To provide comfort.
Straining during
defacation might
put pressure on the
uterus which could
injure the already
compromised fetal
health.
To enhance pt’s
participation in the
67
on the possible
complications the
disease can cause
to the fetus.
Discuss
importance of
having an
adequate blood
circulation going
to the placenta.
Administer
oxygen as
indicated
Administer
medications as
prescribed.
treatment regimen.
To facilitate faster
recovery
Assessment Nursing Diagnosis Scientific Objectives Intervention Rationale Expected Outcome
68
Explanation
The patient
may verbalize:
pain on the site
of IFC
insertion
palpitations
thirst
The patient
manifested:
An indwelling
foley catheter
is inserted into
her urethra
The patient
may manifest:
Increased pulse
rate
Risk for infection r/t
invasive procedure
Instrumentatio
n of the
urinary tract or
catheterization
can be a
precipitating
cause in the
development
of UTI
especially if
the catheter is
unsterile or
contaminated
with
pathogens.
The most
common route
of infection is
transurethral
(ascending
infection), in
SHORT-TERM:
After 3 hrs of
nursing
interventions, the
patient will
demonstrate
techniques to
prevent / reduce
risk of infection
LONG TERM:
After 3 days of
nursing
interventions, the
patient’s IFC will
remain intact
without any
purulent drainage
> Establish
rapport
>Monitor and
assess VS
>Assess the pt’s
general physical
condition
Observed for
localized signs of
infection at the
insertion site
Stress proper
handwashing
techniques by all
caregivers
handling /
coming in contact
with the pt
To gain pt’s trust
and cooperation
To obtain baseline
To determine
presence of
abnormality
To detect presence
of infection
A first line defense
against nosocomial
infections / cross
contamination
The pt shall have
demonstrated
techniques to prevent
Risk of infection.
The pt’s IFC shall
have remained intact
without any purulent
drainage
69
Increased
respiratory rate
Fever
Chills
diaphoresis
which bacteria
colonize the
periurethral
area and
subsequently
enter the
bladder by
means of the
urethra. In
women, the
short urethra
offers little
resistance to
the movement
of
uropathogenic
bacteria.
Maintain sterile
technique for
invasive
procedures (IFC
insertion)
Cleanse insertion
site daily and prn
with povidone
iodine or other
appropriate
solution
Provide regular
catheter / perineal
care
Instruct pt to
wash hands when
coming in contact
with the insertion
To reduce risk of
acquiring UTI
To reduce risk of
ascending
infections and to
provide comfort
which will enhance
pt’s well-being
To help flush out
bacteria or
pathogens
Friction and
running water
70
site
Instruct
significant others
of measures to
prevent spread of
infection
>Administer due
meds
>Check and
regulate IVF
>Attend to pt’s
needs
effectively remove
microorganisms
from hands
To give appropriate
treatment to
abnormalities as
early as possible
To obtain desired
flow rate
71
72
Assessment Nursing Diagnosis Scientific
Explanation
Objectives Intervention Rationale Expected Outcome
The patient may
verbalize:
Change in bowel
pattern
Unable to pass
stool
The patient
manifested:
Pt spends most of
the time lying in
bed
Perform little
gross motor
movement
32 weeks
pregnant
Risk for constipation r/t
insufficient physical
activity
Pregnancy,
tegether with
an insufficient
physical
activity slows
intestinal
peristalsis /
decreases
gastric
motility and
emptying time
of the stomach
which may
lead to
constipation
Physical
activity
increases
peristalsis
which could
SHORT-TERM:
After 3 hrs of
nursing intervent
ions, the pt will
dwmonstrate
behaviors leading
to prevention of
constipation such
as intake of fruits
and vegetables
LONG TERM:
After 3 days of
nursing
interventions
ions,the pt will
perform range of
motion exercises
> Establish
rapport
>Monitor and
assess VS
>Assess the pt’s
general physical
condition
Auscultate the
abdomen for
presence,
location, and
characteristics of
bowel sounds
Evaluate current
dietary and fluid
intake and
To gain pt’s trust
and cooperation
To obtain baseline
To determine
presence of
abnormality
This reflects bowel
activity
To determine
which food must be
increased to reduce
The pt shall have
demonstrated
behaviors leading to
prevention of
constipation such as
intake of fruits and
vegetables
The pt shall have
performed range of
motion exercises as
appropriate for her
condition
73
The patient may
manifest:
dry, hard, formed
stool
strainig with
defecation
severe flatus
lead to
evacuation of
bowel contents
as appropriate for
her condition
implications for
effect on bowel
function
Review
medication (new
and chronuc use)
Instruct pt to eat
a balanced high
fiber diet
Encourage
activity or
exercise within
limits of
individual ability
risk of constipation
To evaluate if any
drugs is being
taken which has a
corresponding
effect on bowel
function
To improve
consistency of stool
and facilitate
passage through the
colon
To stimulate
contractions of the
intestine
74
Discuss
physiology and
acceptable
variations in
elimination
Encourage
patient to
maintain
elimination diary
if appropriate
Check and
regulate IVF
Give due meds
May help reduce
concerns /anxiety
about situations
To help monitor
bowel pattern
To obtain the
desired rate
To treat
abnormalities
75
>Attend to pt’s
needs
Assessment Nursing Diagnosis Scientific
Explanation
Objectives Intervention Rationale Expected Outcome
The patient may
verbalize:
lack of sufficient
skills in parenting
The patient
manifested:
young age (15
years old) with an
AOG of 32 weeks
low self-esteem
The patient may
manifest:
Risk for impaired
parenting r/t physical
illness secondary to
severe preeclampsia
Due to patient
manifesting
different
objectives of
lack of
optimum
growth, the
risk for
impaired
parenting
increase which
can reslut to
bad / negligent
actions done
by the parent
SHORT-TERM:
After 3 hrs of
nursing
interventions,the
pt will verbalize
understanding of
the health
teachings given
LONG TERM:
After 3 days of
nursing
interventions, the
pt will manifest
good hygiene,
> Establish
rapport
>Monitor and
assess VS
>Assess the pt’s
general physical
condition
Encourage
personal hygiene
Create an
environment in
which
To gain pt’s trust
and cooperation
To obtain baseline
To determine
presence of
abnormality
To reduce risk of
infection
Learning is more
effective when
the pt shall have
verbalized
understanding of the
health teachings
given
The pt shall have
manifestes good
hygiene, strong
body, joy, and
optimism
76
stress
anxiety
strong body, joy,
and optimism
relationships can
be developed and
needs of each
individual met
Make time for
listening to
concerns of pt
Encourage pt to
identify positive
outlets for
meeting their
own nee
Check and
regulate IVF
Give due meds
To obtain the
desired rate
individual feel safe
To have a deeper
understanding on
the pt’s emotional
status and to
promote respect
Promotes general
well-being
To obtain the
desired rate
To treat
abnormalities
77
To treat
abnormalities
>Attend to pt’s
needs
78
VIII. CLIENT’S DAILY PROGRESS CHART
DAYSAdmission
01-29-13
Day 2
02-05-13
Day 3
02-06-13
Discharge
NURSING PROBLEMS
1.Acute Pain
+
- -
2. Decreased Cardiac Output
+
- -
3. Activity Intolerance
+
+ +
4. Excess Fluid Volume
+
+ +
5. Risk for Fetal Injury
+
- -
6. Risk for infection
+ + +
7. Risk for constipation
- + +
79
8. Risk for impaired parenting
- + +
Vital Signs Blood Presure- 200/110 mmHg
Blood Pressure – 110/80
mmHg
Pulse rate – 78 bpm
Respiratory rate – 20 cpm
Temperature – 37 C
Blood Pressure – 120/80
mmHg
Pulse rate – 70 bpm
Respiratory rate – 22 cpm
Temperature – 36.5 C
DX AND LAB PROCEDURES
HEMATOLOGY+
URINALYSIS+
DRUGS
Cefuroxime + +
Metronidazole + +
FESO4 + +
80
Mefenamic Acid
+ +
Nifedipine + +
Aldazide + +
MEDICAL MANAGEMENT
1. PNSS 1L + MgSO4
+
2. D5LRS + +
DIET
Diet as tolerated, low salt low fat
+ + + +
ACTIVITY
Bed Rest + + + +
81
IX. DISCHARGE PLAN
DISCHARGE PLAN
METHOD
M- Instruct patient to continue medication as ordered
E- Instruct the patient to do minimal exercise as tolerated such as walking to
prevent contractures and bedsores and further complications
T- Instruct the patient to comply with treatment regimen
H-
Instruct to increase fruit juices and low fat milk in diet for nourishment
Instruct to avoid food rich in sodium like processed food, dried food and
can good food.
Avoid too much saturated fat and cooking using animal oil, instead use
vegetable oil
Instruct client regarding his activity
O- Instruct to come back for follow-up check up on the Doctors schedule date
D- Instruct the patient to a diet as tolerated but preferably avoiding salty and fatty
foods
82
X. CONCLUSION AND RECOMMENDATION
The key to the successful management of patient with severely elevated blood pressure is
to differentiate hypertensive crisis from hypertensive urgencies. Patients with hypertensive
urgencies, but without clinical evidence of acute end organ damage. Rapid antihypertensive
therapy is not warranted for these patients. Hypertensive crisis constitute a distinct group of
clinicophatological entities associated with acute target organ injury. These patients require
immediate BP reduction to prevent end organ damage. Hypertension associated with cerebral
infarction or intra cerebral hemorrhage only rarely requires treatment.
The time frequency of heart rate variability showed different change during cooling in
pregnancy induced hypertension as compared to normal control but the blood pressure and heart
rate themselves showed no fixed tendency. Those findings indicate that time – frequency
analysis is of importance to evaluate the physiological stress test.
Our recommendation would be to increase fluid as well as protein; we all know that cell
membranes are composed of protein molecules which govern the passage of fluid into and out of
each cell. Blood vessel walls are particularly sensitive to this lack of protein. As the protein is
needed in third trimester for the needs of the fetus, protein molecules are robbed from wherever
they are most available. So, logically, one would increase dietary protein, and allow sufficient
water to ease the strain on the kidneys and allow protein re-absorption into the general blood
flow. But not to overload the kidneys with excess fluid, which dulls the appetite.
83
X. CONCLUSION AND RECOMMENDATION
http://en.wikipedia.org/wiki/Intravenoustheraphy
http://www.worcestershirehealth.nhs.wk/WAHTLibrary
http://www.greenhosp.org/pe_dpf/surgery
http://nwmdgp.org-au/pages/afterhours
www.guideline.gov
http://www.ashfordstpeters.nhs.uk/intranet/ashferel
http://www.healthsystem.virginia.edu/uvahealth/peds_hrpregnan t/pih.cfm
http://prenatal-health.suite101.com/article.cfm/pregnancyinduced_hypertension
http://findarticles.com/p/articles/mi_m0887/is_n5_v15/ai_18403814
http://www.fagellaw.com/Information_Center/Pregnancy_Induced_Hypertension.aspx
http://www.doh.gov.ph/chdcar/index.php?option=com_content&task=view&id=49&Itemid=1
Black, Joyce M. and Jane Hokanson Hawks. Medical-Surgical Nursing: Clinical Management
and Positive Outcome Volume 1.USA.2005.
Udan, Josie Q. Medical-Surgical Nursing: Concepts and Clinical Application-A Reference Book
and Study Guide First Edition. Philippines.2002
84
